Articles Posted in Medical News

Spinal cord stimulators have been around for many years. In fact, the FDA first approved the use of such devices back in 1989. These devices can provide relief to those who live in chronic pain. Many of our clients have benefited from these devices, though not all patients have success with them. The FDA recently approved a new version of spinal cord stimulator, which can provide pain relief without causing an uncomfortable tingling sensation.

This new spinal cord stimulator is called the Senza System, manufactured by Nevro Corp., based in Menlo, California. The pain relief can be accomplished without the tingling (also known as paresthesia) through “high frequency stimulation (at 10 KHz) and low stimulation amplitudes.”

Obviously, any increase in the ability to control chronic pain is of benefit to the injured worker that we encounter every day. A reduction of narcotic medication, which has significant and dangerous side effects, is always an advantage. This chronic pain can be a result of many types of conditions, including failed low back syndrome (after surgery did not relieve the pain), and Complex Regional Pain Syndrome (CRPS, also known as Reflex Sympathetic Dystrophy [RSD]). We also note, in passing, that an aggravation of a preexisting low back condition can still form the basis of a valid workers’ compensation claim in Pennsylvania.

As with any medical treatment, it is important to discuss thoroughly with your doctor whether a spinal cord stimulator may be of benefit to your specific condition. Advancements in pain relief, though, give hope to all injured workers.

In 2009, we discussed an article in the Journal of the American Academy of Orthopaedic Surgeons, which advised patients to try physical therapy before resorting to low back surgery for degenerative disc disease. Now, six years later, a University of Pittsburgh study found that surgery and physical therapy achieved roughly the same success rates for “lumbar spinal stenosis.”

Perhaps the first thing to address is what are “degenerative disc disease” (DDD) and “spinal stenosis.” As the name implies, degenerative disc disease is the damage, the wear and tear, that is caused just by years of activity. As with grey hair, bad eyesight or other physical traits, some people are more prone to this condition than others. “Spinal stenosis” is a narrowing of the spine, which can lead to a nerve being irritated. This can be caused by DDD or by another condition (scoliosis or arthritis, for example). A herniated disc can also cause the canal in which the nerves pass to become much narrower.

Why, then, would this topic be of interest to injured workers, you might ask. If this is a degenerative problem, then what could work have to do with it? As it turns out, work often has a great deal to do with it. Many people, some say the majority of a certain age, have these degenerative changes, but have no symptoms. Often, a work injury “aggravates” these degenerative changes, making something symptomatic which never was before. It is important to know that an aggravation of pre-existing condition, such as degenerative disc disease, is a “new injury” for workers’ compensation purposes. The work injury need not “cause” the disability; simply aggravating an already existing condition is enough. And that makes sense – after all, if you were able to do your job before the work injury, and then were no longer able to do your job after the work injury, shouldn’t you be compensated?

Back to the main topic, this new study continues to enforce what had been said in the past – lumbar surgery for these conditions should not be a primary response. The lead author of the recent article, Tony Delitto, chair of Pitt’s physical therapy department, stated, “they should exhaust nonsurgical options, which include physical therapy, before they consent to surgery.” Certainly sounds like a reasonable way to proceed.

One of the more common injuries we see in Pennsylvania workers’ compensation is a tear of the rotator cuff in the shoulder. We have discussed this kind of injury previously on the blog. This kind of injury can happen suddenly, or it can occur progressively, over a period of months, or even years. Regardless of the timing, a tear in the rotator cuff can certainly be disabling and, if caused by work duties, make one entitled to PA workers’ comp benefits.

A recent study on rotator cuff tears showed that the degree of pain one suffers is NOT necessarily based on how significant a tear has occurred. This would certainly be of interest to the many physicians who perform Defense Medical Examinations (officially, and humorously, called “Independent” Medical Examinations), who seem to automatically question the truth of a patient who complains of significant pain without having a substantial tear reflected on an imaging study, such as an MRI. This is further proof that medicine is not an exact science, and that the history, and complaints, of a patient must be given true attention.

It is also important to keep in mind that having had some shoulder problems in the past, such as degenerative joint disease, may not prevent receiving Pennsylvania workers’ compensation benefits, if work duties materially worsen the condition. We call this an “aggravation,” and it is treated as a new injury for the purposes of workers’ comp.

There are many different kinds of injuries and conditions we face in Pennsylvania workers’ compensation matters. One common thread in those injuries and conditions, however, is pain. Often, the pain is to a level that is severe, requiring significant medications to obtain relief. Various types of medications are classified differently. Basically, the more powerful, or dangerous, a medication is perceived to be, the more limited the access to the medication.

Starting early next month, Hydrocodone Combination Products (HCPs) will change from a Schedule III drug to a Schedule II according to the Controlled Substances Act. To the injured worker, this is important for several reasons. First, all hydrocodone prescriptions will now require an actual written “hard copy” prescription. In other words, telephone, fax, verbal and email prescriptions are not acceptable. Second, there are no refills available for this classification of medication. Third, any existing refills for hydrocodone prescriptions will be void as of midnight on October 5, 2014.

