Online Health Chat with Michael Steinmetz, MD, and Philippe Berenger, MD

September 11, 2015

Description

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 disturbs sleep.

Take this opportunity and have your questions answered by our specialists Michael Steinmetz, MD, and Philippe Berenger, MD. This chat will discuss different types and causes of back pain, how pain affects quality of life, 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

Co-director for the Cleveland Clinic Center for Spine Health, staff physician Michael Steinmetz, MD, is board-certified in neurological surgery. His specialty interests include cervical spondylosis, chiari malformation, complex spine instrumentation, degenerative spine disease, and spinal cord and spine tumors.

Dr. Steinmetz completed his residency at Cleveland Clinic in neurosurgery after graduating from medical school at Texas Tech University School of Medicine in Lubbock, TX. He completed his fellowship in spine surgery at University of Wisconsin Hospital and Clinic in Madison . He sees patients at Cleveland Clinic main campus.

Philippe Berenger, MD, is a staff physician in the Department of Pain Management at Cleveland Clinic. He is board-certified in pain management and internal medicine and sees patients at both the main campus and the Ambulatory Surgery Center in Lorain. His specialty interests include acute and chronic neck and back pain, spine and joint pain following surgery or injury, abdominal pain, spinal cord stimulation and neuropathic pain. He also has an interest in painful conditions related to work injuries.

Dr. Berenger served his internal medicine residency at Cleveland Clinic after graduating from medical school at Faculte de Medecine d'Amiens in Amiens, France. He has also completed fellowships in interventional pain management at Cleveland Clinic and in occupational medicine at Robert Wood Johnson University Hospital.


Let’s Chat About Managing and Treating Back Pain:

The Pain Source

dflow: I have lower back pain and also pain in my left buttock. The pain management doctor says it is coming from my sacroiliac. He did injections into it five months ago, and it did seem to help for three months. The pain came back with a vengeance, and he did injections again two weeks ago. It may have helped some but the pain is still there, especially if I do any manual labor. Also, I felt something pop in the center of my lower back, and then there was bad pain on the left side of my lower back and buttock. I had an MRI and the orthopedic doctor said my spine was full of arthritis and I had spinal stenosis. I also attended physical therapy for six weeks and sometimes was pain free, but it always came back. The pain management doctor said there was a lot of dark areas he noticed while giving me the injection in my sacroiliac. Is there any surgery that might be appropriate for me?

Philippe_Berenger,_MD: Pain in the low back can be midline (axial along the spine) and can radiate to the buttock and further down the leg – OR NOT. Certain pain patterns can point us toward a joint or structure in the spine or adjoining areas including the hip, sacroiliac joint, discs, facet joints , pelvic/abdominal organs and even arteries as the structure that is MOST LIKELY the source (or generator) of pain. Frequently, x-rays will show degeneration (or "wear and tear" osteoarthritis) in multiple areas including the spine, discs, sacroiliac joints, etc. Very often, some of these arthritic structures can have the same distribution or pain pattern, so it can be difficult to come to a decision as to which of these arthritic structures is responsible for the reported pain.

Injecting an anesthetic into a structure or joint with a needle will render that structure insensate (or numb) so that if pain is coming from the injected structure, it will be pain free for four hours or more (much longer if a steroid is combined with the anesthetic).
This is usually referred to as a diagnostic injection because it helps in narrowing down which of the different joints is responsible for generating pain. In your case, your sacroiliac joint was injected. If your doctors feel that other structures may be involved, further diagnostic injections may be helpful. Only if you are certain of the pain generator can you consider surgery on any of these structures or problems, be it your sacroiliac or your spinal stenosis.

robo: How much does belly fat contribute to back pain?

Philippe_Berenger,_MD: Usually not very much, other than certain spine conditions in which an increase in arching of the spine (lordosis) in response to the load of the obese abdomen can exacerbate these conditions. More frequently, smoking, genetics, associated diseases (diabetes, arterial disease/ narrowing, psychological factors) contribute more to back pain and the degree of difficulty in controlling this pain.

acho7: Can a hip replacement cause back pain?

Michael_Steinmetz,_MD:  Hip problems can clearly cause back pain. If there is a problem with the hip replacement, i.e., loosening, back pain may be present.


Diagnosis and Treatment

Anxious: Could you explain radiofrequency lesioning? My doctor thinks it's an option for me. Thank you.

