Online Health Chat with Crawford Barnett, MD and Kush Goyal, MD

November 11, 2016

Description

Eighty percent to 90 percent of people in the United States will suffer from back pain at some point 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 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. Sometimes, the source of back pain can be difficult to diagnose. It may be related to discs, joints or soft tissue supports (including the muscles, ligaments and tendons) of the back. Many different conditions, including osteoporosis, fractured vertebrae, bulging and herniated discs, and compressed spinal nerves, can cause pain and may require surgery.

Warning signs that should prompt urgent medical evaluation include the presence of fever, worsening pain, progressive movement of the pain from the back into the leg, numbness in the area of the injury or down the leg, or new bowel/bladder incontinence.

While there are many different types and causes of back pain, there is no doubt that pain can affect quality of life. This chat focused on treatment options for chronic back pain, ways to measure pain, and how best to communicate the pain you are experiencing so your health care providers can make an appropriate assessment of the source of your pain and recommend an effective treatment plan.


About the Speaker

Crawford Barnett, MD, is an anesthesiologist and interventional pain management-trained physician specializing in the diagnosis, evaluation and management of chronic pain, including pain originating in the spine. Dr. Barnett graduated from the Medical College of Georgia in 2004 and completed his internship, residency and fellowship at the Mayo Clinic in Rochester, Minnesota. He has been practicing in Ohio since 2009. His specialty interests include interventional spine procedures, management of musculoskeletal and neuropathic pain, and neuromodulation.

Kush Goyal, MD, is a physical medicine and rehabilitation-trained physician specializing in the diagnosis, evaluation and management of neck and back pain in Cleveland Clinic’s Center for Spine Health. Dr. Goyal graduated from the Medical College of Ohio (currently University of Toledo Health Science Center) and completed his training in physical medicine and rehabilitation at Wayne State University, Oakwood Hospitals. He has been with Cleveland Clinic since 2013. His specialty interests include cervical, thoracic and lumbar disorders, interventional spine procedures, medical management of spinal disorders, degenerative spine disease, sciatica, sacroiliac joint dysfunction, sports medicine, and spinal stenosis.


Let’s Chat About Treating Chronic Back Pain

Treatment First Steps

stevest12: I have had back pain for more than 15 years. I am only 31, so my back pain started when I was a teenager. It has been isolated to the lower right quadrant of my back. When it occurs, it seems to last anywhere from a day to three weeks. It is a continuous pinching feeling with spurts of extremely sharp pain, especially with certain movements, that tends to shoot down my leg. I have seen a physician who recommended I start physical therapy. Is this the typical path for treatment? Why wouldn't an additional test, such as an MRI, be recommended to figure out what is causing the problem?

Crawford_Barnett,_MD: Physical therapy for chronic pain (with no recent changes) does sound like an appropriate first step. Focal pain in the lower right region of your back could be musculoskeletal in nature. Depending on the pattern of your shooting pain, as well as how far it goes down the leg, there is also the potential for nerve root irritation as well, possibly from a bulging disc. If there are no deficits (areas of numbness, focal weakness, altered reflexes, or acute loss of bowel or bladder control), it is not unreasonable to proceed with physical therapy. Should this not prove beneficial, obtaining an MRI to gain more information may be worthwhile. If there are no medical contraindications, using a short course of non-steroidal anti-inflammatories (ibuprofen or similar medication) may also be reasonable during this initial phase of evaluation and treatment.

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

Kush_Goyal,_MD_: Losing weight can decrease the load on the spine and its supporting structures such as the discs, joints, muscles and nerves. A stronger spine and "core"' can provide better support, which can help decrease pain and improve function.


Individual Disorders

Connie2Four: What can be done for spinal stenosis? Is there any way to prevent spinal stenosis as you age?

