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Managing Pain Spring 2013

New mild® Procedure for Lumbar Spinal Stenosis

As we age, we begin to understand just how important it is to take good care of our bodies. One area that often degenerates is our spines, which can lead to lumbar spinal stenosis (LSS). This medical condition happens when the spinal canal narrows and compresses the spinal cord and the nerves of the lumbar vertebra. These five large vertebrae between the ribs and the pelvis permit movement and serve as the primary support for the weight of our bodies.

Thankfully, doctors have developed a minimally invasive treatment for lumbar spinal stenosis that lessens the pain. Cleveland Clinic’s Department of Pain Management offers this minimally invasive outpatient treatment for moderate-to-severe lumbar spinal stenosis. It is called the mild® procedure for minimally invasive lumbar decompression.

“This state-of-the-art technique decreases pain and increases mobility while maintaining the stability of the spine,” explains Nagy Mekhail, MD, PhD, of Cleveland Clinic's Department of Pain Management and leader of the mild® program.

More on LSS

LSS is a painful condition that can greatly affect patients’ quality of life, Dr. Mekhail says. It causes low back or leg pain and limits a person’s ability to stand and walk. This is because when the patient stands or walks, the spinal canal narrows even more. Patients who have moderate-to-severe LSS often cannot stand longer than 5 minutes or walk farther than 300 feet. The average age of patients seeking treatment for LSS is 73, and it is diagnosed by magnetic resonance imaging (MRI).

Many patients who undergo the procedure are able to get back to activities such as grocery shopping or golf, Dr. Mekhail says—and it’s not uncommon for them to progress to walking at least a mile without having to stop.

Treatment options

Nonsurgical treatment for LSS includes nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and/or epidural injections to relieve inflammation and swelling. However, these treatments are effective only in a small percentage of patients, and if they do work, the effect is not always sustained.

Some patients who have LSS can benefit from open spine surgery in which part of the spine is removed to relieve some of the pressure in the spinal canal. Not all patients are candidates for open spine surgery, especially older patients with other conditions. Patients who have not responded to these treatments and those who are not candidates for open spine surgery could potentially benefit from mild®.

The procedure

The mild® procedure is performed under deep sedation through a 1-centimeter incision, says Dr. Mekhail, who has been performing the surgery for three years. The clinician uses a small tool to go into the bone to remove ligament tissue and widen the spinal canal to decrease the nerve compression.

Patients typically recover quickly and have no complications. They are able to walk within 24 hours and are encouraged to walk regularly and/or participate in physical therapy. After a few years of performing this procedure, Dr. Mekhail and colleagues have found that patients report a significant reduction in pain in the long-term following the procedure.

With more than 10,000 Baby Boomers turning 65 years old every day, Dr. Mekhail says that more patients are seeking innovative treatments such as mild that will allow them to stay active and maintain their quality of life. And the good news is that Medicare began covering mild in July 2012.

Dr. Mekhail sees patients at main campus for a variety of pain management conditions. To make an appointment with Dr. Mekhail, call 216.444.PAIN (7246).

Olympic Athlete’s Pain Is Conquered with mild® Procedure

For Olympic athlete Nagui Asaad Youssef, a newer less invasive spine surgery gave him back his life. He had been dealing with the progressive pain of lumbar spinal stenosis (LSS) since the year 2000, and began having debilitating back pain in 2008.

Mr. Youssef, 67, is a former international-level track and field athlete from Egypt who today serves as a professional coach for the national Egyptian track and field teams. A few years ago, he was having more pain management procedures, including epidural injections, physical therapy and massage, to try to manage the progressing pain. But as his condition worsened, these treatments began to diminish in their therapeutic relief.

“The pain created limitations in my coaching role as well as my time with my wife and grandchildren,” he says. “I would say I was in agonizing pain for the last 18 months before I had the spine procedure.”

When Youssef learned about minimally invasive lumbar decompression – known as the mild® procedure – at Cleveland Clinic, he traveled from Egypt to the United States to visit his daughter and have his case assessed by Nagy Mekhail, MD, PhD.

Using the mild® procedure, Dr. Mekhail makes a small incision and uses a tool to go into the bone to remove ligament tissue and widen the spinal canal and decrease the nerve compression. Mr. Youssef was especially surprised to learn that mild is an outpatient surgery and does not require any post-operative physical therapy.

By the time Mr. Youssef came to Cleveland Clinic for surgery in 2009, his walking was limited and he had to sit after just 5 minutes of standing. For an athlete and active person, these symptoms were discouraging to say the least. On the day of the surgery, he arrived at Cleveland Clinic at 7 a.m. to have the mild procedure performed by Dr. Mekhail, and he was discharged at noon that same day.

