Throughout the coronavirus (COVID-19) crisis, infectious disease expert Dr. Anthony Fauci has been a source of calm help.  He has been the most prominent physician in the country, putting government policies into medical context and helping us all understand why flattening the curve is so important.

Dr. Fauci appeared on The Daily Show last week for a great update on the crisis.  For a watch.

- DKP
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As our community copes with the fast-moving spread of the COVID-19 coronavirus,  we hope you and yours are in good health during these stressful times.

As you all know, the information and knowledge about this virus is changing, often several times a day.  It can be quite unsettling and scary.  I will provide as much current information as I can at this page.

Public officials of Contra Costa County have ordered shelter in place through April 7. https://813dcad3-2b07-4f3f-a25e-23c48c566922.filesusr.com/ugd/84606e_1870398d90a14bc09ff09bc944fcf71e.pdf   Since medical facilities are on the essentials list, hospitals and many offices are still open.  Other medical practices are closing and only interacting with patients via telephone and/or video conferencing.  I have decided to do the same at least through April 7.  

If you are scheduled to see me in the next two weeks, you should receive a call from my office to discuss a TeleHealth visit instead.  You may also call my office directly. I was in test mode this week with several live patient TeleHealth visits using Skype and FaceTime.  These visits went well, despite a few connection issues. We will continue to test and tweak to improve the process more and more each day.  

During this restricted period, I may see a very limited number of patients in my office depending upon the need.  If a rare exception is needed, we have modified our office practice to try to protect you and us. We are doing extra sanitizing and have eliminated all shared items like, pens, magazines, etc.  We will be screening in advance each person entering the office, including a temperature check to minimize the risk of bringing the virus into the office. Any patient seen under these conditions will be limited to one additional person: caregiver, Case Manager, etc.
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We hope you will be open to doing your visit via telephone or video conferencing.  We expect to modify our routine and schedule as the pandemic response evolves. We diligently monitor throughout each day the medical updates that could affect all of us.  We appreciate your understanding as we all try to navigate and remain healthy, during this unprecedented time in our lives.

Coronavirus Tips and Reminders to Stay Safe:

1. The most common symptoms of COVID-19 are fever, cough, shortness of breath and breathing difficulties. Contact your primary care physician if you are experiencing these symptoms, particularly if your symptoms are severe, if you have traveled internationally in the last month, or if you have been in contact with someone who tested positive for COVID-19 
2. The best prevention you can take includes frequently washing your hands with soap for at least 20 seconds or using hand sanitizer. 
3. Cancel any unnecessary travel. 
4. Exercise hunkering down at home with your immediate family and physical distancing from all others as best as you can.  Reduced exposure does protect you and helps society contain the spread of this virus.
5. Stay home if you are sick.
6. Cough into your elbow or a tissue and not your hands.  
7. Once again: wash your hands thoroughly.​

- DKP

Radiculopathy (Latin radicula + English -o- + -pathy) means anything irritates or injures the nerve root.  Examples are a disc herniation into the spinal canal (formed by the vertebral body, pedicle, lamina and spinous process where the spinal cord “lives” ((see the picture above)) or into the neural foramen where the root exits the spine to go to the shoulder.  Other causes of a radiculopathy can be a spinal stenosis, where the canal is narrowed generally due to a combination of factors. Irritation of the nerve root can cause pain and/or weakness in the neck, shoulder and down the arm to the hand.

Treatments of a radiculopathy are: 1. Exercise, 2. Therapy, which may include traction, 3. Acupuncture, 4. Manipulation, 5. Anti-inflammatory medication (Ibuprofen and Naprosyn as well as Celecoxib and Aspirin are examples), Steroids, either oral or injected around the root through an epidural approach.  In general, an epidural is more effective than a pill because the steroid is placed where the nerve is compressed and swollen.
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Neck and Arm Pain/Cervical Facet Syndrome:

Different from radiculopathy is irritation of the facet or joint between two vertebrae.  In this case the nerve root is not irritated, but either the joint or the nerve twig that supplies the joint is irritated or inflamed.  This process affects sensory nerves, not motor. It does not cause weakness, although because of pain you may feel weak.
The pain can be in the neck, shoulder and arm.  It usually does not cause pain into the hand.

