Online Health Chat with Daniel Leizman, MD and Santhosh Thomas, DO, MBA

September 17, 2013


Eighty to 90 percent of people in the United States will suffer from back pain at some time during their lives. Back pain is the second most common reason people visit their family doctors.

On any given day, almost two percent of the entire United States workforce is disabled by back pain. It is the cause of enormous healthcare expenses.

Many back disorders can be evaluated and treated successfully by a primary care doctor. However, for severe or persistent pain, evaluation by a medical spine or pain management specialist is recommended. Sometimes the source of back pain can be difficult to diagnose. It may be related to discs, joints or soft tissue support (including the muscles, ligaments and tendons) of the back. Many different conditions, including osteoporosis, fractured vertebrae, bulging and herniated discs, and compressed spinal nerves, can cause pain and may require surgery.

Warning signs that should prompt urgent medical evaluation include the presence of fever, worsening pain, progressive movement of the pain from the back into the leg, numbness in the area of the injury or down the leg, presence of a lump or area with an unusual shape, and pain that is unrelieved at rest or disturbs sleep.

While there are many different types and causes of back pain, there is no doubt that this pain affects your quality of life. Appropriate assessment of your pain and communicating this experience to your health care providers can help others understand the source of your pain and how to treat it best.

About the Speaker

Daniel Leizman, MD, is a board-certified physician in Cleveland Clinic’s Department of Pain Management. His specialty interests include treating pain associated with spine care, interventional spine procedures, musculoskeletal care, pain management and sports medicine. He also specializes in exercise prescription, complementary and alternative medicine, electrodiagnostic testing (NCS/EMG), interventional pain management for neck and back pain, and impairment and disability evaluation. Dr. Leizman completed his physical medicine and rehabilitation residency at the Medical College of Wisconsin Clinics, in Milwaukee, following graduation from medical school at The Ohio State University College of Medicine in Columbus. Dr. Leizman is now seeing patients at Cleveland Clinic main campus and Hillcrest Hospital.

Cleveland Clinic Center for Spine Health physician Santhosh Thomas, DO, MBA, is board-certified in physical medicine and rehabilitation. His specialty interests include electromyography, evaluation and management of back and neck pain, interventional pain management, and sports medicine. Dr. Thomas completed his fellowship in interventional spine/pain at Florida Spine Institute, in Clearwater, Fla. He completed his residency in physical medicine and rehabilitation at New York University Medical Center, in New York, and an internship at Massapequa General Hospital, in Seaford, NY, after graduating from medical school at New York College of Osteopathic Medicine, in NY. Dr. Thomas also completed graduate school at Case Western Reserve University Weatherhead School of Management. He is currently seeing patients at Cleveland Clinic’s Richard E. Jacobs Health Center, in Avon.

Let’s Chat About Chronic Back Pain

Moderator: Welcome to our chat ‘Ask the Experts: Chronic Back Pain’ with Cleveland Clinic specialists Dr. Daniel Leizman and Dr. Santhosh Thomas. We are very excited to have both physicians available to chat today! Let's begin with some background information about the topic and then continue with the questions.

Spinal Stenosis and Modic Changes

McTier: I have been diagnosed with spinal stenosis and have severe sciatica nerve pain from time to time. What do you suggest to prevent this pain and, when it occurs, to relieve the pain?

Santhosh_Thomas,_DO,_MBA: Spinal stenosis is often a slow, progressive process. You will have to pay attention to your body mechanics and activities. It is hard to know what triggers your particular pain, but I suspect it is usually due to activities.

scubamom: I am a 72-year-old woman with spinal pain due to compressed discs. I regularly do exercises suggested by my doctor. The pain is radiating into my hips whenever I stand too long. He has also suggested muscle relaxers to help relieve the pain. I only take them, though when I am really in pain. What are the current thoughts on this problem? Is there anything else I can do? How do you lessen this problem?

Daniel_Leizman,_MD: You may also have a component of spinal stenosis. The symptoms may improve with a spine injection procedure.

Joan: Does typical aging go hand-in-hand with lumbar stenosis? Is there anything that can be done to prevent it—either when young or when you’re older?

