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CT Spine & Pain Center at
BristolHospital Brewster Rd., P.O. Box 977 Bristol, CT 06011-0977 860-585-3040
Accredited
MANA
EMENT
ISSUE ONE
Welcome to the newsletter of the Con-
The cliscographer inserts a needle in the patient's back into thc center of the disc.
necticut Spine and Pain Center at
Radioglaphic dve is then injected into thc clisc, and if injecting the dye recreates the paticnt's normal pain (concordant), it is then inferrccl that the specific disc is the source of pain firr the patient. If the pain is unlike their normal
Bristol Hospital. Pain medicine is an exciting and gtowing medical specialty that deals with the diagnosis and
treatmerit of acute and chronic pain conditions. Ovet recent years many chernical and
anatomic pain pathways have been more cleady identified. Newer medi-
cations and techniques in interventional pain medicine have helped to identiS' and to reduce or
Discography Annette Macannuco, MD A-.\'pine t; Pain Center
The CT Spine and Pain Center at
Discography is a diagnostic test perf<rrmed t<r view and assesses the internal structure ofa disc. This procedure is most frcqucntll'usecl to determine if degenerative disc cliscase is the cause of a patient's pain (discogenic krw
Bristol Hospital is the only CARF ac-
back pain).
credited pain centet in Connecticut, providing a multidisciplinary ap-
,\
eliminate sources of pain,
proach to the diagnosis and treatrnent
of pain. I(/e hope that this newsletter provides you with some insight into the specialty ofpain medicine. Jonatban Kost
Medical Director
Jonathan Kost, MD MedicalDirector
Annette Macannuco, MD Pain Management Specialist
Frank Lee, MD Pain Management Specialist
Deborah Rosenberg, Ph.D. Pain Management Psychologist
Rafael Cordova, RPT Physical Therapist
tliscogram ser\ es as a prc-opcrativc invcstisational tool and is perfrrrmed on
patients who have not responded
pain (discordant) it can be inferred that cvcn though the clisc mav krok degenerated on an N{RI scan, it is in fact not the source of the patient'.s pain. Thc tcst itsclf is painlul because the patient needs to bc awakc ancl au'are in older to tell the cliscoerapher what kind of pain is ecncratccl b1'thc injection. Afier the procedure, (lT Scan is utilizecl lor lurther cr aluation of thc discs. Discoqcnic pain mat be treated surgicalh' or bv a lcss inr.asive trcatment such as nucleoplas6'.
Contained Disk Herniation
t<r
consef\.ative treatmcnt. The procedure als<r identifies the rnoqphokrgical appearance of the disc from eadl'deecncrative changes, such as fron.r ring-shapcd tcars to the disc with leakage ofcontrast to thc epiclural space.
j
tr
Radiofrequency
Facet joint pain is the most widel1'treated pain
Frank Lee, MD CT .lpine d: Pain Center
s1'ndrome with radiofrequency. This is due to
The tcrm Radiofrequcncy (RF) esscntiall), mcans utilizing electriciE'to manage pain. RF is an alternating electric field
with an oscillating
fi'equencl of 500,000 HZ. Heat is producecl in tissr,re surrounding a RF electrode becausc bocly tissue acts as a resistor. By'gencratine heat around a nerve, thc nen.e's abilitt' to pain is destroyed, thus ablating the
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Nucleoplasty
Radiofrecl-renc), ablation
used
Nucleoplasty is a minimally invasive
for over 25
)/ears
of
of
meclical publications stronell, support thc use
the nucleus (nucleus pulposis is the center gel-like substance of the disc.) The outer
of racliofrequencl' for treatment of chronic
band-Like substance of the disc is the annulus fibrosis. Typicaily,when a disc herniates, the annulus fibrosis opens and allows the nucleus pulposis to protrude and compress strucrures such as nerves. Nucleoplasg' does not involve an incision. A special access needle is placed into the disc under x-ray guidance. A wand-like device is then insertecl through the needle and into the disc. The device uses heat to
arc also being cler.eloped f<rr trcatment of
remove disc material and seal the channel made by the needle. Several channels are
made depending on how much disc material needs to be removed.