Treatments may differ from those offered for treating the nerve root.  It does not usually involve an epidural steroid injection but may involve a facet (steroid) block.  In this case the doctor may try to inject the facet or the branch nerve that supplies sensation to the facet (called a medial branch block).  In some cases, the doctor may offer to “burn” the medial branch nerve to the facet joint with a procedure called Radiofrequency Ablation (RFA).  This can be done because there is no weakness caused by the block. The facet block may provide pain reduction for days to three months. The RFA may provide pain reduction for up to two years.  However, most insurances require a good result from a facet block before approving an RFA procedure.

All other treatments used for radiculopathy are used for facet syndrome beside an epidural injection.


Neck and Arm Pain/Myofascial Pain Syndrome: 

Another major cause for neck, shoulder and arm pain is muscle generated pain, i.e. trigger points.

In this instance, it is believed that there was an injury to the muscle, and probably a tear that was microscopic, meaning you can’t see it with existing technology.  In the healing process a scar of the tissue develops that is not as flexible as the tissue previously was. Because of this inflexibility, with muscle contraction or stretching, pain is caused in the muscle and frequently has pain in a defined referral pattern.

Treatments are stretching, massage, acupuncture, trigger point injections (that are followed immediately by stretching).  Anti-inflammatories are used but are typically less effective since inflammation is not always present.

Summary: 

While this is not an exhaustive list of causes or treatments for neck and arm pain, it is the most common.  It is also very common that all these causes exist at the same time, thus making evaluation and treatment much more difficult.

​- DKP

Hello! Welcome to the first of many blog posts about pain, it's causes, and ways we treat it in my practice. My hope is that this blog will help patients learn more about their conditions and steps that they can take to self-manage so they can live full and healthy lives.

For our first topic, we're going to talk about neck and arm pain.

To start, let's consider what can cause your neck and arm pain:

1. Radiculopathy 
2. Cervical Facet Syndrome
3. Muscle strain/sprain and trigger points
4. Thoracic Outlet Syndrome
5. Referred pain from elsewhere
6. Other causes

This list is not exhaustive but will require multiple posts to cover all numbered items.  I will, over subsequent posts, discuss each topic. I will discuss cause, symptoms, diagnosis, treatments, self-management.

So, let’s begin.

Anatomy

The anatomy of the neck and shoulder is complex.  There are bones, ligaments, muscles, fascia, skin in addition to blood vessels and nerves.  

The neck contains 7 vertebrae. (For completeness, the spine has the skull/or cranial bones, 7 cervical bones, 12 thoracic bones, 5 lumbar bones, the sacrum and the coccyx.)

The spine bones, or vertebrae, have a shape a little like the Star ship Enterprise, from Star Trek.  There is a round front part, called the body, and a ring off the body with 3 knobs or wings off the body. ​
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These are called “processes”- 2 transverse processes and a spinous process.  Remember that I am writing in general terms.  The vertebrae have different appearances depending on their level in the spine.
The body has a “joint” with the vertebra above and below.  The ring has joints with vertebra above and below through 2 facets on each side of the ring (a total of 4 facets on each ring).  The ring itself has different parts that have variable shapes, depending on the level, but in general has 2 pedicles and 2 laminas.  The pedicles are immediately off the body and the laminas are between the facet joints and spinous process.

Attached to the spine are various ligaments that strengthen the spine.  There are also muscles attached to various points of the spine. In addition, there is connective tissue, called the fascia, that wraps around the bones and muscles.  The ligaments, muscles and fascia together are identified as “soft tissue” as opposed to bone which could be called “hard tissue” (although we do not do so), and theses soft tissue allow us to bend, twist, etc. without falling apart!

Unfortunately, in addition to developing arthritis in the joints of the spine, (the same as in you can in knees, hips, fingers), you can develop problems with the “soft tissues” such as sprains and strains (which are degrees of the same), tears, etc.  The arthritic or degenerative change that is seen can be along the ligament attachments to the bone as well as in the facet joints. All these tissues and attachments can be areas where pain can arise.
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Because there are so many parts in the spine, it is difficult to diagnose problems.  X-rays, CAT Scans, MRI’s give us good information, but current technology often does not allow us to be exact in our diagnosis, which is in part why there are so many people with pain that doctors can’t completely treat. 
In my next post I will begin to discuss the individual parts in more detail.

​- DKP