Crawford_Barnett,_MD: Central spinal stenosis is the narrowing of the spinal canal (where the spinal cord or nerves coming off of the spinal cord pass through the spinal canal). There is also foraminal stenosis, which is a narrowing of the smaller openings where individual nerves exit the spinal canal. Spinal stenosis can result from disc bulging, arthritis of the small joints of the back and even thickening of ligaments within the spinal canal. Much of this is, unfortunately, a process that occurs to a small or large degree as we age. It becomes an issue when the nerves become impinged or irritated and one gets pain, or even weakness, going down one or both legs. Physical therapy is absolutely worthwhile in this situation. Epidural steroid injections may help decrease irritation of nerves within the spinal canal, which can both decrease pain and improve mobility. If symptoms progress and functionality diminishes despite more conservative approaches, surgical consultation could be considered to help determine if decompressing these areas of tightness may reduce pain and improve function.

chatter23: I have one painful facet joint on the left side of my thoracic spine with numb skin over that area. I haven't had any imaging of the area. It only bothers me after I have been on my feet for more than an hour or so, and then I get sharp pains and muscle spasms. It was diagnosed as arthritis based on my description. I was told that injections and physical therapy are the only treatments and that the condition will worsen over time. I have chosen not to have injections at this time. Is there anything else I can do? Thank you.

Kush_Goyal,_MD_: First of all, your condition won't necessarily get worse. Typically, I order x-rays during my evaluation, as well as recommend physical therapy by a therapist who is well trained in the spine. There are also medications we typically use, such as NSAIDs, muscle relaxants and other pain medications for numbness. I recommend an evaluation by a spine specialist to see what injections may benefit you. You don’t necessarily need to see a surgeon.

gtom: My issue with back pain is limited to getting out of bed in the morning. The pain is in my lumbar region and varies in pain level from a minimum pain of a three to a high level of nine. If and when that occurs, I can't walk erect when getting to the bathroom. However, the pain slowly subsides during the next 15 to 20 minutes. During the remainder of the day, the pain subsides to a level two and is more of a soreness. I was told I have minor arthritis in one of the spinal discs. I purchased a firm mattress a few months ago, but have experienced no noticeable improvement. In addition, I went to a chiropractor about six months ago, but again did not find sustainable relief. I will be interested to hear if there are any further recommendations.

Crawford_Barnett,_MD: It may be worthwhile having a more thorough evaluation regarding your low back pain. As I understand your symptoms, they are localized to the low back without pain radiating down either leg or feelings of weakness in either leg. X-rays of the low back may demonstrate arthritis of the small (facet) joints of the lumbar spine. While a firm mattress may be beneficial, a course of formal physical therapy with the goal of developing a home exercise program to be performed daily could be quite beneficial as well. Core strengthening should be a part of this. If this does not help, and x-rays demonstrate arthritis, which is also provokable on physical exam, there are procedures that could help to reduce your pain. Facet blocks may give therapeutic benefit as well as diagnostic information. If these do not give durable relief, radiofrequency ablation to the nerves leading to the small joints may be able to give prolonged relief.

johnjf4: These are my test results: MRI lumbar spine without contrast INDICATION: RADICULOPATHY LUMBOSACRAL REGION NOTES: right hip pain radiates down right leg x months nki no surgery tingling and numbness in right leg # images 142 COMPARISON: Multilevel degenerative disc disease bulging disc at L1 to centrally. Mild bulge at L2-L3. At L3-L4 there is hypertrophic facet arthropathy and a bulging disc with a moderate circumferential central stenosis. At L4-L5 there is a more prominent central protruding disc and facet arthropathy with moderately severe central canal stenosis, as well as left lateral recess and foraminal stenosis moderately severe. L5-S1 level demonstrates degenerated mildly bulging disc. No malalignment or fracture no conus lesion. Impression Moderately advanced central canal and left lateral recess stenosis L4-L5. Pain mgt.- gabapentin, Topamax, Tramadol & 2 epidurals with little effect. Referred to neurosurgeon who recommended "shaving" some off the disc. 2nd opinion?

I have severe aches in my buttocks and rear of both legs even with physical therapy, medication and two epidurals. I live in Erie, PA, and the local neurosurgeon to whom I was referred suggested shaving off some of the L4 and L5 discs. I was wondering about the possibility of using the Coflex® device.

Crawford_Barnett,_MD: Your MRI results do demonstrate moderate spinal stenosis at L3-4, as well as moderate to severe stenosis at L4-5 (think of how an hourglass narrows). There are also elements of foraminal stenosis (where the individual nerves exit, left and right, on each side). Physical therapy and gabapentin, as well as epidural steroid injections are all reasonable first-steps in your treatment plan. I'm sorry to hear that these have not given you good benefit. Discussing surgical options is a reasonable next step. In many cases, the disc can be decompressed without causing instability (and the need for spinal fusion). Getting a second surgical opinion is never a bad idea, and I would recommend getting both physicians take on the appropriateness of using the Coflex® device in your specific situation.


