Cleveland_Clinic_Host: Welcome to our Online Health Chat with Daniel Mazanec, MD.
Daniel Mazanec, MD is the Associate Director for the Cleveland Clinic Center for Spine Health and Co-Director for the Spine Medicine Fellowship Program. In addition, he is also a staff member in the Department of General Internal Medicine and the Department of Rheumatic and Immunologic Disease at Cleveland Clinic. Board-certified in Internal Medicine with a subspecialty in rheumatology, Dr. Mazanec's clinical interests include evaluation and management of back pain, osteoporosis and bone disease, acupuncture and adult rheumatology.
During the next hour, Dr. Mazanec will answer your questions about the medical management of back pain. Dr. Mazanec, thank you for joining us today to answer questions. A lot of information has been shared and we hope that it will increase awareness of the options for managing back pain. Let’s begin with some general information about back pain.
Causes of Back Pain
adv57558_2: My lower back pain is worst upon arising from bed or from a chair.
Speaker_-_Dr__Daniel_Mazanec: There are many reasons for back pain. Pain on changing position whether arising from a bed or a chair is commonly termed Mechanical Back Pain. Mechanical back pain is normally a result of change in spinal joints and discs, sometimes called arthritis.
bobbieman: How do you determine whether your pain is back pain or actually a bad hip?
Speaker_-_Dr__Daniel_Mazanec: The symptoms of hip arthritis can superficially resemble spinal pain or sciatica. Hip joint pain is typically felt in the buttock, groin or even in the front of the thigh descending to the knee. A careful physical examination by your physician can usually distinguish hip arthritis from a spinal cause. A plain X-ray of the hip is usually performed to confirm the presence of arthritis. In some persons with both spine and hip disease, a X-ray guided hip injection is helpful to pinpoint the primary source of the pain.
davidm: What can one do to relax back muscle spasms after a fall?
Speaker_-_Dr__Daniel_Mazanec: Muscle spasm may be alleviated with thermal modalities such as a heating pad or hot pad applied to the area of discomfort. Heat should be applied for 20-30 minutes several times during the day. Massage may also be helpful in reducing muscle spasm. Prescription muscle relaxants may be of help particularly shortly after the injury. The most common side effect of muscle relaxants is sedation. In resistant muscle spasm, local injection (trigger point injection) of the area may be of benefit as well.
tabboo: My posture distresses me, but it is painful to straighten, even for a few minutes. For several years, I’ve exercised 20-25 minutes every day, plus some walking. Any hope?
Speaker_-_Dr__Daniel_Mazanec: First of all, you need an evaluation to determine the cause of your postural difficulty. Sometimes postural abnormalities are related to primarily muscular or ligamentous abnormalities which are often greatly improved with an active back exercise program, usually developed by a physical therapist. Alternatively, some postural difficulties are due to an underlying curvature in the spine (“kyphosis”).
doglover: Please discuss the sciatic nerve problems and treatment there of medication?
Speaker_-_Dr__Daniel_Mazanec: Sciatica refers to leg pain which in many cases is due to irritation or pinching of a nerve of the lower spine. Most persons with sciatica recover well with medical, non-surgical treatment. Medical treatment includes a carefully supervised physical therapy exercise program. Medications are also helpful in relieving pain and inflammation. Sometimes, for severe pain, an epidural injection may be performed. Other modalities including acupuncture and manipulation are sometimes of benefit. If symptoms persist despite aggressive medical treatment, surgical consultation and treatment may be required.
pantond: What causes compression fractures?
Speaker_-_Dr__Daniel_Mazanec: Compression fractures may be traumatic or nontraumatic. Traumatic compression fractures may occur after injury or falls even in persons with healthy bone. More commonly fractures are nontraumatic and occur because of structural weakness in the bones of the spine (vertebra) due to bone loss (osteoporosis). This disease weakens the structural integrity of the vertebra to the point that they may not even support the body weight against gravity resulting in a collapse or fracture of the bone.
zarkon: My diagnosis is Spondylothesis and I have been seen by neurology and spine clinic doctors. I am still in constant pain, getting progressively worse in the past few months. Taking Neurontin and Ultram, PT, acupuncture.. Old fx L5-S1 detected on MRI. Cannot sleep or function. Please advise.
