lower_back_painFailed back syndrome, or lumbar post-laminectomy syndrome, is the term given to patients who have had back surgery for back pain, but continue to have pain after surgery. Even worse, their back pain can be worse after the surgery. The main problem is the fact that low back pain is not an indication for back surgery – any more than neck pain is an indication for neck surgery (failed neck surgery: cervical post-laminectomy syndrome). Surgery done for the sole purpose of relieving neck or back pain is doomed to failure. Many spine surgeons make the false assumption that if a patient has back pain and there is a spine MRI abnormality – this is the cause of the pain and surgery to “fix” the MRI abnormality, and consequently the back pain, is necessary. In actuality, just the opposite is true. Most causes of neck or back pain cannot be identified and more importantly, do not require spine surgery.

Failed back syndrome (FBS) has many different causes. Some of these are a direct result of surgery: operating at the wrong level, failure to remove the entire herniated disc fragment, trauma to the exiting nerve root, continued pressure on the nerve root, scar tissue and inflammatory changes at the site of surgery. Back surgery typically involves removing some of the boney part of the spine. This can result in spinal instability. This causes additional spine pain. Predisposing factors to FBS include smoking, diabetes and obesity.

Persistent low back pain, following back surgery, may be due to any number of causes. The surgery itself causes scar tissue to form, which can cause more spine joint pain. Spinal hardware, such as screws put in to stabilize the spine, can cause pain. These screws are put into the vertebral bodies to secure metal plates or other hardware to stabilize the spine. This is frequently done plus inserting bone fragments, for a spine fusion procedure, to further add more stability. The screws can cause pain in and of themselves. They can be put in incorrectly or touch a nerve root. The spinal fusion can fail to take and therefore the spine is not as stable as it should be. All of these things combined can result in additional pain or worsening of existing pain. Taking the screws out does not always result in clearing the pain – plus this requires another back surgery, leading to a viscous cycle.

Back surgery fails for a number of reasons. The three main reasons for failed back surgery are:

1. Surgery was not indicated in the first place for pain treatment,
2. The surgical procedure performed never would have achieved the desired outcome,
3. Correct surgery performed but did not get the intended results.

The main message here is that there are many reasons not to have back surgery. Unfortunately, over 500,000 Americans undergo spine surgery annually. Over 50% will have little or no relief for of the symptoms. It is not unusual to find patients such as this who have had two or more spinal surgeries – both neck and back operations. The majority do poorly. Failure rate with second spine surgery is about 70%. Three or more spine surgeries experience greater than 90% failure rate.

FBS symptoms include persistent, dull back pain, which varies in intensity. Patients can have sharp back pains that may radiate down one or both legs – sciatica. In almost all cases of failed back syndrome, more surgery is the worst thing that can be done, as this only compounds an already bad situation. Most of these patients are disabled and are on narcotics for pain relief. Narcotics are addictive and surgery is not reversible.

Fortunately there is non-surgical, non-narcotic treatment for patients with post-surgical neck or back pain. Platelet rich plasma (PRP) therapy is a simple, in-office procedure that can naturally provide dramatic, lasting relief. PRP (platelet) therapy does not require anesthesia, rehabilitation or any down time. Platelet rich plasma (PRP) is derived directly from your own blood. PRP is blood plasma with a high concentration of platelets. Contained within platelets are the active healing proteins and growth factors that promote new tissue regeneration. Growth factors are necessary to initiate tissue healing and regeneration. With concentrated amounts of these proteins in an injured area, healing and tissue repair is started and accelerated. Stem cells, respond to the growth factors, into the area, further aiding in healing. Healing can occur in various tissues including tendons, ligaments, muscle and bone – as stem cells will change into whatever damaged tissue is needed. Along with tissue repair, the regeneration process also stimulates new blood vessel growth to promote healing process.