Santhosh_Thomas,_DO,_MBA: Not everyone will become symptomatic with lumbar stenosis. Ideal weight and good exercise are important to the prevention of lumbar stenosis—and it helps to have good genes as well.

gogetter: What is phase one of back degeneration of the disc?

Santhosh_Thomas,_DO,_MBA: I am not sure what this really means, but there are three types of degenerative changes that are noted in the lumbar spine often referred to as Modic changes. This is basically how a healthy disc is noted to go through changes and eventually stiffens. This is noted in most of us as a normal change over time.

Multifidus Muscles and Back Pain

pilatesgirl: I read some studies about the multifidus muscles being strongly involved in lower back pain. Do you have any experience with this?

Daniel_Leizman,_MD: Multifidus muscles are the small muscles that interconnect vertebral segments. They aid in back extension, lateral flexion and rotation of the spine. Strain of these muscles—due to injury or inability to withstand the demands placed on them—can lead to symptoms including pain. This is why it is important to keep these muscles limber and strong, so they are in good shape to handle their work load.

Bone Spurs and Back Pain

vickyohio: I have bone spurs throughout my spine which cause nerve problems. What causes bone spurs, and is there a way I can prevent these? I have them in my neck as well as in my feet.

Santhosh_Thomas,_DO,_MBA: Bone spurs are commonly seen. This is often due to degenerative changes. As there is more pressure on the bone, it remodels and spurs form for stability. This leads to stiffness. If the narrowing in the spine is compromised by the spur, you can have pain in your extremities.

Kinetic Chain of Dysfunction

pilatesgirl: I have learned from a physical therapist that when there is a joint that is painful, also look at the joint below and above. With back pain, I always look at a person's standing posture, gait and sitting posture. I often find foot pronation, or hip tightness, resulting from poor usage of the muscles for holding the spine long. Are doctors addressing these aspects of cause, as well as working to improve the consequences? What percentage of patients seem willing to put in this effort? Who do you tend to refer to for this functional work of healing?

Daniel_Leizman,_MD: It is useful to evaluate the ‘kinetic chain,’ i.e., the other joints contributing to human function or dysfunction as you state. Also, watching how someone walks is very beneficial. Physical medicine and rehabilitation physician specialists and physical therapists are particularly suited to this type of functional evaluation. They often work together in treating patients in this regard. Patient’s first need to recognize and be educated that treatment involves their active involvement, time and work effort. This is typically the biggest challenge. Pilates can be a terrific vehicle for strengthening muscles, improving gait and alleviating back symptoms in certain patients.

Chronic Back Pain and Associated Medical Conditions

swalker20: I have lupus, atrial fibrillation, high blood pressure, osteoarthritis, rheumatoid arthritis, PE, and Raynaud's disease. I suffer with chronic lower back and hip pain mostly on my right side. I cannot walk too far for several reasons, but the pain in my back does not make my life any easier. I cannot have any injections in my back because I am on Coumadin® (warfarin sodium). Do you have any suggestions?

Daniel_Leizman,_MD: I recommend you schedule an appointment for comprehensive evaluation with a spine specialist. You may be a candidate for a comprehensive chronic pain management program involving education, medication prescription and physical therapy.

Danny: My doctor told me I'm obese. How would losing weight affect my back pain?

Daniel_Leizman,_MD: Losing weight is probably the most important thing an overweight person can do for chronic low back pain. Of course, to lose weight successfully one must exercise, which we highly recommend for chronic back pain. Another important measure is to stop smoking cigarettes if you do smoke.

neuropathy123: I am an 84-year-old diabetic with neuropathy in my feet and in my legs. I also have severe back pain especially between my waist and mid-back. Is there a connection and what is the treatment?

Santhosh_Thomas,_DO,_MBA: There is no clear connection with diabetic neuropathy and back pain. Diabetes damages small nerves in your extremities and back pain is often due to degenerative changes in patients with advancing age. The treatment for diabetic neuropathy is managing good blood sugar control and treatment for lower back pain is often based on the cause of the lower back pain.

Spine and Neurological Evaluation

Branch63: What type of doctor should you see for burning leg pain, which I believe is coming from my back? My back doctor doesn't seem to think this is coming from my back.

