Ask the Experts: Chronic Back Pain
April 18, 2014
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. 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.
About the Speakers
Cleveland Clinic Department of Pain Management physician Daniel J. Leizman, MD, is board certified in physical medicine and rehabilitation and is now seeing patients at Cleveland Clinic main campus and Hillcrest Hospital. 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 served his physical medicine and rehabilitation residency at the Medical College of Wisconsin, in Milwaukee, after graduating from The Ohio State University College of Medicine, in Columbus.
Cleveland Clinic Center for Spine Health physician Garett Helber, DO, is board-certified in physical medicine and rehabilitation. His specialty interests include management of back and neck pain, interventional spine procedures, international pain management and non-operative spine care.
Dr. Helber completed his fellowship in spine medicine at Cleveland Clinic after his residency at Thomas Jefferson University Hospital in Philadelphia. He graduated from medical school at Ohio University College of Osteopathic Medicine. He sees patients at Cleveland Clinic main campus and Medina Medical Office Building.
Let’s Chat About Ask the Experts: Chronic Back Pain
Moderator: Let’s begin with your questions
Healing after Back Injury
ellisor: I was injured in October 2007. Is there a time or age limit after which your back can't be healed? I am now 71 years old.
Daniel_Leizman,_MD: The spine is a living biologic structure, always able to change to some degree. However, once significant injury has occurred with residual symptoms after a year, one should think in terms of managing the symptoms rather than counting on healing or resolution to occur.
Cause and Treatment of Paraspinal Muscle Tension
mintyfresh: What is the best treatment for paraspinal muscle tension? Also, what causes it when it is a long-term problem?
Daniel_Leizman,_MD: Stretching, yoga and aerobic exercise can be beneficial for paraspinal muscle tension. An underlying spine bony or disc abnormality could be the cause if persistent.
Pain after Spinal Cord Stroke
hutchg: After having a spinal cord stroke, is it possible to get progressively worse since I left the hospital? I also have extreme numbness, cold and pain in my feet and legs from the knees down.
Daniel_Leizman,_MD: You should follow up with your treating physicians for further evaluation.
Positional Nerve Root Irritation
sally2103: Have had low back pain for 25 years since a fall, but now I have pain down the front of my thighs that is worse when sitting and lying. My low back burns when standing. Moving is the only time when it is better. Is this a symptom of something specific?
Daniel_Leizman,_MD: This is a sign of positional nerve root irritation and would require spine imaging to better assess.
Sacroiliac Joint Dysfunction and Piriformis Syndrome
Pattis: After being injured by a physiotherapist two years ago, I was diagnosed with sacroiliac joint dysfunction and secondary bilateral piriformis syndrome. After two years of physical therapy and cortisone injections, I'm at a loss as to what to do next. What are the best diagnostic tests and therapies I should be pursuing? Why is this condition so difficult to diagnose and treat? What is your view on sacroiliac joint surgery? What is your view on piriformis release surgery?
Daniel_Leizman,_MD: Sacroiliac joint dysfunction and piriformis syndrome are difficult areas to diagnose. I recommend getting a second opinion from a spine specialist, certainly before considering any surgical intervention.
Pattis: I have already had many second and third opinions already. What is your view on either piriformis release or fusion surgery? I've been told to do both.
Garett_Helber,_DO: Piriformis release would likely pertain to treatment for piriformis syndrome, which is a difficult diagnosis. Before proceeding with release I would pursue obtaining more diagnostic information to increase your chances of a successful surgical outcome. These treatments may include diagnostic injections of the piriformis, sometimes with ultrasound guidance and/or an electromyogram/nerve conduction study (EMG/NCS) looking for nerve and muscle damage of the affected area. Sacroiliac (SI) fusion can also be beneficial for sacroiliac joint pain, but again before proceeding I would recommend successful diagnostic sacroiliac joint injections. Successful diagnostic injections prior are more likely to result in a better surgical outcome.
Pattis: I had magnetic resonance neurography (MRN) that showed sciatic nerve entrapment at the level of the piriformis tendon and possibly the obturator internus. I'm 56 years old, and have been suffering with this for more than three years. Is there a surgical option offered at Cleveland Clinic?