The procedure is performed in a surgical center with fluoroscopic (x-ra1) guidance . Nucleoplasty is done with the patient lying prone. lntravenous sedation is given to help with comfort and relaxation. The skin is cieaned with an antiseptic solution ancl the back is numbed with a local anesthetic before the procedure is performed. The
d with
may be an appropriatc candidate f<>r radiofrequencl'ablation of the spine ncrves.
nen'e s has been
contained or mild11' herniated discs.
monitore
examination. If d-ie diagnostic testins indicates 50t% or greater rclie f of pain, thcn the patient
to treat a \.ariet)' ()f
severe, chronic pain probicms. Latelv, thcre have been notable improvements in the equipment and techniquc. Scveral reccnt
procedure deveioped to treat patients with
patient is
underso a detailed history ancl phvsical
:':::1lt,
Annette Macannuco, MD CT Spine b Pain Center
Nucleoplasry literally means removal
the cliscrete and well-c]efined innen'ation of these particular joints. Patients rvith suspected spine pain due to facet joint problems should
neck and back pain. Radiofrequenqr tcclniclues
occipital heaclaches, thoracic spine pain and certain tt'pes of svmpathetic pain sl,ndromcs. The techniquc itself is rather simple, ancl can bc tl-ror-rght as comparablc to the r-rsc of microwavcs t() he2rt food. Radiofrequcncy currcnt at 500,000 Hz is used to generate heat at thc tip ofan insulatcd needle placed at the Lrcatiorr oF thc nervc. This energy passes t() acljaccnt tissue heatin.q it to abor,rt 80 degre es Cclsius and stops transmission of painfr-rl impulses. The pcriod of time in which the nen.e cloes not conduct pain impulses lasts an\rvhere fr<>m 6 months to sevetal years. The
proceclurc usuallf is performecl on an outpatient basis, with light sedation. Use of
Radiofrequency Lesion Procedure with RF Needle at site of Median Branch Nerve
,\
rcvicrv t>f thc meclical literature shorvs that this techniquc is verl'effbctivc fbr treatme nt <>f chronic spine pain car-rscc'l bt' facet joint
problems. Lons-term pain lclief can bc obtained ancl vcrl' lew con'rplications have bccn
noted. Aclclitionally, relief of chronic spinc pain has been associatcc'l rvith resolution of psychol<>uical distress, redr-rced use of oral
mcdications, lcssened disabilitl and an impn;r.ed return t() usual lifestl'le activities.
fluoroscopy' is mandatorl' to ensure c()rrect placement of microelectrodes.
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electrocardiogram, blood pressure cuff and biood oxygen-monitoring device.
Normaiil', the entire procedure takes 20 to 30 minutes, and the patient is readl' 16, walk out of the clnic in about an hour
with no hospital stay required. Disc Nucleoplasty percutaneous disc clecompression is designed to offet a fastacting option to drug therapies and steroid
injections ancl a minimally invasive alternative to open surger)r Radiofrequency Generator System
The biofeedback therapists pror.ide other techniques in addition to biofeedback. Patients
usualll' are taught some form of rclaxation
exercisc. Some learn
to icientify
the
circumstances that trigger their s1'mptoms. Thcl' may also be taught how to ar<;id or copc with these stressful events. N{ost ale encouraged to chanqe thcir habits, and some are trained in spccial techniques for gaininu such self-control. Biofeedback remincls us that
behavior, thoughts, and leelings proftrunclly infl uencc phvsical health.
