Episode 10: Cervicogenic Headaches, Nerve Blocks and the Birth of Chronic Pain Medicine in Ontario Part 1

There was a time in Ontario when chronic pain patients who didn’t respond to physiotherapy or surgery were often given only basic advice to exercise or referred to a psychologist or psychiatrist to ensure they weren’t suffering from depression. But then, Dr. Peter Rothbart changed everything by founding the first community-based chronic pain clinic in the province.

In this episode, I interview Dr. Howard Jacobs, who, alongside Dr. Rothbart, played a pivotal role in creating the field of chronic pain management in Ontario. Together, they revolutionized the way chronic pain is treated, paving the way for modern pain management practices.

Ever wonder what it takes to create an entirely new medical field? Join Dr Karmy to find out.

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Chapters

• 0:36 Introduction to Dr Howard Jacobs and the Innovation of Pain Management along side Dr Peter Rothbart in Canada Through The Establishment of Cervicogenic Headaches by Dr Nikoli Bogduk
• 24:58 Do Accessory Nerve Blocks Help with Headaches?
• 30:13 Dr Peter Rothbart and Dr Howard Jacobs Introducing Nerve Blocks To Ontario - History of the Landscape of Pain Management in Ontario, Involvement of U of T Professors
• 34:54 Dr Karmy’s Final Thoughts

Transcript

Dr Howard Jacobs: 0:00

Chronic pain management went a long way from the headache. It started as headache management and then it progressed to the whole concept of chronic pain management. And, someone like myself who was from primary care, had no place in that area. What was I doing there? And that's the story in itself. But that's what was Jacobs doing there? The only family doctor. I was the first and only family doctor that was ever, that ever gave an injection into the neck in Ontario. The bottom line was I was his first protege of doing this as a primary care.

Dr Karmy: 0:36

Hello, this is Dr. Karmy, and today we have Dr. Howard Jacobs to talk to us about the origin of pain management in Ontario. Starting something new, in medicine is not actually as easy as it sounds. There is this sort of impression that you come up with a service that patients need desperately and everybody rushes to you because you're providing this very useful service. And then you become famous and perhaps wealthy. And you have all this acclaim because you are providing something that's very, very useful. But in real life, things are very rarely that simple. And, you know, to understand why you have to understand a little bit about how medicine works on practical basis. And medicine as a field actually does not reward innovation. If anything, it discourages innovation. Medicine typically is built on standards and guidelines and standards and guidelines by their nature encourage you to do things that's always been done rather than doing things by that have not been done before. You have a lot to lose, such as your medical license to practice medicine if you step out of line, and especially if a patient has a bad outcome. Every approach in medicine has some risks involved, but if you are doing something that everyone else is doing, then generally speaking the risks are accepted. But if you are doing something new and different, it is much more risky to your license because it is much harder to justify. Also there's other things like who's going to pay for this new service that you're providing? How will the medical community as a whole react to the service that you're providing? A lot of medicine is incredibly bureaucratic. The sort of an idea you discover something new and useful and the world embraces you doesn't typically work out that way in practice. Now what's unique about, pain management is that it is relatively young field. Most of the specialties that we know of has existed since 1930s. It is very rare that a new field actually arises. Dr. Jacobs has been in a very unique position to be present almost at the birth of a new field. Also, what's unique about pain management, at least in Ontario, is that it didn't arise as a result of multiple people contributing over time. A lot of time specialties arose by initially family doctors doing services such as delivering babies or managing heart attacks, and then some of them decided to narrow their field of practice to do obstetrics and gynecology or cardiology. In other words, it's not necessarily doing something new, but rather narrowing your scope of practice. What's unique about pain management in Ontario that it was essentially started by a single person, Dr. Peter Rothbart, who was an anesthesiologist in 1970s. The thing to remember about anesthesiologist is that the vast majority of their training is not about managing chronic pain. They certainly manage acute pain. I would guess the bulk of what they did in 1970s was to put people under general anesthesia to do surgery. So I guess one of the questions in my mind, and I don't really know that there is a simple answer, is how did Peter Rothbart decide to get into chronic pain management? So today with us we have Dr. Jacobs. He has a very long and elastrous career in pain management. He has been practicing pain for almost 40 years. And among multiple roles he played in the field, he has been chair of Ontario Medical Association section of chronic pain. He was also inspector for College of Physicians and Surgeons of Ontario, which is the organization that gives us our license to practice. And he was also one of the first doctors to work with Dr. Rothbart. Howard, do you have any idea how Peter Rothbart decided to get into this field?

