Cleveland Clinic Web Chat Transcript

Back Pain --- February 5, 2008

Lokesh Ningegowda, M.D

Associate Staff
Anesthesiology Institute

Cleveland_Clinic_Host: Welcome Dr. Ningegowda, and thank you for joining us today. Dr. Ningegowda, it is wonderful that you can join us. We look forward to an interesting chat today. Welcome! Let's begin with one of the questions!
Speaker_-_Dr_Ningegowda: Thank you for having me here today. There have already been many great questions come in - so I am ready to begin!

Causes of Back Pain

rajesh308: Hi I can't get rid of my backache. What do you suggest?
Speaker_-_Dr_Ningegowda:
First of all we need to know how long this has been occurring and what treatment or workup has been done so far.

jpr: What can one do to relax back muscle spasms after a fall?
Speaker_-_Dr_Ningegowda:
The most important thing after a fall is to rule out any bony injury or fractures. Once you are evaluated and bony injury is ruled out, you can apply ice or heat to the affected area. NSAID’s can be taken to reduce inflammation. Gentle stretching exercise & physical therapy can be instituted.

the1andonlydfigs: Can even a minor weight gain affect back pain?
Speaker_-_Dr_Ningegowda:
Minor weight gain with good posture should usually not effect back pain. But, it is always advisable to lose weight and be active.

acwoman_3: Is it true that smoking can aggravate back pain?
Speaker_-_Dr_Ningegowda:
Yes - smoking will aggravate back pain.

acwoman_3: also, can stress be a factor in increased back pain?
Speaker_-_Dr_Ningegowda:
Yes.

kelly: What kind of purse is better for your back? A shoulder purse or one with a short handle?
Speaker_-_Dr_Ningegowda
: Usually a purse with short handle is better for back (Neck). But care must be taken that the purse is not heavy.

ppr: Is it bad to cross your legs when sitting?
Speaker_-_Dr_Ningegowda
: Well, maintaining good posture helps preventing back pain.

Diagnosing Back Pain

gabe1: I was diagnosed with stenosis when seeing the doc for lower back pain (right side), I have gone to PT and pool PT without results that diminish my pain. An MRI has been taken. I have completed 5 full weeks of PT. What do I do now to find relief from the pain?
Speaker_-_Dr_Ningegowda
: If the conservative measures like PT/ aqua therapy have not helped, next step would be to try a series of epidural steroid injections along with continued PT/ Aqua therapy.

newtonm: I have foot pain/numbness with lower back pain, without leg pain? Could this be from spinal stenosis or a herniated disk?
Speaker_-_Dr_Ningegowda
: This may be due to herniated disk or stenosis. You may need to consult your doctor for further evaluation.

Arlene: I get low back pain occasionally (1-2 yr cycles). It starts usually with a twist motion or bending, no heavy lifting, and feels like a light pinch. A day later I can hardly move. My chiropractor says it is a sciatic nerve irritation. I do not have associated leg pain. What might your assessment be?
Speaker_-_Dr_Ningegowda
: I see that you predominantly have back pain. Sciatic nerve irritation usually causes pain going down the lower extremity. Most probably your pain may be related to lumbar sprain/ strain, facet arthritis or disc related.

badboy: How does one distinguish between back pain from disc problems and those back pains caused by statins and other “modern” medicines?
Speaker_-_Dr_Ningegowda
: Back pain caused by medications usually is generalized muscle pain- achy or cramp-like in nature. They may have associated other symptoms like malaise. Patient will have history of specific drug intake. Blood work may show elevated levels of CPK (creatinine-phosphokinas).

