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How Can Chronic Lower Back Pain Be Treated?

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Posted on Mon, 4 Sep 2017
Question: Dear Dr. Saghafi. Thk u for asking. I am not doing well at all. I think I told. U before that my Dr. Retired and I had to get a new pain management. I think I told you. Well he has decided to reduce my pain meds to 10 mg 2x a day because I had plans to take. I undertand all that stuff but what is your opinion
On my lower back
MRI from 5 18 17. 3herniated disc, narrowing foraman, nerve compression, and central canal area,
I am sorry I am not
a good texter

The pain is gonna kill me. Not really, I have too much to live 4

I have contacted the laser spine institute and they don't if they can help. Me.

Please tell me why I have to live with so much pain. Bye
doctor
Answered by Dr. Dariush Saghafi (11 hours later)
Brief Answer:
Good morning young lady from The Big Apple

Detailed Answer:
My goodness.....I'm sorry you're in pain....it's a beautiful XXXXXXX day in XXXXXXX (not common!) and the temperature is comfortable....although change is in the air as you are well aware I'm sure....Summer has been all too short as it is for we who continue to climb the ladder! I am going to do my best to give you a worthwhile suggestion for a common problem that many of my patients also have but for whom varieties of treatment options don't seem to work...or at least not for very long....

On your first statement about reduction of the pain medications that your new doctor is recommending. I know you understand the movement afoot which has been scrutinizing the use of controlled substances and especially opioids by doctors for their patients. I was never (and still am not) one to prescribe very much in that realm. First, I'm not a pain management person but rather a neurologist but more than that...I truly believe in doing one's best to address the root problem and then, to use appropriate medications depending upon the problem. In others words, if there is swelling and inflammation then, ANTI-INFLAMMATORIES, if there is an architectural problem such as a tear, herniation, or fracture....surgery to the extent possible to either repair or remove and replace. Again, in the musculoskeletal world these days you'd be amazed at some of the things they have available. For example, artificial and injectable disks that can be placed in the spinal column......have you heard of such things? This would be the domain of an orthopedist for example. They are also looking at doing segmental replacements of the spinal column for deteriorated vertebrae that are affected with a lot of osteoarthritis and calcification. But to my knowledge a lot of that is still being worked on....not yet ready for prime time.

I wish I could endorse service such as "laser" this that and the other. I've had several patients go and spend 10's of thousands of dollars in Florida and other nice resort locations and you know what they came back with? Much less money in their bank accounts and the same if not more pain than starting. I honestly put no stock in those types of services because the use of LASERS is of no value to fixing the underlying problem. Cauterization procedures that have been around for half a century or longer achieve the same ends....just not quite as fancy.

I can only imagine your pains since I have patients with the same complaints. If you were to have any type of surgical procedure I would be very careful to talk with the doctor about the likelihood that all of the 3 herniated disks themselves are contributing to the pain. Or is it the nerve compression.....or are there mutliple nerves being compressed.

A study done on people with herniated disks suggested that 50% of people with nerve compression pain will resolve about 50% of their pain ratings on the 0-10 scale by simply doing conservative things such as standard pain management, combined with appropriate exercise, anti-inflammatories, good nutrition and weight management.

I'm assuming that you're previous doctor has already tried you on the standard regimen of pain management drugs that most of us probably think of for lower back pain problems such as Neurontin, Lyrica, Pamelor, Tizanidine, Motrin, Naproxen, etc. Am I correct? Opioid management may have a role but it's limited for chronic pain of this type because the body simply upregulates its receptors to the drug over time but since the cause of the problem (nerve compression in your case..and possibly some arthritis) is not being directly addressed and the drug is merely trying to BLOCK PAIN signals....the potency of the intervention wanes over time. Same thing is true for spinal blocks and injections and those carry risks of steroid induced tissue toxicity which can weaken the structural integrity of the ligaments and tendons that support the column causing more muscle fatigue which contributes to pain.

In my opinion and what I try and encourage all my patients to get to is a place where even though they have pain...they can still engage in physical activity and exercise.....yes, it's painful...but it's going to be painful anyway if you don't move about. The XXXXXXX Arthritis Foundation has an excellent website with tons of solid suggestions for exercises as well as PROGRAMS that are in your local area for things such as AQUATHERAPY which I highly promote. In place Water jogging is absolutely one of my favorite exercises to give to patients with low back pain who have compressive radiculopathies (such as yours).