Tried Treatments, Now What?

bergem: I wake up with a backache, but feel better after I do flexion and extension exercises 50 times. However, during the day, when I stand up for 10 minutes, I get a backache and have to wear a back belt. I have had several physical therapy sessions over the years, which haven’t helped much. Spinal injections provided only temporary help. Do you have any suggestions? Thank you.

Crawford_Barnett,_MD: I’m glad to hear that morning exercise benefits you, even if incompletely. As a generalization (without having examined you or seen imaging), physical therapy, daily home exercises and core strengthening should be the mainstay of back pain management. Back braces may be beneficial for use during heavy lifting and strenuous activity; however, when used routinely, they can weaken the core muscles and, ultimately, lead to increased discomfort. I do not know what spinal injections you have had; if you have received epidural injections, these may not always benefit focal back pain if there is no associated pain radiating down the legs. If there is arthritis on imaging and it is provokable on physical exam, consideration could be given to addressing the small (facet) joints of the back directly. It may be worthwhile to see a spine specialist and, if appropriate, obtain new imaging.


Previous Back Injury

J@CC: I have a herniated disc from way back when I was a teenager playing football. It has plagued me all my life coming and going. I do a lot of sit-ups to keep my core strong, and now it only acts up occasionally. My question: I take yoga. Are the stretches in yoga a problem for someone with a problem disc? I can do most of them, but I worry I am irritated the disc. Is there any guidance you can give on what I should or should not do?

Crawford_Barnett,_MD: Physical therapy and core strengthening (with an emphasis on daily exercises) are absolutely essential in this situation. Yoga can be quite beneficial as well. Without knowing the specific severe situation or seeing a recent MRI, I would let pain be your guide on which exercises not to do. While back pain may be secondary to herniated discs, there is also the potential that you have developed arthritis in the joints of the back, and this may need to be evaluated as well. Formal evaluation by a spine specialist may help guide care and therapy moving forward.

jida976: I hurt my back in 2006, and my pain level has stayed at a seven. Morphine worked for nine years, but I’ve been now taken off of it without another solution to my thoracic back pain. The MRI showed a slightly curved spine, but nothing else. Therapy was no help, injections were no help and nerve ablation was no help. Bending, twisting, squatting and heavy lifting make the pain worse. The pain is always on my left side, mid-back close to the spine. Do you think surgery is an option, or do you have any ideas for pain relief? I am 58 years old. Thank you.

Kush_Goyal,_MD_: It sounds like you have been dealing with this for a long time. It’s difficult to give advice about surgery via a web chat. Typically, I examine the patient, review imaging and any previous injections (if available) to help decide if a different injection or if surgery is an option. In general, a well-trained spine physical therapist can help you strengthen your back, decrease your back pain and help improve your function.

feab: I was in a car accident 15 years ago and herniated the disc at L5-S1. My back goes out once or twice a year and the steroids help, but I live with pain every day. I gained weight, but losing weight did not help my back pain. I can’t take NSAIDs because of stomach issues. I have been using a TENS unit, therapy and narcotics for years, which I stopped taking because they did not help. My question: What else can be done? I’m not interested in surgery.

Kush_Goyal,_MD_: A disc herniation from 15 years ago may not be the same issue you have now. You may need to be re-evaluated and get new imaging. Often, physical therapy can help strengthen your back. Spine injections and physical therapy may help improve your function even without surgery.


Medication Messages

Maryl: Are there any medications that provide effective pain relief that are stronger than over-the-counter ones but less strong than the scary opioids we are trying to avoid? If there are none currently on the market, do you know of any being developed?

Kush_Goyal,_MD_: There are some over-the-counter medications that can be taken in higher doses if prescribed by a physician, such as Motrin and Aleve. There are other medications we typically use, such as prescription NSAIDs, muscle relaxants and other pain medications. If you have back pain, I recommend an evaluation by a spine specialist to see what medication or injections may benefit you.

