By Robert Heary
WebMD Live Events Transcript
Event Date: 8/27/2001
You've heard that death and taxes are unavoidable, but maybe back and neck pain should also be on that list. It seems we all experience it in some form, from mild to serious, sometime in our lives. Robert Heary, MD, from the American Association of Neurological Surgeons, presents the latest information on prevention and treatment options.
The opinions expressed herein are those of the guest's alone. If you have
questions about your health, you should consult your personal physician. This
event is meant for informational purposes only.
Moderator: Welcome to our live event with Robert Heary, MD, from the American Association of Neurological Surgeons. Dr. Heary is here to answer your questions about back and neck pain. Before we get to our member questions, can you take a moment and tell us about your background?
Heary: Sure. My training is as a neurological surgeon, however I have also done training in orthopaedic spine surgery during my fellowship. As a result, I feel comfortable with problems that might be typically handled by either an orthopaedic surgeon or a neurological surgeon.
Moderator: What are some of the most common causes for back or neck pain, and what can the average person do to avoid injury?
Heary: The most common cause of low back pain is due to problems of the disc between the bones of the lower back. Disc problems can include either a herniated or a degenerated disc. Both can cause pain in either the leg, back, or both. As far as the neck goes, again the most common problems are related to the disc located between the bones of the neck. Problems in the neck can cause arm and neck pain, but also problems in the entire body if the spinal cord is compressed. This is a very serious situation, although it doesn't occur with high frequency.
lynne_webmd: I have had upper neck and mid-back problems all my life. The fact that I am tall and work on a computer to make my living has compounded my problems. I'll be fine for awhile, then stress my neck and back. Even with a chiropractic adjustment or two, I'm left with a stabbing pain in my back and cramped muscles. What can I do?
Heary: This problem is not uncommon. Frequently people have occupational difficulties if their work station is not ergonomically ideal. It is very important to have the work environment examined to assure that both the back and neck positions are normal and comfortable while you are working, and to make sure your hand positions are comfortable with respect to the keyboard. Any of these misalignments can lead to difficulties.
janice519_webmd: Yesterday I went in to have a steroid shot in my back. Instead the doctor did 3 nerve blocks. Is there a difference?
Heary: Often people refer to nerve blocks or a steroid block in similar fashion, but ordinarily a nerve block is different from a steroid block. Steroids may be injected around a nerve or the spinal cord itself. These are very strong anti-inflammatory medicines, utilized in an attempt to decrease pain. Nerve blocks are normally performed with a local anesthetic. The difference between a nerve block and steroid injection is that the nerve block lasts a shorter period of time.
cubs629_webmd: I sit at my desk all day long every day working at my computer. I often suffer from neck pain when I go home in the evenings. Should I see a neurosurgeon?
Heary: It is reasonable to be evaluated by a spine specialist. It may be difficult to get an appointment with a surgeon before any preliminary work-up has been done, so most patients first consult their primary doctor in order to begin the workup process. The work-up may include X-rays and possibly an MRI or CT scan, and in some situations, a course of physical therapy may be performed. If the preliminary workup identifies any specific neck problems which may be benefited by surgery, then an appointment with the neurosurgeon would be excellent at this point.
nanbi_webmd: My MRI stated "leftward eccentric bulge at l4-5" and "bulky facets contributing to borderline canal diameter and left L4 neural foraminal narrowing ..." Can a bulging disc cause the same severity of pain as a herniated disc? Thank you.
Heary: Very good question. It's a commonly seen problem. The difference between them is oftentimes how one radiologist will report a given study. Many times the two may refer to the same problem. The nerves need to leave the spine through bony holes or foramina in the spine. If the openings are narrowed, that causes problems with the nerve route. In addition, if a disc is herniated or bulging it can lead to further problems with the nerve route. As a general rule, nerve route problems show up as pain in the leg. There may also be weakness and/or numbness in the leg as well.
wiredone1_lycos: Do you feel that nerve damage problems such as
bilateral radiculopathy in both legs and feet should be treated by an ortho,
neurosurgeon, or a
pain doctor? I had ALIF L5-S1 that has left me with this (done by ortho). My ortho says he can do nothing more for me and I am only 30.