As far as the pain management let me share with you one pearl that I've learned and applied over the past few years and that is the use of BOTOX injections for compressive neuropathic pain or lower back and/or neck pain. I find that the complication rate is lower, effects can be as long or in many cases longer lasting than standard analgesic/steroid combos and the amount of tissue toxicity when depoting the shots is minimal since BOTOX is completely hydrolyzed and there are no known toxic effects to the injected tissues which could cause them to weaken or thin or time as steroids are known to do.

BOTOX injections for this purpose is clearly an OFF LABEL indication and so you would have to find someone knowledgeable and competent in the placement of the shots (usually 8-12) in the lumbar paraspinal areas with a duration of 10-12 weeks but then, necessitating reinjection.....until the actual problem can be addressed.....IF it can be addressed.

I'm going to give you the website URL for the Arthritis Foundation that also promotes and advocates healthy nutritional options for people who have arthritic complications and types of foods that are believed to reduce complications in this aspect...not only that but good dieting can lead to weight management and exercising leads to good conditioning which in sum total can DECREASE and greatly REDUCE a person's total burden of day to day pain.

See what you think.....here's the GENERAL HOMEPAGE:

http://www.arthritis.org/


Here is the page on Arthritis Diet recommendations:

http://www.arthritis.org/living-with-arthritis/arthritis-diet/


And finally here is the page on Exercises especially for people with Arthritis:

http://www.arthritis.org/living-with-arthritis/exercise/


I hope as before that at least some of this information is different and gives you some other perspectives from what you've heard before. Try and change the focus from REACTIVE.....to PROACTIVE......In my mind and from what I've seen with the patients who have experienced success in fighting back pain....this offers better and longer lasting solutions rather than searching for the next medication to cure everything because as you've discovered....that's not really a reality yet with our present day technology and knowledge.

All the best to you.

You were very generous on the last question you asked of me. I hope I didn't disappoint on this one though I wish I could offer you a bit more concrete FIX IT steps to take all your pain away....but I'm sure you understand what a tall order that really is...be careful of those who SAY THEY CAN DO IT (Laser Institutes, etc)!

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 45 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi (9 hours later)
WEll Doc, you have certaintly scared the loving daylights out of me. My Laser Institute app't is scheduled. I don't know what else to do. I can't live with the pain anymore. I can't do anything anymore.

It's really my last hope. I can't thank you enough for answering my questions. I wish you would keep in touch and I will let you know what happens.
Pray for me. I'm scared.
Friends, XXXXXXX XXXXXXX XXXX
doctor
Answered by Dr. Dariush Saghafi (4 hours later)
Brief Answer:
No intent to "scare" you but rather inform you of experiences of others

Detailed Answer:
Thanks for your return response and there's nothing to be SCARED of......let's look at the bright side and say that they likely have a lot of experience with many patients and so there is certainly all the hope in the world and I am certainly rooting for you when you have your appointment....if you feel it's the best thing for you to do....won't you consider though that in fact, THAT procedure is not the last option you have in the world......please look at the information I've provided...nothing says you can't put these suggestions in play even following the procedure, right? In fact, you will in all likelihood need rehabilitation and recovery time and I can't think of anything better than combining whatever the Institude tells you to do as part of their program as well as this program including diet and even the number of other things they do and recommend that are conservative but effective measures when it comes to fighting arthritic disease. I am delighted you are interested in staying in touch and letting me know how things are going.....That would make me very happy to hear of your progress. In fact, if your experience turns out to be very good then, I will certainly remember that use that story to tell my patients about people who have had successful outcomes. You could become FAMOUS! LOL....

There's not much of a way that I can keep in touch with you using this telemedicine platform.....I don't think you'll get to XXXXXXX any time in the near future, would you? We have a beautiful city......and by the way....we LOVE NEW YORK....I have family there!

But you can write to me and keep me up to speed as to what's going on.....you can certainly keep some of the other suggestions I've given you about the BOTOX injections and if you do come to XXXXXXX let me know by calling my office and I'll be happy to do the injections for you.....I think they're better than any of the standard injections they use.

Cheers young lady. I feel good Karma coming your way....and with a little motivation, perseverance, and faith on your side....you will do well. Don't forget everything I've told and showed you that can help you down the road following this procedure.

Be well!

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, and of course, UPDATES.