Santhosh_Thomas,_DO,_MBA: Various healthcare providers could help. In my opinion, it is best to first see a spine specialist. You probably do not need to see a spine surgeon at first unless there is a need for surgery.

jsnydlov: What is the first course of action you would take if I came in for an evaluation? I have low back pain and a burning sensation in my legs after walking for 20 to 30 minutes. Are scans of some type always required? Can causes be determined without MRI or any type of scan?

Santhosh_Thomas,_DO,_MBA: Scans are only confirmatory and are not required. They are recommended if you are going to have invasive procedures. There is no substitute for a good physical examination.

demakers: I am a 37-year-old female with back pain from an injury in 1999. During this last year, things have been going downhill. Sometimes the smallest thing, like bending over, will send incredible pain through my back and down my left leg. It will leave me in bed for a couple of days. I like to walk and stay active, but my left leg and knee feel very weak all the time now. I purchased a knee brace to wear while exercising two weeks ago, and it helps some. I also have tingling through my left leg down into my ankle and toes. I am a busy mom, so I have to keep going. Some days it takes a toll on me.

Daniel_Leizman,_MD: I would recommend evaluating your condition with a specialist and considering obtaining an MRI scan of your lumbar spine to establish a diagnosis and treatment plan.

sinaihospital: I have had a very bad back for a long time. I tried physical therapy medications and injections by pain management. I was going to a chiropractor, but he messed my back up. In severe pain I called 911 to take me the hospital to give me give intravenous pain medicine. Can surgery help me for this?

Daniel_Leizman,_MD: I recommend you schedule an appointment for comprehensive evaluation with a spine specialist. You need to follow up with another physician now that your prior spine surgeon is gone.

bueford: I have a compression deformity of T7 from an injury. Is there anything I can do to improve the injury and pain?

Daniel_Leizman,_MD: The compression of the vertebra will not get better itself, but the pain typically does. A general bone strengthening program with a good diet and exercise program are recommended. Evaluation with a spine specialist to determine whether the pain is actually coming from the T7 vertebral region should be considered, and then exploring further treatment options.

jc7: I have been suffering for six months with pain running down my buttocks and lower back. I am very active (walking, biking, aerobics, weightlifting, etc.). I am unable to bend over, jump or do the normal things that I used to do. I have been doing physical therapy, but they have released me stating that I should continue to strengthen the core and continue doing the exercises at home. (I have been doing this at home.) I am also experiencing lower rib pain and my knees are taking a beating from the compensation from my back. Based on an MRI, at L5-S1 there is disc desiccation. Additionally, ‘broad-based herniated nucleus pulposus (HNP, herniated disc), central and left paracentral, 10 mm in AP dimension effacing the thecal sac, and abutting and displacing the descending left S1 nerve root’ is noted. The more shallow, broad-based underlying disc protrusion encroaches into and is mildly narrowed. Would you recommend surgery or another treatment?

Daniel_Leizman,_MD: I recommend a spine specialist at this time for comprehensive evaluation.

Psch222: I just had an MRI at Cleveland Clinic and the radiologist says he sees nothing. I have been treated for past six years with epidurals, physical therapy, etc. My doctor cannot find any reflexes. I am in constant pain and can neither stand nor sit for more than two to three minutes. I am losing feeling in my legs, and actually fell as a result. I have a consultation with a neurological specialist tomorrow. What can I do? Can I have another radiologist read the MRI? My physician and her partner see major swelling pinching the nerves.

Santhosh_Thomas,_DO,_MBA: It is best to keep the appointment tomorrow. We do not treat reflexes, as it is not uncommon to have either diminished reflexes or hyperreflexic limbs as normal findings. Additionally, pain is not always associated with harm. You can certainly have another radiologist review the images. Remember, MRI and x-rays only show anatomy—not the cause of pain, which could sometimes be elusive.