Garett_Helber,_DO: Surgical intervention may be warranted, but would likely be determined by further evaluation that is best done in an office setting. We would be happy to evaluate you here at the Cleveland Clinic and discuss what options may be available to you, surgical and non-surgical, to address your pain.
Herniated Disk with Associated Bladder and Bowel Symptoms
SLE2014: I have systemic lupus erythematosus (SLE) ,fibromyalgia, inflammatory arthritis and a herniated disk. I was told this would heal. However, it has been over one year. My brothers also have had herniated disks. My problem now is my lower back, hips, inner thighs and right gluteal ache moderately. This pain is during early mornings and at night. My rheumatologist increased my methotrexate to 18 mg per week and Neurontin® (gabapentin) 600 mg three times per day, Plaquenil® (hydroxychloroquine) 200 mg twice per day, and Lidoderm® (lidocaine patches) as needed. I cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) because I am on Plavix® (clopidogrel) and methotrexate. I cannot take narcotic medication because it makes me very ill. I have requested cortisone shots three days ago, but have yet to hear from rheumatologist. I am concerned because of this pain seems to be causing a feeling of impending incontinence of my bowel and bladder. I have made an appointment with pain management. What might you suspect to be causing this problem and what should I do? My primary care physician referred me to a rheumatologist.
Garett_Helber,_DO: Due to the multiple areas of pain, the pain is likely multifactorial and, therefore, would require a multi-pronged approach to treating it. Pain that radiates down your leg may be due to a disk issue and varies depending on the location of that disk. Cortisone injections are sometimes helpful for this type of pain and can provide additional diagnostic information. Inability to void either your bladder or bowel can represent a very serious neurological issue. Your healthcare provider should be contacted immediately should these symptoms arise. Obtaining further evaluation with pain management and rheumatology is an appropriate start to evaluating your pain.
T426: Do you have experience with spine, bone and marrow sarcoidosis lesions?
Daniel_Leizman,_MD: This is a rare disorder, so most individual physician’s experience would be limited. This is one reason we tend to collaborate with specialists from various specialties here at Cleveland Clinic, in this case pain management, spine, and rheumatology.
Parkinson Disease and Back Pain
knlowes: I was diagnosed with Parkinson disease seven years ago. I also suffer from constant back pain for the past six months. I had a mini discectomy two years ago which relieved pain at that time. I am 52 years old. My 75-year-old father, who was diagnosed with Parkinson disease shortly after I was, also suffers from chronic back pain. Does Parkinson disease and back pain have a direct relationship to each other or is our pain due to other reasons? Both of us have been farmers most of our lives.
Garett_Helber,_DO: I am not aware of a direct relationship between Parkinson's disease and back pain other than possible resulting gait difficulties may place abnormal stresses across the back. Low back pain due to degenerative changes is more common in those who perform heavy labor. Your time spent as a farmer may have contributed more to your back issues than Parkinson’s disease. However, back pain is often multifactorial with several contributing causes.
Degenerative Disc Disease Progression
lindairene: How does degenerative disc disease progress? I am 64 years old, and was diagnosed six months ago. I want to know what to expect in the future years.
Garett_Helber,_DO: The degenerative disease cascade often begins at the intervertebral disc where loss of disc height and hydration result in a decreased ability to absorb applied loads and stress. These forces are then transmitted to surrounding structures including the vertebral bodies and joints that make up the spine. These changes often occur with aging and are not uncommon as we progress through life. These changes may progress, but there is no way to tell to what degree they may advance. I encourage patients to eliminate smoking, maintain a regular exercise program including core exercise strengthening, and maintaining an ideal body weight in an effort to maintain good spine health and minimize progression of these degenerative changes.
Foraminal Stenosis Treatment
Ajzamorano: What are the best non-surgical treatments for foraminal stenosis? Would 15 years of chronic neck pain caused by foraminal stenosis make me a patient for surgery? If so, how is the surgery performed?