Back Pain and Aging

tmeilander_2: Is it normal to experience back pain every day, especially as we age and/or engage in repetitive strenuous activities (i.e. lifting children, sitting at a computer, etc.)? What is the most common origin of back pain (muscle, connective tissue, bone, combination, or other)?
Speaker_-_Dr_Ningegowda
: The most common cause for back pain is due to mechanical causes mainly - muscle strains or joint and ligament sprains. Back pain may be experienced as we age/engage in repetitive strenuous activity. Maintaining good back posture and avoiding unnecessary strain on the back would go a long way in preventing injuries. Back support is especially important for patients who spend lot of time sitting in an office chair. Avoid slumping forward while sitting in the office chair and use lumbar back support. Care must be given to make sure that osteoporosis (or weak bone) - which is commonly seen in elderly is addressed.

ovawrkd: When I get up from sitting, it is difficult to stand erect. I get numbness and tingling in my legs and feet at night
Speaker_-_Dr_Ningegowda
: Usually, these types of symptoms in the elderly population are caused by stenosis. I would recommend an evaluation with a physician.

Osteoporosis and Vertebral Compression Fractures (VCF)

kdn: What causes vertebral compression fractures?
Speaker_-_Dr_Ningegowda : - Osteoporosis- due to aging or menopause, long term steroid use.
Speaker_-_Dr_Ningegowda : - Trauma or fall
Speaker_-_Dr_Ningegowda : - Pathologic fractures- due to preexisting disease like tumors, cancer spread to spine or infections.

newtonm: How serious is a 3.0 bone density loss and is it possible to rebuild bone density once you have been diagnosed with osteoporosis?
Speaker_-_Dr_Ningegowda
: • Normal bone: T-score better than -1.
Speaker_-_Dr_Ningegowda : • Osteopenia: T-score between -1 and -2.5
Speaker_-_Dr_Ningegowda : • Osteoporosis: T-score less than -2.5
Speaker_-_Dr_Ningegowda : It is possible to rebuild bone density after being diagnosed to be having osteoporosis. Treatment modalities include- Weight bearing exercise, Nutritional supplement of calcium and Vitamin D, Medications- Bisphosphonates, Calcitonin, and hormone replacement. Please consult your doctor for information regarding medications.

ptn: Are facet block medications similar to epidural steroid injections, and do those have any effect on yearly IV Bisphosphonate medication?
Speaker_-_Dr_Ningegowda : Facet block is different from epidural injection. For diagnostic facet nerve block some physicians do not use steroid and some do. The physician who is doing the procedure is aware of the recommended dosage. If it is within recommended limits there need not be any change the medications for osteoporosis.

Spinal Stenosis

ptn: Can compression from lumbar canal stenosis cause pain under the rib cage, as well as upwards in the neck? Also, does osteoporosis and vitamin D deficiency affect spinal stenosis?
Speaker_-_Dr_Ningegowda : Osteoporosis can affect spinal stenosis. Compression from lumbar canal stenosis by itself is unlikely to cause pain under the rib cage or upwards in the neck. Arthritis in the thoracic or cervical spine can cause pain in the above mentioned areas.

cantmove: My posture distresses me, but it is painful to straighten even for a few minutes. For several years, I’ve exercised 20-25 minutes every day, plus some walking. Any hope?
Speaker_-_Dr_Ningegowda : You need to get evaluated to r/o spinal stenosis. Good physical therapy with professional help. Aqua therapy usually will help with the symptoms. If you don’t get relief from conservative measures, trial of epidural steroid injection may help.

acwoman_3: I know I have a herniated disc and stenosis. When would you recommend surgery and what is best treatment for it?
Speaker_-_Dr_Ningegowda : Surgery is recommended if conservative therapy fails to improve pain. Also if there is any nerve compression manifested in form or weakness or new onset of bowel or bladder symptoms. You need to discuss with the surgeon for specific surgical plan.

Herniated Disk

Sasha: I've been diagnosed with 3 herniated discs in my back and the doctor is quite surprised that I am not in an extreme amount of pain. Can herniated discs heal on their own without surgery?
Speaker_-_Dr_Ningegowda : If the patient does not have any symptoms from the herniated disk, usually surgery is not indicated. Herniated disks do not self-heal but progression can be prevented by good posture, exercise and back strengthening.

cappy: Will disk tears repair themselves?
Speaker_-_Dr_Ningegowda : Most disk tears without any herniation usually heal by scar formation. If there is herniation, healing is difficult but most of the people will still have symptomatic improvement with time & conservative measures.

