Online Health Chat with Teresa Dews, MD, and Shrif Costandi, MD
Wednesday, March 25, 2015
Eighty percent 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 2 percent of the entire United States workforce is disabled by back pain. It is the cause of enormous health care 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 that disturbs sleep.
This chat focuses on treatment options for chronic back pain, ways to measure pain and how best to communicate your experience of pain with your health care providers, family members and others working with you.
About the Speakers
Cleveland Clinic Department of Pain Management physician Teresa Dews, MD, is board certified in anesthesiology and anesthesiology – pain medicine. Dr. Dews sees patients at Hillcrest Hospital and Chagrin Family Health Center. Dr. Dew’s specialty interests include the evaluation and management of many chronic pain conditions including back and neck pain. As an interventional pain management physician, she utilizes nerve blocks as part of an individualized comprehensive pain management approach to improve pain and overall function.
Cleveland Clinic Center for Pain Management physician, Shrif Costandi, MD, is board certified in anesthesiology. Dr Costandi see patients at the Richard E. Jacobs Health Center, Cleveland Clinic Main Campus, and Avon Hospital. Dr. Costandi's specialty interests include interventional pain management, management of chronic pain, and spinal cord stimulation
Let’s Chat About Chronic Back Pain
Moderator: Welcome to our chat about Treatment Options for Managing Chronic Back Pain with Cleveland Clinic specialists Teresa Dews, MD, and Shrif Costandi, MD. Let's get started with our questions.
Back Pain Basics
parents&child: Is there a cure for sciatica pain?
Teresa_Dews,_MD: Most people who have an acute episode of sciatica will recover. Chronic pain is more difficult and may require significant lifestyle changes, medical and procedural treatments as well as appropriate and ongoing exercise. Sometimes, psychological treatment is helpful in managing chronic sciatica.
acho7: Some mornings I get out of bed and almost can't straighten up. What to do?
Teresa_Dews,_MD: Consider stretching prior to going to bed and discuss with your doctor medications that may assist with the morning pain/stiffness. As appropriate, exercises to strengthen your back muscles will help over time.
Dillard: I've been diagnosed as having a "herniated disk" (L4). My question: Are a herniated disk and a slipped disking the same, and does a herniated/slipped disk heal over time? Also, how does degenerative disk disease fit into the first question, and what conservative treatment options (other than surgery) would be recommended?
Teresa_Dews,_MD: Slipped disc and herniated disc are really the same and are used to describe types of disc degeneration. These are diagnosed by radiology imaging (MRI or CT with contrast). There are different grades and descriptions ranging from disc bulge, herniation and extrusion. The description does not always correlate with symptoms. Yes, there is a chance for healing. Remaining as active as tolerated and using mild, non-narcotic pain medications can help. Some people respond to physical therapy. Lastly, epidural steroid injections can sometimes decrease the pain temporarily to facilitate physical therapy.
pirate2002: What are your thoughts on tension myositis syndrome (TMS)? Could tension, stress and anxiety be the cause of back pain and issues if nothing mechanical is found wrong?
Teresa_Dews,_MD: Yes, tension, stress and anxiety can cause or increase back pain and many other pain conditions. This can occur with or without mechanical issues.
Jack_in_Florida: For lower back pain, what is the recommended protocol with respect to the sequence of medical appointments? Should the first visit be with an internist, a neurologist, an orthopedic specialist or whom?
Teresa_Dews,_MD: Internist first then pain specialist (I may be biased here!). A neurologist and/or spine surgeon (orthopaedic or neurosurgeon) can be accessed as needed.
Dillard: Can weakness in the legs be caused by a herniated disk?
Shrif_Costandi_MD: Absolutely. Acute disc herniation resulting in weak legs may be due to a single or multiple root compressions from a herniated disc causing unilateral leg weakness, such as a foot drop for example. Bilateral leg weakness and/or bowel and bladder disturbance may be caused by a large central disc herniation resulting in cauda equina syndrome.
Diagnosis and Testing
baglady: What are the best tests to have to determine if chronic back pain is not an underlying symptom of a more serious condition such as cancer or another disease? Thank you.