Speaker_-_Dr__Daniel_Mazanec: Spondylolithesis is a term describing a forward slip or movement of one vertebrae on the one beneath it. It may produce back or leg pain when symptomatic. If your pain has not responded to the full spectrum of non-surgical options and is severely affecting your daily activities, you may consider a consultation to a spine surgeon for surgical stabilization of the symptomatic slip or segments.
Treatment of Back Pain: Medications
abc123abc: What is the alternative to the medications Celebrex, Vioxx and Bextra? What’s the solution?
Speaker_-_Dr__Daniel_Mazanec: For many persons with back or leg pain, a simple pain reliever or analgesic can produce significant improvement. Simple analgesics include Acetaminophen (Tylenol) as well as prescription drugs. Unlike Celebrex which is an anti-inflammatory and analgesic, pure analgesics are less likely to produce GI problems, kidney impairment or cardiovascular side effects.
kat12671: There are so many medications for Osteoporosis; what is best for a woman 81 years old with least side effects?
Speaker_-_Dr__Daniel_Mazanec: Treatment of osteoporosis begins with ensuring that you are ingesting adequate amounts of calcium and Vitamin D. For most individuals, at least 1500mg of calcium is necessary daily to maintain balance. Many Americans are deficient in Vitamin D and supplementation is required. For most individuals, this means a minimum of 800 units daily.
The most common medication recommended for persons with Osteoporosis is a diphosphonate (Fosamax, Actonel, Boniva, Reclast). These drugs have been shown to slow the progression of bone loss and reduce the risk of spinal and hip fracture. Some individuals may experience heartburn or swallowing symptoms with these drugs. Alternative medications include Evista and Calcitonin. For a few persons with severe osteoporosis who continue to have fractures despite adequate treatment, Forteo may be recommended.
xanadu: With the elimination of the major arthritic meds off the market, what do you recommend now as an effective anti-inflammatory?
Speaker_-_Dr__Daniel_Mazanec: Although several so called NSAIDs have been removed from the market by the FDA because of potential cardiovascular side effects, a number of older and effective anti-inflammatory drugs remain available. For younger persons without any history of stomach ulcers, older medications such as Naproxen, Ibuprofen and others are effective and safe. In older persons at greater risk for side effects particularly cardiovascular, careful use of older medications with a more frequent monitoring is a reasonable approach.
In some persons at higher risk for side effects, a better choice is a pure pain reliever or analgesic (Tylenol.) Many persons with arthritic spinal or joint pain are taking Glucosamine with or without Chondroitin. This combination may provide pain relief in up to 50% of persons taking sufficient amounts (1500 mg Glucosamine daily). Unfortunately, there is little evidence that Glucosamine/Chondroitin actually slows progression of arthritis.
hardtoreach: Can you discuss acupuncture for low back and leg pain? I have spinal stenosis in upper back, legs are numb and my balance is off. Would acupuncture help?
Speaker_-_Dr__Daniel_Mazanec: Medical acupuncture can provide effective pain relief for a wide range of spinal problems, including back, neck and leg pain. Medical acupuncture incorporates a blend of traditional Chinese medicine with other acupuncture-like Western adaptations of needling techniques.
Acupuncture includes body acupuncture, ear acupuncture as well as scalp acupuncture. In most persons it should be combined with other facets of treatment particularly physical therapy.
hardheaded: Are epidural blocks dangerous? Do epidurals make your bones brittle?
Speaker_-_Dr__Daniel_Mazanec: Epidural injections or blocks are procedures in which medication, usually cortisone and a local anesthetic, are injected into the spinal canal. Epidural blocks can provide temporary relief of sciatic (leg) pain.