Here in Sarasota, platelet rich plasma therapy is available. At Sarasota Neurology, Dr. Kassicieh, a Sarasota PRP doctor, has been doing platelet rich plasma therapy for tissue regeneration (regenerative medicine) since 2009. He has successfully treated several hundred patients with back and joint pain – all without surgery. Our success rate in treating failed back syndrome, knee pain, shoulder injuries and even plantar fasciitis is over 80%. Many patients become pain free. If you have persistent cervical (neck) or back (lumbar) spine pain, call now for a consultation for platelet rich plasma (PRP) therapy with a board certified neurologist and PRP doctor.

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Lower back pain is a common complaint seen by almost every primary care doctor in the United States. So common in fact that 80% of the population will experience at least one episode of significant low back pain in their life. Many will experience recurrent episodes of lower back pains. Of those patients, one third will have some degree of leg pain in one or both legs. Back pain and most cases of associated leg pain do not originate from lumbar (lower back) spinal disc problems. There are many pain fiber bearing structures in the lower back including muscle, tendons, ligaments, vertebral joints and bone itself. The good news is that over 97% of all low back pain problems can be treated without surgery. Low back surgery is the most commonly overly performed surgical procedure in the United States and all too frequently the results are poor and even worse, makes the patient’s condition (back pain) more severe.

In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a comprehensive, conservative treatment plan. Most patients show significant back muscle spasm with tenderness. Some will have exquisite tenderness in the sacroiliac joint where the tail bone meets the hip bone – a condition known as sacroiliitis. Piriformis Syndrome can cause low back pain and leg pain, but there is no spine involvement in this condition. The patient’s neurological exam is usually normal – it is uncommon to find clinical evidence of lumbar spinal nerve root compression (“pinched nerve”). In any clinical setting however, non-surgical treatment is indicated. Even in individuals who have evidence of a disc herniated, on exam, need conservative therapy – physical therapy, massage and anti-inflammatory medication. The natural history of disc herniation is to heal without the need for surgery or other invasive procedures such as epidural spine injections. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered back stretching exercises will result in favorable outcomes the majority of the time While not clinically needed, many patients undergo CT or MRI scanning to look for the cause of their low back pain. This is where the road splits on the proper decision to use appropriate conservative therapy or improper decision to go to with an invasive route such as spinal injections or worse, surgery. Studies have shown that epidural steroid injections are no better than placebo. Other studies have shown that the outcome of back pain patients treated surgically is no better than those treated with best medical therapy. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain.

For patients that do get MRI studies, it is not uncommon to find spine MRI abnormalities. The important fact is that these abnormal MRI findings do not necessarily explain the pain that that individual is experiencing. To account for an individual’s back pain or sciatica (leg pain), the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain or sciatica have been done. The results have shown that approximately 55% had bulging discs at one or more levels, 28% had disc herniation on the MRI scans. More than 70% of the MRI scans showed abnormalities and yet the patients had no symptoms! These MRI scans were done on patients who never had any back or leg pain – 70% of the MRIs were “abnormal.” The conclusion that just because the MRI scan shows “something”, does not mean that the findings are the cause of any given patient’s back or leg pain.

With conservative treatment and patient cooperation to do the back exercises, most patients have significant relief with clearing of their pain within 4-6 weeks. It is then important that patients continue to do their back exercises on a regular basis, as part of their daily exercise routine. Physical body reconditioning and core strengthening will also help a great deal. Back surgery (or neck surgery) can almost always be avoided. If you have back or neck pain that is troubling you, contact Dr. Kassicieh now for treatment.

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What do you think of when you think of neck or back massage therapy? Most people think of the type of massage you would receive if you went to the spa for the day.  That type of massage therapy is known as a Swedish Massage. Swedish Massage is only one of over 40 types of massage that a person can receive. When you say you went to see your doctor today, what do you think of?  If I went to see my family doctor, my image would be different than if I said I went to see my Cardiovascular surgeon.  They are both doctors, but the exams and procedures that they perform are vastly different.