Shrif_Costandi_MD: An MRI of your spine should detect any other serious conditions in the spine that may cause pain, such as a tumor or vascular malformation.
baglady: Could a severe, sharp lower back pain indicate nerve damage or a torn muscle, ligament or tendon? I am having trouble getting this diagnosed.
Shrif_Costandi_MD: Severe, sharp, lower back pain can be indicative of several things. It can be due to a pinched nerve from a ruptured disc, a muscle spasm, fracture, or a torn muscle or ligament.
MC: I've already had therapy and it is not working. Currently, epidurals are the only thing relieving pain. I have a pacemaker so an MRI is not possible.
Shrif_Costandi_MD: If more studies are necessary, a CT myelogram will help.
noname: How can you differentiate between bone pain and muscular pain?
Teresa_Dews,_MD: Sometimes it's hard to differentiate between them. We get a clue by your history, physical examination and supportive imaging.
MC: I can't have a myelogram because I am allergic to contrast dye.
Shrif_Costandi_MD: If you can't have an MRI, then a plain CT is the only other option.
rebma02: What treatment recommendations would you make for someone with spinal stenosis who has tried multiple epidural injections and only receives relief for a few weeks at a time?
Shrif_Costandi_MD: It largely depends on your symptoms. If you are experiencing something called neurogenic claudication, which is characterized by progressive aching, weakness and pain in the back or legs when you walk, and you have MRI evidence of lumbar stenosis, a lumbar decompressive surgery (laminectomy) may benefit you greatly. The surgery is typically well tolerated and requires a one- to two-day hospital stay postoperatively. The surgery usually brings near immediate relief of your symptoms. If you meet these criteria, I recommend an evaluation with a spine surgeon to determine if you are a surgical candidate.
krklnd: I have been dealing with chronic back pain for 11 months. It started as a burning sensation on the side of my lower leg. It has progressed to constant pain across my lower back and down my right leg, but can at times be on both sides. It presents itself as sciatica. MRI did not show anything significant. An orthopedic doctor said there was not anything else he could do. I have had two rounds of oral steroids and a steroid shot in the hip. I have tried a chiropractor a few times, had six visits to an acupuncturist, physical therapy, a nerve conduction study and a CT myelogram. I have been given muscle relaxers and nerve medicine (Neurontin). I am now seeing a physiatrist who has given me a steroid shot in the piriformis muscle that had no effect, and two weeks ago, I had an epidural shot. It has not done anything. At this point, I don't have any reason to believe more epidural steroid injections will help. I have a follow up appointment this Thursday. I am wondering if I need some kind of non-invasive procedure to actually get in there and make room for this pinched nerve (it is between L4 and L5).
Shrif_Costandi_MD: At this time, it is a good idea to be evaluated by a spine surgeon. You have tried several conservative modalities with no relief, and you have evidence of neural compression that may be amenable to surgery. It is essential to bring an MRI or a CT myelogram with you to your appointment, as a spinal surgeon can analyze the findings and determine if you are a surgical candidate.
lsmith1taz: Is it better to wait as long as you can to get any surgery if that is what is indicated, as the procedures may improve with time?
Todd_Francis,_MD,_PhD: It is highly advisable to wait as long as you can before having spine surgery. This isn't because of more advanced procedures, however, it is because of your symptoms. You should wait to have spine surgery until the symptoms are so bad that you cannot stand it anymore.
LJK123: I cannot sit for more than 10 minutes without the lower back pain starting. Five of my discs on the left side have herniated. I am 80 years old and need some relief. The steroid injections did not work, and I try to get along on one 50mg tramadol. What else can I do? What can I take for headache safely since I am on the tramadol?
Shrif_Costandi_MD: If you have not yet had an MRI of the lumbar spine, I recommend obtaining either an MRI or CT myelogram of the lumbar spine and consultation with a spine surgeon.
LJK123: I had transforaminal epidural steroid injections for my low back pain. Unfortunately they did not help. What can I do now? Thank you.
Shrif_Costandi_MD: I would recommend an MRI of the lumbar spine and consultation with a spine surgeon. If you have not had physical therapy, I would recommend this as well.