Exercise and Physical Therapy

ohmyachingback: Do you think that weight or strength training exercises are very valuable for back problems? What about walking?
Speaker_-_Dr_Ningegowda
: Exercise for back pain varies depends upon the patient’s specific diagnosis and level of pain. It is important to consult your physician prior to starting individualized back exercise program and to obtain instruction on using the correct form and technique.

ohmyachingback: How soon after a muscle strain or sprain can one begin exercising again?
Speaker_-_Dr_Ningegowda : For muscle sprain/ strain, active exercise and stretching is typically necessary to help reduce pain and encourage healing. It is advisable to start stretching as soon as possible.
Speaker_-_Dr_Ningegowda : For most back conditions, active exercise and stretching help reduce pain and encourage healing. A patient’s back pain exercise program should be comprehensive, working the whole body with target to the back. The exercise program should include a combination of stretching, strengthening, and low impact aerobic conditioning.
Speaker_-_Dr_Ningegowda : Strengthening the core muscles will decrease the stress placed on lower back.
Speaker_-_Dr_Ningegowda : Walking definitely helps in conditioning of the body.

spasms: Is it better to use the treadmill or bicycle for back pain?
Speaker_-_Dr_Ningegowda : Bicycle and elliptical trainer usually offers less impact and strain to the back.

alex: Would you suggest any specific type of exercise to benefit a spinal stenosis condition?
Speaker_-_Dr_Ningegowda : Aqua therapy is excellent. Flexion exercise includes a combination of specific stretching and strengthening exercises with focuses on: Stretching the muscles of the back that hold the spine in extension (backwards bending) and strengthening the muscles that bring the spine into flexion (forward bending). Please consult you physical therapist for assessment & specific exercise programs.

gabe1: Not wanting to pursue injections, can I find help with continued PT? Could sore muscles also be part of the pain?
Speaker_-_Dr_Ningegowda
: Continued PT, strengthening and stretching exercises definitely help. Sore muscles may be causing low pain. Usually your therapist will suggest Myofacial release if the pain is due to sore muscles.

jpr: I have been told I have curvature of the spine, but that was not addressed. I have such bad pain, even pain pills don’t help. What can I do?
Speaker_-_Dr_Ningegowda : You can start with physical therapy & muscle strengthening exercise. If the pain is significant, you may need to get evaluated to consider whether you are a candidate for surgery.

Treatment Options

jpr: How do osteopaths and medical personnel view chiropractic treatment for back pain?
Speaker_-_Dr_Ningegowda
: Spinal adjustment or manipulation is a form of therapy chiropractors use to treat restricted spinal mobility. The main aim is to restore spinal movement and improve function and decrease back pain. Chiropractic treatment may help acute back pain due to sprains (Although majority of the acute back pain is self subsiding).
Speaker_-_Dr_Ningegowda : It is not appropriate to seek chiropractic treatment if patient has osteoporosis, symptoms such as numbness, tingling or loss of strength in a limb, hand or foot- which may indicate nerve damage, patients with prior history of spinal surgery, prior history of stroke vascular disease and if patient has h/o fever, chills, sweats or unintentional weight loss (infection or tumor has to be ruled out)

acwoman_3: Why wouldn't it be advisable to seek chiropractic help if you have nerve damage?
Speaker_-_Dr_Ningegowda : You may aggravate your injury from manipulation.

the1andonlydfigs: What are your thoughts regarding acupuncture for lower back pain?
Speaker_-_Dr_Ningegowda : Acupuncture may help pain caused by Myofacial sprain/ strain. The efficacy is not proven for pain due to nerve compression.

