The FAQ will be updated periodically and additional questions answered.
Disclaimer: The opinions expressed here are for general information and based on my own professional experience. They are not intended to replace the advice of your health care provider on your particular condition.
1. Question: I did 6 weeks of physical therapy and they really helped my back pain, but every now and then I have a dull ache in my lower back. The physical therapist gave me a paper and said I should do the exercises at home to strengthen my core. What does that have to do with my back?
Answer: Mechanical pressure on the lower back is one of the consequences of our evolution to walking on 2 legs. The structures that keep us upright include the vertebrae, discs, ligaments, back and abdominal muscles. Of course our legs and ankles also play an important role. Weak core muscles or bad posture, result in more stress, wear and tear on the structures and joints of the lower back, arthritis, and pain. Strengthening the core muscles can alleviate or prevent back pain.
2. Question: I am 55 years old and I have worked in construction for 35 years and never missed a day of work. I pulled my back at work 6 months ago. I did PT but it did not help. I had cortisone injections at a pain clinic in New Hampshire, and they burned the nerves, but it only eased my pain for 2 months. I am taking Ibuprofen 3 times a day, and I use CBD oil but my back still hurts. I asked my doctor to fill out my disability papers but she said that I should get another test. Why do I need another test if I say that I cannot go back to work?
Answer: With a few exceptions such as complex regional pain syndrome (commonly known as RSD) which is often associated with characteristic changes in the skin, and affected limb, determination of functional impairment and disability cannot be based on subjective symptoms of pain alone. Most people in your age group have degenerative arthritis changes in the spine that do not necessarily reflect the degree of chronic pain. Testing such as functional capacity evaluation can provide objective evidence to assist your doctor determine your level of impairment, readiness to return to work, and possibility for gainful employment.
3. Question: I have had back pain off and on for 5 years. The pain started to go into my right leg just before Christmas last year, and I was limping and really in bad shape. My surgeon performed a laminectomy in my back in March of this year. He said that he removed a bone spur from my nerve. My leg pain is gone, and I am walking fine, but why does my back still hurt?
Answer: A variety of arthritic changes occur in the structures of spine from wear and tear, and can result in back pain. The usual treatment includes exercise, good posture and ergonomics, physical therapy, proper diet, and weight control. When arthritic bone spurs develop or the intervertebral disc herniates, the back pain may travel to the leg. If conservative measures and steroid injections do not control the leg pain, some patients may require surgical decompression to take the pressure off the nerve root and relieve the leg symptoms. The primary goal of such surgery is to treat the leg pain and related nerve symptoms, and not to alleviate the back pain. We have described the ongoing back pain as part of the “Post-surgical spine syndrome.” [MORE INFORMATION]
4. Question: My 82 year old grandmother has fractures in her spine and she is taking 2 Oxycodone 5mg tablets a day. Her helper puts the pills in a daily pill organizer for her. When I came with her to the pain clinic last month she was told to take a urine drug test. Do they think that she is a drug abuser?
Answer: No. There are several reasons to do periodic urine drug screen (UDS) and the most important is patient safety. It is reassuring to find prescribed medications in the test. Failure to find the Oxycodone may indicate that she is taking it but her body is not absorbing it, or that she is not taking it. It is possible that her helper loaded the organizer with a different medication. UDS also helps to alert the prescriber if your grandmother is taking another prescribed or over the counter medication which may have an adverse interaction with Oxycodone.
5. Question: I had an epidural injection in my back in Florida during the winter and I no longer have pain in right leg. A few months later I was having pain in my right hip. I sent the reports from Florida and I wanted to get another epidural, but the Nurse Practitioner said I had to come in to be examined. She said that I had bursitis, and I am glad to say that I had the bursa injection, and after 3 days I was pain free. Why didn’t they do the bursa injection in Florida?
Answer: You said that the epidural injection took care of your leg pain. The likelihood is that you had a “pinched nerve” and that the inflammation of the nerve subsided with the epidural steroid injection. A bursa is a fluid filled cushion that is close to the muscles and ligaments of joints. Bursitis is the term used to describe inflammation of the bursa, and it often manifests with pain in the proximity of the joint.
6. Question: I have diabetes and take insulin. I started to have severe burning pain in my feet and legs 6 months ago. The pain wakes me up every two hours. I take Ibuprofen and it’s starting to hurt my stomach, but it does nothing to the pain. My primary got an MRI of my spine and sent me for cortisone injection. I came to your clinic and the doctor looked at the MRI, showed me the pictures of the disc degeneration and said that he did not see the reason for my pain, and ordered a nerve test. Am I missing something? I thought an MRI is to show what is causing my pain.