LJK123: Over the last seven years, I have tried physical therapy for herniated discs along with tramadol. I tried epidural steroid injections last week using x rays. Tramadol helps, the injections did not. The therapy helps if used in very small time frame. Going for an hour of therapy leaves me unable to get up and walk for days (I am 80 years old). Is there such a thing a 15- or 20-minute therapy? I try to do the therapy on my own for about 10 minutes a day now. I was told not to have a back operation since I have five different discs in the lower back, which makes it too confusing.
Shrif_Costandi_MD: Depending on the symptoms you are experiencing, surgery may be a possibility. It might benefit you to obtain a consultation with a spine surgeon if alternative therapies are not working for at this time.
ARMINIUS: Thanks for your answer, Dr. Francis. I failed to mention that I have seen a neurologist and have had nerve conduction studies, and there is no significant neuropathy. I have had an MRI and a myelogram. The pain does not radiate, but is localized in my lower back. Is there anything more you can tell me with this additional information?
Shrif_Costandi_MD: The low back pain you’re experiencing may be a result of the deformity in your back. You might be a candidate for fusion surgery. I recommend consultation with a spine surgeon for a full workup.
LJK123: I have had an MRI and have seen a spine surgeon. He recommended the transforaminal epidural steroids, which were given by a pain specialist doctor. This did not help. Should I see a different spine surgeon?
Shrif_Costandi_MD: No. I would return to your existing spine surgeon and explain that the shots did not help. If he or she does not wish to perform surgery, then you are welcome to seek a second (or third) opinion.
pa2four: For 11 years now, I have suffered donor site pain of the iliac crest resulting from a spinal fusion at L-5, with no relief from oxycodone to stims to epidurals. It is a 24/7 stabbing pain. Has Cleveland Clinic ever successfully treated "donor site pain," this particular pain problem?
Teresa_Dews,_MD: If the chronic pain is due to a nerve injury, then you may respond to a radiofrequency ablation (RFA) procedure.
MC: I have a history of a 2009 back surgery. Recent chronic pain and a subsequent CT scan of my lumbar spine indicates L1-L2 posterior osteophytes, chronic bulge and moderate bilateral neural foramen narrowing. There are moderate to severe degenerative changes, especially at the L1-L2 and L3-L4 discs. The prior surgery was on L4-L5: pedicles screws transfixed L4-L5, transfixing the grade 1 anterolisthesis of L4-L5. My pain currently is managed with epidural injections. A recent fall aggravated the S-1 L-5 area. Is therapy really a very likely or viable treatment given the above?
Shrif_Costandi_MD: At the outset, I would recommend evaluation with pain management and physical therapy, as this can definitely help you overcome your pain related to the recent fall and your current situation. If this fails to help you, I recommend repeating the lumbar MRI and seeking evaluation with a spine surgeon.
corridck: I have spinal stenosis. I have been having a lot of pain lately. At the end of the day, I’m bent over and leaning over to my right side. Would spinal stenosis shots help? I would appreciate your opinion. Thank you.
Teresa_Dews,_MD: Depending on your overall medical and surgical history, the spinal injection my assist with reducing the severity of your pain as part of a comprehensive pain management strategy.
lsmith1taz: What kind of injections are available for pain, and are they limited in that they only help for a while? That is, you may experience relief the first three times you have the injection, but then they don't seem to work anymore.
Teresa_Dews,_MD: There are many different injections for pain including nerve blocks, spinal injections and radio frequency ablation (RFA). The choice of the injection depends on your pain. Most last for a short period, from days to months. The role for the injections is to either confirm the diagnosis or to temporarily decrease the pain while the patient does other things (physical therapy, medication management and time). If the injections seem to stop working, the mechanism for the pain may need to be reevaluated. The pain may be coming from a different area.
yless1: My doctor tells me he can find nothing in my back x-ray to explain my mid-back pain and muscle spasms. Would a cortisone injection in my spine be helpful, and how safe are they? What are the side effects?
Teresa_Dews,_MD: I think you need to see a pain specialist who would make recommendations based on your symptoms, examination and appropriate imaging. You may not need spine steroid injections.
betomiller: With the current move away from the use of narcotics for pain control, how is long-term pain to be addressed in a meaningful way?