Heary: Again, this is a somewhat common problem. Radiculopathy is the term used to describe pain related to a nerve route. This will be best treated by a physician comfortable dealing with nerve root problems. In some communities this expert may be the neurosurgeon, and in others it may be the orthopedic surgeon. Every community is different and individualized. As far as a pain specialist, these are ordinarily doctors who treat pain but do not perform surgery. Most pain specialists are anesthesia doctors. My advice is if you are only 30 years old and have severe leg troubles, a second opinion would be in order. Since surgery has already been performed, get the second opinion from a good spine surgeon. This surgeon could be an orthopedic surgeon or neurosurgeon. Due to my training, I am a little biased towards neurosurgeons.
mountainman7777_webmd: I had surgery last week due to a pinched nerve in area 15 and still have some feeling in one buttock and slight numbness across top of my right foot. Is this normal, and will it get better or did they not take enough out? Also, I'm having leg cramps in my shin area, and fluctuations, like it's more nerve controlling, and that seems to be causing the cramps. Thanks.
Heary: With having undergone surgery only one week ago, these are very common problems. Often when a herniated disc is removed the nerve root must be manipulated in order to remove the bad portion of the disc. This nerve manipulation, however gentle, can lead to symptoms of pain, weakness, or numbness which may take a few weeks to resolve. If there are any specific concerns that something may be wrong (doesn't sound like the case here), you could contact the operating surgeon and be seen.
wiredone1_lycos: I will be having steroid nerve blocks done by a new pain doctor. What is the success rate with these?
Heary: Steroid injections have very variable results. Some patients derive benefit for months at a time; whereas others may only receive benefit for only a few days. Some do not receive any benefit at all. It is very hard to predict which patients will have a positive response to steroid injections. As a general rule, if the injections are performed by a skilled specialist, they are quite safe with very little risk.
wiredone1_lycos: I had an MRI show straightening of the cervical spine. Could this cause cervical radiculopathy? The doctor also noted I have hyperreflexia.
Heary: Straightening of the cervical spine can often occur from a cervical sprain. This may just be a temporary muscle problem or it may be a more longstanding problem. More important than the straightening of the spine is whether there is any nerve root or spinal cord compression. This can be determined on the MRI and correlated with the patient's physical exam. Hyperreflexia means the flexes are overly reactive, which can be a sign of spinal cord compression. This requires a detailed neurological exam to determine if there are other signs of spinal cord compression, as well as a review of the MRI by an expert.
cubs629_webmd: I recently hurt my back playing tennis. I experienced a sharp pain down my leg and a pain in my lower back. I was given an anti-inflammatory and went through physical therapy. My back is still sore and I'm told to continue to stretch and exercise. Will that hurt my back more?
Heary: This is an interesting and difficult problem. Years ago if someone had a herniated disc they were put to bed rest for 6 weeks. It is now very clear that this is not the best way to treat a disc herniation. What this patient is describing may be a herniated or bulging disc causing nerve root irritation. Nowadays we normally recommend that the patient allow the nerve to "cool off:" which may take one, possibly two weeks. After this cooling off period, it is reasonable to begin an exercise program. As a general rule, this will not hurt the back any more. The regular program of abdominal and back exercising is advisable for this patient and [for] almost all people to keep their back conditioning in its best shape possible.
doda711_msn: I have had neck, arm, and shoulder pain since my cervical surgery a year and a half ago. I am now considered a chronic pain patient. I am told that I will be on pain meds forever. I also have small lumps within the muscles that cause me a lot of pain. Do you think that this problem will ever get better?
Heary: This is a hard question to answer with certainty. One thing I can recommend to any patient who has had surgery more than one year ago and continues to have problems is to have a re-evaluation by a spine surgeon. I strongly recommend the first re-evaluation be performed by the individual who performed the initial surgery. However, if the operating surgeon says there is nothing to do, it is advisable to get a second opinion from a different surgeon, since all spine surgeons do not agree on whether something can be done or not.