Biofccdback places r-rnusual demands on patie nts. Patients need to examine theil dal'
What is Biofeedback? Deborah Rosenberg, Ph.D. CT .\pittt' d: Pnin Cctlrr
to-da1' lives
to lcarn if thel' mav
be
contribr.rtins to their own distress. Thcl'
Biofeedback is a trcatmcnt tecl-rni<1ue in which people are trainccl to improve their health by Lrsins sisnals from the ir own bodies. Psvch<>logists use it to help tense ancl anxious cLients learn to relax ancl to hclp thcir patients cope rvith pain.
recognize that thel'can, b)' their own effirrts, influencc some ph1'sical ailments. They must commit themselves to practicing biofecclback or rclaxation exercises ever1, da)'. Thet' bccome aware of bad habits, even ease up ()n some g<;od ones. N{ost important, they mLlst accept
much of thc rcsponsibility for maintainins their owr-r hcalth.
Chances are \'()u har.c usccl biofeedback vor,rrselL Yrrr-r'r'c usccl it
if
\<ru have ever taken
or steppcd on
Biofecclback is often aimed at chansing
vour bocl\''s conclition. Armcci with this
habitual rcactions to stless that can affcct pain or cliscasc. N{any clinicians believc that sotne of tl'reir patients ancl clients have f()rgotten how to relax. Fccclback of ph1'sical responses sr-rch as skin tempcraturc and muscle tension
inftl'matior-r, 1'ou can takc stcps r<ru'r'e learned
ptor.iclcs information
to irtrprorc thc c,rtrtliti,rn.
recognize a rclaxccl state. The feedback signal mav act as a kind of reward lor reclucing
Clinicians rcll'on bioleedback machines in somcrvhat the same v-at' that \'or-r reh'on \<rur scale or thermometer. Inftxmation about bodilv fr-rnctions mav bc valuablc in gauging and directing the proercss of trcatment.
tension.
\'()Lrl tcmpcfaturc
a scale. Tl-rc
thcrmomctcr tells r'ou whether \r)u're running a
fcvcr, tl're scale rvhe ther trru'r'c gainccl rvcight.
Both devices "feeci back" inf<rrmation about
()ne commonll'
r-rsecl typc of machine, fbr example, picks up clectrical sisnals in tl.re muscle s. It translate s the se signals into a f<rtm that patients can detect, such as a bccp r>r a g'raph. If patients want to relax tcnsc musclcs, tl-rct'try to slow- dolr,'n the beepine or change the direction of the graph. The biofccdback trainee makes inte rnal acljustmcnts that altcr
signals. The biofeeclback thcrapist acts as a coach, stancling at thc siclclincs setting goals ancl limits on g'hat t() c\pect and giving hints on h<xr,tr> improve performance.
t1.re
Rescarcl-r has clcmonstlated that biofeedback can hclp in thc tleatment oi manl cliseascs ancl painful cr>nditions. It has shorvn that rr'c havc moLe control over inr'oluntarv boclilt' function than rve once th()usht possiblc.
to help patients
The vrltrc of biofcctlback as an instrument in hclpinupaticnts t() manxsc pain c,rntintres to be a vital tool in pain manaeement. The feedback illustrates to the patient that pain
can be influcncerl. This rcassurance olten encourages thcm tr> continue their efforts. .\'rnrtr: Xilirnal lrctitrru ol ,\lrrt'il llurllL
2003 FuNcrroNAL Acrrvrrv Scern
2003 PnrN Scerp Seterc
.\'et.,ere 10
fs
Linitel_
3% Improvement
38% Improaement
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A review of the collected outcome data for 2003 shows, on avefage, a 33"/u improvement in pain score ancl a 3B%, improvement in activitl, tolerance in those patient's who received interdisciplinarl. care at the CT Spine & Pain Center. These results afe as recorded by the patient in pre- and post-treatment documentation orrer a three-month window of treatment time. (.ontpi /ed
The CT Spine & Pain Center at Bristol Hospital PO Box 977, Brewster Road Bristol, CT 06011-0977 860-585-3040
Visit our Website at
www.bristol hospital.org for directions.
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