Dr Howard Jacobs: 6:35

Sure, that's a nice introduction to the to what we're going to talk about today. And we could probably talk about this for many hours as you have been a colleague of mine for many years as well, and always supportive of the field, and now an expert yourself in that area. Also, I should say, you said I was the chair of the section. We also, started the Canadian Academy of Pain Management, which was the largest multidisciplinary organization in Canada, dealing with chronic pain management. There are members that are physiotherapists and chiropractors and many people involved in the field. So that was also a big development in the field. But let's go back to the very beginning. I joined Peter in the early 90s I think it was around 1990. So Peter had already been in in managing the pain by the time I joined him. He had started his career working as an anesthesiologist. I believe Scarborough General was where he started and he had enjoyed doing anesthesia. What really brought him into the field was a neurologist Dr. Gawel, who was a neurologist at Sunnybrook. And he was very interested in the treatment of chronic head pain, migraine, facial pain, and chronic daily persistent headaches and everything related to headache pain. So he approached Peter and they discussed the pathophysiology between the relationship between the neck and the head, which obviously we know they can't exist without each other. But there was a deeper connection from a pathophysiological and physiological connections, which Dr. Gawel had studied. So he became very frustrated that a lot of the medications that they would be using at the time were not working well, especially for the chronic daily headaches, and as we know, years later, it became a whole field. What happened was, Peter had been approached by Dr. Gawel, and after they discussed what could possibly be the certain mechanisms, he asked Peter if there was a way that they could inject into the head, an anesthetic in order, to see whether this would affect the headaches, especially the types of headaches that Dr. Gawel was seeing were not only migraine and not only chronic daily, they were also post traumatic headaches. And they were also patients who had been in motor vehicle accidents. He saw quite a lot of those and he was unclear of why these headaches were were so severe. And what was the underlying mechanisms? They decided that there was a connection between the neck and the nerves that go from the neck to the brain via the central nervous system, and they decided that they would inject into areas or nerves that traverse the central nervous system by the spinal cord, and that nerve was called the occipital nerve, which became legendary in its own right, especially in Ontario. So the occipital nerve was what they felt would be a way to get into the central nervous system. They weren't the first people to make that connection that there was occipital nerve pain, and there was headaches that were due to occipital nerve pathology. There was occipital neuralgia. This was a different approach. This was not the pain of occipital neuralgia, which is a different type of headache than the headache that they were trying to treat. So the first entrance of Peter into this field was the use of the injections of occipital nerve blocks into the area of the head. And to see what the response would be, which before, traditionally, occipital neuralgia was a specific type of headache, which was well known, obviously, for many years, and well known in the neurological field. What happened after that was that the field of headache management was the area that Peter decided to explore in much greater detail.

Dr Karmy: 10:44

So obviously occipital neuralgia exist, but are not very common, whereas chronic daily headaches is much more common. So, what you are saying is the novelty wasn't so much that, uh, Peter Rothbart was first physician to ever do occipital nerve block for a headache. There was precedent for that, but what was new is the fact that he tried to apply a treatment that was used for a very rare type of headache to a much more common type of headache. And of course, nowadays, there is actually a great deal of literature of using occipital nerve blocks for a number of headaches, including cluster headaches, including migraine headaches, and of course, chronic daily headaches, but it sounds like at that point, the only headaches that occipital blocks were used for was occipital neuralgia. So he broadened the application of this particular treatment.

Dr Howard Jacobs: 11:50

Right. it was based on the understanding that there was a connection between you know, what was going on in the neck region and headache which leads us to the next stage. It started off by looking at the occipital nerve as an entry point into the central nervous system, but then Peter noticed that the patients, he was seeing that there was an entity that seemed to be coming from the neck, and that was causing, headaches. Now, at that time, this was very significant. Again, Peter did not invent this concept, but it was extremely controversial. They knew people when they had neck pain, they would have headaches, but no one made the connection from a pathophysiological perspective. They said, and as people know historically, that it was all a muscle pain and the muscles sent an impulse to the muscle of the head. And the muscles became in spasm, and that's what the reason there was headaches. You may remember that the ads on TV that showed tension type headaches and they would show these diagrams of the neck with the muscles going into spasm and the pain going up into the head. And that's how they sold their drugs their Tylenols and their Advils. So Peter explored this. And at the time there was a European group that were also exploring it as well. One of the leaders in that area was a physician called Shastet. And Peter looked into the literature and saw that in Norway, they were dealing with this type of headache and there was a coining of a term called cervicogenic headache. So again, Peter was innovative in that he pursued this whole area with great vigor in order to understand what the connection was between the neck pain and headaches. And that is where he became very innovative and became very controversial. Now, the reason why it was controversial was because in Canada, the concept of a headache that was coming from the neck wasn't accepted. And there were many Professors who were very against the idea that a headache could be coming directly from the deeper structures of the neck. So when I joined Peter, this was the beginning of the whole concept, at least in Canada, of cervicogenic headaches, which became, the most controversial area of what we did in chronic pain management in Ontario at that time.