This query has utilized a total of 85 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi (17 hours later)
I'm scared. But I have read every word u wrote. I Feel like I have to give this laser spine institute a chance. I don't know what else to do. I can't do anything any more. I can't climb stairs or get off the toilet. I am bad. I am putting my trust in XXXXXXX I feel like my life is over, the pain is just so bad. We r going to XXXXXXX Labor day week. Please say a prayer for me.
Love you, XXXXXXX XXXXXXX XXXX
doctor
Answered by Dr. Dariush Saghafi (15 hours later)
Brief Answer:
You are coming to XXXXXXX

Detailed Answer:
Well, young lady....you decided to take my offer and visit Cleveland? How exciting! I know, I know...."Calm Down" you're saying....It's not YOU we're coming to see....it's the Laser Institute. I get it.....but my goodness. Have you been to XXXXXXX before? Do you know the city since XXXXXXX has been parking its trailers and vans regularly over the past 10 years in and around town? LOL. Have you heard that the Indians and Cavaliers are a happening thing.....the Browns...well....

Perhaps, you'd like to set up some type of consultation appointment prior to your procedure with me in the office so we can have a relaxed sit down face to face? As I said previously, my purpose at this point would not be to dissuade you in any way from the procedure you have looked into and feel is has the best chance at offering relief.

Nevertheless, if you're coming all the way out from NY to C-town.....I just wanted to offer you that option. Our office is located in a moderately bustling suburb of the city....I'm sure that would be NOTHING for a NEW YORKER....but WE consider it a moving area at least with lots going on. While you're here you must take some time to enjoy things as well as see the people at that Laser Institute. Of course, everything is contingent on how you feel but you never know how this procedure can turn out for you, right? I'm assuming it's an outpatient type of thing...or at the very most an overnight stay?

I'm clearly rooting for you and hoping that the Laser Institute (Cleveland Clinic I presume?) runs smoothly and gets the job done. I would love the opportunity to have you in the office and see if I can help you understand why I feel that by no means should you feel that they are your "last hope." I understand your problems with climbing stairs or doing some of the basic activities of daily living which has you down. But there is a lot to be said for both the approach of the Arthritis Foundation as well as other treatment options that you may not have tried just yet which can give relief and all of these things can still be done both in concert with as well as after your procedure.

I don't know that I mentioned a device called a THERMAZONE unit that you can look up on the internet. It's a bit pricey but it does have attachments that can be used for lower back pain as well as what I primarily prescribe it for which is MIGRAINE HEADACHES. Take a gander and you'll see what I mean. I don't know if your insurance would pay for such a device but the good news about this machine is that you can USE IT AS MUCH AS YOU LIKE....it's NONINVASIVE.....and completely controlled by the wearer so it should never become uncomfortable to use in any way.

I'll just push my number along your way on a little piece of paper in case you wish to take a look at it....and by all means I'm keeping fingers and toes crossed that the folks at the Laser Institute have the solution you've been looking for...I'm sure you'll come through the procedure just fine. Our number at Parma Neurology if you wish to give a call to set up an appointment is: 440.842.3816.

We do have FLEX hours to accommodate patients who are both out of town as well as on odd work schedules so that opening on weekends and holidays (such as Labor Day) is not out unusual in special case. And you young lady....would be a special case indeed if you wished to set up an appointment.

All the very best to you and let me know please if there's anything else I can do to help....be well and safe travels.

This query has utilized a total of 115 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Dariush Saghafi

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How Can Chronic Lower Back Pain Be Treated?

