Learning about multiple sclerosis can be intimidating. Let our experts walk you through the facts, the questions, and the answers to help you better understand this condition.
Video timeline: 0:24 What is multiple sclerosis? 1:15 Types of multiple sclerosis 1:29 Who gets multiple sclerosis/risk factors? 3:11 Multiple sclerosis symptoms 3:40 How is multiple sclerosis diagnosed? 4:39 Treatment options 5:29 Coping methods/ What now? 6:23 Ending
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Most sciatica is caused by problems that affect the L4, L5, or S1 nerve roots. The nerve may be compressed or irritated, usually because it’s being rubbed by a disc, bone, joint, or ligament. The resulting inflammation makes the tissues and the nerves more sensitive and the pain feel worse.
Damage to or pinching of the sciatic nerve, or the nerves that feed into it, can have several causes.
One of the most common causes of sciatica is a herniated disc in the lower part of the spine. It’s also called a slipped disc, though there’s no slipping going on.
Spinal discs are tucked between the vertebrae, where they act as cushions to keep the bones from touching one another. The discs absorb all the forces placed on the spine from walking, running, sitting, twisting, lifting, and every other activity we do. They also absorb forces from falls, collisions, and other accidents.
The spinal canal protects the spinal cord and the nerves that run up and down the spine. Spinal stenosis is the narrowing of the spinal canal. When this occurs, nerves can be compressed, causing pain. Because the lumbar vertebrae undergo the most consistent stress and support the most weight, lumbar stenosis is the most common type of spinal stenosis.
The bones of the spine are stacked on top of one another, separated by discs. Spondylolisthesis occurs when one spinal bone slips forward in relation to the bone below it. When the L4 vertebra moves over the L5 vertebra, it can cause a kink in the spinal canal leading to pressure on a nerve root and sciatica.
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Pain is useful to survival, and therefore is evolutionarily conserved. There is a very rare syndrome with the congenital inability to experience pain that Is caused by mutations in the SCN9A gene, which codes for a sodium channel (Nav 1.7). Research on this channel has apparently produced some advances in pain medication, but not as much as expected.
Individuals with insensitivity to pain have many accidental injuries which can cause blindness, mutilations of the extremities, and other severe problems. Lack of ability to feel pain is serious handicap.
Pain is generally a useful red flag that warns us to stop the painful activity, or guides us into the doctors office; about half of all medical visits involve pain of some sort.
Considered as a symptom, pain helps guide the physician into the proper diagnosis and treatment. Normally the pain stops when the condition that produced it is corrected. Pain sometimes outlives it’s usefulness, however, and becomes a major problem on his own. The most obvious condition is “phantom limb pain”. Most people who have had an amputation will continue to experience pain in the extremity that is no longer present.
Back pain that has no valid surgical treatment will sometimes drive individuals to surgeons who will operate on them unsuccessfully. A second opinion, preferably by a medical doctor like a neurologist, is always a good idea with back pain without sciatica, numbness, or other localizing symptom to tell the doctor where to operate.
Neuropathic pain is another conundrum. I know of an individual who was bitten on the foot by a dog, and continued to have severe foot pain for many years after the original injury healed.
All pain is interpreted in the brain, and continuing circles of central nerve activation is the leading theory of phantom limb and neuropathic pain. Pain is not objectively measurable; there is no meter that you can attach to the patient and find how much pain they are actually having. The doctor must assume that the patient has the pain they are describing, and ask the patient to rate it on a 0 to 10 scale, describe its severity, time course, quality, and any factors that will make it better or worse. Most often this produces an avenue to treatment, but sometimes not.
A few decades ago, busy doctors would label the pain that they could not diagnose as “psychological”, and dismiss the patient to suffer in silence. Much of the pain, however, was very real to the patients, who joined in patient advocacy groups and produced a political backlash which induced doctors to overtreat the pain, often with opioids.
The over-prescribing doctors, and unscrupulous drug companies led to the flooding of the market with opioid medication, leading to the opioid crisis that is now being addressed. There is difficulty in making scientific progress on an adversary that cannot be measured properly.
Some doctors, usually anesthesiologists, specialize in treating the chronic, severe pain that standard medical practice has been unable to diagnose or alleviate.
They may use nerve blocks, antidepressants and combinations of different pain medication. Judicious propofol has been used also not only for chronic undiagnosed pain, but also depression.