Moderator: Member question: I have very little curve in my neck. The muscle the runs from the back of the neck to the chest (where the Vulcan death grip would be placed) becomes inflamed and spasms. This causes pain with arm movement and also triggers migraines. Swimming and massage have helped, but what else can I do?
Heary: The first thing is to get an evaluation by the general family doctor. There is a very good chance that at least X-rays, and probably an MRI, will be performed to eliminate the possibility of a surgically correctible cause of the symptoms. If there are no surgically correctible causes then the problem may be muscular, which would be best treated by a physiatric doctor. If the symptoms are related to a cervical spine abnormality, then an experienced spine surgeon is the best doctor to see.
Moderator: Member question: I'm 52 and have had lower back pain since 1997. I've tried everything. I'm ready to try epidurals. Then pain medicine or microscopic surgery. What do you recommend?
Heary: As a general rule it's best to attempt to avoid surgery. We refer to conservative therapy as any nonoperative treatment regimens. For the low back, this ordinarily begins with a back and exercise program, which is done at home as a patient or in a formal physical therapy program. In addition, it is important to maintain as close to an ideal body weight as possible, since being overweight can worsen back problems. Other treatments which in general are quite safe and worth looking into could include epidural injections. There are also positive reports from patients who have received treatment via chiropractic, acupuncture, or biofeedback. It is not always possible to explain why a person has a good result, but if any of these modalities are able to help one avoid surgery, this is in their best interest. Most patients will regret rushing to spine surgery. If none of these assorted conservative methods are successful it is reasonable to consider surgery.
Moderator: Member question: I had x-rays of the lumbar spine and it showed "marked degenerative intervertebral disc space narrowing at the L5-S1 level with moderate anterior subluxation of L5 on S1. There may as well be pars interarticularis defect at this level." What does this last sentence mean in laymen's terms? I also have osteoporosis in region L-2 - L4 (-3.2 compared to young adult). Is it OK to have chiropractic adjustments when one's bones are osteoporosis? I am a female, age 66.
Heary: The L5 S1 slippage is referred to as spondylolisthesis. This is most commonly seen at the L5 S1 level and can be associated with pain. It's an abnormality found in 5% of all people in the U.S. If there are symptoms related to this problem they are most often treated with a spinal fusion procedure. The pars defect refers to an absence of bone in the low back. There should normally be a complete ring of bones around the nerves in the lower spine, and the pars defect means the ring is not complete. As far as chiropractic manipulation with osteoporosis, this is best addressed with the chiropractor directly. There is some increased risk of complications with manipulation in this case. A value of minus 3.2 is quite low and should cause you to see your medical doctor to determine if there are any medications which may be used to help increase your bone density.
wiredone1_lycos: How successful are spinal cord stimulators in reducing leg pain symptoms compared to opiod and antispasmodic medications?
Heary: Unfortunately, all of these topics are for patients with severe spinal problems. They are usually utilized after patients have failed surgical intervention. Spinal cord stimulators, morphine pumps, and baclofen pumps are all utilized when people are having significant back pain that is not treatable with spine surgery. The most important point to remember is to confirm that spine surgery will not be helpful. Just because a single surgeon does not feel spine surgery is indicated, not every surgeon will agree. In general, if the problem can be corrected with spine surgery, then the results will be better than if a stimulator or a pump is necessary. As far as comparing spinal cord stimulators with morphine pumps, it depends on the specific problem treated and the doctor implanting these pieces of equipment.
gailmom42_webmd: Why is it that I have two herniated discs and some stenosis yet the doctor says this is quite common although I suffer from pain?