“I was so thrilled waking up in the post-operative recovery unit because I was able to move my legs,” he says. “And within a few days of the surgery I was able to walk for four miles without any pain.”

Now, he is back to his active role with family and his coaching responsibilities, and he is able to play with his grandchildren and grocery shop with his wife.

Says Mr. Youssef, “I feel that my life clock has been rewound to before the year 2000 when the pain started.”

The Many Options for Managing Back Pain

When oral pain medications or physical therapy fail to help patients with back pain—or when there are ongoing signs of weakness—seeking further evaluation from a pain specialist is the best course of action. There are many treatment options to consider, says Shrif Costandi, MD, of Cleveland Clinic’s Pain Management Department.

“My colleagues and I base treatments and therapy on the underlying cause of your back pain,” explains Dr. Costandi. Here is rundown of common back pain causes and the interventions that can be done to manage the pain:

  • Lower back pain is often caused by degeneration of the posterior facet joints. Usually a diagnostic nerve block is done to confirm the diagnosis. If this is the cause of your pain, pain specialists will often do a radiofrequency ablation (RFA) of the nerves for long-term relief. This is removal of the nerves causing the pain using alternating electric currents. The average duration of relief from RFA is six to nine months.
  • When the nerve roots in the spine are being compressed or irritated by herniated or bulging discs (radiculopathy), this can lead to back pain shooting down the leg, along with weakness and/or numbness. If there is no improvement with oral medications, epidural steroid injections can be considered to alleviate pain, facilitate physical therapy and early return to work.
  • Pain emanating from the sacroiliac (SI) joint – the joint between the spine and hip bones- can be managed by joint steroid injections and physical therapy to strengthen core muscles. If these injections provide relief but the effect is temporary, RFA may be used.
  • Disrupted discs – or discogenic pain -- can be managed with two newer treatments. Biacuplasty is a minimally invasive procedure that applies radiofrequency heat through probes to destroy painful nerve fibers of the disc. The second option is “fibrin sealant” injections. These treatments can improve disc stability and encourage tissue repair.
  • For persistent pain after spine surgery, called postlaminectomy syndrome, epidural steroid injections are the first line of therapy after failing to respond to oral medications. These are usually done in combination with physical therapy and medical management. If these provide temporary or insufficient relief, permanent implantation of a spinal cord stimulator may be considered.
  • For spinal stenosis, oral medications are tried first, if there is no improvement then interventions are warranted. The first option is epidural steroid injections along with physical therapy. Decompression surgery also has traditionally been considered. Today a newer outpatient procedure called mild® (minimally invasive lumbar decompression) is available (see the story on the mild procedure in this issue). Cleveland Clinic studies have shown great improvements in standing time and walking distance for patients who have had the mild procedure.
  • For intractable back pain, certain pain medications can be infused around the spinal cord through an implanted programmed pump to provide adequate relief of the pain. Typically, this is done as a last resort.

In some cases, pain can be coming from a malignancy. A pain specialist can help to rule this out or help to manage it effectively with other treatments.

A Multidisciplinary Approach

Having different options to manage pain is key to successfully helping patients, Dr. Costandi believes. And so is collaboration among providers.

“We refer patients to physical therapy to supplement most medical interventions,” says Dr. Costandi. “Our patients also are seen by a pain psychologist for behavioral modification or stress-coping techniques. A multidisciplinary approach really is the best way to deal with pain.”

Dr. Costandi sees patients at Cleveland Clinic’s main campus and the Richard E. Jacobs Health Center in Avon. To make an appointment with Dr. Costandi, call 216.444.PAIN (7246).

The Down Side of Painkillers

Opioids aren’t for everyone. In fact, they’re often reserved for patients with severe pain from terminal cancer.

“We prescribe opioids only when other treatments and pain medications don’t work,” says Benjamin Abraham, MD, of Cleveland Clinic’s Department of Pain Management. “Because of the challenges that can come with using opioids, patients who take them require careful monitoring and regular follow-ups.”

One of the biggest challenges is risk of abuse. Opioids are highly addictive. In the past decade, the number of deaths from painkillers, including opioids, has quadrupled to nearly 15,000 per year in the United States.

But even when used as prescribed, opioids can cause unwelcome side effects including:

Constipation. Constipation is the most common side effect of opioids, affecting up to 90 percent of patients, according to one study. It can set in almost immediately, after only a day or two of opioid use. Complications can range from uncomfortable hemorrhoids to life-threatening bowel obstruction. That’s why most patients on opioids are advised to take stool softeners, laxatives or both.