Pain Management Consultation for Chronic Back Pain

misslottie: I am 61 years old and suffer from lower back pain in the tailbone area. In 2006 it was determined that I had spinal stenosis in a few spots. Is that something that is going to progressively get worse with time? I also have osteoarthritis and had a total hip replacement in 2007. (When I was in my 20s, I fell out of a moving van trailer.) I occasionally take low-dose prescription pain medications, low-dose aspirin and Tylenol® (acetaminophen). I am always in some pain. I cannot keep up with my little granddaughters or go on fun activities away from home that include walking. I am overweight because of limited activity for the past 10 years. Is this going to keep getting worse?

Daniel_Leizman,_MD: Evaluation with a pain management specialist will be beneficial in reviewing alternative medication options for you, as well as other treatment methods.

Diagnostic Spinal Injections

Branch63: Can a person be sedated or completely put out while they do the dye test? Also, which is better, a facet injections or dye?

Daniel_Leizman,_MD: Typically patients are sedated to diminish discomfort, but still conscious during spine injections. Some spine procedures are diagnostic; others are therapeutic in nature. Some can serve as both for us.

Back Brace Use

swalker20: My back hurts the most when I stand up, walk and lying flat on my back. Is there a back brace I could wear while I am up moving? Whenever I took a test in the hospital that required me to lie on my back, they used different types of wedges and Styrofoam™ tubes to prop-up my feet. Is this a good idea? I do sleep on my back most of the times.

Daniel_Leizman,_MD: Try sleeping on your side, even with your legs curled up some. We typically don’t recommend continued use of back braces, as this can lead to weakened core abdominal and spinal musculature, which we want to strengthen.

Moist Heat Therapy

swalker20: I often put heat on my back when my back and hip hurt. Is heat the correct method?

Daniel_Leizman,_MD: Use of intermittent moist heat is oftentimes very beneficial. I recommend it.

jsnydlov: What is the best source of ‘moist’ heat? I have used a heating pad, but this does not provide moist heat.

Daniel_Leizman,_MD: I like over-the-counter heating pads that are placed in a microwave to heat for 15 to 20 minutes and then allowed to cool before use.

Aquatic Physical Therapy and Land-Based Exercises

Ljt913: What is the role of aquatic physical therapy in managing pain?

Daniel_Leizman,_MD: Aquatic physical therapy is beneficial for facilitating movement and exercise while alleviating much of the effects of gravity. This can be very beneficial for spine-related problems as symptoms are often times worse with weight bearing. It is important to continue an exercise program—either in a pool or on land—once the formal aquatic therapy has been completed.

swalker20: I am taking aquatic—‘aqua therapy’— twice a week and land-based exercise therapy once a week to help my all of my conditions. While I am in the water my body feels relaxed. My father thought we could buy one of those bath tubs that have jets built in. What do you suggest to help relax my lower back?

Daniel_Leizman,_MD: Continue with regular exercise, including stretching and dynamic postural exercises, such as yoga. You may also want to try application of moist heat. Also, a comfortable bed for good sleep is important.

MASKU: What exercise programs are available for recurrent lower back pain and leg pain? How can I find out more about appropriate programs?

Santhosh_Thomas,_DO,_MBA: There are too many to list and they should be tailored —not generic—to meet your needs. Often centralization exercises are used to help. A group of exercises known as McKenzie (or back extension) exercises have been helpful in many cases.

mschnip11: I have what my physical therapist described as T4 syndrome. He manipulated the spine over several sessions, and I achieved some relief of the discomfort I have. What can I do at home to help maintain comfort? I have inversion boots at home. Would that be an option?

Daniel_Leizman,_MD: I am not certain about the meaning of T4 syndrome, but I suspect he is referring to your fourth thoracic vertebral level. Yoga exercises may be beneficial at home. You can try the inversion boots if you are comfortable using them.

jsnydlov: Does Cleveland Clinic offer classes in Pilates and/or yoga, or do you have any recommendations for instructors of these practices? I hesitate to begin one of these for fear my condition will worsen and want to make sure I work with a very good instructor.

Daniel_Leizman,_MD: Yes, Cleveland Clinic offers Pilates and yoga classes through its Wellness Institute in Lyndhurst, Ohio.

Physical Therapy for Herniated Discs

yesenia143: I get really bad tension headaches for days, which are secondary to neck injury and herniated discs due to a car accident. Do you have any advice? Sometimes when I exercise and bend, the pain is bad.