For additional information, you can visit the website for Injured Workers Pharmacy (IWP), a mail order prescription service used by many of our clients.

For some time now, it has been known, or at least suspected, that high doses of pain-relieving agent acetaminophen can lead to serious liver damage. Acetaminophen is sold over the counter on its own (Tylenol), or as an ingredient in more powerful pain medications, such as Percocet (oxycodone and acetaminophen) and Vicodin (hydrocodone and acetaminophen). Back in 2011, the Food and Drug Administration (FDA) issued a release, taking steps to reduce the risk of liver damage from acetaminophen.

Essentially, the FDA called for two things of medicines containing acetaminophen. First, there must be a clear warning on the box, detailing the potential risk for “severe liver injury.” Second, prescription medications should be limited to a maximum of 325 milligrams of acetaminophen per tablet, pill or capsule.

Recently, the FDA issued a statement that all manufacturers of medications containing more than 325 milligrams of acetaminophen per dosage unit have stopped marketing such products. Additionally, the FDA also issued a statement reminding health care providers not to prescribe such products, and pharmacists to stop dispensing them. In short, the position of the FDA is that “(t)hese products are no longer considered safe by FDA and have been voluntarily withdrawn.”

Injured workers, and others with chronic pain, can safely continue to use medications containing acetaminophen, according to the FDA, within these guidelines. As with any medication, it is important for users to follow the dosage recommendations of their physicians, or their pharmacists, to assure that these (and other) medications remain safe, and risks or harmful side effects are lessened.

A couple of months ago, we mentioned the FDA approval of a new pain medication, called Zohydro. The same properties which make Zohydro so exciting for the medical profession, and injured workers everywhere, caused great angst among government and addiction officials. Fast and effective relief of severe pain, unfortunately, also can lead to misuse and/or abuse of any substance. These concerns had officials lobbying the FDA to revoke its approval for this medication.

Recently, the FDA issued a Fact Sheet about Zohydro. After taking a close look at the benefits and risks of this medication, the FDA determined that its approval (for its intended usage) was correct. In fact, the FDA issued this release, in part, to correct some misconceptions about Zohydro.

Specifically, the FDA noted that Zohydro is available in varying strengths. Since it is designed to be a time-release medication, though Zohydro contains more hydrocodone than some other products, it is actually less potent than other opiate-based pain relievers currently on the market, as they are immediate-release products. Further, there is evidence that abuse-deterrent properties of some competing medications, such as Oxycontin, are not completely effective at preventing abuse or addiction. The FDA also recognized that, even if Oxycontin has some abuse-deterrent properties not found in Zohydro, Oxycontin “does not meet the medical needs of all people in severe pain.”

In the end, the FDA could not justify keeping fast and thorough pain relief from those in severe pain. As usual, we must rely upon the doctors, and the patients, to make sure this medication (as we would with any medication) is used safely and effectively.

Once limited to a role in science fiction books and movies, nanotechnology is getting ready to invade our lives in beneficial ways. Nanotechnology is the study of, or use of, extremely small things, often at the atomic level. How small? One nanometer is a billionth of a meter, or, in other words, there are 25,400,000 nanometers in an inch. Obviously, we cannot see these things with the naked eye (or even a basic microscope).

Scientists have discussed how nanotechnology could impact medicine for years. Or, at least, they have done so in theory. Nanobots could, in theory, perform surgical tasks in a human body; sort of a real version of the 1966 movie, Fantastic Voyage. Nanotechnology could also assist in prosthetics, medical tools and processes. The possibilities are truly endless.

But, some uses of nanotechnology have left the realm of “theory” and moved into that of “reality.” One recent example is an experiment conducted using an injection of magnetic nanoparticles in place of traditional anesthetic for an ankle block. The study was successful, demonstrating that this process does work (at least in rats). By identifying specific areas in which nanotechnology may benefit us, these researchers are helping other scientists refine realistic use of the nanotechnology.

A common theme we see with work injuries in Pennsylvania, whether with a complex regional pain syndrome, failed back surgery, brachial plexopathy, knee, hip or shoulder replacement, or other permanent conditions, is an injured worker dealing with chronic pain. As a result, we always keep an eye out for new methods of helping patients deal with the lingering agony that can accompany a serious work injury.

While many of these new methods, whether it be medication or other treatment option, arrive quietly, one new medication is coming with quite a fuss. Zohydro ER, manufactured by Zogenix, Inc., is a powerful new hydrocodone product. This medication was recently approved by the FDA, and, as stated in the press release issued by the FDA, “is the first FDA-approved single-entity (not combined with an analgesic such as acetaminophen) and extended-release hydrocodone product.”