Philippe_Berenger,_MD: This is also known as RFA or radiofrequency ablation.
It is the application of radiofrequency waves via a radiofrequency needle in proximity to a nerve. These waves will heat up the tissue and in the case of a nerve will render that nerve incapable of pain transmission for a period of time, until that nerve regenerates (usually six months to a year). It is most commonly used in patients who have axial (non-radiating, non-sciatica) cervical, thoracic or low back pain. These patients may undergo a nerve block with anesthetic to the nerves supplying the vertebral facet joints via a needle and under x-ray/fluoroscopy guidance. The anesthetic will numb the facet nerves for approximately four to six hours. If the spine pain is coming from the vertebral facet joints the patient should be 70 percent to 80 percent pain free for four to six hours after the block. If the patient is not 70 percent to 80 percent pain free after this facet block, then we will conclude that the pain is not generating or being caused by the facet joint structures and no further block or procedure for the facet joints would be recommended.
If the patient is 70 percent to 80 percent improved for four to six hours after the facet block, then radiofrequency lesioning or ablation can be performed with the expectation that pain relief would be sustained for six to 12 months following the procedure.

gomer2009: I have lower back pain caused by bulging discs L1 through L5. Any physical activity requires ice and the use of a T.E.N.S. unit. What suggestion would you have to ease this pain?

Philippe_Berenger,_MD: Disc pain is usually worse with sitting, straining and forward bending at the waist. If the pain is purely midline and not radiating to the legs, a course of dynamic lumbar stabilization, core strengthening, a trial of traction and regular exercise (which can include aquatics) may be beneficial. Physical therapy and a home exercise program are key for long-term control of disc pain. Treat acute flare ups with over-the-counter anti-inflammatory medications.

1stvett: What was the treatment for stenosis prior to fusion? Are there any other options? The idea of a brace for three to four months and six to 12 months total recoup seems excessive.
 
Michael_Steinmetz,_MD: Fusion is not the treatment for stenosis. Laminectomy without fusion is the treatment for this condition. Many options exist, from medications, physical therapy, injections and surgery if symptoms are severe. Bracing for a prolonged period of time is a bad idea. We do not use a brace after laminectomy or even fusion with screws and rods.
 
crystalclear: Can facet joint injections (RFTC) obtain permanent results for pain caused by arthritis? If not permanent, how often is it safe to have the procedure repeated?

Philippe_Berenger,_MD: Facet joints can be either blocked with an anesthetic or with added corticosteroid. The anesthetic will help in determining if the facet joints are generating the pain or not. If the pain improves by 70 percent to 80 percent after the block, the option is to do radiofrequency ablation (RFA). The expectation is that RFA would provide similar relief to the block for a period of six months to one year. The best option is to combine RFA with an exercise program so that with more muscle support of the spine, the pain can be controlled for the longest period of time possible. RFA can be repeated every six to 12 months, as necessary, as long as relief obtained lasts at least six months.

bbm: Several years ago, I was diagnosed with degenerative SI joints. I also have a herniated disc at L4/ L5. I received pain injections about a year ago, which seemed to help. A few months ago, I developed right hip pain that gets worse when I lie on my right side. I went back to the pain doctor, and he is electing to inject the SI joints again, without getting a current x-ray of my hip. Is this the standard of care that is commonly practiced?

Philippe_Berenger,_MD: Patients frequently have combination wear and tear osteoarthritis of the hips and spine. If you have pain on the side of your hip when you lie on it and it is sensitive to touch, you may have inflammation of the hip lining called the BURSA. This is referred to as trochanteric bursitis of the hip. An injection of this bursa can be done in the office. If this is the cause of your hip pain, you should experience immediate relief.


Donor Site Pain

Kwie: I recently underwent both a procedure for a compression fracture and surgery for a spinal fusion. I continue to have pain issues, and I am allergic to most narcotics or they simply have no effect on me. I have been told by my surgeon that it is his opinion that I have a hypersensitivity to pain due the fact that I have rheumatoid arthritis that has gone untreated due to the surgeries. The source of most of the pain is the site where they harvested some bone marrow (iliac?), and the surgeon injected the site several days ago with no results so far. Might you have any suggestions for me?

Michael_Steinmetz,_MD: Donor site pain is an uncommon but troubling condition following bone graft harvest during a spinal fusion. There is no easy treatment for this kind of pain, especially surgically. We do not re-operate on the area for treatment of pain. A rheumatologist may be able to help with treatment of pain if it is due to rheumatoid arthritis. Some pain management doctors use a spinal cord stimulator in a non-FDA format directly at the site of pain. This is termed peripheral field stimulation. This may be an option. It is performed by pain neurosurgery here at the Cleveland Clinic.

pa2four: I have had donor site pain for 12 years, and ALL therapies/interventions have failed. Have you at Cleveland Clinic ever personally had success with alleviating the pain by addressing the scar tissue where it may be coming from?

Michael_Steinmetz,_MD: We have not had success with scar tissue resection, as the scar tissue is rarely the cause for the pain. An alternative may be a peripheral field stimulator, an off-label use of a spinal cord stimulator. This is placed directly at the site of pain.