Santhosh_Thomas,_DO,_MBA: Herniated discs can cause headaches but more likely, whiplash may be your cause. Rehabilitation with physical therapy is going be helpful along with some periodic use of medications, ideally NSAIDS (nonsteroidal anti-inflammatory drugs).

Transcutaneous Electrical Nerve Stimulation (TENS)

swalker20: I use a transcutaneous electrical nerve stimulation (TENS) unit, but it does not work—at least from my perception. What is the purpose of a TENS unit?

Daniel_Leizman,_MD: The TENS unit is prescribed to reduce symptoms, particularly pain. If you have tried it with proper instruction, and do not find it beneficial then I suggest discontinuing it.

Medications for Chronic Back Pain

vickyohio: I am 51 years old and have been taking Mobic® (meloxicam) for the past four years for severe arthritis in my spine. This does not seem to be helping. Is there another medication that you would recommend?

Daniel_Leizman,_MD: You may want to ask your prescribing physician to consider a trial of an alternative nonsteroidal anti-inflammatory medication and/or Tylenol® (acetaminophen) for starters.

yesenia143: Can you provide some examples of nonsteroidal anti-inflammatory medications (NSAIDS)?

Santhosh_Thomas,_DO,_MBA: Nonsteroidal anti-inflammatory medications are often available over-the-counter such as Aleve® (naproxen sodium), Advil® (ibuprofen) and Motrin® (ibuprofen). There are too many to list, but some of the prescription ones include Celebrex® (celecoxib), Mobic® (meloxicam) and Relafen® (nabumetone).

tamlynken: I have two herniated disc in my lumbar spine. Will I ever be able to function normally again? I have nerve damage in my right leg into my foot. I also have an overactive thyroid condition. Could Tapazole® (methimazole) 5 mg cause inflammation in my back?

Daniel_Leizman,_MD: There may be medication and or spine injection procedures that will improve your symptoms. Joint and muscle pain is a known possible side effect of methimazole medication. I recommend you review this with your prescribing physician.

balduct: I have suffered from back pain for two years and have been treated by three doctors, including epidural and a nerve-killing procedure at pain management, treatment at two physical therapy centers, and weekly massages by a chiropractor. I take Celebrex® (celecoxib) daily and Ultram® (tramadol) as needed. What should I consider next? I am 68 years old and otherwise in good health. I weigh 213 lb.

Santhosh_Thomas,_DO,_MBA: If you are stable and pain is manageable, stick with what you are doing. Weight modification and regular exercise also will help.

Steroid Long-term Use

sdaniels: So often we hear the statement, ‘Do not use for extended time or not for long term use.’ What are the time limits for these general terms? Referring to prescription use of steroids for back pain?

Daniel_Leizman,_MD: Oral corticosteroids for back pain should only be considered for severe flare ups of symptoms for a limited time frame of one to two weeks, and only on rare occasions—once or twice a year at most, for instance. Injections of corticosteroid—‘spine block injections’—oftentimes occur in a series of up to three injections over two to three months. After that, one would want to refrain from further injection for at least several months. Typically, the number of corticosteroid injections in a year should be no more than four to six at most.

Pain Management with Platelet Inhibitor Use

kmo123: I am a 58-year-old man with severe pain from spondylolisthesis. I currently take the platelet inhibitor Effient® (prasugrel) because I had a stent placed for a coronary artery blockage last year. I cannot stop the Effient® until December. I no longer get substantial back pain relief from stretching or over-the-counter or prescription pain medications. I would like to have spinal injections for pain relief, but the Effient® is a problem. Can you recommend any types of injections that might not be a problem with the Effient®, or any other treatments that I can look into that might help manage my pain?

Daniel_Leizman,_MD: There may be oral medications that can help with your symptoms until such time that you can be off of the platelet inhibitor for a brief time. I recommend you schedule an appointment for evaluation with a spine specialist.

Spinal Injections: Nerve Blocks and Facet Injections

LJK: What exactly is a spine block injection? And will it work long term for low back pain due to disc problems?

