Dr. Hillary Fausett, MD, Pain Management

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ContributorDr. Hillary J. Fausett, MD, Pain ManagementRead Full Bio


Hilary J Fausett, M.D. is a Board Certified Pain Management Specialist. She received her undergraduate degree from the University of Southern California and her Medical Degree from the University of California, San Francisco. Dr. Fausett completed all of her post-graduate training at Harvard University Hospitals. Following her Residency in Anaesthesia at the Massachusetts General Hospital, Dr. Fausett completed her Fellowship in Pain Management at Beth Israel-Deaconess Medical Center. Following her training, she served on the Pain Management teaching staff of Harvard Medical School at the Beth Israel-Deaconess Medical Center. After leaving her academic position at Harvard University, Dr. Fausett was a Director of Pain Management at Kaiser Los Angeles before creating the Foothill Center of Wellness and Pain Management in 2003. She was the Co-Editor of the Manual of Pain Management (Lippincott Williams 2002).

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ContributorDr. Robert G. Watkins IV, MD, Orthopedic SurgeonRead Full Bio


Robert Watkins IV, M.D., is co-director of Marina Spine Center and Chairman of the Surgery Department at Marina Del Rey Hospital. Dr. Watkins is a board-certified orthopedic spine surgeon, specializing in minimally invasive spine surgery, computer-assisted surgery, spinal-deformity treatment, and disc replacement. Dr. Watkins earned his medical degree at the University of Southern California’s Keck School of Medicine and completed his residency in orthopedic surgery at the L.A. County/USC General Hospital. He then worked as a traveling fellow in Europe, specializing in artificial-disc replacement and scoliosis surgery. Over the past decade, he has lectured on spine issues to doctors, patient groups, athletic trainers, and physical therapists; led research teams that have published studies; and taught surgeons on specialized techniques. He is the spine consultant to many Los Angeles sports teams, and has treated professional, college, and high school athletes from all over the country.

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I'm Dr. Hillary Fausett. I've been a pain management specialist for 20 years. I did my undergraduate at the University of Southern California. And when I went to UC San Francisco to complete my medical education, an entire world opened up for me. And I found I liked to help people in a very physical, tangible way. That's what people who do surgery do. That's what people who do procedures do. You actually use technology, interacting with somebody, to make that person better.

Better physically, and better able to function. One of the things we're all taught in medical school is if you listen to the patient, the patient will tell you the diagnosis. Now that I've been doing this for about 20 years, I can assure you that is completely true. I walk into a room, and I see the person. Are they sitting? Are they standing? Are they leaning? That body language tells me immensely, what area of the body are they protecting? What area of the body are they depending on? Then we start to ask questions.

When somebody tells me certain coughing, sneezing, moving, and they-pain shoots down the leg. Suddenly, I start thinking about their discs. Their nerves. Will they need a medication to make them better? Will they need a steroid injection to make them better? So, when your body is inflamed, we can use medications that are anti-inflammatory. Anti-inflammatory medications can be wonderful. They can really help to bring down the amount of pain somebody feels. They reduce the inflammation in the little joints of the spine, allowing you to do physical therapy and core exercises.

Sometimes we need to use medications that are approved for other indications, like seizures. Or antidepressants. These help to calm the nerves. Some of the most powerful medications we have are narcotic medications. These medications are tools to achieve a particular goal. One of the problems we have in the United States right now is addiction. And it's become an epidemic. I have patients who come to me, who clearly need pain medication, and they're afraid to start pain medication because they're afraid they will become addicted. I tell them that this medication will cause 100 percent of people to become physically dependent.

Now that means your body grows to expect the medication. And if you take the medication for somewhere between two to six weeks, you may indeed become physically dependent on the medication. That's different than being psychologically addicted. Psychological addiction is when you crave the medication for a non pain reason. It makes you feel good. You want it. In order to receive this medication, you must be seen every 30 days by your physician. You cannot receive these medications without a face to face interaction with a health care provider.

That means that's the perfect opportunity for you, every month, to reassess. Is this the correct medication for you? Are you on track? Is this medication helping you achieve your goals of exercise, your goals at work, your goals for your home life? Patients can be surprised that their surgeon sends them to a pain doctor. And you should be grateful that your surgeon sends you to the pain doctor, 'cause what your surgeon wants to know is, firstly, can this problem be treated without surgery?