Stages of Treatment

jwt: I have chronic back pain because of lumbar spinal stenosis (LSS). Treatments include injections, RFA, massage therapy and various exercises and stretching. I still have pain. Is surgery a better alternative? What surgery would give me the best results? I still want to golf. Joe from Michigan.

Michael_Steinmetz,_MD: Surgery is very effective for LSS. It sounds like you have performed significant conservative therapy with no effect. If you have had some temporary improvement with injections, surgery or at least a surgical consultation is likely the next best step.

77ginger77: I have a pinched nerve in my lower back. The doctor wants me to do physical therapy, but my husband just had a heart attack and will be having open heart surgery in October. I don't have the time to do this now. Is there anything else I can do, such as an injection? I am in constant pain. Thanks.

Philippe_Berenger,_MD: If you have radiating pain from your low back into your buttock and further down the leg, several options are possible, including physical therapy and an x-ray. If you have any weakness in a muscle group in your leg (weakness walking on your tiptoes or heels, etc.), then further imaging may be recommended (lumbar MRI).
If you have significant leg pain and NO weakness, it may be an option to consider an injection of anesthetic and corticosteroid in your spine (called an epidural steroid injection), which may help the leg pain until you have the time available to do the other options mentioned. Also, certain medications taken by mouth can help lessen nerve pain in the leg.

gatorfrog: Thank you for any help or information. I have several back issues: herniated discs (two), spinal stenosis and sciatica. Over the last two years, I have had several procedures or injections: epidural injections, trigger point injections and radiofrequency ablation. I am very frustrated because either they work for a short period of time or they don't work at all, and I am so tired of hurting all the time and not being able to exercise. We live in the mountains and I want to hike but I can't. Should I keep trying, or is there something else I should do? Thank you.

Philippe_Berenger,_MD: You have probably had x-rays, an MRI and used other tools and interventions (epidurals, etc.) with only partial or equivocal results. It may be time to consider reviewing your current imaging /x-rays and all procedures done and discussing whether surgical options or other interventions are indicated.

sinaihospital: I have had back pain for a long time. My back pain was diagnosed by the late spine surgeon Dr. Harry Herkowitz. I have had MRIs, shots, physical therapy and medicines for my back pain, which have helped me very little or not at all. Can surgery help me in this case? Thank you for your advice.
 
Michael_Steinmetz,_MD: We certainly miss Dr. Herkowitz. It is hard to say surgery will be effective. If you have instability or deformity, fusion may be effective. Perhaps re-evaluation by a surgeon is the most prudent move at this time.

cfran727: What can be done for spinal stenosis? Thank you.

Philippe_Berenger,_MD: Spinal stenosis symptoms are low back pain and or leg pain or weakness, which worsens with prolonged standing or walking and requires sitting to obtain relief. The simplest and first option is a physical therapy program using flexion exercises and progressing to lumbar stabilization exercises, along with over-the-counter ibuprofen (depending on age and if this can be tolerated with kidney function, cardiac issues etc.). Lumbar epidural steroid injections at the level of the narrowing in the spinal canal can help you regain walking ability and help you perform an active exercise program (aquatics also are very helpful). If epidural injections and exercise help, they can be repeated several times a year. If the patient reaches a point when these injections do not last long enough, then consideration can be given to a surgical option of relieving the stenosis with or without a fusion, which depends on several factors that need to be discussed with your surgeon.

thinker: What is the treatment progression leading up to surgery?

Michael_Steinmetz,_MD: This is very hard to comment on. We always try conservative therapy first, which is often very effective, and thus we avoid surgery. If symptoms progress, treatment typically progresses to medications, physical therapy, different medications, injections and, lastly, surgery if indicated.


Accidents and Injuries

Tracy Tightback: On April 20, 2014, I fractured my femur, and on April 21, 2014, I had three screws put in. I found out the bone stopped getting blood and it died. On Sept, 8, 2014, I had a total hip replacement. I first noticed I was bending over in July 2014, with tightness to the right of my spine. The tightness has gotten much worse, and I am bent over even more. The tightness at night after I have had dinner gets so bad it is difficult to breath and goes around to my stomach. I also have six large gallstones that the doctor said might be the problem. My kidneys are fine. You should also know that I was diagnosed with Parkinson's disease nine years ago. After seeing the MRI, the doctors have said that I have spinal stenosis along with arthritis in the lower spine. My spine also has a curvature of 30 percent. The last doctor said the reason for the pain is a broken bone in my back along with a broken rib. My question is: what could be causing all this tightness that pulls me over as well. The only relief I get is curling into a ball on my back on the bed.