Hormone imbalance. Opioid use often causes low levels of testosterone or estrogen, the male and female sex hormones. People may experience erectile dysfunction, reduced libido, fatigue, hot flashes, menstrual irregularities, low energy, weight gain and depression. And hormone imbalance can lead to more serious complications, such as infertility and osteoporosis.

The best resolution is to stop taking opioids. Another option is hormone replacement therapy, although estrogen replacement in women sometimes brings other medical concerns.

Worsened pain. It may seem ironic, but opioids can actually intensify pain in some people — sometimes within minutes of taking the drug. The reasons aren’t clear. People with this side effect are either transitioned to a different drug or weaned off opioids altogether.

Weakened immune system. Your body’s ability to fight off infection weakens immediately upon taking opioids, even if you don’t get sick for months later. With no tried-and-true way to boost immune function, the best way to manage this side effect is to stop taking opioids.

Depression. Studies show that about 10 percent of patients using opioids develop some kind of depression. If discontinuing opioids isn’t preferred, antidepressants may help.

“These side effects are not limited to people who abuse opioids or have been taking opioids long-term,” says Dr. Abraham. “They can occur in anybody — even patients who just started an opioid regimen.”

That’s why opioids should be used cautiously and only as a last resort.

“For those struggling with chronic pain, pain management specialists can offer an array of other treatment options with fewer if any side effects,” says Dr. Abraham.

Dr. Abraham sees patients at Marymount Hospital and Elyria Family Health Center. To make an appointment with Dr. Abraham, call 216.444.PAIN (7246).

Interventions Help Headache Sufferers

If you suffer from headaches, you are not alone. More than 40 million Americans endure chronic, recurring headaches, according to the National Headache Foundation. Migraine, the most common type of headache, affects 29 million Americans.

Thankfully, there are effective contemporary interventions to address migraines and the many types of headache pain people experience. Sumit Katyal, MD, of Cleveland Clinic’s Department of Pain Management is dual certified in pain medicine and headache medicine. He performs a variety of procedures designed to alleviate and manage chronic headache pain for the long-term.

“There are a number of procedures we can perform to give patients long-term relief from pain that they may have suffered with for years,” says Dr. Katyal. “We provide comprehensive pain management, which may include both interventional treatments and medication management.”

Procedures include specialized nerve blocks, medication injections, epidural blood patches and stimulation therapy depending upon the source and type of headache. These highly sensitive procedures, done near the nerves causing the pain, can alleviate headaches in some patients for six months or more.

“For the most part, these interventions are not very painful and require minimal sedation,” says Dr. Katyal. “But it’s important that the procedure be completed by a pain management specialist who has the appropriate training to minimize risks during these procedures.”

In some instances, Dr. Katyal will do blocks in conjunction with radiofrequency ablation (RFA). RFA uses an electric current to heat up a needle and create a targeted lesion on the nerve to help block the sensation of pain. In some cases, a couple of diagnostic block procedures are performed to assure that the headache pain is relieved. If they are found to have a beneficial effect, then RFA will be done for longer lasting relief.

Botox® injections are another procedure that can be done to alleviate pain. In 2010, the FDA approved Botox for treatment of migraine headaches. This involves Botox injections in different areas including the head and neck as needed. Pain relief typically will last 3-4 months after a treatment and the procedure can be done 3 to four times a year.

Dr. Katyal often works in collaboration with neurological specialists from Cleveland Clinic’s Neurological Center for Pain, including Stewart Tepper, MD, who also does Botox treatments. Dr. Tepper will sometimes refer patients to Dr.Katyal for interventional procedures done for other types of headaches.

“I may, for example, have a patient who presents with a continuous one-sided headache which could be caused by one of three conditions,” says Dr. Tepper. “I will refer that patient to Dr. Katyal for a procedure. If a certain nerve block is effective, this will help us pinpoint the exact cause of the pain. The way in which a patient responds tells us a lot about the type of headache we are dealing with.”

Cleveland Clinic has a deep and rich team of specialists and programs to help people suffering with headache pain. It is a true multidisciplinary approach to helping patients who suffer from chronic headache pain.

Says Dr. Katyal, “Our teams from Pain Management and Neurology are focused on setting patients on the right course of treatment for their headache pain so they can have the best quality of life.”

Dr. Katyal sees patients at the main campus.To make an appointment with Dr. Katyal call 216.444. PAIN (7246).