COR Spine & Pain Center

At COR Spine & Pain, we believe in taking a comprehensive and holistic approach to pain care. Our team of experienced physicians and specialists work together to develop individualized treatment plans that not only address the physical aspect of pain, but also the psychological, environmental, and emotional components of an individual’s pain experience. We strive to provide our patients with the most comprehensive and effective care possible.

No, one pain management treatment does not fit everyone. Pain management treatments are tailored to meet the individual needs of each patient. At COR Spine, we take a comprehensive approach to pain management, considering various factors such as medical history, lifestyle, and individual preferences in order to develop a personalized plan of care. Our goal is to identify the root cause of your pain, and to work with you to find the most effective and long-lasting solutions.

Yes, inflammation can play a significant role in the management of chronic pain. At COR Spine, we specialize in utilizing a multi-disciplinary approach to reduce inflammation and alleviate pain. Your pain management team will create a personalized plan to help you manage your pain and reduce inflammation. During your first visit we provide education and introduce remedies targeting inflammation. On your second visit, taking stock of any progress, the next inflammation targeting treatment should be considered. As an example, NSAIDs, once individual risks are discerned, could be introduced. As always, educating and watching the patient for potential side effects for this class of medicines is important. Visit three, for instance, may allow your clinician an opportunity to offer further inflammation control by way of an injectable anti-inflammatory should more extensive treatment be necessary. Our goal while working with our patients is an awareness that pain relief is possible through other and less adverse medicine or practices. Usually, a patient who has longstanding pain medicine requirements feels stuck. Providing an alternative that is successful, safer and devoid of the stigma attached to narcotics can be groundbreaking. Each opportunity is taken to provide alternatives to a patient looking for an opportunity to reduce usage of tolerance forming medication.

Similar steps can be taken that target muscle relaxation as explored with joint and spine pain. Where step one might be simply stretching, this can be expanded to include physical therapy. Step two may offer modalities such as heat, or possibly assistive technologies like a TENS unit to augment results. Antispasmodic medicines could be added. Finally, invasive avenues such as dry needling or trigger point injections, with or without steroids could be explored.

Likewise, nerve modifying treatments can be included. It is well documented that certain injuries or disease states can irritate or inflame the nerve. Data supports that the pressure of said inflammation, as well as, the chemical makeup can act to trigger the nerve. Such an irritant alone can drive pain states into existence or increase its intensity. The good news is that inroads are now being made into not only understanding how the source, such as inflammation, can be treated, but also how to modify the nerve response. There are several medications that can help modify nerve responses. The precise mechanism of action is not fully elucidated, but generally they have actions of calming nerve sensitivity. That is, while on the medicine a given amount of irritant will have less impact on the nerve. This is achieved by adjusting the threshold at which the nerve fires. Less firing, less pain is the principle.

Our mind modifies all the sensory input throughout the body and, as such, is an important arena for the treatment of various pain states. Mind calming has many approaches. The simplest of these treatments are relaxation techniques. Rates and depth of breathing can help reduce anxiety, often lessening pain along with it. Biofeedback helps many use their cognitive reasoning to find positions of relief and train their body in appropriate mechanics to avoid painful events. Several medicines target relaxation, stress relief, anxiety, sleep needs and depression, which are another form of brain modification as related to pain. As always, careful guidance and physician oversite is advised. Finally, in regard to mental approaches to pain, there is a significant role for behavioral insights. Whether through a pain/behavior psychologist or psychiatrist, these techniques and medicines can have a profound positive impact, by identifying pain triggers or their resultant impact.

Since nerves are susceptible to change, pain is beholden, as well. Slower or no transitions from one state of alert to another is preferred by both entities. As such, what may seem like reasonable treatment at the time may, by virtue of starting and stopping a pain treatment, startle the condition of calm into one of unrest, and therefore aggravation or pain. An example, gabapentin should not be stopped abruptly because it can take a relaxed nerve to an agitated state. Just as some medicines should not be fluctuated or used with alcohol, especially in significant concentrations or volumes should be avoided. As with any central nervous system depressant, of which alcohol is a depressant, serious side effects may occur, especially in someone simultaneously struggling to balance pain cycles and medicines with their associated physical and emotional challenges. Thus, slow gradual adjustments should be made to any pain management plan.