The field of massage is similar in its sub-specialization within the scope of massage therapy. Swedish Massage is great for relaxation and stress reduction, but if your back just went into spasm and is  locked up, you would be much better served going to a Massage Therapist that specializes in Rehabilitation and back pain relief.   Neuromuscular Therapy, Myofascial Release, Positional Release and Muscle Energy are just a few of the specialized massage techniques that were developed to treat muscle pain and skeletal dysfunction.  These techniques are focused on looking at the role of the soft tissues in causing pain. Soft tissues include muscle, tendon, ligament and fascia. Fascia is the covering over muscles and internal organs that provide stability and strength. Neuromuscular therapy treats fascia and muscle pain. Myofascial Release treats connective tissue disorders, particularly tight fascia which is a painful syndrome that frequently accompanies muscle pain and spasm. Positional Release treats muscle spasms, muscle energy treats joint restrictions.

These techniques are taught to Massage Therapists as advanced, highly specialized postgraduate courses. Just as a doctor can practice medicine after four years in medical school, he/she must first participate in a postgraduate internship and residency program to specialize in his/her specific field of medicine.  A Massage Therapist who is treating patient for acute and chronic muscle and joint pain should have more than just basic, Swedish Massage training. What patient’s want most is pain relief.

In summary, specialized massage therapy for medical conditions, requires advanced training on the part of the massage therapist. Many hours of postgraduate massage therapy education and training is necessary for successful outcomes in the treatment of patients suffering from pain in the neck, back, head or extremities. For more information visit Soar Point Massage or contact Jack Ryan, LMT a 941–993-3339 for an appointment.

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A recent report in the Journal of the AMA (De Vos, et al JAMA 2009) reported that platelet rich plasma therapy was no more effective for chronic Achilles tendinopathy than standard, conservative therapy. This study was inherently flawed in its design resulting in incorrect conclusions. Platelet rich plasma is the healing component of blood. It is derived and concentrated from a patient’s own blood and then injected into the affected area. Not all PRP is the same. Blood processing is the key, levels of growth factors are of utmost importance and successful outcomes will vary with the technique, protocol and level of expertise the clinician possesses. Different PRP extraction equipment and how the blood product is handled during this process is also critical.

De Vos et al commented “A limitation of the study was that the amount of platelets and quantity of activated growth factors that were present in the PRP injections were unknown.” This introduces several variables that would invalidate the data and the study’s conclusion:

1. What PRP processing system was used?

2. Were the levels of Growth Factors therapeutic? Therapeutic level ranges  are usually 4-5  times the baseline.

3. No levels or PRP concentrations were taken or reported.

All of these are significant study design flaws that will result in invalid study conclusions. Additionally the study stated “Platelets are slow to activate by exposure to tendon collagen, but it might be that therapeutic pressure within the tendon, a large amount of PRP diffused rapidly out of the tendon thereby reducing its effect.” Additionally thrombin – a critical component in PRP therapy – was not used to activate the platelets. PRP and growth factors will not activate or be as effective if thrombin is not used in this procedure.

Perhaps most significant study design error was that only one PRP injection was given. The study patients, by design criteria, were required to have chronic Achilles tendinopathy that had responded poorly to prior therapies. Chronic tendon injuries, particularly those in the Achilles tendon, heal poorly due to inherently poor blood circulation. The standard PRP technique in this type of injury would be a series of three injections over a period of 3-4 months. A study that specifies treating a patient with a chronic tendinopathy with a single PRP injection is setting up the patient unnecessarily for failure. Lastly, the study had a low number of subjects in it to make any clinically significant conclusions. Only 27 subjects were treated, each with a single PRP injection and there were 27 control subjects.

