Fellowship Trained & Board Certified in Pain Medicine

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  Contact : 205-208-9001
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All posts by Brian Thoma

Interpreting online reviews of pain management practices

While online reviews of  service industries are helpful, they should be read with some skepticism, especially when it comes to pain management practices.  Some reviews are fraudulent, created by people who have never been to the practice or perhaps created by a computer program.  Legitimate, enthusiastic positive reviews may have more to do with likability of the physician rather than his or her care, and negative reviews are no different.

Frequently, a pain management practice will see a new patient and recommend weaning the patient off controlled pain medications such as opiates or avoiding them altogether.  This often results in tremendous dissatisfaction for some patients, and many of these patients will go online immediately to post a negative review.  Often these reviews go on to criticize other aspects of the practice or simply misrepresent the truth.  Please consider this hypothetical example.  A patient is seen at initial evaluation and the pain physician tells him that his MRI and physical exam do not show or suggest a problem that is severe enough to put the patient on an opiate such as hydrocodone.  The patient then leaves the clinic angry and posts an online review stating that the physician treated him “like an addict.”  This is false and misleading.  Of course, the clinic cannot respond because doing so risks betraying the patient’s privacy as it relates to his health.

It makes sense that if opiates have been over-prescribed in recent years, pain management clinics will see new patients that they believe should not be on opiates.  This news, even when delivered compassionately in a manner that focuses on the diagnosis and the risk of the medication, is often not well-received.  Conversely, while most physicians strive for excellence, a 5-star review may not always be accurate.  Therefore, one should consider pain management reviews carefully.

Other data that might be helpful to consider when choosing a physician include board certification, fellowship training, the reputation of the physician among other health professionals in the community, and the experiences of people you know and trust.

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As always, the mission of our practice is to provide excellent, compassionate care, and we thank you for being willing to share feedback to help us grow!

You can click the link below to submit a review. Don’t feel obligated to include your full name, as these reviews are public. Your feedback is valued!

If your experience has not been to our high standard, please feel free to call us and ask for our practice manager, Lynne Marston.

Thank you for your continued support and feedback!

Sincerely,
T. Wade Martin, M.D.
R. Brian Thoma, M.D.

https://cahabapain.com/how-did-we-do/

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Low back pain

Kyphoplasty for Vertebral Compression Fracture

Treating Vertebral Compression Fracture

A short video demonstrating Kyphoplasty, a procedure Dr. Martin and I use to repair vertebral body compression fracture. This procedure often produces immediate pain relief and improvement in function. Patients at particular risk of a Compression Fracture include those with Osteoporosis or Cancer.

Patients who suffer compression fractures can be referred directly to our office and will be scheduled for an evaluation without delay.

-Dr. Thoma

Kyphoplasty (Balloon Vertebroplasty)



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How do you perform your spine injections?

How are spine injections performed?

Other than the obvious answer “very carefully,” there are a few things are characteristic of nearly all our spine injections.  We perform the procedures in our office.  The procedures are done after cleaning and sterilizing the skin which minimizes the risk of infection to the patient.  You’ll notice that for this lumbar injection Dr. Thoma is working with a sterile drape placed over the patient’s low back.  The skin was cleaned with the sterilizing solution before the drape was placed.  The patient is lying on his stomach on the procedure table.

Some patients have their injection done while they are awake, and Dr. Thoma will numb up the skin and superficial tissues with lidocaine.  Other patients may receive a valium or even IV sedation for their procedure.  Patients who receive sedation will need a driver and have more specific dietary restrictions on the day of their procedure.

The machine in front of Dr. Thoma is called the C-arm, or fluoroscope.  This transmits low-dose radiation (less than a typical x-ray) so that we can simultaneously view both the needle and the important landmarks of the spine.  Those labels are attached to the photograph.  We use the c-arm for all our spine procedures including epidural steroid injections, radiofrequency ablations, kyphoplasty, spinal cord stimulation, etc.

At Cahaba Pain and Spine Care, we are proud to offer more interventional procedures than most other pain or orthopaedic clinics can.  We have many highly functional patients that come to us for procedures only.  Patients do not need to be on pain medication to have their procedures done here.  If you are interested in referring a patient or scheduling a procedure with us, give us a call today at 205-208-9001

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Headache Management

Headache is a common problem

Nearly everyone knows someone who suffers with the chronic pain of headaches.  This may include tension headaches that arise during stress, migraines, or cluster  headaches. Tension headaches tend to follow a band-like distribution, and they are primarily frontal in location.  Migraine headaches are usually one-sided, and may respond to vasoconstricting drugs that make blood vessels tighten.  Cluster headaches are somewhat unique in that they can cause tearing in the eye on the side of the head affected as well as isolated congestion in that half of the nose.  There are also headaches related to excessive use of medication.  Medication overuse headache is thought to be the result of some repeated exposure to a rescue medication.