Arrive with loose fitted clothing so your treatment site is more easily accessible Arrive with clean skin - No lotions or oils can be on the treatment area No post-procedure instructions are needed for this procedure

5 days prior to your Epidural procedure Discontinue all prescribed blood thinners Discontinue any use of aspirin and baby aspirin 3 days prior to your procedure Discontinue all anti-inflammatory medications 4 hours prior to your procedure Nothing to eat or drink (sips of water are ONLY OK when taking approved medication)

You will be placed face down on the exam table Our technician will raise your shirt and slightly lower your pants to expose your lower back area The Fluoroscopy Machine (Live X-Ray) is placed around you This will be used to guide Dr. Witmer to the treatment area Dr. Witmer will then clean and sterilize the area with cold swabs Once the area is sterilized it is important to keep your hands away from the area being treated to prevent contamination Dr. Witmer will now numb the area You may feel the initial stick of the needle like trigger injections Under live x-ray Dr. Witmer will guide the epidural needle to the treatment area Now the medicine will be inserted You may feel the medicine being administered. This feeling is different for everyone. Feeling pressure in the area where you experience symptoms is normal. Your comfort is most important to COR Spine & Pain Center-if the pressure is building please let Dr. Witmer know. Once the procedure is complete our technician will wipe down the area and give you a band aid. When you are ready you can check out and schedule your follow up appointment

Any medications that you stopped, you can now resume Ice the injection site 20-30 minutes at night for any discomfort or pain Avoid heat such as heated pads, hot tubs, sauna, and baths for 3 days after injection. This may cause inflammation and pressure at the injection site. (Showering is OK) Drink lots of water. KEEP HYDRATED! Light walking is encouraged 3 days after injection. This can help spread the medication Take it easy the first couple of days following the EPI Procedure Most importantly, listen to your body. It is normal to have pain and or discomfort for up to 2 weeks after the injection. If the pain is severe or unbearable, please seek medical attention or go to the emergency room.

Generally non-steroidal anti-inflammatories (NSAIDs) are thought to have a positive role in assisting patients and Physicians aiding them as they navigate painful spine states. As with many good concepts, there resides within it a caveat. While NSAIDS are generally safe, assuring such in its usage requires forethought and some knowledge of how the medicine works within, and is ultimately cleared from the body.

NSAIDs or non-steroidal anti-inflammatories are medicines that are available either by prescription or over the counter. Common prescription names are Celebrex (celecoxib), Mobic (meloxicam) and Voltaren (diclofenac sodium). Do be advised there are many others, they should in packaging labeled NSAID. The common over the counter versions are Aleve (naproxen sodium) and Advil (ibuprofen), amongst many other varieties.

It is advised that the two versions of NSAIDs not be taken simultaneously as they represent the same class/type of medicine, and as such can have additive side effects or as combined build to toxic levels.

After checking with your physician and pharmacist, it may be acceptable to add certain over the counter pain relievers. Never start such pills without the approval and awareness of all of your treating doctors, including specialists. Once cleared, Tylenol (acetaminophen) is a commonly combined agent. Excreted differently from the NSAID pathway (liver for acetaminophen, kidney for NSAID) this provides a differing mechanism of pain relief while not targeting inflammation. Your doctor may find this an appropriate avenue of treatment for non-inflammatory causes of pain, or as an add-on when NSAIDs are already in use. Acetaminophen should be cautiously dosed since a toxic level is reported for an average patient at 3200 milligrams (mg). Care should also be taken to inspect closely all other medicines as acetaminophen is often a combined agent in other medicines, especially those with a pain focus.

An NSAID when circulating in the body takes on a role of inflammation reduction. It does so by using its chemical role as a blocking enzymes involved with the chemical reaction that makes up inflammation. The enzyme it blocks, cyclooxygenase, would typically allow a larger byproduct of inflammation (also a gastric protective substance), prostaglandin to be produced. However, once introduced, the NSAID blocks the chain in the reaction, dropping the overall expansion of inflammation and its irritating, expanding chemicals so that less pain is a result.

There are many pain or swelling conditions that may run their course or not need medicinal approaches. This is in large part due to the fact that the same system producing the inflammation has systems in place to remove it. Some people improve with the administration of cold therapies. Cold or ice packs decrease molecular interactions in a way that reduces inflammation expansion or acceleration. It is only when inflammation is either too broad or of such rapid onset that cold therapies aren’t effective enough and NSAIDs become necessary to initiate.