Daniel_Leizman,_MD: Cervical spinal foraminal stenosis can be treated with exercises, medications, injections and surgery. The specific treatment regimen would be individualized based on a variety of factors including age, general health, activity level and severity of stenosis on spine imaging.
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
5jake925: I have osteoarthritis pain in my back, shoulders and thumbs, as well as weakness in my leg. The best relief is from non-steroidal anti-inflammatory drugs (NSAIDs), but warnings now say, "Use may cause sudden heart attacks or even death."
What are safe medications that enables one to enjoy motion and an active life? Are there any new medications and research?
Daniel_Leizman,_MD: All medications have potential side effects and risk. NSAIDs are generally reasonably safe—although if taken regularly, one should review with his/her physician.
Long-term Medications for Back Pain
Phillie: My problem is sciatica and spinal stenosis. I take hydrocodone and acetaminophen 10-325 mg every six hours for pain. I've been doing this for at least two years. Is it safe to continue with this dosage?
Daniel_Leizman,_MD: I am concerned about this as a long-term treatment approach.
Radiofrequency Ablation (RFA)
hatterasjack: I am an 83-year-old male with spinal stenosis, osteoporosis and arthritis— I have it all! Had XLIF surgery (lumbar lateral interbody fusion) at L 3, 4,5 in 2009. Also, laminectomy for L1,2 in 2012. I have tried it all—acupuncture, transcutaneous electrical nerve stimulation (TENS) and many epidural steroid injections (ESI). I have had 2 ESI in facets. It worked well and I am now going to have a radiofrequency ablation (RFA). Am I going in the right direction? Do you have something more aggressive for the pain?
Daniel_Leizman,_MD: This depends on your current symptoms—is it more back pain or leg pain? If just back pain and the facet injections were efficacious then considering RFA with your physician is reasonable.
Pain after Lumbar Back Surgery
acedozerman: I have had three lumbar back surgeries. I am still having pain in my lower back and my left leg is numb down to the knee. I feel like I am being shocked all the time. What could be the problem?
Daniel_Leizman,_MD: The problem could either be consistent entrapment of nerve root or permanent nerve root injury/damage. However, with specialty spine care treatment may be possible which will improve symptoms.
Grannyscott: I am an 85-year-old female who has spondylolisthesis, which bothers me to some extent every day. I understand that there is no effective treatment other than surgery, which I do not want. More recently I had an episode of a different strong pain in my hip, which lasted for several weeks and especially interfered with my sleep. It has now eased, so I have put off scheduling the recommended steroid injection to treat that. Could a steroid injection prevent it from recurring, and could it also possibly help with the spondylolisthesis regular pain?
Daniel_Leizman,_MD: The injection will not be preventive. However, it may help with the "regular" pain you are having.
Flgirl: When should one seek back surgery for stenosis at 2-3, 3-4, 4-5 and herniated disc 2-3?
Garett_Helber,_DO: There is no guarantee with surgery. Spine pathology can certainly result in hip pain. Thus, surgical decompression or intervention may result in resolution of your hip pain. Sometimes selective spine injections can provide diagnostic information in addition to therapeutic benefit. It may give you and your surgeon additional information that may increase your chances for a successful surgical outcome. There are also other etiologies (causes) arising from the hip outside of arthritis that may contribute to hip pain. Further evaluation may be warranted to assess for these. We would be happy to look into these further and discuss possible surgical benefits from any surgical interventions at Cleveland Clinic.
Cleveland Clinic Evaluation
Suzy Q: I had a laminectomy seven years ago to L3-5, but no fusion. I have progressed to pain in L5-S1 and S-I joints such that I can barely carry anything without getting incapacitating pain. My neurosurgeon has suggested surgery L2-5 with fusion or referral to Cleveland Clinic. The Department of Pain Management wants to do a nerve ablation. What would work up at Cleveland Clinic include that I haven't heard about so far?
Daniel_Leizman,_MD: We would be happy to evaluate you here at Cleveland Clinic, review your spine images and discuss treatment options with you. When considering a second spine surgery, getting a second opinion is generally a good idea.