Regenerative medicine – Platelet rich plasma – has been FDA approved for medical use for 20 years. It has been used widely in dental, cardiac, orthopedic medicine to assist in and improve medical outcomes. The professional horse racing associations widely use PRP therapy to heal leg injuries in their million dollar race horses. Major league sports such as the NFL and MLB consider platelet rich plasma therapy an important treatment option to get their elite athletes “back into the game” in as short of time as possible. PRP healing typically takes six weeks, particularly when combined with rehabilitation. In conclusion, PRP is a highly effective medical treatment for ligament, tendon, muscle and other knee/shoulder injuries as well as lower back pain. Even patients with post-operative knee pain or shoulder pain can benefit from PRP therapy.  Outcomes are entirely dependent on the preparation and handling of the blood, equipment used and experience as well as skill of the treating physician. Additional information on PRP can be found at PRP Stops Pain. Excellent clinical study references can be found by clicking here.

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As a neurologist who sees many patients with neck, back and various joint pains, I practice an area of medicine known as neuro-orthopedics. As such, I treat patients for their pain without surgical intervention. Many patients with neck, back and joint pain (knee pain, shoulder pain, elbow pain, etc.) can be successfully treated without invasive surgery and the many risk that go along with this. With surgery there is also a prolonged recovery time and need for extensive rehabilitation. The area of medicine that applies to successfully treating patients without surgery or use of narcotic medications is known as regenerative medicine. In this field, platelet rich plasma is injected into the affected joint, tendon, ligament or soft tissue area that has pain and is failing to heal completely. Tendons attach muscle to bone and ligaments attach bones to bones. Platelet rich plasma (PRP) is the concentrated healing components of the blood. Only one percent of the blood contains the bioactive proteins and platelets that are involved in healing. Through a specialized process, we can take the patient’s own blood and concentrate the platelets and bioactive proteins up to 500%. This small amount of concentrated PRP is then injected into the joint or other body area, that needs regeneration, after local anesthetic is administered. The PRP graft is then activated with thrombin and the healing process begins. Using the patient’s own blood eliminates the risk of transmitting disease and prevents graft rejection. PRP also has the benefit of being antimicrobial, killing off bacteria thereby limiting the risk of infection. David Crane, MD published an excellent overview of platelet rich plasma.

Platelet rich plasma works by first being injected into the affected area and activated. The activated platelets attach themselves to the damaged tissue, whether that be tendons, ligaments, muscle or bone. The platelets release alpha granules and dense particles. The small packets contain powerful bioactive proteins that begin the healing process. The alpha granules contain clotting factors, growth factors, cytokines and adhesion molecules. These substances allow the PRP graft to attach to the damaged tissue and start recruiting other healing cells to migrate into the area. The dense particles contain proteins that allow the platelets to clump together, forming the structural matrix of the PRP graft.


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How many times have you had an appointment in your doctor’s office, gotten there on time and then had to wait 30 minutes, an hour or even more? We all have. It is one of the frustrating aspects of visiting your doctor’s office. Dr. Kassicieh, at Sarasota Neurology, understands that. He respects patients’ time and makes every effort to see patients at their scheduled appointment time. Dr. Kassicieh does not want his patients waiting for more than a few minutes after they check in, to be seen. He values their time as much as they do and understands his patients have other commitments and time constraints.
Dr. Kassicieh and his staff strive to make sure that his patients are seen in time, tests scheduled and they can leave within a reasonable amount of time. The availability of his website, www.DrKassicieh.com, patients can read about Dr. Kassicieh’s background and learn about the neurological problems he treats. These include neurological problems such as migraine headaches, neck and back pain, Parkinson’s disease, Botox medical therapy and many others. New patients have the availability to download all the required forms, allowing them the freedom to complete these accurately in the comfort of their own home. This saves a tremendous time for the patient in filling out paperwork in the office.
Once the patient comes into Sarasota Neurology, they are pleasantly greeted by our front office manager. Insurance is verified and the patient is brought back for their appointment in a very short time. With the state of the art electronic medical record keeping, Dr. Kassicieh is able to provide better, more efficient care to his patients. Consultations, lab and x-ray as well as other tests and referrals are generated electronically. Once your visit is completed, the completed office visit is immediately faxed to your primary care physician and any consulting physicians you request. Your prescriptions are already printed and waiting for you at check out.
In summary, we here at Sarasota Neurology strive to make the patient comfortable and have a pleasurable experience. You are provided with timely, state-of-the-art medical and neurological care – based on evidence based medicine.  We look forward to seeing our patients and treat them with the respect they deserve. Thank you for visiting our blog site and would invite you to visit Dr. Kassicieh’s website for more information.