A variety of patients are advised against the use of NSAIDs based on the properties of such medicines and their potential for certain side effects in light of the patient’s coexisting condition. Understanding the mechanism of removal or excretion from our body for NSAIDs occurs by way of the kidneys, patients with conditions that may involve the kidneys must largely avoid such medicines. It should be noted that this restriction exists even in regard to those NSAIDs available over the counter. Kidney or renal disease is often diagnosed by lab tests by the primary doctor, and once discovered are often followed by a nephrologist/kidney specialist. Diabetics have a predilection for kidney dysfunction and, as such, should prompt close scrutiny. As the anti-inflammatory medicine flows through the stomach and ultimately the blood stream, patients with stomach/gastrointestinal histories must navigate the concept of NSAID usage with extra caution. Key to this discussion is an accurate history of such conditions such as, but not limited to, ulcers, Crohn’s disease, Ulcerative Colitis and gastroesophageal reflux disease (GERD). History taking and current review of symptoms may not be enough; often invasive diagnostic studies are required to accurately deduce the degree of such conditions. The concern with such conditions lies in the predilection of the anti-inflammatory class to induce, as a dose effect or over time, an erosion of the gastrointestinal wall. How this process occurs has multiple theories, among them is the fact that as an anti-inflammatory reaction is blocked so is the formation of a gastrointestinal (GI) protective substance, namely prostaglandin. A patient with one of these conditions and has concerns regarding NSAID side effects should speak with their primary doctor or GI specialist. They may advise avoidance or possibly proceeding with the course of medication, while also monitoring or providing additional medications that protect the GI system. Blood pressure concerns can arise while taking anti-inflammatory medicines. Though the overall incidence is low, a mindfulness of blood pressure history and current status is paramount. Typically, an NSAID can be safely introduced after clearance by the supervising or prescribing doctor for the condition. It may be started at a less than full dose and gradually increased if no ill effects become present. Monitoring closely with a home blood pressure machine is advised to catch any variability in the readings as soon as possible. Should any increases be seen, the medicine should be stopped and increased blood pressure reported to the involved doctors immediately. Those with heart conditions should be made aware that studies have tied the incidence of some cardiac events and stroke to the use of NSAIDs. While the percentages are low, those with recent cardiac surgeries or instability in their status should pause any such medicines until their specialists approves. Higher risks were found tied to higher doses or longer term use. Some cardiac states require blood thinners, of special concern, addressed below. If ever any doubt whether NSAIDs are safely started, defer starting until cleared by your specialist.

Blood thinners, even baby aspirin, can present a challenge to those interested in a course of anti-inflammatory medications. The issue lies in the fact that NSAIDs lengthen your bleeding time. If such a medicine is taken while also on a medicine designed to ‘thin’ the blood by chemical blockade of the natural clotting in the body, a bleeding risk occurs. Common, but not an exhaustive list of blood thinners, would include Plavix, aspirin and Coumadin (warfarin). Other NSAIDs as noted are often available over the counter and found as a part of cold medicines or other elixirs. None of these should be used in combination with a prescription anti-inflammatory.

Alcohol use can present significant escalation in side effect risks when taking anti-inflammatories. The stomach symptoms of heartburn or ulcer are at an increased risk while simultaneously using alcohol. Prior use can lead to liver dysfunction which would amplify the bleeding risks noted in other Q&A. Also, eating late at night may increase GI reflux and as such should be minimized if symptomatic while on NSAIDs.

Many inflammation states can be helped by alternative treatments like cold packs or ice. This along with physical therapy to protect and support the offending area acts to help many such conditions. Injectable anti-inflammatories such as Cortisone can be used to locally expel inflammation. These steps could be used concordant with NSAIDs or as a replacement.

As noted above there are medical histories that may predispose some patients to an elevated side effect risk. Those not at high risk are still advised to be mindful that certain reactions or side effects are possible. Nausea, vomiting, gas, diarrhea or constipation, dizziness, balance difficulties, and difficulties concentrating have been reported, though only occur in a small minority.

As symptoms come under better control, your physician will typically advise gradually tapering off the medicine, while simultaneously advancing other treatments like physical therapy and icing. If symptoms return it may indicate that a longer course of NSAIDs was needed and may be restarted.

