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August Nunez: All the King’s Horses and All the Kings Men

Kim Patient Story“All the king’s horses and all the king’s men couldn’t put Humpty together again,” August Nuñez says, quoting the nursery rhyme. “But in my case they did.”

Nuñez is a beneficiary of the teamwork of neurosurgeon Daniel H. Kim, M.D., FACS, FAANS, and interventional pain management specialist Nadya Dhanani, M.D. Thanks to their specialized expertise and close working relationship, the 70-year-old is walking, touting the quality of care he received and going about his life pain free.

Nuñez first saw Dr. Kim in 2011 with severe lumbar stenosis and spinal disease – the result of aging and arthritis. “He had developed significant neurogenic claudication that caused right sciatic nerve pain. We were able to resolve the problem and provide relief with a simple decompressive laminectomy,” says Dr. Kim, who is director of reconstructive spine and peripheral nerve surgery at the Memorial Hermann Mischer Neuroscience Institute at the Texas Medical Center and professor of neurosurgery at McGovern Medical School at UTHealth. An expert in minimally invasive spinal surgery, Dr. Kim is a preeminent researcher in peripheral nerve repair through nerve transfer and nerve graft, and is also recognized for his work in neurorehabilitation through robotics and cortical stimulation, spinal biomechanics and innovative neuromodulation treatments for chronic pain.

After the decompression, Nuñez did well for about a year. When he developed new symptoms that included pain in the opposite leg, he underwent a second surgery at another institution. Three months later, he was back in Dr. Kim’s office with severely worsened leg pain and, after two spinal surgeries involving the removal of bone, instability in the affected lumbar vertebrae. In March 2012, Dr. Kim performed a revision spinal fusion and fixation using titanium hardware.

“There is no spine surgery that resolves everything and ensures the patient will never need another surgery,” Dr. Kim says. “No matter how good we are at spine surgery and how successful the procedure is, the result won’t last forever. Patients may get a few good years but as they continue to age, the problem continues to worsen. When pain recurs, it’s not uncommon for them to shop around for another spine surgeon. Often their next experience is negative. I’ve had over 20 years of experience performing spine surgeries in my career. I’ve heard the stories of many patients.”

“My pain felt like I was dragging a lead ball behind my back. Other doctors had tried to relieve it but nothing worked. I took all kinds of arthritis medicine and had two spinal injections that didn’t help. After seeing Dr. Dhanani, the pain went away. I may be Humpty Dumpty but I’ve been put back together again by some very good doctors.”"

— August Nuñez

A year and a half later, in December 2013, Nuñez came back to Dr. Kim when he developed recurrent low back pain. “August said he did really well after his last surgery but now suddenly had lower back pain again. We see this often, which is why we decided to build a comprehensive spine program.”

Dr. Kim recruited Dr. Nadya Dhanani from The University of Texas MD Anderson Cancer Center. Fellowship trained in pain medicine and specialized in interventional pain management, she focuses primarily on spine- and cancer related pain. When Nuñez returned after his third surgery, Dr. Kim referred him to Dr. Dhanani, who prescribed a bilateral medial nerve branch block.

“Patients may have flare-ups of pain but don’t need or won’t tolerate another spine surgery,” she says. “By injecting an anesthetic near the small  medial nerves that connect to specific facet joints, we can deaden the nerve endings to relieve pain. Typically we inject several levels of the spine in one procedure. A selective block of painful nerve endings around the spinal joints can eliminate back pain syndrome.”

The "Fifth Vital Sign"

In the last decade, pain management has assumed a more central role in medicine. Physicians and other healthcare providers are more aware of the effects of pain on the body; some refer to pain as the fifth vital sign as a result of the Veterans Health Administration’s 1999 initiative to focus the attention of medical professionals on the measurement and documentation in the electronic medical record of patients’ self-report of pain.

“Debilitating pain becomes the primary focus of those who live with it,” Dr. Dhanani says. “Because we know that pain affects mood, emotional state, the ability to be effective at work, relationships with people and response to treatment, we’re more aggressive about treating it.”

She describes pain medicine as part science and part intuition. “We observe best practices, but the treatment I deliver is also a little bit of me trying to figure out the source of the pain. Much of what we do is data driven, but to some extent pain medicine is an art, which is why research in pain medicine is so important. In the grand scheme of things, it’s a fairly new field. The potential to develop it further is what attracted me to pain medicine, but the down side is that we as clinicians know we have a lot more to learn.”

For his part, Nuñez is pleased with the result. “My pain felt like I was dragging a lead ball behind my back,” he says. “Other doctors had tried to relieve it but nothing worked. I took all kinds of arthritis medicine and had two spinal injections that didn’t help. After seeing Dr. Dhanani, the pain went away. I may be Humpty Dumpty but I’ve been put back together again by some very good doctors.”

Dr. Dhanani describes Nuñez as a very motivated patient. “He didn’t want to be on medication for a long period of time,” she says. “He wanted to remain active, doing what he enjoys. He was a little at the end of the rope when he came to me, and wasn’t convinced that any treatment would make a difference. Fortunately, we were able to help him, and I feel great about that.”