Santhosh_Thomas,_DO,_MBA: There are number of injections, and they basically are used to block the pain generators that are believed to be the cause of pain. These have been used for decades for pain control. Some need only one injection and some may need more than one to get adequate relief. There is not permanent solution that is consistent for these pain generators.

Monalea: I am 67 years old, and was told I have moderate spinal stenosis in the lumbar area. My main symptoms appear when walking. After about a half mile during my walk, my lower back aches so much that I can hardly keep going. What I do for temporary relief is to bend over and touch my toes for a couple of seconds. However, when I start walking again the pain starts up. Do you have any suggestions for relieving the pain that comes with walking? Does it hurt the back if you walk through the pain anyway?

Daniel_Leizman,_MD: I suggest that you consult a specialist. Your symptoms seem to be relieved with flexion posture, i.e., bending forward. You can try walking in a slightly flexed posture, although you probably already do. You may benefit substantially from a spine block injection in conjunction with some physical therapy to establish a home exercise program. This may improve your walking distance prior to postural muscle fatigue and onset of symptoms.

LJK: I am a 78-year-old female. My MRI from seven years ago showed a large inferiorly migrated disc extrusion with moderate stenosis at L1-L2 on the left. There is left foraminal stenosis at L5-S1 due to osteophyte formation. No right-sided disc herniations or significant sacrococcygeal abnormality seen. My lower back is quite painful when I sit for more than a few minutes. It is better when walking, but I am limited because of a 22-year-old left hip replacement. The back pain also makes my legs and feet feel as if they are on fire. I have tried Ultram® (tramadol hydrochloride) 50 mg twice daily and Mobic® (meloxicam) 7.5 mg, which caused constipation or a raise in blood pressure. These did not help much. I am currently taking aspirin. Can you recommend a pain medication I can ask my doctor for that would work better and without these side effects? Also , I was told because I have so many herniated discs that surgery would probably not be successful. Is that still the case today, seven years later?

Daniel_Leizman,_MD: I would suggest you get a current MRI scan of your low back. You may be a candidate for a spine block injection in conjunction with some physical therapy to establish a home exercise program.

Branch63: What does a person do if they are afraid of shots and the doctor wants to give four facet shots? Is there an alternative?

Santhosh_Thomas,_DO,_MBA: The needles are very small, and at times you can ask for some sedation. This is not necessary in most cases.

vickyohio: Do you typically give pain medication prior to giving facet blocks?

Santhosh_Thomas,_DO,_MBA: This is operator dependent. I have done these for over 12 years and have in a few cases given Valium® (diazepam) for anxiety.

Radiofrequency Ablation (RFA)/Lesioning

Amykr: I am 38 years old and was in a serious car accident this past January. I have never had a firm diagnosis yet. I was first told it was my sacroiliac (SI) joint. Now my doctor thinks my S-1 joint may have had some nerve damage from the accident. I have tried epidurals, physical therapy and even a chiropractor. I have been in pain management, but get no relief. I have always been an active person, and I am depressed because I cannot keep up anymore with my 10 year old. I do not know how to handle this chronic back pain, and am I looking for some suggestions to help. My doctor is now suggesting radiofrequency ablation (RFA) for me. What is RFA?

Daniel_Leizman,_MD: RFA is a method of destroying small nerves of the spine and sacroiliac joints that are thought to contribute to back pain in some patients. We typically do a test injection prior to the RFA procedure, to see if it is likely to be beneficial. I think you should have a comprehensive evaluation with a spine specialist to try to establish a diagnosis, and then consider appropriate treatment options that may or may not include RFA.

D.J.: Is radiofrequency lesioning (RFL) of the medial branch of the posterior nerve in the zygapophyseal joints recommended for L5-S1 chronic, moderate-to-severe pain?

Santhosh_Thomas,_DO,_MBA: zygapophyseal joint are often known better as facet joints. The lesioning should be performed only after two injections have been done to isolate the pain generator. Each joint gets innervation from more than one nerve, so you have to lesion at least two medial branches to address a single joint.

Surgery for Chronic Back Pain

LJK: Is it really advisable to have a back operation when you have many herniated discs in the lower spine along with stenosis?