Teresa_Dews,_MD: There are many options for long-term management of pain. There is no evidence that narcotics really help most patients, and they are associated with significant side effects.
Monalea: I have chronic lumbar spinal stenosis with moderate to severe pain. Will gabapentin help? I can only walk about a half block before the pain gets severe, so I haven't been exercising all winter. Is there any help? Will gabapentin help severe pain from lumbar spinal stenosis and in what dosage?
Teresa_Dews,_MD: Gabapentin can help; however, the dosage depends on many factors. I would also have you consider a spine surgery opinion after you try conservative therapy (medications, physical therapy as appropriate). A pain specialist would be able to evaluate you and recommend a treatment plan that is appropriate for your pain and health status.
MC: With respect to long-term pain management, can you elaborate on some of the alternative new options that are to replace narcotics. Also, have you ever considered medical marijuana for pain management?
Teresa_Dews,_MD: The options to replace narcotics aren't really new. Medical marijuana is still controversial, and the studies for its use are preliminary. There is a lot of anecdotal experience, but not enough evidence yet for most mainstream clinicians to feel comfortable prescribing it.
betomiller: That was not true in my case. Fentanyl was helpful, as were the Lidoderm® patches, but both of these have been removed from the Medicare prescription list as of January 1. I was injured in a rear-ended collision on a freeway one night, have had several series of injections and fusion of four lumbar levels. The pain is decreased, but remains a problem.
Shrif_Costandi_MD: A four-level lumbar fusion is a big surgery. It is not uncommon to still experience pain long after the surgery. Depending on when the surgery was done, further x-rays may be indicated to ensure that you’re healing properly. I would consult with the surgeon who performed the surgery originally, or a new surgeon if that surgeon is currently unavailable.
Maybe it’s Not Your Back
cmsgtdlk: I have had chronic back pain for 11 months that presents itself as sciatica or a pinched nerve, with pain going down my right leg. I have had x-rays, an MRI, steroids/steroid shots, physical therapy, chiropractic treatment, acupuncture, a CT myelogram and a nerve conduction study. I have a healthy spine, allegedly no pinched nerves, no cancer, arthritis or reason to have this constant pain. The doctor gave me Neurontin to try. (I have already done muscle relaxers and steroids.) He is done with me and has nothing else to offer. I am wondering what to do now.
Teresa_Dews,_MD: I recommend that you get a second opinion from a pain management specialist. Your pain may not be coming from the back, and other reasons for the pain need to be evaluated. For example, spasm of a muscle in the buttock called the piriformis muscle may mimic sciatica.
puderwink: I had a back fusion, fifth lumbar to sacrum, in 1993. Three years ago, I started having a pain in my right side. Some days it feels like what I believe appendicitis would feel like. The pain goes down to the groin area, and, sometimes, there is pain and burning on one or both sides where the kidneys are or what I would expect a hip flexor to feel like. I had an MRI and they said it wasn't my back so am wondering if it could be my hip? I am 69 years old and was exercising six days a week. I took a three-week break, but the pain is almost non-existent while exercising. However, an hour after and especially at bedtime, I can hardly stand to roll over. Any idea what it would be? Thank you.
Shrif_Costandi_MD: This can absolutely be attributable to hip pain, as hip pain due to arthritis or bursitis can oftentimes mimic back pain or sciatica. It is especially concerning if you have pain in your hip on movement of your leg or pain when you press on this side of your hip. If this is the case, it would be prudent to seek a consult with an orthopedic surgeon who specializes in hips.
jan13283: Back pain can be caused from heart problems, correct? If so, how do you know it is heart versus other forms of back pain?
Teresa_Dews,_MD: Heart problems and concerns related to the aorta, which is the large artery coming from the heart, can sometimes refer pain to the upper back. This is evaluated by your physicians from your pain history, medical and surgical history as well as your physical examination and imaging.