Because a good surgeon does not wanna operate on you if you don't need it. Secondly, what is the least amount of surgery you can do for a problem? Sometimes we need to determine, Is one part of the spine more involved in your pain than another? That involves a very targeted injection, putting small amounts of dilute steroid with concentrated local anesthetic to a particular region of the spine, and asking a very simple yes no question. When this particular anatomic structure is kept comfortable, when the pain generators are stopped, do you feel better? Yes no.

That information is given to your surgeon. That's information that you can use to help you decide what's the best surgery for you. The epidural refers to a potential space in the body. That's where we're gonna put medication. The epidural can be used in labor, to give dilute anesthetic so that you don't feel the pains of labor. In pain management, we use it to provide a steroid medication close to the region of pain. Steroids serve three functions. They cause pretty close to immediate pain relief, but mild. They bring down inflammation, and they also change how your body feels.

We wanna give a high dose targeted to the area of pain. Whoever's doing this procedure for you will find this area of your body, under some type of guidance. Usually X-ray, fluoroscopy is real time X-ray. Some doctors have a procedure suite like this in their office. For many physicians, they will use a surgery center. If you have problems staying still, you may be given sedation for this. You will be awake. It's a twilight sort of sleep, similar to what happens when you have a colonoscopy. You fast. You don't eat for the day. You take only the medications as instructed to take. You wanna make sure nothing pinches. Your legs feel good, your arms feel good.

You'll probably be monitored. That will mean a blood pressure cuff, EKG leads, and a pulse oximeter to check your oxygenation. After n-the numbing medication, the lidocaine, is applied, very specialized equipment is put in under X-ray guidance, exactly to the area. Now, it's important to remember, something is now in your body where nothing has been. There can be a lot of stretch. What this stretch means is you may feel weak. You may feel nauseated. These are different types of nerves than have ever been stimulated in your body before.

It's also important to allow your body a chance to rest. We also don't want you to twist. So respect that. Give your body a chance to heal. Sometimes you'll hear the term nerve block, as opposed to epidural. Remember, you-we never wanna touch our nerves. Nerves can be very easily damaged by any sort of crush, any sort of needle stick. So using the X-ray guidance, the medication is put around the nerve. Sometimes surgeons want this, because they wanna know, Is this very small, particular region of the body affecting the pain that you feel?

In between the bones of our spine is something called the facet joint. That's where we bend. Now, if the joints where the one bone hits against the other is inflamed, you'll feel a lot of tightness. That tightness can even radiate across the back into the buttocks and into the thigh. One of the procedures you may have is a very small needle, put exactly into this joint. The medication will have a local anesthetic in it, as well as a steroid. One of the things I do with my patients, I like them awake after this procedure.

We wait about five minutes, and then we ask them to move. People are usually astounded at how much better they feel. Now, I tell them, That's the lidocaine. Lidocaine lasts about 45 minutes. So we know the medication's in the right place. Most often the steroid that you're given will take a day or two to really start working. That steroid will stay in your body five days, maybe even 10 days. But its effect in your body can last for weeks or months. Steroids are wonderful because they powerfully bring down inflammation.

If you have a steroid, and you have any type of diabetes or borderline diabetes, you may have high blood sugar afterwards. You may find yourself urinating more. For some people, they're very sensitive to steroids, and they have difficulty sleeping after the injection. A lot of people have problems with their stomach. For some people, this means that they eat more. For some people, it means that they eat less. Now, for some people, even after they've received a steroid injection, the pain relief doesn't last very long.

So for four weeks, six weeks, maybe even two months, they feel great. And then that pain starts to come back. For this one area of the body, we can actually use a technology and denervate, that means take away, the nerve sensation that goes to this joint of the body. Under X-ray guidance, a needle is put into your body, very close to this joint. And a stimulating current is given. What the patient starts to feel is a pressure over the area where they feel the pain.

Once your particular pattern has been mapped out... you're then sedated, and a very high energy current is run through this needle. That stops the nerve from firing, so even if we access the joints nerves that we can, we cannot get all of them. So the joint isn't completely numbed. We take away about 50 percent of the sensation, though. That's often enough for people to have a good length of time to build up their core muscles, to lose weight.