It is tempting to reach for a pharmacologic solution, but many headache syndromes can at least improve with lifestyle modification.  Among known headache triggers are alcohol,  a lack of sleep, stress, and certain foods.  For the clinician, good headache management starts with taking  a comprehensive history.  Identifiable risk factors should be modified when possible.   Patients who ingest excessive amounts of caffeine should scale back.  The same goes with alcohol, especially for those who may drink red wine (which for many is a  particularly strong headache trigger).  The importance of sleep cannot be overstated either.  While many of us can push through a hard day  on little sleep, it certainly appears that sleep quality and duration make a difference in headache frequency.

Pharmacologic management of headache

Depending on the type of headache and numbness or other associated symptoms,  more workup may be necessary.   The patient who has significant neurologic symptoms in the setting of headache may need  brain imaging to rule out  an intracranial mass or process.  Additionally the patient who suffers with frequent frontal headaches and has sinus complaints may need an evaluation by otolaryngology.  Only after these anatomic causes of headache are ruled out, should a pharmacologic strategy be considered.

The pharmacologic management of headache involves 2 major classes of drugs: Prophylactic medications that prevent headaches from starting, and abortive medications that rescue the patient after the headache has begun.  Common prophylactic medications include  beta blockers,  topiramate, and amitriptyline.  While these may be very helpful for many patients, they also have significant side effect potential.  Physicians will typically discuss these potential side effects with their patients, and this is important because the side effects can certainly influence functionality and quality of life by themselves.

Abortive medications, on the other hand,  are medications only taken after the patient feels the headache coming on.  These medications are designed to work quickly to relieve the pain from the headache.  Other than anti-inflammatories,  the most common medication in this class is the ergot derivatives.  These medications cause vasoconstriction in the head  which often relieves headaches especially those that are migraine.  This counteracts what has been observed in the study of patients with migraine which is a local dilation of the blood vessels in the head.   Of note is the risk that taking these rescue medications may increase blood pressure, and they are not recommended for patients who have suffered a previous stroke. Frequent reliance on rescue medications may in fact  lead to further headache issues.

Additional management options

There are other alternative therapies some patients report to be helpful.  Many patients have gotten good relief with acupuncture.  Routine exercise has also been shown to be beneficial in decreasing headaches.  There are other nonprescription substances that can be taken as well.  Supplemental magnesium has been shown to be helpful as well as riboflavin (vitamin B2).  These supplements should be tried by anybody who has frequent headaches after discussion with his or her physician.  Because many of these alternative therapies  have relatively benign side effects, they’re often under utilized.

Take-home points

If headaches are a common problem for you, take inventory of the things in your life that might be risk factors.   If you seek medical advice, be sure to give your health care provider a thorough history.  Often lifestyle changes will be enough to improve your headaches.   If you and your physician are discussing medications to treat headache, be sure to ask about side effects and ask about non-prescription options.

 

 

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FDA Approves New Peripheral Nerve Stimulation Device

Short-term Peripheral Nerve Stimulation for Acute and Chronic Pain

The FDA recently approved a new peripheral nerve stimulation (PNS) system called SPRINT, the latest in PNS technology.  PNS involves placing an electrode under the skin near a target peripheral nerve thought to be responsible for a patient’s pain pattern.  SPRINT is labeled for acute and chronic pain.  The electrode is connected to a battery source and can transmit an electrical current to the nerve and surrounding area, relieving acute or chronic pain.  Conventional PNS therapy involved having the device surgically implanted under the skin.  Although the stimulation is often beneficial, the surgically placed electrodes are subject to complications like migrating away from the target nerve suddenly or over time and the lifetime risk of infection.

SPRINT, conceived by SPR Therapeutics, is unique in that it can be placed under ultrasound guidance in an outpatient setting (clinic or same-day surgery) but only stays under the skin for up to 30 days.  It is then removed without requiring an incision and sustained pain relief has been observed in the studies that have been done.

This is an encouraging development for those that treat or suffer from focal peripheral nerve pain syndromes.  However, whether peripheral nerve stimulation is covered by one’s insurance plan and the extent of that coverage can vary greatly among insurance plans.

To read more about about the SPRINT device, Click here.

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Birmingham pain clinic - Cahaba Pain HMP Sign

Opening September 14th!