My wife had a pain problem which responded to a combination of two simple medications, motrin and acetaminophen. The suggested overall approach is to get the best medical care available to diagnose the cause of the pain, and ask for a pain management referral if a solution is not found.
More information can be found in the appended Wikipedia article.
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“…telemedicine can improve through both sustaining innovation (incremental improvement upon what we are already doing for patients) and through disruptive innovation (simpler solutions for patients with simpler needs and/or patients we are not currently serving).”
Most telemedicine in its current form is a sustaining innovation. There has been incremental improvement in telecommunication technologies from the traditional phone to current videoconferencing software integrated with electronic medical records, development of secure platforms for short messaging service (SMS) between patients and providers, and introduction of connected devices that can monitor and transmit patients’ health data to their providers.
Beyond improving the way care is already delivered, telemedicine may also serve as a vehicle for disruption in overlooked health care markets, particularly low-end or new-market segments. Many customers are currently overserved by traditional care delivery in the form of regular visits (in-person or virtual) with a physician, which are structured to provide more than what they need and less of what they want.
Coronary artery bypass graft (CABG) was supported as superior to fractional flow reserve (FFR)–guided percutaneous coronary intervention (PCI) for three-vessel coronary artery disease (CAD). PCI failed to meet noninferiority criteria at 1-year follow-up in a study comparing outcomes between FFR-guided PCI using contemporary stents and CABG. This adds to existing evidence showing superior outcomes with CABG in patients with the most-complex CAD.
The sodium–glucose transporter-2 (SGLT-2) inhibitor empagliflozin was found to be beneficial in heart failure with preserved ejection fraction. Empagliflozin is the first medication shown to improve outcomes in this population. It’s unknown if this is a class effect of all SGLT-2 inhibitors, but this could be a game changer.
Poor-quality carbohydrates were linked to cardiovascular mortality, around the world. Consumption of higher-glycemic-index carbohydrates was associated with higher rates of cardiovascular disease and mortality in countries all around the world. These data are particularly important because lower-income countries often have diets high in refined carbohydrates, which may worsen cardiovascular disparities.
New guidelines for managing valvular heart disease were released. These new guidelines add or elevate several recommendations for transcatheter therapy, and they lower thresholds for intervention in some conditions.
The editors of Circulation: Cardiovascular Quality and Outcomes addressed racial-ethnic disparities. The editors affirmed that structural racism is a public health crisis and that the scientific publishing community can play a role in addressing it.
Tricuspid annuloplasty for moderate regurgitation during mitral-valve surgery was of unclear benefit. Annuloplasty was associated with less progression of moderate tricuspid regurgitation but more pacemakers at 2 years. Unfortunately, this mixed outcome does not clearly inform the decision on performing annuloplasty at the time of surgery, and longer-term follow-up is needed.
Immediate angiography was not beneficial in out-of-hospital cardiac arrest without ST elevation. Patients with out-of-hospital cardiac arrest who did not have ST elevation on their initial ECG did not benefit from immediate angiography. Although a potential coronary culprit was identified in about 40% of patients, neurologic injury was by far the most frequent cause of death, negating any benefit from coronary revascularization.
Many statin side effects are related to the “nocebo” effect. A creative study enrolled 60 people with statin intolerance and gave them 12 randomly ordered 1-month treatment periods: 4 periods of no medication, 4 of placebo, and 4 of statin. Symptom intensity did not differ between placebo and statin periods and, interestingly, some even had more symptoms on placebo. This demonstrates that some cases of “statin intolerance” may be related to the “nocebo” effect.
Shorter duration of dual antiplatelet therapy following PCI/stent placement was found to be acceptable in patients with high bleeding risk. A large, randomized trial found that 1 month of dual antiplatelet therapy provided similar clinical outcomes and a lower bleeding risk than 3-to-6-month regimens for this challenging patient subset.
“De-escalation” of dual antiplatelet therapy for patients undergoing PCI for acute myocardial infarction (MI). This industry-funded study evaluated patients who had received 1 month of aspirin plus ticagrelor after acute MI and stent placement and “de-escalated” half to aspirin plus clopidogrel. At 1 year, there was significantly less bleeding in the de-escalation group and a nonsignificant trend toward fewer ischemic events as well.
Dr. Leonard Lee, a cardiac surgeon, explains every common tool he uses when he performs heart surgery in his operating room.
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Doctors Without Waiting Rooms 