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How many people do you know who tell of back pain that has no cure? Or sciatica or leg pain than doctors cannot find the cause for. They tell you that the MRI scan was normal, back injections of steroids do not help and no medication has relieved their pain. There are tens of thousands of people with back pain and sciatica who never get the right diagnosis despite having several MRI scans and seeing numerous physicians. There is a high probability that these individuals suffer from a condition called piriformis syndrome. Unfortunately piriformis syndrome is frequently misdiagnosed as sciatica.

The piriformis muscle is a triangular shaped muscle that is in the middle of the buttocks. The base of the triangle attaches to the side of the sacrum (tailbone) and the tip attaches to the top of the femur (the major bone in the hip and leg.) An excellent piriformis diagram is found on the Institute for Nerve Medicine website. Injury or sprain to the piriformis muscle causes spasm, which in and of itself is painful. This can cause back pain and buttocks pain. Prolonged sitting will make the pain worse. Walking, climbing stairs or bending can be difficult and painful. The sciatic nerve comes out of the spine, exiting just below the piriformis muscle. In approximately 15% of individuals, the sciatic nerve pierces through the lower border of the piriformis muscle. It is these individuals who are predisposed to developing sciatica with injury to the piriformis muscle. Even without this, a strained, inflamed piriformis muscle will cause irritation to the sciatic nerve thereby causing sciatica.

There is no specific test, MRI or EMG findings in piriformis syndrome. It is a diagnosis made on the basis of getting the patient’s history, unique set of symptoms and detailed physical exam. Ordering an MRI of the back and getting an EMG will only help to exclude other causes of back pain and sciatica. Remember, just because you may have a “bulging disc” or “herniated disc” does not mean that this is causing your back pain or sciatica. Thirty percent of the general population have disc herniation on their MRI scans that are causing no symptoms. Therefore disc herniation does not equal back pain or sciatica Once the diagnosis is made, treatment should be started as soon as possible. The first is to educate the patient about the condition and identify activities that they are doing that irritate the piriformis muscle. Avoiding these activities and holding off on sports activities will help to stop straining the hip muscles. A set of stretching exercises for the back and hip muscles should be done twice daily to relieve the spasm, which will reduce the pain. Muscle Ventures has an excellent diagram and explanation of the piriformis stretch, even with a video.  With this stretching, an anti-inflammatory medication, such as ibuprofen or naproxen, can be taken to lessen the pain and treat the inflammation in the muscle, tendon and sciatic nerve. Physical therapy can have a part in treating piriformis syndrome. It takes a therapist familiar with the condition to effectively provide relief. This in combination with deep neuromuscular therapy in the buttocks region will also help. Injections into the piriformis muscle are rarely performed due to its close relationship to the sciatic nerve and risk of injury to the nerve. Surgery has been tried but it is a major procedure and the effectiveness of this remains in question.

In summary, piriformis syndrome is a condition of strain and injury to the muscle. The sciatic nerve runs immediately below or just exits through the lower piriformis muscle. When injury occurs to the piriformis muscle, the sciatic nerve becomes irritated. This causes lower back and buttocks pain with sciatica. Diagnostic tests can only help in excluding other causes of back and leg pain. Therapy for piriformis syndrome consists of daily stretching, antiinflammatory medication and physical therapy. Affected individuals should avoid activities that aggravate their back pain and sciatica. Healing time can be weeks to months.