Dr Karmy: 14:36

I guess, uh, well, so two, two comments. One is cervicogenic headaches are now well established and in classifications of headaches that neurological societies put out, it's right in there. Second of all, it's one thing to, know or accept that the headache could be coming from the neck. Another is to actually try to do something about it. The question is, and I dont know to what extent I should go into details, but, I suppose occipital neuropathy means that the occipital nerve is damaged in some way, or maybe compressed. Cervicogenic headaches means that it's coming from structures in the neck. And of course there's multiple structures. There's many different muscles in the neck. There's facet joints in the neck. So was the concept of cervicogenic headache, did it imply that the pain is coming from the facet joints? Was it just a more broad idea? And were other places like Norway treating neck with injections in order to treat cervicogenic headaches?

Dr Howard Jacobs: 15:56

The concept of the cervicogenic headache was discussed by Peter with Dr. Gawel. They knew the literature in Europe had already published a number of papers on this concept. But it became very difficult for the acceptance of it in Ontario, and the main thrust of Peter's career and myself, I became part of this whole field was to get the acceptance of the fact that the structures of the neck could be a source of pain as distinct from just muscle causing, pain because of spasm, which was proven later not to be actually accurate. And the field started to expand with Peter advocating for the acceptance of cervicogenic headache as an accepted actual entity. Now, if we go back a little, the other big player in the cervicogenic field it was, a physician in, New South Wales called, Bogduk and Dr. Bogduk was an anatomist. What I'm trying to paint for you is a lot of the research was there for now on a very basic level. But the acceptance of the community for this idea of a new entity was extremely controversial. Peter was the fish that caught the hook and he wants to explore further. So as part of the literature that was done on it, on pain in the neck, or at least pathophysiological problems related to the neck, was this Professor Bogduk. And he was , one of the main researchers in developing and exploring the anatomy of the neck. And not to complicate things, bottom line was he found connections between the nerve supplies of the joints of the neck and the structures of the neck that communicated with deeper structures and deeper connections in the spinal cord that relayed impulses to the brain, and caused headache. Let's put it simply, and this made a lot of sense because he was an anatomist. He was not a physician. That was the first in the world to actually decipher the nerve supply in great detail to prove that there were direct connections between the structures of the neck. But his interest was, what causes pain in the neck? And in order for you to have pain, you have to have a nerve that relieves the pain. Otherwise, no pain, no nerve. That's the way it works. So he wants it to understand the structures of the neck, what is their nerve supply? And when he tracked it, he found out that there was a very marked connection between the pathology in the neck and the development of headaches. Now as this was going on from the anatomical perspective, Shastead in Norway was taking this literature and applying it clinically to patients who have certain types of headache, and he came up with very strict criteria of cervicogenic headaches. To keep the story going, Peter was also doing the clinical work here in Canada, starting to go from the occipital nerve and to go into a deeper structures. He was the first to do them. So just to complete this part of the story, he decided with his experience as an anesthesiologist, that he would try to inject structures of the neck to the areas where the pain had been shown by Bogduk to maybe have originated from to see whether this would affect headaches in general. He started to inject the neck, not the muscles, very important point. He did very deep injections into the structures of the neck to see what the response would be.

Dr Karmy: 19:56

Uh, my understanding is Dr. Bogduk he was one of the most important scientists to show that facet joints, which are the joints of the spine, are important source of pain in multiple conditions, including whiplash injury. He's a PhD. He is a very famous scientist. In terms of injections so you have the muscles and then deep to the muscles, you have the facet joints that Dr. Bogduk was researching. At that point because one couldn't prove that the medicine actually went to facet joints, even though most of it probably went to the facet joints and the nerves that supplied the facet joints, the injections were not called Facet joint injections. I think they use the broader term called paravertebral injections recognizing that the medicine in addition to facet joints might go to, other surrounding structures, including a little bit into the muscle. Facet joint injections was I think reserved for x ray guided injections that provided more specificity, but for all intensive purposes, the majority of the medication injected ended up treating the facet joint pain. Am I wrong?

