Oh, My Aching Back! with Edward Benzel, M.D.

Last Editorial Review: 10/23/2003

WebMD Live Events Transcript

Join neurosurgeon Edward Benzel, MD, to discuss surgical and non-surgical approaches to lower back pain and lumbar spinal stenosis.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD LIVE!  Our guest today is Edward Benzel, MD, and the topic is "Oh, My Aching Back!".  Edward Benzel, MD, is the director of Spinal Disorders at the Cleveland Clinic Foundation. His clinical interests include the management of Chiari malformations, spinal instrumentation, instrumentation design and complex spinal pathology. He is a member of the American Association of Neurological Surgeons.

Dr. Benzel: Thank you for inviting me.  

Moderator: When should a person seek a neurosurgeon vs. an orthopedic surgeon?

Dr. Benzel: Currently, in the year 2000, the neuro and orthopedic surgeon are thought of the same, in terms of surgery. Therefore, neurosurgeons intervene surgically and non-surgically in the disorders that cause backache. Usually, the first line of defense for the management of back disorders is the individual's primary care physician. If the primary care physician is uncomfortable with the management of this disorder, or if the patient is concerned about the problem, it is best to see the surgeon. These are cases of deep, persistent pain in the back that hinders upright posture or daily activities, and are relieved by bed rest. This is the type of pain a surgeon may help. Pain that extends into the legs may be of concern and addressable by a neurosurgeon.  

Moderator: Can a cause often be found for back pain?

Dr. Benzel: Unfortunately, we cannot often find a cause. There are often no anatomical findings on X-ray, CT, or MRI scans. But the most common cause is overuse. This is most commonly superimposed on a deconditioned back. The back and abdominal muscles are relatively weak. Lifting a heavy object can exacerbate this, inducing an episode of back pain. Most often, such an episode is best treated non-operatively. 

Moderator: Dr. Benzel, how important is the type of bed or pillow on which a person sleeps?

Dr. Benzel: This is a difficult question. If you ask a number of surgeons, you may get a variety of answers. In my opinion, the type of bed and pillow doesn't matter significantly. In general, a relatively firm mattress and small pillow are best for managing this pain. But, it may be wrong to spend a lot of money on a specialized mattress with no proven value.  

Moderator: Are there alternatives to surgery?

Dr. Benzel: There are many alternatives for the majority of patients. We must break spinal disorders down into their causes. Relatively few patients have an "instability" that would benefit from a surgical fusion procedure. Furthermore, few patients have disc herniations that require surgery. So, the majority of cases don't require surgery. Those that have refractory symptoms are the optimal candidates for surgery.

Moderator: How successful are alternative medications for treating back pain?

Dr. Benzel: Herbal meds and supplements haven't been shown in studies to improve the pain in the back or leg. Most physicians don't prescribe these. Still, they aren't harmful, and if they're helpful, the individual can take them without significant risk. But, there is no proven efficacy among these treatments.

Moderator: How prevalent is back pain?

Dr. Benzel: Indeed, it is. It is the 2nd most common cause of lost work days in the US, after the common cold. This is because, in part, of the labor and activities most people perform. For example, a dog walks on all four extremities, and disperses the load on the spine. But when we lift heavy objects, we put all the stress on the back. This is common when individuals are deconditioned, meaning, they don't have strong backs and aren't used to heavy lifting, so when they do, they strain uncommonly used muscles, beginning an episode of back pain.

Moderator: When does back pain merit surgery?

Dr. Benzel: Back pain is multi-faceted, with many causes. The only type that should be considered for surgery is mechanical back pain. From a symptom-perspective, this is deep, and worsened with activity, improved with bed rest. This should correlate with an anatomical finding, like excessive motion, in imaging surveys. The individual that is considering surgery should try all other options aggressively first. They should try exercising, weight loss, and smoking cessation.

Moderator: What is spinal stenosis?

Dr. Benzel: Spinal stenosis is an imaging diagnosis. An MRI scan or a myelogram are necessary for establishing the presence of a neuro spinal canal. An individual with spinal stenosis that is symptomatic, however, has a condition that does not enable excessive walking without having heavy legs. This can cause severe pain and neurological loss in the form of weakness. Those afflicted may find that their symptoms are relatively improved with the use of a shopping cart in a grocery store, when they can flex their spine and relieve the pressure. One must keep in mind that imaging studies often indicate stenosis, or a narrow canal. This doesn't imply that the patient needs surgery. Only when the diagnosis is assured should a patient seek surgery. Most candidates are middle-aged to older, very rarely younger.

Moderator: I wasn't aware that smoking was related to back pain. How is it linked to back pain?

Dr. Benzel: We are not sure why smoking is associated with back pain but several large clinical studies have demonstrated a relationship between smoking, neck and back pain, and arm and leg pain. Further, they find a correlation with the reduction of this pain and the cessation of smoking. The exact relationship isn't clear. Cigarettes contain many toxins, not just nicotine. They can reduce crucial blood flow, which may have an effect. No cause-effect relationship has been determined but the relationship is proven. I often tell young patients that the most significant step they can take to improve back pain is to stop smoking.

Moderator: Are all back pains preventable?