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Migraine is a very common medical condition. Migraine headaches are the second most common cause for work absences secondary only to low back pain. Unfortunately migraine is the most prevalent in the working population age group. Fortunately many new migraine treatments have been developed. The newest migraine medication that has been FDA approved is Treximet. Treximet is a combination medication. It has Imitrex with RT technology in combination with naproxen sodium (the active ingredient in Aleve.) Imitrex was the first drug in the class of triptan medications that are migraine treatment specific. Studies have shown that the Treximet formulation of the two component drugs is more effective in migraine treatment than with either drug alone. Overall, Treximet has about a 10% greater effectiveness in stopping a migraine attack with the first dose, over either of the other migraine drugs, taken alone or together.

There are several other migraine treatment medications including Maxalt, Zomig, Relpax, Frova, Amerge and Axert. All of these medications are “designer drugs” formulated specifically to treat an acute migraine attack. The most important step for any patient who suffers from headaches is to get in to see a headache specialist. Migraine and headache treatment has become a specialized area in neurology. Neurologists who treat migraine, cluster and other headache disorders take a different approach to treatment of headaches and improving the patient’s quality of life. For additional information on migraine and headache treatment click here.

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Neck and back pain are some of the most common conditions for which patients seek out medical care. It is estimated that 8 out of 10 Americans will have at least one significant episode of back or neck pain in their life. For many, this can be a recurrent or persistent problem. Fortunately over 90% of the cases can be treated without surgery or other invasive procedures. The most common underlying cause for back pain is poor body conditioning. With our sedentary life styles, it is no wonder that we become deconditioned. Even persons who exercise regularly are prone to developing back or neck pain problems. Without doing specific back and neck stretching and strengthening exercises, we are setting ourselves up to have back pain. Something as simple as bending over to tie a shoe, reaching up in the cupboard or even sneezing can trigger an acute back pain episode. Neck pain is frequently caused by “sleeping wrong at night”, sleeping on a plane or just straining the neck when lifting or playing sports. All of these variations of neck and back pain have as a cause, muscle, tendon and ligament strain. Particularly in the back, individuals will have gradual tightening of the back and hip muscles and not even feel it. Then, when a “minor event” such as coughing occurs, these already tight muscles go into sudden spasm which then is felt as pain. With the acute spasm, patients can have trouble turning their head, bending over, walking and sleeping. Fortunately most of these conditions can be treated without surgery, invasive procedures or even MRI scanning.

In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a treatment plan. Most patients show significant back and/or neck muscle spasm with tenderness. Some patients can have exquisite tenderness in the sacroiliac joint – where the tail bone meets the hip bone. The rest of their neurological exam is usually normal. In these individuals having a CT or MRI scan of the neck or back is not a necessary part of the initial treatment plan. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered neck and back stretching and strengthening exercises will result in favorable outcomes the majority of the time. Sometimes anti-inflammatory medications or muscle relaxants can be of benefit. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain. In very specific cases, limited use of nerve blocks in the sacroiliac area or lower neck may be helpful. Epidural steroids, for the most part, are not particularly helpful and carry significant complication risks with them; particularly in the neck. For patients that do go on to have MRI studies, it is not uncommon to finding xray abnormalities but these do not necessarily explain the pain that that individual is experiencing. The important message is that the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain have been done. The results have shown that approximately 38% of these MRI scans showed abnormalities and yet the patients had no symptoms. The conclusion is that just because the MRI scan shows “something”, it does not necessarily mean that that is the cause of your pain.
With careful management and patient cooperation to do the exercises most patients have significant relief with subsequent clearing of their pain within 4-6 weeks. It is then important that patients continue to do their neck and back exercises on a regular basis, as part of their daily exercise routine. With doing this back surgery or neck surgery can almost always be avoided. The most important step in getting better is to seek out care from a knowledgeable, medical physician such as a neurologist or physiatrist who specializes in the non-surgical treatment of neck and back conditions. More information on back disorders can be found at my website or at Spine Universe.

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