Nearly all side effects present when initially starting an NSAID or when the dosage has been adjusted. While some risks are greater by dose and over time, most are identifiable and reversible without long term ill effects. The keys for making sure your use is safe are clear communication of your medical history and ongoing diligence in monitoring for any concerning trends in side effect symptoms.

The spine has four main components: bones, discs, nerves and ligaments. The bones of the spine or vertebrae are the main structural supporting body. Calcium rich, these bones are the strong matrix providing for protection of what lies beneath, or within the spine, the nerves. With openings centrally, the canal and to the side, foramen, the nerves can pass from the control centers of the brain and spinal cord to the action centers of the muscle and skin. These are very strong and protective, but also quite rigid. To encase the nerves for maximal protection, these vertebral bones form a ring around them. Stacked one on top of another, these vertebrae twist and bend based on what rests between them, discs. These cartilaginous, soft and spongy structures allow for separation of the bones and with their elasticity, provide for the spines ability to flex or angle, allowing for greater functionality. The outer disc or annulus fibrosus is the strongest layer and rests on the perimeter, closest to the nerves. Inside of this annulus is the nucleus pulposus. This gel-like material is less rigid, in fact soft in nature, allowing for even more in the way of flexibility and impact or shock absorption. The nerves are central to and encased within the bones, and adjacent to the discs. Starting from the brain, the nerves traverse the stacked vertebrae, top to bottom, some pairs exiting at each subsequent layer down. The ligaments are tough cartilage strands that lie along the sides or are intertwined amongst bones and discs of the spine. Muscles of varied lengths, while technically outside of the spine proper provide beams, or columns of support for all of the above structures

While bones are rather rigid and resistant to impact, they do have a breaking point, literally. A fracture is rare and most commonly is portended by osteoporosis, or decalcification of the bony matrix. The bone, with enough downward impact can compress causing the appearance of a wedge. Higher velocity or force of impact can lead to the bone spreading or breaking of the ring into what’s known as a burst fracture. These situations are rare since the spine has a built-in protection, or shock absorber for the bone in the form of a disc above and below each vertebra. Like bones, however, the disc has a breaking, or at least, a bulging point. Just as the bone may collapse, compress or burst with too much force, the disc itself might bulge, protrude, extrude or herniate. This process can be abrupt but usually occurs over time through a process of wear. First to change with wear is the outer disc ring or annulus. Once this is stretched or fissured, the nuclear material is free to escape from the inside to out. In doing so, it can occupy space closer to or encroach upon the nerves adjacent.

In the ideal world our spine would be in perfect alignment without bending, lifting, or twisting. While this dictum could possibly be adhered to by a small minority, the reality is that most of us can, at best, modify how we approach life’s daily requirements. In approaching our daily tasks correctly from the spine’s perspective some postural cues are helpful. First, the lower back (lumbar curve) bears much of our weight, while our 12 to 15-pound heads are supported by the cervical spine. Next, the spine discs should be recognized and appreciated for what they do: shock absorb. As such, wear and tear is likely, the end result being pain by way of leakage of chemicals from within the disc. The resulting, excessive inflammation irritates nerves driving pain and spasms. To adequately protect the spine from this cascade, avoidance of impact, aligning correctly and strengthening the adjacent muscular structure is paramount.

A visual for alignment would be attempting to retract shoulder blades in a fashion where they nearly touch as they close in on the spine. Notice how excessive thoracic kyphosis or bend is now reduced, which results in a more appropriate neck angle of chin retraction and neck lengthening. Another great visual reminder is to picture your spine as an accordion, where too much squeeze causes too much pressure. The pressure in turn drives disc leakage, inflammation and pain. As such, all daily activities can try to adhere to less downward pressure or twisting motions.

Workouts and fitness routines should adhere to principles of low impact. At each opportunity the patient should trade out the higher impact training in favor of lesser. Treadmill may be less impact than pavement walking. Flat trails may be less impact than hill climbing. Aquatic training may be less impact than ground or weight-based training. Squats, cleans and jerks are tougher on spine angles, whereas leg sleds with the spine in a supported neutral position is preferable. Exercise is important for spine health, but always consider the most beneficial based on your physical condition and injury history. If in doubt consult with COR Spine’s team for low impact exercise options.