Diagnosing, treating and managing a patient’s chronic pain can be the most challenging task for a medical provider.  Your physician has only a short span of time during your visits to obtain a comprehensive history of your pain and it’s components.  The various features of your chronic pain including but not limited to the items listed below, can assist your physician with identifying your pain source and creating an appropriate treatment plan.

Onset- how your pain came about

Duration - how long you have had this pain

Frequency- how often does it occur in a period of time or is it constant

Aggravating Factors- what makes your pain worse

Alleviating Factors– what makes your pain better

Past Treatments - what has helped to decrease your pain

This multitude of information about your pain is important to help with medical decision making.  Additionally, once treatment is applied whether with medications, physical therapy, injections or surgery, your physician will then need to know your response and the change in your previous pain.  Information pertinent to therapeutic trials include:

Quality/Quantity of Relief - how much does it help

Improvement in Function - how much more and what can you do afterwards

Frequency- how much and how often do you need treatment or medications

Efficacy of Medications - how many is required, how long does a dose last, what does it allow you to do

Adverse Effects - what are the untoward side effects you experience with treatment or medications

To depend on just your memory to recall these various pain symptoms over a period of weeks, months, or even years to report to your physician is an impossible task.  Many chronic pain doctors ask their patients to track the frequency and properties of their pain and symptoms.  The goals for this is to track the efficacy of a new treatment, identify common triggers, confirm suspicions, or determine a diagnosis. Tracking your pain efficiently and effectively can play a crucial role in better pain management.  In the past, it was done with pen and pencil.  With modern technology and the advent of smart phones and smart devices, it can be done electronically.  If you have quoestions about tracking your pain, speak to one of the pain management specialists at the Virginia Spine Institute for further guidance.

How do you track your pain symptoms?

Below are a few examples of pain diary apps from the iTunes Store, ranging from $0 .99 – $7.99

My Pain Diary: Chronic Pain Management

Chronic Pain Tracker

Pain Tracker

Patients who develop pain, numbness or weakness in the arm or leg are often diagnosed with an acute disc herniation. When a patient comes in for a consultation, a couple of preliminary questions typically arise; “how did this happen or what caused this?” and “is this a slipped disc, a herniated disc, a ruptured disc-what is this?”

To answer these questions, it is important to understand what a disc is: A disc is a strong ligamented structure that connects one bone to the next thereby allowing the spine to move.  This strong ligamented structure is what allows us to bend forward, backward and sideways.

A disc herniation, by definition, is displacement of disc material beyond the normal confines of the disc space.  The terms disc protrusion, disc bulge, disc herniation, ruptured disc, and slipped disc all imply that disc material has extended beyond the confines of the normal disc space. These lumbar ligaments (discs) function just like knee ligaments and shoulder ligaments do and can be injured in the same way.  The difference is, when the disc is stressed and ruptures, a piece of the disc from the central or peripheral portion will break off this circumferential structure and extend outward.  When this extends into the spinal canal where the nerves sit, a nerve can be pinched by the mass, which is now present in the spinal canal and cause severe pain in the path of the nerve being pinched.  Specifically, a disc fragment that would enter the spinal canal and pinch a nerve to the arm would cause arm pain, whereas in the low back a piece of disc that breaks off and pinches a lower extremity nerve would cause leg pain.  Depending upon which nerve is pinched will produce different pain patterns as the different nerves provide sensation to different portions of the extremity. Classic sciatica, which is pain down the back of the thigh and calf, is usually caused by a herniation at one of the bottom two levels of the spinal canal pinching the L5 and/or S1 nerve and producing pain in that pattern.

Another common question is, what does a herniation look like? You can see from the photos that these pieces of disc material would occupy significant room in the tiny space that is the spinal canal; thereby compressing the nerves. The consistency of a disc depends upon whether it is the outer tough annular portion or the central soft nuclear portion. All of these fragments represent a combination of annular and nuclear herniation that you can see in the photos.  In lay terms many compare the consistency of a disc herniation to that of lobster. In the cervical spine (neck), herniations are extremely small because the discs themselves are small and a tiny fragment of just several millimeters could cause severe arm and/or neck pain.  In the low back, typically the herniations that are symptomatic are much larger.

The good news is that when properly identified and treated most patients will improve non-operatively. For the few that the compression remains too much, minimally invasive surgical interventions are usually highly successful in eliminating the symptoms and allowing people to return to a full and active lifestyle. We have performed these operations in both the neck and the low back on professional athletes and allowed them to return to their chosen sport without limitation or restriction once the tissue is healed. Typically, we would wait two to three months prior to return to that elite level of play.  For simple daily activities, we would hope that someone would return to those within a few days of the microsurgical outpatient procedure.

What were your first symptoms of a herniated disc?

The photos demonstrate catastrophic herniations with massive fragments:

Don’t underestimate tingling, numbness, or pain in your arms. Get to the root of the problem — it could be caused by a pinched nerve in your wrist, elbow, or neck.

Tingling in your thumb as well as index and middle fingers?
This is often related to irritation of the nerve at the wrist.  If you spend countless hours writing or typing on the computer, then you’ve probably heard of carpal tunnel syndrome. Furthermore, these symptoms can be associated with pregnancy, as there is often fluid retention and additional swelling in the hands and wrist.  We’ve all woken up during the night with our hand “falling asleep” and then have to shake it hands in order for the tingling and numbness to go away.  If that sensation is due to pinched nerves in the wrist, there should not be any pain or numbness in the elbow or shoulders.  The symptoms should be isolated to the hands or wrists.  It is often treated by resting the nerve or wrist by wearing a wrist splint, taking anti-inflammatory medications, and occasionally doing injections around the wrist to help decrease inflammation. Physical therapy can often help decrease inflammation, but if it is not effective, surgery will take pressure off the nerves and is often helpful.

Numbness in your forearm, ring & pinky finger?
If so, it may be due to a pinching of nerves around the elbow.  The ulnar nerve can often be stretched and irritated around the elbow.  This irritation is called cubital tunnel syndrome. Did you know Cubital is from the Latin term for elbow? Non-operative treatments including resting and bracing can often help. However, surgery may be indicated to decompress the nerve if non-operative treatments are not successful. .

Pain radiating down your entire arm?
If you are experiencing numbness and tingling radiating down the entire arm, often accompanied by pain around the shoulder blade, shoulder, arm, hand, and fingers, this may be related to a pinching of nerves in the neck. Some people will find that placing their hand above their head will take pressure off the nerve and relieve some of their arm and shoulder pain.  Others find that tilting their head one way or the other causes the pain to improve or worsen.  This may be a sign they are having nerve irritation due to a disc herniation or arthritic spur in the neck.  These are symptoms of cervical radiculopathy.

Initially, cervical radiculopathy is treated with non-operative, conservative treatments with a goal of decreasing inflammation with medication and/or rest.  Cervical traction can also help take pressure off the nerve briefly, which may also decrease inflammation around the nerve.  However, if the non-operative treatments are not effective, then surgical intervention may be indicated to take pressure off the nerve.

If you have tingling or numbness in the arms, it is important to specifically identify where you are experiencing pain to better understand where it is originating.  Pinching of the nerve in the wrist, elbow, or neck can all cause different symptoms and they need to be treated in with unique approaches.  In most cases these symptoms can be treated non operatively. For the surgical candidates, most are back to all activities within a couple of weeks or months and most are back at full sporting activities after a full recovery.

Causes of arm pain range from mild annoyances to severe and potentially life-threatening occurrences.  Seek a doctor’s diagnoses as treatments depend on the underlying cause.