Construction of our Birmingham pain clinic is coming along well.  We’ll be opening our doors on September 14th ready to offer comprehensive pain management services.  Our friends at Kassouf & Co are now taking applications for those interested in joining our team (see our Careers page).  We look forward to providing excellent patient care to those suffering from chronic pain.  Call us at 205-208-9001 to set up your appointment today!

 

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Obstructive Sleep Apnea- When the Snoring Stops

While snoring is hardly a medical problem itself, it may be one of several signs that a patient suffers from obstructive sleep apnea (OSA). OSA results when the upper airway relaxes during sleep and breathing is interrupted. Friends or family may observe the snoring progress to what sounds like choking and eventually apnea where breathing actually stops. During this time carbon dioxide (which is exhaled during normal breathing) starts to accumulate in the bloodstream. Simultaneously, oxygen levels fall. Eventually, the brainstem detects these changes and stimulates the patient to breathe. This may result a gasp or an awakening, the patient resumes breathing, and the cycle repeats itself.

This is important because decreased oxygen levels constrict the blood vessels in the lungs and force the right side of the heart to work harder to pump blood through them. Over time, OSA can lead to chronic hypertension, and in some cases, heart failure over time.

Patients with OSA often complain of sluggishness as they don’t enjoy normal, restorative sleep patterns. Patients may experience a sore throat, headaches, and may doze off repeatedly during the day even while at the wheel.

OSA is especially important to diagnose and treat in patients who are on or will be put on pain medications or anti-anxiety medications since these drugs may cause the soft tissues of the mouth and upper airway to relax, thus increasing the likelihood of apneic episodes. Additionally, opiate medications such as hydrocodone or morphine decrease the brain’s responsiveness to higher carbon dioxide levels. There are well documented cases where patients with untreated OSA have died after being put on opiates after surgery without proper monitoring of their oxygen levels.

Risk factors for OSA include: obesity, thick neck circumference, use of sedatives including alcohol, age (older), smoking, chronic throat problems, and male gender.

A diagnosis of obstructive sleep apnea is made with a sleep study during which the frequency and severity of the apnea are recorded.

Treatment usually involves having the patient sleep in a mask that delivers positive pressure to to the airway (e.g. CPAP mask). Sometimes surgery is offered if removing tissue can open up the throat passages.

In summary, if a patient complains of poor sleep and energy levels, has high blood pressure, is overweight, falls asleep easily during the day, and snores loudly or experiences episodes of apnea as witnessed by others, he/she probably needs a sleep study. In this case, a physician would be wise to order a sleep study before starting a narcotic medication (especially a long-acting drug). Patients with OSA or who are suspected of having sleep apnea should have their oxygen levels monitored when placed on pain medication in the hospital if they are not wearing a CPAP mask.

As hard as it for some patients to get used to wearing the CPAP mask, many experience an improvement in their blood pressure and feel a renewed sense of energy. Symptoms like headache may disappear, and the threat of right heart failure may be eliminated.

If you suspect that you or a loved one suffers with obstructive sleep apnea, consult your physician.

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The Risks of NSAIDS- It’s only ibuprofen…

Recent years have seen an increasing awareness of the risks associated with NSAIDS (non-steroidal anti-inflammatory drugs) which include a variety of medications from over the counter Ibuprofen (e.g. Advil®) and Naproxen (Aleve®) to the commonly prescribed Meloxicam (Mobic®) and Diclofenac (e.g. Arthrotec®).

These medications have been prescribed for years, and most of us take them without any problem.  Last year, however, the FDA strengthened its warning about the risk of heart attack and stroke with NSAID use.  Although Aspirin is an NSAID, it is does not increase one’s risk of heart attack or thrombotic stroke and is not covered by the latest warning.

What many are surprised to learn is that the risk of having a gastrointestinal or GI bleed may be as high as 2-4% with routine use of NSAIDS for prolonged periods of time.  Kidney disease is also a potential consequence of NSAID use.  Even without causing catastrophic complications, NSAIDs can interfere how well antihypertensives (medications that treat high blood pressure) work.

Certainly NSAIDS have a role in the treatment of inflammatory pain, but patients must be educated on the risks involved in taking them.  This would include providing them with signs and symptoms of a GI bleed for example.

Takeaway points

  • Patients (especially those with risk factors or history of heart disease, stroke, kidney problems, etc.) should talk with their physician before starting an NSAID, even one available over the counter.
  • Tylenol may be a safer analgesic (pain reliever) for patients who cannot take NSAIDs
  • Aspirin is cardio-protective. It inhibits platelet function, therefore offering some protection from heart attack.  It remains the best thing for patients having cardiac chest pain to take as they are headed to the ER.
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