GNT: I was diagnosed with degenerative disc disease more than 20 years ago. After two back surgeries (hard fusion of L4, L5), I am left with severe neuropathy on my right side (all the way to my toes and resulting in numbness in three toes). I have constant pain in my lower back and sciatica mainly on my right side. I also have cramping in my toes, and sometimes at night, my legs jerk uncontrollably from spasms. Is there any hope of my not having to live with this constant neuropathy pain? I currently take four to five Percocet 10/325 tablets per day, and my life revolves around pain medicine wearing off then waiting for the next pill to work. I have an appointment with my doctor in two weeks, and I’m hoping to discuss the possibility of switching to a pain patch in order to avoid the constant ups and downs of taking a pill every four to six hours. (Before my first back surgery, I was on a Fentanyl patch, which worked much better than the tablets). Should I bring this up to my doctor? I would appreciate your advice/suggestions.

Crawford_Barnett,_MD: I am very sorry that you are having ongoing neuropathic pain despite surgery. With the information I have at this time, there are several things that could be considered. When looking at medication, opiates (in your case, Percocet) tend to poorly benefit neuropathic or nerve-related pain. Medications that are often more beneficial include gabapentin (Neurontin) and pregabalin (Lyrica). Additionally, while opiates can be quite helpful at reducing acute pain occurring after injury or surgery, they do tend to have diminishing returns over time. Think of running on a treadmill when somebody keeps increasing the speed. You have to keep running faster and faster to stay in the same place, and, ultimately, you simply cannot keep up. Although chasing pain with increasing doses of opiates may work in the short-term, their benefit declines greatly as our bodies become tolerant to the medication. This is one of the reasons that opiates are recommended less-and-less for chronic pain. Unfortunately, it appears that despite taking moderately high-dose Percocet, this class of medication is no longer significantly or consistently benefiting you. To be clear, this is no fault of yours; this is simply the way our bodies react to this class of medications over time. It may be worthwhile to be re-evaluated for your condition and, possibly, obtain new imaging. In addition to looking at alternative medications, it may well be that there are therapeutic, procedural or surgical options available to you.


Determining Diagnosis

delaware: I have been seen for co-occurring back pain and hip pain by several types of doctors over the past five years. At this point, I have three different diagnoses from two different types of doctor (physical medicine and rehab, and neurology). They are meralgia paresthetica, piriformis syndrome and degenerative disk disease. The implications for treatment are different, and I don't know what step to take next. Are there more tests I should pursue, and/or how should I choose a treatment plan, given the diagnoses lead to different treatment plans? Any suggestions you may have will be appreciated.

Kush_Goyal,_MD_: During my appointments, I work to determine what the primary "pain generator" is for the patient. Sometimes, there can be many contributing factors. Meralgia paresthetica can be diagnosed by EMG by someone who regularly tests for this. Piriformis is often over-diagnosed. Degenerative disc disease is not a disease, rather a normal part of aging when the disc degenerates over time. Sometimes, the degeneration can cause pain. In other cases, it does not cause any symptoms.

Melissa: 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.

Kush_Goyal,_MD_: I agree. I find the smiley faces for pain scale is often inaccurate and silly. The Center for Spine Health uses questionnaires during our initial and follow- up visits that help us in evaluating and monitoring progress with treatment. They can also help with quantifying a patient’s function or lack of function. During an appointment, the practitioner should listen to you communicate how the pain affects your life and function.

delaware: Since meralgia paresthetica can be diagnosed by EMG by someone who regularly tests for this, is there a specific doctor. at Cleveland Clinic that regularly tests for this? If you don't know, how can I find this out? I am willing to travel.

Kush_Goyal,_MD_: Dr. Shamir in Physical Medicine and Rehabilitation does EMGs. If you make an appointment for an EMG, you can ask the scheduler if that physician is familiar with testing for meralgia paresthetica for lateral femoral cutaneous nerve. Just be aware that is not an easy nerve to stimulate in obese patients.

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

Kush_Goyal,_MD_: Progressive weakness, bowel/bladder incontinence, worsening clumsiness and/or poor balance are a few surgical indicators.