Because Zohydro ER is so potent, there is great concern in the medical and news community that the product will cause addiction and health issues. According to ABC News, Zohydro ER can have up to ten times more narcotic than Vicodin. In fact, that same article stated that “the FDA’s own advisory committee voted against approval.”

According to CBS Philly, local police and safety officials in the Philadelphia and Bucks County areas are also concerned that Zohydro ER will cause an increase in both pharmacy and home burglaries, as desperate people seek the drug. In the article, Bensalem Public Safety Director Fred Harran said, “We’re going to see a spike in burglaries, robberies and thefts across the nation. We’re going to see more heroin overdoses, more overdoses of this drug because it’s so potent, it’s so powerful.”

While, in theory, any medication can be abused and can lead to an overdose. Many medications are known to potentially cause addiction. These things, however, do not seem like a reason to deny relief to folks who live each day in excruciating pain because existing medications cannot achieve an acceptable level of relief. Those lobbying the FDA to revoke its approval probably never found themselves in the chronic pain faced by an injured worker.

To properly represent injured workers in PA, we feel it is critical that we be educated not only on the law, but also on the medical side of things. The more we can understand all aspects of a case, the better we can represent our clients.

One of the more common types of work injuries we see are those to the spine, both neck and back. In reviewing and litigating a case, we have to digest all types of medical records, including diagnostic studies. Magnetic Resonance Imaging (MRI) is a type of test frequently performed with spinal injuries. Being lawyers, not doctors, we certainly do not want to be reading films, but we do want to understand what things mean when we see them in MRI reports.

With this in mind, I attended a seminar last night given by Dr. Lisa Sheppard of Garden State Magnetic Imaging. A Board Certified Radiologist with a Certificate of Additional Qualification in Neuroradiology, Dr. Sheppard thoroughly explained the anatomy of a spine, and how it appears on an MRI study. Dr. Sheppard described what abnormal findings on an MRI study may indicate a chronic, perhaps degenerative, condition and what findings would be more suggestive of trauma.

Additionally, Dr. Sheppard discussed what each term in an MRI report, prepared by a radiologist, would actually mean. In other words, the terms we see thrown around, like whether a disc is herniated, extruded, protruding or bulging, all have a specific meaning, based on the anatomy of the disc. Plus, the position of the disc abnormality, relative to the nerve, has significance for whether the nerve is impacted (called a “radiculopathy”).

I came away from the seminar better understanding both the anatomy of the spine, and how that anatomy is seen on an MRI study. Given the experience and knowledge displayed by Dr. Sheppard, I would not hesitate to have my clients treated by Garden State Magnetic Imaging.

Injured workers in PA are like every other person in society. They are susceptible to conditions that affect everyone else. One of those conditions is a scary disorder called Chronic Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD). Having had trauma, through a work injury, the injured worker may be even more at risk.

We have previously discussed CRPS/RSD on our blog. One of the most frightening aspects of CRPS/RSD is how much the experts don’t know. For example, it is not known how or why a person develops the condition. According to the National Institute of Neurological Disorders and Stroke, CRPS/RSD is caused by an injury or trauma, but not necessarily a severe one. The condition has been known to develop from sprains, strains, cuts, burns or bruises, in addition to fractures or surgical procedures. Most commonly, CRPS/RSD occurs in a patient between 25 and 55, and women are three times more likely to develop the ailment than men, says the American Society for Surgery of the Hand.

Another area that makes CRPS/RSD difficult is the problems in reaching a proper diagnosis. The hallmark symptom is extreme pain, which appears out of proportion to the injury suffered. There may also be changes to the skin of the injured worker, including discoloring, swelling, dryness, tightness, redness, rashes, changes to the hair or nails and/or an increase or decrease in sweating. Many of these symptoms are common to other conditions as well. Worse, according to a recent presentation by Dr. Pradeep Chopra, Assistant Professor at Brown Medical School and Director of the Pain Management Center in Rhode Island, diagnostic tests, such as x-rays, MRI, bone scan and EMG are “not helpful for diagnosing RSD,” though they may be useful to rule out other causes and diagnoses. Therefore, CRPS/RSD is essentially a “clinical diagnosis,” best made by a physician’s personal observations of the injured worker.

There is no single “best” way to treat CRPS/RSD. The case must be examined on a patient-by-patient basis. Treating with a physician experienced with CRPS/RSD is critical, says Dr. Chopra. Options include one or more medications, drawn from several different types, injections, spinal cord stimulators and therapy.

Since CRPS/RSD is difficult to diagnose, and the causes are so vague, this condition is often met with litigation in the Pennsylvania workers’ compensation system. Much like a patient should consider using a physician with experience with the condition, when the patient is an injured worker in PA, he or she should consider using an attorney certified as a specialist in the practice of workers’ compensation law (as both of the attorneys at Brilliant & Neiman LLC are).