Now, even though the studies say 300 days, we have people for which that lasts much longer, and people for which it doesn't last quite as long. One of the technologies we have is called spinal cord stimulation. What we do is stimulate the nerves of the spine to give the sensations we'd like you to have, and not the sensations that you're having. Now that sounds very tricky. So the analogy I use to people is that when you rub an area where you feel pain, you don't feel as much pain. That's because large diameter fibers, touch sensation, vibratory sensation, is being stimulated, and the pain fibers, which are very small and slow, are not getting through to your brain.

Now the technology uses electrodes, and you can see them here. This is actually placed in the epidural space, between the level of where your shoulder blades are. We call that your thoracic spine. And... it's connected to a little device. This little device actually carries electricity-this is the pulse generator, so this is a battery. Giving information to this little device. Which goes in over the spinal cord, stimulating touch receptors.

Now, when I explain this to people, they get a little confused. So you're wearing something that's buzzing. We then change that s-buzzing sensation, so it's only the area where you feel pain, and it should feel like a rubbing. Or a pulsing. Or something much more pleasant. So the idea is that, instead of carrying pain fibers from the peripheral part of your body up to your brain, you're carrying buzzing sensations, vibrating sensations, touching sensations. This is a very powerful tool to use.

This is a tool that allows them to feel something else, rather than pain. There are other types of injuries where nerves have been crushed, nerves have been stretched, that people end up with chronic pain. And this is a way of giving them a different type of sensation, rather than pain. Now, the ideal, of course, would be to feel nothing. In theory, it should be possible to bring the stimulation from a machine like this down so low, that all you were feeling was normal.

Clinically, that's a lot more difficult. But for most patients, once you start to feel something pleasant, and the pain is gone, you quickly learn to associate the vibration you're having, or the quick little pulses that you're feeling, as something positive, because it means that the pain you have been having is gone. We also have the ability to put pumps of medication in your body. Now this is rather amazing. So this little device actually will hold medication in it. We can put pain medication in it.

For people who have spasticity, they can have a medication like baclofen. So that's for children who have cerebral palsy, adults who have had strokes. This machine is connected with a catheter. This catheter actually goes into the body. This stays in what's called the intrathecal space around your spine. There are very small holes here at the end, and it releases medication into the body. You can see this small diaphragm here in front. That's how medication is refilled. So this is underneath the wall of your stomach. And a needle is put through here to give medication. Now this technology has been used, oh, probably, about 30 years.

The indications for this are fairly small. And you wanna have a good discussion with your doctor about the complications. Remember, when we give you medications, we're giving you the effects we want you to have, and we may be giving you effects we don't want you to have. So, we can give you what's called an opiate medication through this drug delivery device. Your body uses opiate receptors for more than just pain. You may have change in how you process temperature. For men, you may have a change in your testosterone level. That's a direct effect of the medication, not the effect your physician wants you to have.

So as opposed to getting a pill, you'll be getting a tiny little drop. It needs to be refilled. Pretty much every three months. This is something that when you have it placed, you need to have a good relationship with your physician. You need to be seen regularly, and you do not want this medication to run out. If you lose this medication, lose its effectiveness, you can quickly go into opiate withdrawal. That is very uncomfortable. So I always tell my patients, if we're coming down to having a discussion about putting in a device like this, we're basically married.

You need to always know where I am, I need to know where you are. Fortunately, all the companies that make this kind of equipment in the United States have patient tracking systems. One of the most import things to remember if you have pain, is to find a clinician that you can work with. Because your pain does become part of you. And I need you to own your pain. Just like I need you to own your body. And I need you to feel that you're in charge of your body, and I need you to feel like you're in charge of your pain.

A lot of people try to put it to the side. They feel shame. They feel embarrassed that they hurt. What I'd want to do with my patients is shine a bright light on it. I want you to feel aware of all of the tricks, and all of the tools, and all the technologies that are there, really to help you. So what do you do with your pain? Well, what's so boring about it is very often you have to do the exact same thing for it that you did yesterday. You have to stretch. You have to take your pill. You have to do your physical therapy exercises. And it's boring. And I get that.

And in our culture, you have to pretend a lot. And I think that's why pain clinics are so important. Because you get to go somewhere where we hear you. At the beginning of the year, we always tell people, What's your goal for the year? We write it down. And every month when they come in, we ask them, Have you achieved that goal? And sometimes it's silly, it's lose five pounds. Sometimes it sounds really small. I wanna use a cane instead of a walker.

Sometimes it's huge. I wanna run a half marathon. But what's important is that my patient has set that goal. And that has set the tone for the office visit, and that's what keeps us going.

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