Dr Howard Jacobs: 21:34

What he showed was that the facet joint, which is what he studied first, and then later they studied other sources of pain in the neck. His studies were first to try and track the anatomy of the nerves that supplied those joints, and there were very specific nerves that supplied those joints. Again, we don't have to get too technical, but the joints ended up having very specific nerves and they were branches of the central nervous system that came off from the spinal cord. And he was able to track the actual nerve supply to those joints. So once he was able to track that. And he was able to prove it by doing certain, testing on patients who had neck pain, and he was able to show that these were the nerves that were the nerve supply, to the joints. Now there were other nerves as well. At the beginning, he found that there was a specific nerves, but there were other what are called nociceptors. There were other nerves that also relayed pain. So whenever there was any inflammation in the joint itself, there was a possibility that not only the nerves that he studied, but they fanned later. Or other nerves that would cause pain. The point of the whole thing was that he was able to show that the joints themselves had a nerve supply that was causing the patient to have headaches. And he could connect the dots from where the nerve went from that joint into the central nervous system up through the spinal cord and hitting a relay station in the spinal cord, and then going to the brain. And that was the breakthrough area that he had studied. What Peter did, after looking at what they were doing in Norway, he explored this connection in, from a clinical perspective, and he utilized it in order to treat this entity that was, known in Europe as cervicogenic headache, and was, again, as I said, extremely controversial in, in Canada. The question is, of course, why was it so controversial? Why was it not accepted? Not just an acceptance of this clinical entity, it had the hallmarks of the of any good analysis of a disease. There was a nerve supply, there was a structure, there was a connection. It was all very clear from the point of view of anatomical and physiology that would be acceptable. And, I could mention names of very famous neurologists, but I won't, who scoffed at it at the beginning. These were university professors who absolutely tried to destroy the whole area in Ontario. It would have been stuck back 30 years, if it wasn't for Peter, and may I say also myself, that pursued this vigorously against great opposition from the powers that be. I remember that there was no OMA section of pain. There was no college acceptance. So the battles were incredibly difficult because of the college, because of the government, because of the so called experts who all or completely against even the concept.

Dr Karmy: 24:58

So just for my own information, uh when I treat patients with chronic pain have headaches and typically neck pain as well one of the blocks I will do is accessory nerve block, which is a cranial nerve block. It does relax some muscles of the neck. I assume that helps with some of the neck pain. Is there any anatomical evidence that it can also help with headaches or it's a purely there to treat the neck?

Dr Howard Jacobs: 25:32

If you track the accessory nerve it actually passes down into the area that I've intentionally made very simple, but since you go there there is what an area in the brain where the whole relay system is, which brings in another world famous neurologist called Peter Goldsby. So if you look at the literature of everyone I've spoken about, these are the godfathers And of course, Jacobs, because I was doing the clinical treatments. And what they contributed, and I'll get back to your question as part of this, they contributed to this whole area by understanding how pain of the head comes about. So Bogduk worked on the periphery, Goldsby worked on the on the central nervous system and Shastak worked on the clinical. What came about was that the connections from the outside going into the central nervous system through the cervical spinal cord. There's an area called the spinal caudal area, an area that relays pain from anywhere in the head and neck. Even from the muscles, that relays into the spinal cord, and this relay box then sends the signals. So any tracking of an anaesthetic, that can be shown to track into the the spinal cord that passes through this relay box will affect change in the perception and the development of headache. So when the injection for the spine was done through the cervical spine which is the heart bone of the cervical, of the neck structures. It was shown that the anesthetic would not only affect the nerves that were there, but it was shown that the actual anesthetic tracks down to that relay box. So to answer your question, there is connections between the spinal accessory nerve and this relay box in order to affect change in headaches. So its an added advantage that it will reduce down maybe some muscle spasm, but there is a direct way in which you can get effect change at the central nervous system by the fact that the anesthetic will track down as well. So it's quite complicated. It can make changes to the headache as well as stopping the spasm, but the spasm doesn't have to be there. The actual anatomical structure it's called the nucleus caudalis and it's divided into thirds and whatever system is affected by the anesthetic will have connections to different parts of the brain. So that was a very important area that all the action was taking place. And that's what I believe a lot of people had, no understanding of how these nerve blocks actually worked.

Dr Karmy: 28:30

So this is a structure actually I was not familiar with. Is the structure located in the brainstem or in the upper cervical spinal cord?

