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10 Articles in Volume 17, Issue #5
Cross-Linked Hyaluronic Acid Injection for Neuropathic Pain
Discussing Migraine: What to Try When Nothing Is Working
IV Propofol for Treatment of Chronic Intractable Cluster Headache: A Case Series
Letters to the Editor: Rapid Opioid Metabolizer, Intractable Pain, Adrenal Suppression, Traumatic Brain Injury
Migraine Treatment: What’s Old, What’s New
Schizophrenia Spectrum and Chronic Pain: Is Pain Insensitivity a Myth?
Spinal Fluid Flow and Pain Management
Step-by-Step Technique for Targeting Superficial Radial Nerve Pain
The Primary Care Provider’s Role in Diagnosing and Treating Rheumatoid Arthritis
What is the appropriate use of phone texting between physicians and patients?

Spinal Fluid Flow and Pain Management

Editor's Memo June 2017

Spinal fluid flow (SFF) has been a silent subject in pain management. This has to change. For a while, pain practitioners have unknowingly been utilizing a variety of measures that likely enhance SFF. Progressive research that involves SFF has shown how it occurs, how it may promote pain, and how it may impede treatment efforts.1-3

Specifically, our new understanding is that neuroinflammation, neuroprotection, and neuroregeneration, which are critical elements of pain management, are all dependent on some degree of SFF. The basic physiologic functions of cerebrospinal fluid (CSF) are now known. The central nervous system (brain and spinal cord) contains about 125 to 150 mL of CSF. It is produced from serum in the choroid plexus in the brain’s ventral system.

Incredibly, the entire amount of CSF turns over about 4 times a day (total production, 400-500 mL/d).  

Its functions are multiple:

  • Transport of nutrients
  • Barrier to cushion trauma to the brain
  • Lubricant to prevent friction between nerve roots and the canal lining
  • Disposal of waste products (harmful metabolites, drugs, and other substances)

CSF exits the brain and spinal canal through cranial lymph and glymphatic channels to enter the general circulation. Sleep promotes clearance of metabolites and waste, such as amyloid and neuroinflammatory by-products.4 Nutrients that are transported from serum into the CSF include vitamins B1, B12, and C; folate; beta-2 microglobulin; arginine vasopressin; and nitrous oxide.1-3

Interestingly, the pump, or mechanism, that drives CSF downward from the site of production in the brain to the sacral area and then back up to the brain sites for reabsorption in the general circulation is unclear. The best theory at this time is that arterial pressure in arteries around the choroid plexus propels fluid movement. Breathing may also promote fluid movement.

Role of Spinal Fluid Flow in Pain Management

Regardless, SFF does not have an active, visible pump like the heart to drive fluid flow. The relevance of SFF to practical pain management is clear.

Good SFF is:

  • Critical to providing nutrients to the spinal cord canal and cauda equina nerve roots
  • An essential component in preventing friction between nerve roots
  • Needed to carry away waste products from neuro-inflammation
  • Vital for bringing therapeutic drugs to target areas such as the cauda equina

The answers to the major questions for pain management are incompletely known: How do we diagnose SFF impairment, and what do we do about it?

Symptomatically, pain patients with SFF impairment may complain of weakness, headache, blurred vision, tinnitus, or increased pain if they stand or sit too long. Some will have to lie or sit down after standing for only a few minutes. Contrast magnetic resonance imaging (MRI) may now show, for example, spinal fluid on only one side of the cord in the cervical or lumbar spine areas. The thecal sac may sometimes look distended in the lumbar area if there is obstruction in the sacral area.

Some studies of pressure gradients in the spinal cord suggest that anything that protrudes into or narrows the spinal canal may cause pressure gradients across the canal and impede SFF. It is likely that common spinal conditions, such as protruding discs, stenosis, kyphoscoliosis, and arachnoiditis, may all impede SFF. This bodes poorly for the pain patient, as impaired SFF may leave initiating inflammatory waste in the CSF, deprive the spinal cord and nerve roots of nutrition, and prevent therapeutic agents from reaching target areas.

Age-Old Treatments May Help

It may also well be that many of the age-old techniques used to treat basic pain exact their effect by increasing SFF. These techniques include massage and manipulation of the spine. Walking, stretching, cycling, heat, and yoga may all help SFF. The most notable recollection that comes to my mind is that the renowned pain physician, Janet Travell, MD, became John F. Kennedy’s pain physician in 1955 after he had developed multiple spine problems and had failed multiple spine surgeries. Her first treatment was not opioids but was a rocking chair. Janet, do you have any more tips on SFF?

Focus on Headaches

A focus of this issue is headache management. Lawrence Robbins, MD, presents a comprehensive overview of migraine management, including excellent tables and charts. Duren Michael Ready, MD, tackles the issue of what to try when nothing is working for your migraine patients, which has been excerpted from his new book Discussing Migraine With Your Patients: A Common Sense Guide for Clinicians. Lastly, John Claude Krusz, PhD, MD, presents 6 case reports of patients with refractory cluster headaches treated in his outpatient clinic with intravenous low-dose propofol.

Also in this issue is advice from Don Goldenberg, MD, for primary care physicians examining patients with suspected rheumatoid arthritis, and you will find the next installment of our monthly mental health series. This month, David Cosio, PhD, focuses on the new DSM-5 diagnosis of schizophrenia

As always, we hope that you enjoy this issue of PPM, and invite you to send your questions and comments to jodi.godfrey@verticalhealth.com.

Last updated on: June 15, 2017
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What is the appropriate use of phone texting between physicians and patients?

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