The side effects or complications of epidural injections are rare and may include infection and possible temporary leakage of spinal fluid. Because epidural injections contain cortisone, they are limited to no more than 3-4 injections in approximately 9 months time. Too frequent injections can lead to excessive amounts of cortisone which can promote osteoporosis or bone loss.
auntmoie: I recently underwent a cervical laminectomy and am still experiencing numbness in my hands. Now they want me to have a lumbar laminectomy. Is there an alternative to another surgery?
Speaker_-_Dr__Daniel_Mazanec: A lumbar laminectomy would not be helpful in alleviating hand symptoms. If the primary most bothersome symptom is numbness in the hands and you have sufficiently recovered from the cervical surgery, a trial of non-surgical treatment may be of benefit. This would include a carefully supervised physical therapy program as well as prescription of medications which help reduce nerve (numbness) discomfort.
cantonman: What is going on with artificial discs?
Speaker_-_Dr__Daniel_Mazanec: Artificial discs are now available (FDA approved) for the lower (lumbar) spine and in development (experimental) for the neck (cervical). Studies to date suggest that in carefully selected patients, artificial disc replacement in the lower spine is about as effective as lumbar fusion in relieving back pain.
As with any new treatment, there are many unknowns including the durability of the discs, whether the artificial discs really preserve movement that reduces wear and tear on adjacent disc, and really who are the best candidates for disc replacement.
Exercise and Back Pain
adv57558: Are there exercises that will help? I use Cybex machines at the gym.
Speaker_-_Dr__Daniel_Mazanec: Exercise for mechanical back pain is an important part of treatment. An exercise program is best customized in a few visits with a trained physical therapist. The key components of such an exercise program would include stretching as well as strengthening of the core muscles which stabilize the painful segments of the spine.
weekendwarrior: How soon after a muscle strain or spinal sprain can one begin exercising?
Speaker_-_Dr__Daniel_Mazanec: After a back strain such as described, maintaining activity is important to prompt recovery. For the first few days after the injury, this means moving about and going about one's daily activities as tolerated. As pain usually subsides in 1-2 weeks, gradual return to an exercise program is safe and may speed full recovery.
hardtoreach: Which exercise would benefit a spinal stenosis condition?
Speaker_-_Dr__Daniel_Mazanec: Spinal stenosis is a condition in which a diameter of the spinal canal is narrowed leading to pressure on the spinal nerves causing leg pain or numbness. For most persons with spinal stenosis exercises that emphasis forward bending or flexion enlarge the spinal canal diameter and may improve symptoms.
mariak126: Is it better to use the treadmill or bicycle for back pain?
Speaker_-_Dr__Daniel_Mazanec: Exercise for back pain should involve both aerobic activity as well as local stretching and strengthening of the core muscles. Lower impact activity is preferable such as treadmill or bicycling activity. With either activity, it is important to maintain proper posture. Any exercise program should be started gradually, ideally working up to 20-30 minutes 4-5 days weekly.
weekendwarrior: Do you think that weight or strength exercises are very valuable for back problems? What about walking?
Speaker_-_Dr__Daniel_Mazanec: Both strength training as well as aerobic exercise such as walking are an important component of a back program. When weight training, it is important that you support the back during the performance of the exercises. For example - performing bench presses supine on a bench provides support to the back.
On the other hand, one should avoid squats with weight on the shoulders. Walking is an excellent aerobic activity which is relatively low impact and improves overall fitness which has been shown to benefit persons with back pain.
weekendwarrior: With lower back pain, is playing tennis a sport too active to avoid?
Speaker_-_Dr__Daniel_Mazanec: If back pain significantly increases during the activity such as tennis, it probably should be evaluated prior to continuing playing on a regular basis. Many people with mechanical back pain however are able to enjoy playing tennis after an appropriate warm-up exercise routine. Sometimes taking Acetaminophen or Ibuprofen shortly before the tennis game will reduce the symptoms. Also, some individuals play doubles rather than singles to help reduce symptoms.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Mazanec is now over. Thank you again Dr. Mazanec, for taking the time to answer our questions today.
Speaker_-_Dr__Daniel_Mazanec: I've enjoyed the time. It has been my pleasure to address a number of very good questions on this important and very common topic.
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