Dr Howard Jacobs: 28:43

Its at the level of the upper cervical spine, around the C, C2, 2, 3, and 4. goes into directly into the nucleus and four, five, six, there are some connections that go through. So it all relays through the this structure called the nucleus caudalis. So once you realize that there is a relay box that goes through, that all the structures enter through that area, It can give you a lot of reasons and explanation of this whole concept of cervicogenic headaches. And that was Bogduk's contribution, but especially Goldsby. He had studied this in cats and later had applied it to clinical medicine. But this was the big discovery. And what Peter did Peter studied this in great detail and applied it clinically and started getting results that were unbelievable, which is why he started getting known because every urologist started sending him patients that they could not treat and he would inject. And they would get better. Now again, as I said the academia's were completely against this. When you look at where we are today, and as you said, cervicogenic headaches is an accepted entity in the literature, it's written in the chronic pain books, and yet, there was a big opportunity for everyone to work together on this in Ontario, and they wouldn't do it.

Dr Karmy: 30:13

So let's go back then. Dr. Rothbart was collaborating with the neurologist, Dr. Gawel. There was somebody of research to support the work. But, and he started in a hospital has Scarborough Hospital, it sounds so what happened after? How did he end up in his own clinic?

Dr Howard Jacobs: 30:37

No, he decided that because he couldn't get the support in the hospital to do what he wanted to do. And he was finding it extremely difficult to get time to do what he wants to do. And his interest reverted from anesthesia to this area of pain management. Chronic pain management went a long way from the headache. It started as headache management and then it progressed to the whole concept of chronic pain management. Before that, there was very little available for chronic pain in Ontario. There was a few hospitals that were at the odd pinnacle. It wasn't an established deal. So , most fellows also after the illusion or disillusion that the the pain management had to be done by an anesthesiologist only. And, someone like myself who was from primary care, had no place in that area. What was I doing there? And that's the story in itself. But that's what was Jacobs doing there? The only family doctor. I was the first and only family doctor that was ever, that ever gave an injection into the neck in Ontario. The bottom line was I was his first protege of doing this as a primary care. That's why he left and he opened his own clinic and he brought in with him a number of anesthesiologists and he worked with a physiatrist and they decided to open probably the first interventional community pain clinic. I could be wrong. I don't know of any others though at that time. And that's how he started. And because he was able to do his own thing, he was able to, do some research on his own. He started to do studies. He started to discuss what he was doing with other neurologists and academia. It was very interesting because when I joined the clinic my background was internal medicine back in, in Ireland and I did family practice as well. I'd always had a very deep interest in headaches when I was doing my internal medicine. So when I joined him I worked with him for a number of years and we were visited by a group of academicians from Toronto U of T. How it came about was, I had spoken to an anaesthetist who was asking me what I was doing nerve blocks. And he found what I was doing very interesting. So he asked me, can I come and see what you guys do? So when we came they visited, three professors came to the clinic. They spent the whole day at the clinic and they met with the patients. And they became fascinated by what we were doing. This was the first leakage of interest by academics in Toronto. So I eventually went and lectured to the Faculty of Anesthesia and the Faculty of Neurology at U of T. And they asked me to actually start a headache clinic at U of T. So that was quite a jump from the earlier in my career. I ended up not doing it. I wanted to stay in private. I didn't want to go to academics and the reason why I'm telling you the story is that was the first interest that they realized that there was something here that was something of worth. And I gave them the literature, and just because they had ignored it before and didn't take the time to explore this, which you would imagine academics who are dealing with chronic head pain might have known about all this. I was amazed at the time because I thought, what am I going to tell these guys? And again, about caudalis and about the central nervous system and about psychopathy of joints. They knew nothing about it. So they had decided that it wasn't real, but when they did their research, and then they came to the clinic, and then they met with me, and I spoke with them, they changed their tune. But it still wasn't accepted by a number of well known top neurologists in the city, and they became very obstructive to this whole idea, which is why I'm sure you wanted to get to this eventually, why the college eventually intervened and as they say, things went downhill very rapidly.

Dr Karmy: 34:55

What strikes me about this interview so far is how accidental it all seems. One doctor with expertise in headaches talks to a different doctor with expertise of doing anesthetic procedures, and they develop a new treatment for specific types of headaches. Then the doctor with expertise in procedures, is forced to move out to the hospital and start his own clinic. Once he has his own clinic, he needs to train additional physicians to assist him because of expenses of running the clinic and his inability to provide service to all the patients who want to see him. This in turn leads to some of these newly trained physicians, doing things to promote this new form of treatment, which in turn leads to more physicians wanting to be trained in this field. Some of these physicians then went out and started brand new chronic pain clinics throughout Ontario. And this is how it happened. Join me next time for the second part of my conversation with Dr. Jacobs, where we find out what happened to the field in the past 20 years. Thank you.