Dr. Benzel: No. Some aren't. I've seen people who have abused their spines (through sports, heavy equipment, truck driving) who have minimal back pain. But I've seen people who've taken very good care of their spines, who have significant degenerative changes that can lead to back pain. It's preventable in many circumstances, but some people have back pain and have no explanation for the cause. Nothing they would have done may have prevented the pain from occurring.

palmeres_WebMD: My mother has constant back pain which her doctor has not been able to find a cause for. Could there be a psychological reason for her back pains?

Dr. Benzel: Individuals of all types can amplify or deamplify pain. For example, a child who wants to play may pay little attention to a painful arm, while a child who has to go to school may deem the arm pain very significant. Having said that, the same is true with back pain in adults. Still, many people with back pain have no definitive findings on imaging studies that delineate the cause. This doesn't mean the pain is in their head. It just means that we cannot determine the cause. In fact, these syndromes are the most difficult to treat, but it does NOT imply that the pain is "in her head."

palmeres_WebMD: What is your opinion of magnet therapy?

Dr. Benzel: There is no evidence that this is helpful for spinal disorders. A recent study concluded that this has no relationship to therapy of the spine. This is consistent with our current knowledge of pain management. Magnetic energy is not significant enough to affect pain of any type.

palmeres_WebMD: Anything that can be done for immediate relief?

Dr. Benzel: Pain meds are the traditional mechanism by which most people achieve immediate relief. This may or may not be appropriate. Usually, aspirin, Tylenol and other non-steroidal treatments are the first line of defense, unless contraindicated. When pain is severe, it may need medical attention. Severe pain that is refractory to routine medical management should be brought to the attention of a doctor. If the pain is not of major concern from a medical perspective, there are alternatives, like stronger medicine, or a visit to a pain management center or surgeon.

MomaKat41_WebMD: How do I explain to a doctor exactly "how bad" it hurts...how can I get him/her to understand?

Dr. Benzel: One of the problems doctors have is that they can't "feel your pain." This isn't a lack of empathy. All physicians face it. We can try a visual analog scale to try to quantify the pain, or another tool, but these are weak replications. Most doctors have a good "feel" for the extent of the person's pain, but the most experienced physician may make errors. The only way to point out the severity of the pain to the doc is to be honest. This helps to establish the communication. Once this is done, the extent of the pain can be more easily explained.

Moderator: Is back pain usually accompanied by other conditions?

Dr. Benzel: Back pain is common. It can accompany catastrophic conditions, rarely. It can accompany tumors, infections, large herniated discs. More often, the pain is isolated. However, it may often accompany leg pain, if disc herniation is present, so it can present in any number of ways. Most commonly it is isolated. Next commonly, it accompanies leg pain with disc herniated. Then there are a variety of conditions it may acccompany.

palmeres_WebMD: Is spine surgery a relatively new treatment option? What are the risks associated with it?

Dr. Benzel: It's not a new treatment. Surgeons for years have been performing a variety of surgical procedures for this --  removal of discs, fusion of spine. More recently, more approaches have sought to be applied, but these haven't changed the overall goals of surgery. Surgery is at a higher level now than it used to be, and is more effective, but it must be carefully selected. So, those contemplating surgery should have exhausted non-surgical strategies, and must trust their surgeon. This combination of trust, honesty, and conservatism should frequently lead to a positive outcome.

palmeres_WebMD: How does one know whether they should seek out an orthopedic doctor versus a neurosurgeon. I always thought neurosurgeons dealt with mental conditions.

Dr. Benzel: As I stated earlier, neuro and orthopedic surgeons serve the same purposes in management of back pain. Neurosurgeons deal with the spinal column and spinal cord. Neurosurgeons do not only deal with brain problems. 70% of surgeries performed by neurosurgeons are on the spine. We perform the whole spectrum of surgeries on the spine: fusions, disc herniations, etc. Neurosurgeons do NOT limit themselves to brain disorders. They more often care for disorders of the spine.

Moderator: Why does the public have such a perception of neurosurgeons?

Dr. Benzel: I think in part because of history and the name. Orthopedic to most people means bone, and the treatment of bones. Neurosurgeons have been traditionally thought of as those who care for brain disorders. While this is true, the predominant number of operations performed is on the spine. The name neurosurgeon implies nerves and brain, not the structures that support the nerves, like the spinal column. This is a misnomer, since we care for spinal disorders of all types.

palmeres_WebMD: Are there studies of the success rate of using acupuncture and massage for treatment?

Dr. Benzel: There have been studies performed regarding the utility of acupuncture and massage for this. They haven't been performed in a scientific matter, though, so they're efficacy is unknown.

palmeres_WebMD: I'd like to find out about any new treatments/medications that we can be looking forward to.

Dr. Benzel: There are medications that affect bone healing and physiology that may be on the horizon for the management of spinal stenosis. More importantly, as our knowledge increases regarding surgery, we are aware that more aggressive trials of non-operative treatment may have an advantage than previously thought. Medication per se won't be the answer, but the strengthening of the natural stability and flexibility of the spine will be the answer to improvement as a strong, healthy, flexible spine will experience much less back pain than a weak, inflexible spine.

Moderator: Thank you, Dr. Benzel, for taking the time to respond to our audience.

Dr. Benzel: You bet!

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