Other Conditions Complications
BEACHBABIES: I have lumbar spondylolistheses – L4/5, L5/S1. I was diagnosed as a child and am now 53. Just this year, the pain has become a daily issue. In particular, lifting my left leg while getting dressed creates sharp, debilitating pain in my right hip/buttock. Several months ago, I had physical therapy. A month ago, I had a bilateral epidural, which alleviated the pain entirely on the right, but not at all on the left. I am scheduled to have another epidural injection on the left. Assuming that doesn't solve the pain, the anesthesiologist has suggested a procedure to cauterize the nerves. Is this my best bet? I have some questions about the theory, as it reminds me of the story of the boy who put his entire hand on a hot stove and burned it badly, but couldn't feel what he was doing, i.e., killing the nerves to not feel the pain. But what about fixing the problem of what's causing the pain? Thank you.
Shrif_Costandi_MD: If an epidural injection helped, this is a good sign. This indicates that nerve root impingement is the source of at least a great deal of your current symptoms. Radiofrequency ablation is a good procedure and does help considerably. However, with a known lumbar deformity such as spondylolisthesis, you may want to consider surgical intervention as well.
Nanat426: I have systemic sarcoidosis and have multiple enhancing cervical lesions along with hypo and hyper intense lesions in T12, L2, L4 and L5, along with the bilateral sacrum and posterior iliac bones. There are no lytic or sclerotic osseous lesions, and there is no stenosis (per MRI). I have pain in the thoracic and lumbar areas. I am unable to walk or stand for long periods without severe pain. I had facet injection by a spine doctor with no improvement. I have also had bilateral SI injections (three times) from a pain doctor with minimal lumbar improvement, although it did help with pain radiating down my legs. I have been on prednisone (I just stopped) and am currently on Humira®, gabapentin (SFN) and Flexeril® to try to get some sleep. My rheumatologist wants a biopsy, but the CT doesn't show a good spot. I have been trying to walk in a pool to get some exercise when tolerated. I have oxycodone for extremely bad days but rarely use it, as it barely takes the edge off and I don't want to get used to taking it. Do you have any suggestions for pain relief? Thanks so much.
Teresa_Dews,_MD: I recommend a second opinion regarding options for your pain. You may need to review multiple modalities to manage the different locations and components of your pain. I applaud your efforts to minimize medications and to be as active as tolerated. Partnering with the right team (your rheumatologist, physical therapy, an interventional pain specialist who would consider spinal implant therapy as appropriate and psychology) may help.
Nanat426: I have multiple bone lesions in the marrow. My last MRI showed them to be increasing in size and extent. Also, they are more confluent appearing. The facility I go to said the CT didn't show well enough to do a biopsy. When I went to Cleveland Clinic, they couldn't understand why they can’t do one. Does it vary from facility to facility? Since I already have a sarcoidosis diagnosis, they are assuming it is sarcoid but not positive. All my nodules and lesions are atypical for sarcoid. The only biopsy I've had was a parotid tumor that showed positive for sarcoidosis. Nothing is helping with pain. I’m just being told it’s from lesions. Do you have any suggestions?
Shrif_Costandi_MD: If the bony lesions result in compression fractures of the spine, kyphoplasty may provide some relief. This involves inserting cement into the bones through a needle. This is only effective in cases of compression fractures, not in cases of bony lesions without fracture.
mataki: I have degenerative disc disease in my lower back combined with mild scoliosis, and have been in pain now for over two years. I had facet injections on the left, which helped for about two to three months. Does it make sense that it is worse when I have to stand or walk for long periods of time?
Teresa_Dews,_MD: Your pain description makes sense and may be associated with the mechanics of your spine and some muscle spasm.
ARMINIUS: I have been diagnosed with lumbar spondylolisthesis, worn disks between several lumbar vertebrae, stenosis and arthritis. The pain is managed adequately with a moderate dose of ibuprofen and with exercises I was taught during physical therapy some years ago. I was told by my orthopedist that surgery isn't necessary and that the two vertebrae where the slippage is are likely to autofuse because the disk is gone. I've had problems with my toes getting cold even at indoor temperatures for about 15 years, and this has gotten worse. For about three years, they have also been numb, which also appears to have progressed. I recently had a fusion and corpectomy on my cervical spine, which relieved numbness in my fingers, weakness in my arms, tingling throughout my body and an awkward gait, but had no effect on my toes. Could those symptoms be related to my spondylolisthesis or stenosis of my lumbar spine? If so, what would be the treatment?