Philippe_Berenger,_MD: Patients with hip arthritis frequently have combined hip and spine arthritis. Usually, the first to get operated on or addressed is the hip. After this, if spinal stenosis is a problem with low back and or leg symptoms with walking, a lumbar epidural steroid injection along with lumbar flexion exercises may help. Sometimes, the pain can be related to the arthritis in the joints connecting the vertebrae (facet joints), so these can be addressed if they are proven to be painful after a block of these joints has relieved the pain.

c.gre  I'm 22 years old and I was in a car accident in 2013. I've been seeking help but I'm still in pain every once in a while. How do I get my body to heal completely from this tragic accident? I was diagnosed with sciatica and four mildly herniated discs in my lumbar. I'm interested to hear someone else's opinion. Will my back always be like this? The pain also goes up into the right side of my neck and it becomes very tight. My thoracic becomes very tight, too. I know when your back is tight it can cause your neck to be. How do I fix this?

Philippe_Berenger,_MD: If you have leg pain (sciatica) and low back pain, options include decreasing inflammation in disc/nerve root areas with oral medications and possibly an epidural steroid injection. If you have no weakness in the leg and your worst pain is in your back, an active exercise program with postural exercises to relieve pressure on the nerve followed by dynamic lumbar stabilization exercises/core strengthening will be helpful. In some cases, aquatic exercises may be beneficial. Frequently, surgery will not be an option (or fix), and dealing with residual pain may involve adjusting to pain, which can be helped by certain cognitive interventions (biofeedback, mindfulness training). This is frequently done in the context of a multidisciplinary pain program.


Let's Talk Pain

Armstrong: In the introduction for the chat, it is mentioned about ways to measure back pain and ways to communicate the pain you are experiencing. Would you elaborate, provide key words or possible descriptions? I am not a fan of the pain scale with smiley faces because it is so subjective to each individual's pain threshold.

Philippe_Berenger,_MD: Pain scales with either faces or scales from 0 (no pain) to 10 (worse pain imaginable) are useful to judge the degree of pain as a general guideline. They are also useful in judging if and how a patient responds to various medications, treatments and surgery. What a physician will listen for from his or her patient is whether the pain is described as constant or just comes and goes. What position, activity or other factors either worsen or lessen pain. If the pain affects the individual's ability to perform work or recreational activities. Describing if the pain is dull, sharp, shooting, burning or any other descriptor that an individual feels applies to his or her pain can be helpful.

LJE: I have pain in the right lower sacrum area of my back. I had an MRI in March 2015 that shows:

Tarlov Cyst in the left T11-T12 neural foramina measures 9.7 mm.
7 mm Tarlov cyst in the left L5-S1 neural foramina.
2 mm Tarlov cyst noted in the left S1-S2 neural foramina.
At least 5 Tarlov cysts noted in the midline and right sided S1/S2 neural foramina measuring 4.8, 5.4, 7.3, 6.3 and 6.3 mm.
 
I do not have any spinal stenosis. I have been told that the Cleveland Clinic doctors do not treat Tarlov cysts. Aspirating them does not help, as the sacs only fill back up. It seems only a handful of doctors in the entire US will operate on Tarlov cysts in such a manner to reduce the return of the sacs that cause pain. Can someone please tell me why they feel that Tarlov cysts do not cause pain? I did fall a few times and I hear that trauma to the cysts can cause them to cause pain. Thank you.

Michael_Steinmetz,_MD: Tarlov cysts rarely cause symptoms and, hence, very few if any surgeons operate on them. They are present during development and, hence, are not pathologic and do not cause symptoms. They are commonly seen on normal MRI. It is the majority thought process that they are incidental findings and there is another cause of the pain or symptoms.

Trav: I had spinal fusion of C4 and C5 in 1997. Everything was fine until I went snorkeling in 2007. When I blew out the snorkel, a pain went across my body from fingertip to fingertip. When I came out of the water, it was like I forgot how to walk and fell. I was given another fusion, this time C6 and C7. They say it was successful, but I still walk like a drunken sailor. My toes stretch out to grip because of my imbalance. My feet have stabbing pain like neuropathy, but I also get spasms in my legs that make my whole body shake and are very painful. I've used every drug possible from my neurologist, and he wants me to see a pain clinic. Have you ever heard of somebody else going through this? The spinal doctor said there was nothing else he could do. An orthopedic specialist as the University of Michigan said the same. I need to get rid of this pain. It disrupts everything I do and has been gradually getting worse. Thanks for your time.

Michael_Steinmetz,_MD: It sounds like you may have a type of spinal cord injury or cervical myelopathy. If the spinal cord is completely decompressed, further spine surgery would likely have minimal effect. Pain management is likely appropriate. Spinal cord stimulation may be an option, and your pain specialist could comment on this.

Ladyb: I noticed since I gained weight that I have extreme pain in my lower back when I walk. I need to walk to help me lose weight, but walking just a few feet causes the pain in my lower back to increase. Do you have any non-medicinal recommendations so I can start a walking program?