Suzy Q: What can Cleveland Clinic offer? To supplement my information, the laminectomy did not involve discectomy, but involved removal of the spinous process of inferior L3, all from L4, and superior L5. No fusion was done. I have great difficulty walking and my back feels unstable, like I don't have support. If I have to carry anything against the front of my body, like a laundry basket or pile of clothes, I walk bent over because I don't have the strength to walk erect. I have a lot of pain at L5 and my sacrum that is relieved with pain medication or ice pack. Is it common to remove spinous processes and lamina without doing a fusion? My surgeon says I fell into the 10 percent who have a failed back surgery. Does Cleveland Clinic do surgery on patients who have already had a surgery by another doctor?
Daniel_Leizman,_MD: I suggest you get a second opinion. We would be glad to see you here at Cleveland Clinic, exam you, review your imaging studies, and layout treatment options. Yes, we offer surgical treatment when indicated to patients who have had prior surgeries elsewhere.
T426: I have multiple rounded enhancing lesions throughout the lumbar spine, sacrum and iliac bones. It is also now in my thoracic spine and humerus. I know I have sarcoidosis, so I am assuming it is bone and marrow sarcoid. There is moderate facet arthropathy and multiple Tarlov cysts noted in the sacrum involving the bilateral S1 and left S3 nerve roots. I have mild degenerative joint disease (DJD) at C5-C6 and C6-C7 with moderate right and mild left neural foraminal narrowing at C5-C6.
I was treated for 20 years for ankylosing spondylitis (AS), but now I was told I don't have it. Nothing is helping my back pain. I have had bilateral facet injections, but they didn't do much. My spine orthopaedist said she can't do anymore, and that the pain is from sarcoid lesions. She prescribed Neurontin® (gabapentin) 900 mg nightly. It does help with my sleep, but that's all. Oxycodone 5 mg doesn't help with my pain. The sarcoid specialist who is not from Cleveland Clinic said the lesions shouldn't cause pain. I am now on Cellcept® (mycophenolate mofetil), nortriptyline, Neurontin®, oxycodone, Maxalt® (rizatriptan benzoate) and Advair® (fluticasone propionate). Do you have any suggestions? I'm at wits end.
Daniel_Leizman,_MD: This is a complicated one! We would be glad to provide a second opinion here at the Cleveland Clinic, coordinating care with one of our spine specialists as well as rheumatologists.
JonCas: I had two spinal surgeries for spinal stenosis L2-6 with fusion and instrumentation on both procedures. I am now hunched over unable to straighten my posture and experience severe pain when walking even short distances. I become very short of breath and sweat profusely. Could I have ankylosing spondylitis? What is the definitive test for this condition and what type of physician could follow this?
Daniel_Leizman,_MD: You have an extensive spinal fusion, which unfortunately puts you at increased risk for persistent problems with your spine above and below the level of the fusion. A pain management or spine specialist here at Cleveland Clinic would be appropriate to evaluate you.
Catz: What are the most effective lower back exercises to relieve lower back pain? Are there any resources you can provide, such as YouTube, websites, etc.
Garrett_Helber,_DO: Most effective exercises include extension based activities, but core strengthening exercises are also important. An approach to back pain that is often utilized is called the McKenzie Method®. There is a book entitled "Treat Your Own Back" that patients often find useful and which I would recommend. One of the most effective exercises that I find patients benefit from is the use of a Roman chair—which is found at most commercial gyms, but can also be purchased for home use. Instructions on how to use may be found on YouTube.
knlowes: While exercising should I work through the pain? Am I making things worse?
Daniel_Leizman,_MD: Discomfort while exercising is o.k. However, if you are having pain you should avoid that activity and discuss it with your physician specialist.
Alternative Therapy, Medical Food and Supplements
Trykkergirl: Would Limbrel® (flavocoxid) 500 mg help me to get off NSAID Meloxicam15? I take Mobic® (meloxicam) and Coumadin® (warfarin), which is a dangerous combination. Limbrel® is a flavonoid food which has all kinds of Vitamin K things in it. Is that a problem with Coumadin® as long as you remain monitored? Also will Limbrel® help with pain in lower back and other arthritic joints? Or just help to rebuild?