Shrif_Costandi_MD: It is important to distinguish between small nerve disease, such as peripheral neuropathy, and large fiber disease, for example, from a compressed nerve due to spondylolisthesis. If the numbness and sensation changes are localized to the feet, this is more likely to be the result of peripheral neuropathy, which is managed medically. If the pain radiates down the legs and feet or is in the back and buttocks as well, this may be a symptom related to spondylolisthesis and stenosis. It might benefit you to obtain an MRI of your lumbar spine and seek consultation with a spine surgeon in order to be fully examined and have a recommendation either for surgery or consultation with a neurologist.
Not Quite Right for Treatment
lsmith1taz: Are there any new/promising treatments that help promote healing, not just mask pain, for lower back pain due to degenerated discs?
www.sciencedaily.com/releases/2014/03/140308094811.htm - Is this working on humans?
www.ncbi.nlm.nih.gov/pmc/articles/PMC2587664/ - How about this?
I'm a very active 53-year-old woman in constant pain. I want to remain very active.
Shrif_Costandi_MD: Low back pain due to degenerated discs is very difficult to treat. The main issue is trying to pinpoint what exactly the pain generator is in patients, and it can vary from patient to patient. For instance, patients with mechanical back pain experience a deep throbbing, agonizing low back pain that is worsened with activity and relieved with rest. The patients typically have one or more degenerated discs with arthritic changes in the surrounding bone, and these patients typically respond well to lumbar fusion procedures. Other patients have non-typical back pain, burning sensations, sharp sensations or pain in other parts of the body as well. These patient's typically respond poorly to lumbar fusions.
The two attached articles address placement of stem cells or growth factors into discs in order to regenerate them. Currently, this is not an option of spinal surgery practice in humans, as these techniques are very experimental at this time. Definitely more research is needed to determine the efficacy and safety of these procedures in humans moving forward.
Disc replacement surgery, or disc arthroplasty, is an option in the cervical spine at this time. This procedure is available for lumbar disc degeneration as well; however, the data has shown this to be far less effective at treating low back pain than neck pain. I, therefore, would not recommend disc arthroplasty for the lumbar spine. In the cervical spine, the degenerated disc is removed and replaced with an artificial prosthesis that retains native motion of the cervical spine.
Jack_in_Florida: There is a lot of advertising locally in Florida regarding a procedure called VAX-D. Apparently, it involves lying on a split table and mechanically stretching the spine. Several chiropractors offer it as a procedure to try for back pain. Is there any data to support their claims of re-infusing the discs with blood and O2?
Shrif_Costandi_MD: There is no data to support injecting the discs with blood and oxygen. As a matter of fact, this may be harmful and potentially dangerous. Discs in and of themselves do not receive direct blood supply. They receive nutrients passively from the surrounding endplates of bone. Injecting blood artificially into the discs will likely precipitate disc degeneration and worsen your condition.
Moderator: That is all of the time we have for questions. Thank you everyone for participating today; and I would also like to thank Dr. Dews and Dr. Costandi for taking time out of their day and for insightful answers to our questions about back pain.
Shrif_Costandi_MD: I hope that I was able to answer all of your questions accurately. If you have more questions for me or wish to see me in consultation, please come see me in my office for a clinic visit. This can be set up through the Cleveland Clinic appointment line. I have office hours Wednesdays and Thursdays at Hillcrest Hospital in Mayfield Heights. Thank you and best of luck, Todd Francis, MD PhD
Teresa_Dews,_MD: Thank you for attending this webchat. Spine pain is like any other medical condition. You want to concentrate on your overall health because dealing with chronic pain can impact so many areas. Smoking cessation, adequate sleep, stress management, movement (exercise) and good body mechanics, as well as an excellent diet are important for your health and decreasing your pain. A pain management evaluation should review your pain in relationship to your medical, surgical and psychosocial history. There is a lot we can do together to improve your pain. Best, Dr. Dews
To make an appointment with Teresa Dews, MD, or Shrif Costandi, MD or any of the other pain management specialists, please call 216-444-PAIN (7246) or visit us at clevelandclinic.org/painmanagement for more information.
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