Heary: The doctor is correct. This is very common, and many patients don't understand that because you have two herniated discs and some stenosis it doesn't mean that those abnormalities are causing your pain. This is a good example of why a spine specialist (neurosurgeon or othopaedic spine surgeon) should determine whether the herniated discs and stenosis are causing your problems. Unfortunately, many general practice doctors do not have the training to determine if herniated discs or stenosis is causing the pain. It is important the doctor you are referring to be a spine specialist. Just to repeat, spine specialists are generally neurosurgeons or orthopaedic surgeons. Almost all neurosurgeons perform spine surgery regularly. Approximately one out of five orthopedic surgeons perform spine surgery. The orthopedic surgeons who perform spine surgery have done fellowship training. Most neurosurgeons learn spine surgery during residency training, and as a result, they do not ordinarily do spine fellowships. Any fully trained neurosurgeon or orthopaedic surgeon with a spine fellowship should be able to fully evaluate any spine problems.
babyblue007_webmd: I broke my sacrum bone in a MVA. Will it ever be the same? Been in severe pain for over 2 years.
Heary: Two years is too long a period of time to be in severe pain. I suggest an evaluation by a surgeon comfortable dealing with sacral bone injuries. These are relatively uncommon, and even many spine surgeons might not be comfortable handling these problems. Therefore the patient should ask their specialist if he or she is comfortable treating sacral injuries, and if not, get a referral to a specialist specifically treating sacral injuries.
wiredone1_lycos: Can you tell us if the main web site for the American Association of Neurological Surgeons has a doctor finder for specific states program, and if so what is the web address?
Heary: Yes. The main web site has a region called Find a Neurosurgeon at www.aans.org . Through the Find a Neurosurgeon section, a neurosurgeon in anyone's area can be found. Almost all neurosurgeons treat both back and neck disorders, so a referral to a neurosurgeon means you have been referred to a spine specialist.
Moderator: Member question: Can you recommend any a particular exercise regime to help prevent and/or lessen chronic back pain?
Heary: Yes. One of the newer treatment methods we have had a lot of success with is use of a large fitness ball. These are large rubber balls filled with air that are between 22 to 26 inches across. I routinely have patients of mine do both abdominal exercises (sit ups) and back exercises (extension) while laying on the fitness ball. This provides an excellent method for stabilizing abdominal, back, and side of the trunk muscles. By strengthening all the trunk muscles, chronic back pain can be lessened.
janice519_webmd: Where to go now -- I have a significant tear on the back right and a small on the right side (L5 S1). 5/2000 had and the IDET without positive results and performed again 3/ and again without positive results. Pain is in low back (very sensitive to the touch), down both buttocks, then down the outside of the right leg to the knee periodically to the ankle and on the left on the outside to the knee, bypass the calf and the bottom of my foot on the arch. My doctor and I are frustrated because of the multiple symptoms. Which disc do you think are affecting these?
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Heary: This brings up an interesting point. Patient is referring to an IDET procedure (intradiscal electrothermy). This is where the disc is heated with a coil to reduce back pain. I have written an editorial on this topic in the Journal of Spinal Disorders. I see far too many people with this exact same story. I am skeptical of the long-term results with the IDET procedure, and my suggestion to anyone who had this performed and who is not happy with the results, that they be evaluated by a spine surgeon who does open surgery to determine whether or not a fusion would be useful.
Moderator: We are almost out of time. Before we say goodbye, do you have any closing comments for us?
Heary: Yes, I do. I think it is important for all to realize that all neurosurgeons are spine specialists. They have an extensive amount of training with a minimum of 6 years of residency training after completion of medical school. This is the most rigorous residency program of any specialty. As a result, neurosurgeons are highly trained specialists when it comes to spine disorders. To address each area separately, problems in the neck are usually due to a disc that may cause neck pain or into the arms, and possibly the hands. If the spinal cord is affected, the result will be difficulty walking, with balance, hand numbness, and sometimes additional problems with the legs. When the spinal cord is compressed, surgery will be the best treatment. If the spinal cord is not compressed, then attempts at conservative treatment should be tried. As far as the lower back is concerned, as a general rule, it's better to avoid surgery whenever possible. If there is a back problem, see your local doctor for a preliminary workup, and a trial of conservative therapy is appropriate. Only when these have failed should surgical intervention be performed. If you are undergoing surgery, find out who the best spinal surgeon is in your area. Like all specialties in medicine, and outside of medicine, some specialists will have better reputations than others.
Moderator: Thank you for joining us today, Dr. Heary.
Heary: Thank you for chatting with me today.
The opinions expressed herein are those of the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
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