Michael_Steinmetz,_MD: Water walking is an excellent option for your situation. The key is to exercise any way you can do it.

Macbeth: I am a 76-year-old woman who had surgery for spinal stenosis. Two surgeries were performed, the second because of a hospital infection. I had spinal fusion. I am in constant pain now, having had numerous injections, one radiofrequency ablation. Is there anything you can suggest to get rid of some of this pain; it has literally destroyed my life because I can no longer walk without severe pain. I am grateful for any advice. But if the surgery has already been done, then what?

Michael_Steinmetz,_MD: I think it really depends on the status of your spine and fusion at this point. A surgical consultation or second opinion sounds reasonable. If you are fused and your spine is aligned, alternative strategies may be appropriate. An implanted pain pump may be appropriate if your pain is severe. Pain management performs these procedures.


Advertised Approaches

Jack_in_Florida: There has been a lot of radio advertising about VAX-D, some sort of approach to back pain that is referred to as spinal decompression and involves lying on a stretching table and having your spine stretched. Can you comment?

Philippe_Berenger,_MD: This is another way of doing what is called lumbar traction.
This can sometimes be helpful in the case of pain generating from facet joints or discs.
It is not usually recommended in the older individual with lumbar canal stenosis. It is usually trialed as part of a physical therapy exercise program.

mariaelena: How different are "Laser Spine Institute" surgeries from traditional treatments for back pain, and do they have as successful an outcome? Their ads are everywhere and they promise near miraculous relief.

Michael_Steinmetz,_MD: I can only comment on patients who have seen me after they have had surgery at Laser Spine Institute, so it's hard to say. However, many of the surgeries performed there are exactly the same minimally invasive surgeries we perform here at the Cleveland Clinic. We do a large number of minimally invasive spine surgeries here at Cleveland Clinic, all done through very small incisions. The focus of any treatment should be the best treatment for the condition.

hungry: How effective is laser surgery in treating back problems?

Michael_Steinmetz,_MD: It is very hard to define laser surgery. Laser surgery is marketing and not necessarily a treatment. It refers to minimally invasive spine surgery. This type of surgery can be effective, but it depends on the condition being treated. If appropriate, it can be very effective. We perform minimally invasive surgery commonly at the Cleveland Clinic.


Eye on Surgery

Tara: I have flat back deformity and sagittal plane deformity that have decompensated to the point where I'm having increasing disability and my quality of life has been very difficult because of walking. I've had injections with no relief and did pain management, which I feel didn't help me with the pain and ability to stand up straight and walk any long distance. The doctors have recommended a L2 osteotomy with a thoracolumbar pelvic instrumental fusion. One of the images showed 3' standing scoliosis films that showed an SVA of approximately 13 cm, and I have a lumbopelvic mismatch of 46" according to a report from one of the doctors. A neurosurgeon and an orthopedic surgeon would be doing this surgery, and I was just wondering what you can offer me. Thank you.

Michael_Steinmetz,_MD: A flat back is very debilitating. Surgery can be very effective for this problem. An osteotomy is the typical treatment and can restore the lumbar pelvic parameters. It sounds like the operation offered is the same one I would recommend.

Tara: Dr. Steinmetz, would you please recommend for me a doctor I could see at your clinic regarding your comment that this would be the same surgery you would recommend. I would love to talk to someone for a second opinion but have had no help with trying to schedule an appointment, plus I'm not sure who I should see, an orthopedic or neurosurgeon first. I want to make sure I do the right thing as I'm thoroughly frustrated with the pain even though I continue to do as much as I can. Thank you.
 
Michael_Steinmetz,_MD: Tara, you could see me as I specialize in spine deformity. We are a unified spine department. We do not segregate orthopaedic and neurospine surgeons. We are all fellowship-trained spine surgeons.

Tara: Dr. Steinmetz, I would like to see you within the next few weeks. Please send me contact information. Thank you so very much.

Michael_Steinmetz,_MD: Here is the appointment line, 216.636.5860. We look forward to seeing you.

Jbaut: I have been diagnosed with spinal stenosis, thoracic or lumbosacral neuritis or radical unspecified disorders of the sacrum and polyneuropathy of diabetes, which has left me with right-sided weakness and an unsteady gait at times. Would surgery benefit me?
 
Philippe_Berenger,_MD: Diabetic peripheral neuropathy can coexist with spinal canal stenosis. If the right-sided weakness is confined to the leg and worsens with standing and walking, it may be due to the lumbar canal or stenosis (narrowing) at the neural foramen.
The pain pattern of the neuropathy is different and more constant than that of stenosis.
Sometimes, a combination of spinal injections targeting the areas of narrowing along with a trial of a medication used in diabetic neuropathy may help elucidate which of the conditions is causing the bulk of the symptoms. Decisions are based on a careful history of your symptom patterns and an examination and review of imaging and other tests you may have had relating to your neuropathy and diabetes control.