Daniel_Leizman,_MD: I am not familiar with Limbrel®. Especially since you take Coumadin®, you should discuss over-the-counter supplements with your physician prior to taking. You should also discuss taking the Mobic® with the Coumadin® with your prescribing physician, as this raises concern.
jwiesend: What are the treatment alternatives for degenerative disc disease in the L4-L5 disc space?
Daniel_Leizman,_MD: Treatment options vary from exercises, medications and spine injections. Typically, surgery is not a treatment option for this.
Garett_Helber,_DO: I am unsure what you mean by treatment "alternatives" and it would depend on what type of symptoms you are experiencing. Different treatment options exist for those patients with isolated back pain vs. those with a component of leg pain. I approach pain from mainly five different aspects including therapies/rehabilitation, medications, "alternative" treatments (including acupuncture and manipulation), injections and surgery. These are all done in coordination with lifestyle modifications.
Spinal Decompression Machine Therapy
Trykkergirl: I have heard about a spinal decompression machine DRX9000 offered for sciatica, bulging and herniated discs in the lumbar area, which I have. I can barely walk. I read some online reviews that were terrible, and many said it made their condition far worse by injuring them. Do you have an opinion of this machine? I have an appointment with a chiropractor to talk about possibilities of various treatments, but also have an appointment with a neurologist in Orlando to schedule back surgery—which also has its share of failures overall. What is your opinion? Our local physical medicine physician does injections, but no hands-on treatments. I probably need a Rolfer®, but Medicare will not pay for that, so it won't happen. I have also been told Medicare will not pay for myofascial release massage, which would help. I use a stretch strap daily for stretches.
Daniel_Leizman,_MD: I do not recommend this decompression machine. I am familiar with it, and we do not recommend it. There is no evidence-based research that this type of treatment is of value. I recommend you start with a pain management or spine specialist for comprehensive evaluation and treatment recommendations starting with the least invasive and least expensive.
Moderator: I am sorry to say that our time with Daniel J. Leizman, MD and Garett Helber, DO is now over. Thank you for sharing your expertise and time to answer questions today.
Daniel_Leizman,_MD: Thank you for joining us today.
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 clevelandclinic.org/painmanagement.
To make an appointment with Garett Helber, DO, or any other specialist in our Center for Spine Health, call 216.636.5860 or toll-free 866.588.2264, or visit clevelandclinic.org/spine for further information.
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On Chronic Back Pain
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On Cleveland Clinic
Cleveland Clinic Pain Management specialists are among the most experienced in the world, treating more than 10,000 new patients each year. Our board-certified physicians are dedicated to the goal of helping people with chronic pain return to a normal, productive lifestyle. Using the latest in diagnostic technology, paired with medical and interventional therapeutics, they will work with you to identify the source of your pain, eliminate or reduce the pain, and teach you to manage it.
Our multidisciplinary team of healthcare professionals develops customized care plans for each patient, using the latest equipment and innovative procedures to diagnose pain and determine the safest and most effective pain management possible. We are committed to providing state-of-the-art service closer to home, caring for patients at Cleveland Clinic’s main campus and over 20 northeast Ohio locations.
At Cleveland Clinic’s Center for Spine Health in the Neurological Institute, we help thousands of patients with conditions of the back and neck, ranging from the most common to the most complex. At Cleveland Clinic’s Center for Spine Health, our specialists are nationally recognized in orthopaedic surgery, neurosurgery and medical spine care. We provide patients with the latest and most effective medical and surgical treatments available for back and neck problems. We offer medical spine evaluation and treatment for adults, teens and children, including spine injury prevention, interventional spine therapies, spine surgery, spinal and pelvic manipulation, and acupuncture. From periodic monitoring to intensive surgical correction, we provide state-of-the-art management for back and spine problems. Corrective treatments range from minimally invasive decompression to spinal osteotomy, which is highly complex and is regularly performed at only a small number of spine centers in the United States. Neurology and neurosurgery at Cleveland Clinic is ranked best in Ohio and among the top 10 nationally by U.S.News & World Report.
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