maggygirl: Are epidural blocks dangerous? Do they make your bones brittle?
Speaker_-_Dr_Ningegowda : Every procedure has risks associated with it. But if done properly (using x-ray) Epidural steroid injection is relatively safe.
Speaker_-_Dr_Ningegowda : If appropriate dose of steroid is used, the chance of brittle bone is very less.

karensp: Does Glucosamine Chondroitin - MSM really help?
Speaker_-_Dr_Ningegowda : They may help but I am not aware of any studies to prove their efficacy.

lindas: What is the alternative to the anti-inflammatory medications that have been taken off the market?
Speaker_-_Dr_Ningegowda : - The older, non-selective medications include ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), diclofenac (Voltaren, Cataflam) Speaker_-_Dr_Ningegowda: - COX-2 selective agent celecoxib (Celebrex).

bms: What type of mattress is best for chronic back pain? I have minimal back pain during the day. When I wake up, many areas of back and right leg are very painful.
Speaker_-_Dr_Ningegowda
: Using a Medium-firm mattress is usually helpful for patients with low back pain. A mattress with sufficient back support and personal preference should ultimately determine the type of mattress to be purchased.

Seeking a Second Opinion

april63: If all other conservative treatments have been done for Spinal Stenosis, who at Cleveland Clinic do I make an appointment with to discuss an option that will relieve my mother of this debilitating pain?
Speaker_-_Dr_Ningegowda : My first question would be 'Has she been evaluated yet by a Pain physician or a spine surgeon?'

Post-Polio Weakness

sylvia: Does anyone on staff specialize in post-polio weakness, combined with spinal stenosis (arthritis), osteopenia and spinal collapse?
Speaker_-_Dr_Ningegowda : I am not aware of any of our staff who specifically specializes in post polio syndrome. Management has to be a team approach including Specialists from Neurology, physical medicine & Rehab and Pain medicine.

Back Pain & Multiple Sclerosis

checkmyhealth: I have been suffering from back pain with extreme pain down my right leg. A recent MRI narrative of this exam noted: "1. Hypertrophic chance localized to the superior process of the right L2 articular facet. This projects into the right neural foramen along the exiting L2 nerve roots course and is worrisome for potential impingement and irritation. The canal is on the small size of normal, and thee is bulging disks most pronounced at L2-3 resulting in mild central stenosis. 2. Diffuse degenerative changes of the apophyseal joints". I have relapse remitting Multiple Sclerosis and walk with a cane on my left side with my right leg being the weakest. I have burning pain from my buttocks down to my foot with sitting and laying on my side at night. Each side creates pain and burning and I'm unable to achieve a good nights rest. What is your opinion of treatment for this?
Speaker_-_Dr_Ningegowda : Sometimes with MS a patient will have weakness which will affect posture and walking. This in turn can cause arthritis in the spine. At this point of time, it is advisable for you to be evaluated by a pain physician before any treatment modalities are planned.

Blood Thinners

gdovinh: I am on blood thinners Coumadin, Aspirin (81mg) and Plavix. Can I get spinal injections safely?
Speaker_-_Dr_Ningegowda : Yes provided the medications are stopped in advance. In our practice we usually do not stop Aspirin (81 mg).Coumadin- has to be stopped 5 days prior to the procedure. We check the Pt INR on the day of the procedure to make sure clotting is good. Plavix need to be stopped 7-10 days prior to the procedure. It is important to discuss with your PCP or cardiologist before stopping any of the above medications.

Cleveland_Clinic_Host: Thank you Dr. Ningegowda for taking the time to chat with us today.
Speaker_-_Dr_Ningegowda : Thank you very much. It was a pleasure doing this chat and look forward to future chats.

Cleveland_Clinic_Host: If you would like more information regarding back pain, please visit the Cleveland Clinic Center for Spine Health web site at http://cms.clevelandclinic.org/spine/. For general health information you may also wish to visit www.clevelandclinic.org/health

Cleveland_Clinic_Host: Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2008, please use our 'Contact Us' link (www.clevelandclinic.org/contactus) to submit your suggestions.



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