Lolly: What warning signs indicate that surgical intervention may be necessary?

Michael_Steinmetz,_MD: We call these red flags: urinary or bowel incontinence, progressive weakness and/or pain that is out of control. These are the reasons surgery would be recommended in an urgent, emergent fashion. When surgery is indicated outside of the aforementioned red flags, it is largely done when quality of life is moderately or severely affected and not managed with other measures.

GNT: I need your help! I was diagnosed with degenerative disc disease at the age of 23 (I will be 50 in October.) After two "minimally invasive" back surgeries to repair L4/L5 – the first in 2006, the second in 2009 – I ended up with severe neuropathy in both legs, and I still have three herniated discs in my lower back (L1/L2, L2/L3, L5/S1.) I ended up with a fusion to repair L4/L5. L5/S1 has no disc left and the sac is completely dehydrated, so as my back surgeon told me, my spine is like a house with a severely damaged foundation that must be repaired. 1) Is neuropathy permanent? The pain is unbearable most days and the toe cramps and leg jerking uncontrollable at times, which just adds to the misery. 2) When I had my surgeries, artificial disc replacements on adjoining disc levels wasn't an option. The Charite Artificial Disc wasn't even FDA-approved then. Is this still true, and if not what options are there for me?

Michael_Steinmetz,_MD: It is hard to comment on your neuropathy. It could be permanent. A neuromuscular neurologist could likely answer this. If so, no further surgery would improve this. Very few centers perform lumbar artificial disc replacement. The vast majority have completely abandoned this procedure. In fact, most insurance companies do not approve it as an option. Fusion is the main procedure in the US. These disc replacements are currently being done in Europe.


Regarding Lumbar Fusion

Michael_Steinmetz,_MD: There have been many questions regarding lumbar fusion. Fusion is not routinely used for degenerative spine disease such as spinal stenosis. It is only used for instability such as trauma, tumor or infection. When one spine bone moves forward on another, it is called spondylolisthesis. It is often associated with stenosis and a fusion is used. Lastly, fusion is used for scoliosis.

Larry7025: I have been suffering with herniated discs in L3, L4 and L5/S1 since 2006. I have researched back issues and believe that the only option is a fusion procedure. I am not sure if disc replacement is an option in my case. The fusion process really is very intimidating to me. Is it possible to do a replacement procedure?

Michael_Steinmetz,_MD: Fusion is ONLY performed for spinal instability. It is not used in the treatment of herniated discs. It does not sound like you would need a fusion. We have largely abandoned disc replacement in the lumbar spine in the US. It is still performed in Europe.

jga : I have a grade 1 spondylolisthesis with a disc herniation at L5/S1. Almost all of the surgeons I have consulted with want to do an ALIF 360. Do you believe that a TLIF or PLIF will work as well? As a male, I would like to avoid going through the abdomen if I could. Thank you, John.
 
Michael_Steinmetz,_MD: A 360-degree fusion at L5/S1 including ALIF is a very common treatment for your pathology. TLIF and PLIF are alternatives that are effective as well. There are pros and cons of these approaches that must be weighed when making these decisions. A TLIF is a common way to treat this issue from an approach that avoids the abdomen.

jaga : I was told that Dr. Steinmetz does more posterior fusions. Can he comment? I am interested in having a TLIF with posteriolateral fusion? Also, I would like to know recovery time and if he uses BMP in the fusion? Thank you.
 
Michael_Steinmetz,_MD: TLIF is a very effective operation for many conditions. The recovery time is six weeks to three months with or without BMP.


Options for Relief

kirk371: Is there anything I can do for my back: when I stand for a long period of time, it is hard to move and I have to sit or lie down for a while to relieve the discomfort. I also
wear a back belt when working in the yard. It helps some. Also, while riding in a car I use a pillow behind my back, which seems to help, but I stop and walk around when I can. That helps some, but what would cause this type of pain? I have been to a chiropractor a few time for some relief, but it always comes back.
 
Philippe_Berenger,_MD: The type of pain pattern you are describing is an axial (or midline pain along the spine) pain not radiating to the legs. Axial pain with sustained positions, sitting or starting up from a particular position and improved by chiropractic adjustment may be generating from the joints that connect the back part of each vertebra, called the facet joints. An active physical therapy and exercise program may be beneficial along with over-the-counter anti inflammation medications (Aleve, ibuprofen etc.). If the pain persists and after review of other factors (including your medical history, x-rays
etc.), there is the option of a diagnostic/therapeutic block of the nerves that go to these facet joints. Depending on your response to one or two facet blocks, a radiofrequency ablation may be an option.