Daphne: For lower back pain, what is the recommended protocol with respect to the sequence of medical appointments for diagnosis and treatment? Should the first visit be with an internist, a neurologist, an orthopedic specialist, a pain specialist, a surgeon or whom?

Crawford_Barnett,_MD: As an initial starting point, discussing your situation with your primary care physician (who knows your overall medical history) is a very reasonable first step. Quite often, physical therapy or x-rays will be ordered. This is under the assumption that you're having chronic or even recent-onset pain focally in the low back. If there is pain going down the leg, an MRI may be ordered if physical therapy does not resolve your symptoms. Should, at any time, you develop weakness in the leg or lose bowel or bladder control, an MRI would need to be ordered much more urgently. Your primary care physician can also guide you to the appropriate specialist. Other reasonable options do include seeing a pain management specialist. Although spine surgery may need to be considered at some point in time, most back pain does not ultimately lead to surgery.


Procedure Specific

DJ9: I’ve heard the term “spinal interventions.” Can you please explain what that means and if they actually heal or just mask pain?

Kush_Goyal,_MD_: Spinal interventions often refer to spine injections done with x-ray guidance. We use anesthetics such as Lidocaine (similar to Novocain) and often steroids to decrease inflammation and pain. We can inject joints or nerves to help diagnose the problem that can cause back, neck, arm or leg pain. Often, patients can have long lasting relief (months or even years).

Jack_in_Florida: Can you comment on "VAXD," a supposedly therapeutic procedure that involves stretching the spine on a split motorized table. Many claims are made, but I've not found any orthopedic doctor who speaks favorably of it.

Kush_Goyal,_MD_: I've been a spine specialist at the Cleveland Clinic Center for Spine Heath for four-plus years, and I haven't heard much about this treatment at any of the national conferences I regularly attend. At this time, there is no medical evidence that there are any long-term benefits from it.


Closing

That is all the time we have for questions today. Thank you, Dr. Barnett and Dr. Goyal, for taking time to educate us about treatment options for chronic 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 Crawford Barnett, MD, or any other specialist in Cleveland Clinic’s Department of Pain Management, please call 216.444.PAIN or visit us online at clevelandclinic.org/painmanagement.

To make an appointment with Kush Goyal, MD, or any other specialist in Cleveland Clinic’s Center for Spine Health, please call 216.636.5860 or toll-free 866.588.2264.

Learn more about Cleveland Clinic’s Center for Spine Health online at clevelandclinic.org/spine.

For More Information

About Cleveland Clinic
Cleveland Clinic Pain Management
Cleveland Clinic’s Department of Pain Management offers many safe, proven, effective treatments designed to eliminate or reduce chronic pain. Board-certified physicians are dedicated to the goal of helping people with chronic pain return to a normal, productive lifestyle. Our specialists are among the most experienced in the world, treating more than 13,000 new patients each year. Using the latest in diagnostic technology, paired with medical and interventional therapeutics, they will work with you to identify the source of the pain, eliminate or reduce the pain and teach you to manage it.

Our staff is acclaimed for its research and education in pain management. Patients who qualify have the opportunity to participate in clinical trials seeking better, more effective treatments for managing pain. Our physicians regularly publish in leading medical journals and are invited lecturers at medical education seminars across the country and around the world.

Cleveland Clinic Center for Spine Health
The Center for Spine Health's multidisciplinary team brings together the expertise of nationally recognized Cleveland Clinic specialists in orthopaedic surgery, neurosurgery and medical spine, offering patients with back and neck pain the latest, most innovative and effective medical and surgical treatments. Cleveland Clinic's Center for Spine Health at Lutheran Hospital integrates research, clinical practice and education with the goals of improving patient care, developing unique technologies and sub-specializations and promoting the cross-fertilization of ideas among staff.

From periodic monitoring to intensive surgical correction, state-of-the-art management for back problems is provided. The Center for Spine Health team includes a comprehensive range of specialists, including:

  • Medical spine specialists
  • Neurological surgeons
  • Orthopaedic surgeons
  • Physician’s assistants
  • Nurses
  • Rehabilitation specialists
  • Pain management specialists

Commonly treated disorders include herniated discs and other disc diseases, arthritic spurs, scoliosis and back pain problems.

Treatment Guide
Back Pain Treatment Guide

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

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

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