Daniel_Leizman,_MD: This is a situation for which one wants to have very specific objectives and expectations for the surgery before undergoing it. For instance, is it being considered for back pain, leg pain or both? Is a fusion with hardware being considered or just a decompression?

Flowerangl: I have a 60/40 scoliosis curve that was diagnosed when I was 12 years old. Bracing did not help. Since the birth of my daughter, some of the curve apparently calcified. I am now 44 years old, and the weight of this natural fusion is wearing out my sacrum. (I am starting to get bulging and herniated discs. My right hip is starting to get bursitis and other issues are developing.) What should I do next?

Santhosh_Thomas,_DO,_MBA: You will need to be reevaluated. You likely have progression of your scoliosis. Surgery is an option to correct the curvature. You can manage most of the bursitis without surgery. Oral medications and injections can be tried if physical therapy has failed.

Recurrent Pain After Spinal Disc Surgery

pilatesgirl: What percent of people return after spinal disc surgery with recurrent pain? Is a newly injured disc frequent due to poor motion of the fused area? What are the most helpful recommendations you might offer to prevent repeat problems?

Daniel_Leizman,_MD: Patients who have spine surgery for extremity (leg) pain tend to do very well with getting relief of the leg pain. Treating back pain with surgery—and especially surgery alone—is typically much less successful. When one level of the spine is fused, more motion is transferred to the adjacent levels above and below it. To prevent repeat problems, one must appreciate that the postoperative rehabilitation is just as important as the surgery itself to having the best long-term outcome possible.

Activities of Daily Living

neuropathy123: I am 84 years old and have severe back pain. I lean over a lot to pick things off the floor. How does this affect my back pain?

Daniel_Leizman,_MD: Bend from the knees to pick things up. This will decrease the spinal pressures that increase when we flex and bend forward.

Spine Specialist and Surgeon: Qualifications and Selection

jsnydlov: How does treatment with a physician like you differ from treatment offered by a chiropractor?

Santhosh_Thomas,_DO,_MBA: We have four years of additional training after medical school and then a fellowship in spine and/or musculoskeletal issues for another year. We are able to manage you with simple activity modification, medications, rehabilitation, injections and implantable options. We can also assess you for surgical options. We have a much broader exposure and training in musculoskeletal evaluation. We can also do EMG studies to evaluate nerve-related issues.

gogetter: How can I tell if the neurosurgeon I saw after he took an MRI and suggested bone fusion on L5-S1 is a good choice? How do I find out his success rate and so on?

Santhosh_Thomas,_DO,_MBA: This is a tough one. You have to go with reputation. I would suggest you go to a spine surgeon who is fellowship trained and operates on the spine as the majority of his work. Success is measured differently by all patients. Some are happy that they are 30 percent better and some are happy that they can walk. Some are unhappy with 50 percent relief. It is always a good idea to seek a second opinion when it comes to surgery.


Moderator: I'm sorry to say that our time is now over. Thank you, Dr. Leizman and Dr. Thomas, for taking the time to discuss chronic back pain. Your answers were very detailed.

Santhosh_Thomas,_DO,_MBA: I hope this was beneficial for all of you. Please remember that surgery is not indicated in nearly 90 percent of the patients with back pain or leg pain. Be proactive. Keep an ideal weight, don't smoke, exercise regularly, maintain flexibility and feel free to go to your doctor if pain is limiting your function.

Daniel_Leizman,_MD: Thanks for the great questions. I am always very impressed with the level of understanding of medical issues by our patients. Thank you, Dr. Thomas, for participating in this with me. It has been a pleasure.

For Appointments

To make an appointment with Daniel Leizman, MD, or any other specialist in our Department of Pain Management at Cleveland Clinic, please call 216.444.PAIN. You can also visit us online at

To make an appointment with Santhosh Thomas, DO, MBA or any other specialist in our Center for Spine Health, call 216.636.5860 or toll-free 866.588.2264, or visit for further information.

For More Information

On Chronic Back Pain
On Cleveland Clinic

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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2013. The Cleveland Clinic Foundation. All rights reserved.

Reviewed: 10/13