Kwiea: You have mentioned several times the use of a peripheral field and/or spinal cord stimulator for donor site pain. Have you had a good success rate with these types of procedures?

Philippe_Berenger,_MD: There have been anecdotal reports of success. They are generally not covered by insurance. A TENS unit would be the simplest trial of neuromodulation.

alanr: What is your opinion on the use of acupuncture to treat lower back pain, numbness in the right foot and loss of muscle mass in the right leg. I am also doing physical therapy to strengthen the muscles in my leg.

Philippe_Berenger,_MD: Acupuncture can be helpful and it is worth trying for two to three sessions. Residual leg nerve pain can be addressed in part with several medications including Neurontin, pregabalin and other antiepileptics or Cymbalta/Effexor/Savella.
Depending on the cause of the residual leg pain, an epidural injection may be helpful.
Other options can be considered depending on structural issues underlying or associated with this pain (including possible diabetes, peripheral neuropathy, etc.).

miamickey: I have the beginnings of AS. I am in constant pain except when relieved by narcotics or freezing the area. It's worse when I wake up, lie down or even just sit. Is Enbrel a medication that arrests this type of autoimmune pain? I'm praying so. Mia

Philippe_Berenger,_MD: Yes. Enbrel and other so-called disease modifying medications are key in controlling symptoms associated with rheumatic diseases.
Sometimes, associated issues such as nerve-related symptoms need to be addressed with different types of medications.

c.gres_11: I have had the cortisone injections. It has been almost two years since I had them in my back, and my lower back is starting to hurt again. I've done swimming exercises. Does working out help the situation?

Philippe_Berenger,_MD: It really depends on what structure in your spine and/or pelvis is generating the pain. In general, an active exercise program and aquatic exercise are beneficial; however, the type of exercise needs to be determined based on a physical exam, history of your pain pattern and any imaging /x-rays you have had done.

malvern: I’m seeing lots of colleagues getting standing desks. Is this a good long-term benefit for back health, or are they more determinate?

Michael_Steinmetz,_MD: These are extremely popular at this time, however, they can be pricy. We do not know the long-term benefit versus sitting at a desk. However, they may be helpful when someone has a back pain episode or chronic back pain. A standup desk may be part of an ergonomics plan. This may include appropriate foot wear and alternative standing and sitting. An ergonomics consultation would be appropriate when considering this option (if available).

outly: My MRIs included a four-page report and were done six years ago. I cannot have another because I have an ICD. The pain is worse (back) in the morning and ameliorates somewhat after moving for a couple of hours. I deal with bursa involvement. My cardiac rehab has increased to 40 minutes four times weekly of brisk walking (on a treadmill – I cannot do it without support). The biggest problem is I have trouble standing straight due to pain and weakness. I am a 62-year-old male. My BMI is 26. I cannot take NSAIDS due to GI and cardiac problems. Do you have any other treatment ideas? (My medications are carvedilol, lisinopril, rosuvstatin and amiodarone.)

Philippe_Berenger,_MD: Frequently, a detailed history of current symptoms and an examination, as well as a review of the old MRI, may be helpful in charting a course of therapy. Diagnostic injections might be done to determine if your pain is referred to your hip from your spine or if there is an associated hip problem that is combining to make your situation this bad.


Treatment Tales

Jbd: I have fairly severe lower thoracic pain from scoliosis and kyphosis, and had a laminectomy of T8-L1 to remove a 10-inch hematoma. I exercise rigorously for two hours three days a week, do yoga the other three, maintain a BMI of 22 and am 80 years old. I have tried a TENS unit and massage without much effect. Are rods an alternative? Anything else? Where can I read about rods?

Michael_Steinmetz,_MD: Good core strengthening is a must, and you are accomplishing this with yoga. We tend to focus most on spinal balance as opposed to scoliosis and kyphosis. A surgery focusing on spinal realignment using screws and rods MAY be appropriate. I would suggest a surgical consultation to inquire about options.

badresults: Two years ago, I had a laminectomy at L2-L5. My symptoms persisted, including eurocaludication, bilateral, L>RT down to the toes. Four weeks ago, I had a foraminectomy  of L1-L5 and fusion of L2/L3 for retrolisthesis. Postoperatively, I suffered a CSF leak, which was treated conservatively after needle drainage of the fluid (200cc's). Re-accumulation of fluid is moderate. I was advised to treat conservatively and not to re-operate. I was given the odds of 95 percent spontaneous closure. Symptoms improved some but still persist related to posture and prolonged seating. My question: would you advise me to continue conservative management of the fistula at this point? Also, what is the rate of success with surgical closure of these fistulas? Should I expect possible further improvement of my symptoms? Thank you.