Brief Answer: Good morning young lady from The Big Apple Detailed Answer: My goodness.....I'm sorry you're in pain....it's a beautiful XXXXXXX day in XXXXXXX (not common!) and the temperature is comfortable....although change is in the air as you are well aware I'm sure....Summer has been all too short as it is for we who continue to climb the ladder! I am going to do my best to give you a worthwhile suggestion for a common problem that many of my patients also have but for whom varieties of treatment options don't seem to work...or at least not for very long.... On your first statement about reduction of the pain medications that your new doctor is recommending. I know you understand the movement afoot which has been scrutinizing the use of controlled substances and especially opioids by doctors for their patients. I was never (and still am not) one to prescribe very much in that realm. First, I'm not a pain management person but rather a neurologist but more than that...I truly believe in doing one's best to address the root problem and then, to use appropriate medications depending upon the problem. In others words, if there is swelling and inflammation then, ANTI-INFLAMMATORIES, if there is an architectural problem such as a tear, herniation, or fracture....surgery to the extent possible to either repair or remove and replace. Again, in the musculoskeletal world these days you'd be amazed at some of the things they have available. For example, artificial and injectable disks that can be placed in the spinal column......have you heard of such things? This would be the domain of an orthopedist for example. They are also looking at doing segmental replacements of the spinal column for deteriorated vertebrae that are affected with a lot of osteoarthritis and calcification. But to my knowledge a lot of that is still being worked on....not yet ready for prime time. I wish I could endorse service such as "laser" this that and the other. I've had several patients go and spend 10's of thousands of dollars in Florida and other nice resort locations and you know what they came back with? Much less money in their bank accounts and the same if not more pain than starting. I honestly put no stock in those types of services because the use of LASERS is of no value to fixing the underlying problem. Cauterization procedures that have been around for half a century or longer achieve the same ends....just not quite as fancy. I can only imagine your pains since I have patients with the same complaints. If you were to have any type of surgical procedure I would be very careful to talk with the doctor about the likelihood that all of the 3 herniated disks themselves are contributing to the pain. Or is it the nerve compression.....or are there mutliple nerves being compressed. A study done on people with herniated disks suggested that 50% of people with nerve compression pain will resolve about 50% of their pain ratings on the 0-10 scale by simply doing conservative things such as standard pain management, combined with appropriate exercise, anti-inflammatories, good nutrition and weight management. I'm assuming that you're previous doctor has already tried you on the standard regimen of pain management drugs that most of us probably think of for lower back pain problems such as Neurontin, Lyrica, Pamelor, Tizanidine, Motrin, Naproxen, etc. Am I correct? Opioid management may have a role but it's limited for chronic pain of this type because the body simply upregulates its receptors to the drug over time but since the cause of the problem (nerve compression in your case..and possibly some arthritis) is not being directly addressed and the drug is merely trying to BLOCK PAIN signals....the potency of the intervention wanes over time. Same thing is true for spinal blocks and injections and those carry risks of steroid induced tissue toxicity which can weaken the structural integrity of the ligaments and tendons that support the column causing more muscle fatigue which contributes to pain. In my opinion and what I try and encourage all my patients to get to is a place where even though they have pain...they can still engage in physical activity and exercise.....yes, it's painful...but it's going to be painful anyway if you don't move about. The XXXXXXX Arthritis Foundation has an excellent website with tons of solid suggestions for exercises as well as PROGRAMS that are in your local area for things such as AQUATHERAPY which I highly promote. In place Water jogging is absolutely one of my favorite exercises to give to patients with low back pain who have compressive radiculopathies (such as yours). As far as the pain management let me share with you one pearl that I've learned and applied over the past few years and that is the use of BOTOX injections for compressive neuropathic pain or lower back and/or neck pain. I find that the complication rate is lower, effects can be as long or in many cases longer lasting than standard analgesic/steroid combos and the amount of tissue toxicity when depoting the shots is minimal since BOTOX is completely hydrolyzed and there are no known toxic effects to the injected tissues which could cause them to weaken or thin or time as steroids are known to do. BOTOX injections for this purpose is clearly an OFF LABEL indication and so you would have to find someone knowledgeable and competent in the placement of the shots (usually 8-12) in the lumbar paraspinal areas with a duration of 10-12 weeks but then, necessitating reinjection.....until the actual problem can be addressed.....IF it can be addressed. I'm going to give you the website URL for the Arthritis Foundation that also promotes and advocates healthy nutritional options for people who have arthritic complications and types of foods that are believed to reduce complications in this aspect...not only that but good dieting can lead to weight management and exercising leads to good conditioning which in sum total can DECREASE and greatly REDUCE a person's total burden of day to day pain. See what you think.....here's the GENERAL HOMEPAGE: http://www.arthritis.org/ Here is the page on Arthritis Diet recommendations: http://www.arthritis.org/living-with-arthritis/arthritis-diet/ And finally here is the page on Exercises especially for people with Arthritis: http://www.arthritis.org/living-with-arthritis/exercise/ I hope as before that at least some of this information is different and gives you some other perspectives from what you've heard before. Try and change the focus from REACTIVE.....to PROACTIVE......In my mind and from what I've seen with the patients who have experienced success in fighting back pain....this offers better and longer lasting solutions rather than searching for the next medication to cure everything because as you've discovered....that's not really a reality yet with our present day technology and knowledge. All the best to you. You were very generous on the last question you asked of me. I hope I didn't disappoint on this one though I wish I could offer you a bit more concrete FIX IT steps to take all your pain away....but I'm sure you understand what a tall order that really is...be careful of those who SAY THEY CAN DO IT (Laser Institutes, etc)! If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out. Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. This query has utilized a total of 45 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.