Michael_Steinmetz,_MD: I think if you are improving I would continue to treat conservatively. If symptoms persist then surgery would be indicated. Surgery is successful to fix this issue, but it is hard to comment on what type of surgery would be required. It could be as simple as a suture repair of a hole to as complex as requiring a shunt of the fluid. If you are improving, I would sit tight.

rosebu: My husband had back surgery two years ago for sciatica pain down his leg. He had L4 and L5 fused and vertebral stenosis cleared out. The surgery cured the pain in his leg, but ever since he has had pain at the top of the right incision of his back. Pain management determined by numbing the hardware screw under that area that the hardware needs to be removed. The surgeon refuses to do that (this surgery was done at another facility). He does not feel good about having anymore back surgeries since that one did not go well. His pain has gotten to the point that he cannot stand or walk without pain. He has balance issues also that developed after his back surgery. What would you recommend for him to do. One of your surgeons at the Clinic wanted to operate and fuse his spine from L4 up to L2 and clear stenosis and repair discs. He is just not comfortable at this time having more surgeries that may cause more pain rather than fixing pain.

Michael_Steinmetz,_MD: It is hard to comment directly on your non-surgical options. If there is not neural compression or structural abnormalities, alternative pain management strategies may be an option. An example would be a spinal cord stimulator.


Basic Beginnings

Nugee: I had a lobectomy of my thyroid in 2008. How do I know if my parathyroid glands are still working? Thank you.

Krupa_Doshi,_MD: If your calcium is fine (and not low), you have working parathyroid glands.

robtoby: Thanks for the previous answer to my question. What is primary hyperparathyroidism?

Leila_Khan,_MD: Primary hyperparathyroidism is when you are making too much PTH hormone and calcium values increase.


Closing

That is all the time we have for questions today. Thank you, Dr. Steinmetz and Dr. Berenger, for taking time to enlighten us about back pain.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.


For Appointments

To make an appointment with Michael Steinmetz, MD, or any other specialist in our Center for Spine Health, call 216.636.5860 or toll-free 866.588.2264 or visit www.clevelandclinic.org/spine for further information.

To make an appointment with Philippe Berenger, 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.


For More Information

Cleveland Clinic
The Center for Spine Health is part of the multidisciplinary Cleveland Clinic Neurological Institute, which is dedicated to the diagnosis and treatment of common and complex neurological disorders of adult and pediatric patients. Its more than 300 specialists combine expertise and compassion to achieve measurably superior results. By promoting innovative research and care models, the Neurological Institute accelerates development and application of new treatments and technologies for patient care. The Neurological Institute is one of 27 institutes at Cleveland Clinic, a nonprofit academic medical center ranked among the nation’s top hospitals (U.S. News & World Report), where more than 3,000 physicians in 120 specialties colĀ­laborate to give every patient the best outcome and experience.

The Department of Pain Management’s certified physicians are dedicated to the goal of helping people with chronic pain return to a normal, productive lifestyle. Its specialists are among the most experienced in the world, treating more than 13,000 new patients each year. Using diagnostic technology, paired with medical and interventional therapeutics, they work with patients to identify the source of the pain, reduce the pain, and teach patients how to manage it. The department’s physicians are acclaimed for their research and education in pain management; patients who qualify, have the opportunity to participate in clinical trials seeking better and more effective treatments for managing pain.

Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments for back pain.

Chronic Back Pain
Back pain – Cleveland Clinic Center for Spine Health physicians treat various causes of back pain including chronic, acute and lower back pain.
http://my.clevelandclinic.org/health/diseases_conditions/hic_your_back_and_neck/chronic-back-pain-overview

Acute Mechanical Back Pain
Acute mechanical back pain is a common medical problem; it is also known as acute low back pain, lumbago, idiopathic low back pain, lumbosacral strain or sprain or lumbar syndrome. Acute means that it has lasted less than four to six weeks.
http://my.clevelandclinic.org/health/diseases_conditions/hic_your_back_and_neck/hic_Acute_Mechanical_Back_Pain

Low Back Pain
Low back pain involves stiffness and pain in the small of the back; it may extend to the legs and buttocks. Simple exercises and good posture can help.
http://my.clevelandclinic.org/health/diseases_conditions/hic_your_back_and_neck/hic_Low_Back_Pain

For additional health information, visit clevelandclinic.org/health.

Cleveland Clinic Back Pain Treatment Guide
Download our free guide for comprehensive back pain treatment options and find relief from chronic back pain.
http://pages.clevelandclinic.org/back-pain-index.html

Clinical Trials
For additional information about clinical trials: ClinicalTrials.gov.

Your Health
MyChart® is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org.
 
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 eclevelandclinic.org/myConsult.


Contact Information

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