Answer: MRI does not show pain. The purpose of an MRI of the spine is to show the structures, identify any abnormalities such as arthritis, bone spurs, disc degeneration or herniation, fracture, tumor, or infection of the spine. The information provided may help your provider to determine which of the findings may be causing your pain or other findings on examining you. MRI does not identify neuropathy which is a possibility with the burning pain that you describe. The nerve test may confirm the diagnosis, though the test may be normal in some types of neuropathy. Cortisone injection is not the usual treatment for neuropathy. Diabetes is one of the common causes of neuropathy, but there are other causes such as chemotherapy, toxins, vitamin deficiency. Initial treatment may include medications such as Gabapentin, Pregabalin.
7. Question: My chiropractor treated my back for 12 weeks and my back pain is better but I am still having pain going into my legs. He ordered MRI and told me that I have a herniated disc, and that I should see you for an epidural. What is the next step and how do I know if my insurance will pay for it?
Answer: The first thing is that we see you in consultation, obtain a history of your pain and your general medical condition, examine you, and review the MRI scan. If we determine that epidural steroid is best for you, we explain the procedure, potential risks, and other treatment options, and give you the opportunity to ask questions. If you decide to proceed, our office will be able to check and let you know if it is covered by your insurance, and any co-pay that the insurance has determined. Some insurance companies may require prior authorizations and it may take a few days to make a decision. Worker’s Comp may take a week or more to complete their review.
8. Questions: I pulled a muscle in my back 2 weeks ago while lifting heavy machinery at work. I saw the company doctor and she said that I should go for PT. I asked for an MRI but she wouldn’t order one. Isn’t it just a band-aid and waste of time going to PT?
Answer: Most “pulled back”, muscle or back strain, are soft tissue injuries and often resolve within a few weeks with PT or other conservative management. In the absence of significant neurological deficits, an MRI is not likely to change the initial treatment.
9. Question: I had spinal fusion 3 years ago and I have scar tissue in my back and I take Vicodin and Gabapentin. I recently started smoking marijuana to help me sleep. My doctor did a urine test and warned me not to smoke marijuana otherwise the office will stop prescribing Vicodin. But marijuana is no longer illegal in Massachusetts, so what’s the problem?
Answer: There is some evidence that marijuana may have some therapeutic benefit in some conditions such as pain, anxiety, nausea, sleep disorder, seizures, and multiple sclerosis. However, the adverse reactions include short-term memory disturbance, paranoia, psychosis, impairment of motor co-ordination and increased risk of driving a vehicle. Andrew H. Rogers, and colleagues studied the outcome of opioid use alone versus combined use of opioid and cannabis, for chronic pain. They concluded “Potential clinical implications of these findings include that it may be important for clinicians to assess cannabis use prior to initiating opioids for the treatment of chronic pain. The results from this study suggest that cannabis use in the context of opioid use for chronic pain is associated with significantly worse mental health and substance use out-comes.” [MORE INFORMATION]
10. Question: I got a series of 3 epidural steroid injections here 2 years ago and the pain in my right leg went away. Now I am having back pain and it goes into the left leg. My PCP said that I should come back for another injection. I thought that I could only get 3 steroid injections in my life time?
Answer: Steroids have potential side effects with frequent or prolonged use, and they include elevation of blood sugar making it difficult to control diabetes, suppression of immune system and increased risk of infection, osteoporosis and risk of fractures, reduction of adrenal gland hormone production, weight gain, muscle weakness, poor wound healing, erectile dysfunction and loss of libido . In order to avoid these unwanted effects, we monitor the amount of steroid that we administer in epidural injections. As a result we often limit the number of injections to not more than 3 every 6 months. Your thought that it is 3 injections in a lifetime is incorrect.
11. Question: My friend popped a disc in his back and couldn’t walk, and PT was too painful. He got an epidural and 3 days later he said that his back felt much better and the leg pain was gone. When I hurt my back I asked for an epidural; why did the doctor tell me that trigger point injection would be better for me?
Answer: Not all back injury is the same. It is likely that your friend’s injury resulted in a “pinched nerve,” hence the leg pain. In your case, if you sustained back strain and muscle spasm, then trigger point injection of local anesthetic into the muscles would be more appropriate.
12. Question: I crushed my leg 3 years ago and they put screws, but it always felt as if my leg was on fire. Gabapentin was working great but I am now taking 600 mg three times a day, and it doesn’t touch my pain, and I get dizzy. I asked my doctor, but he wouldn’t give me pain medication. He prescribed Nortriptyline. I read on the internet that it is used to treat depression. Does he think that the pain is in my head?
Answer: A number of medications have dual actions and are used to treat more than one condition. One that comes readily to mind is Acetaminophen (Tylenol) which has both analgesic (pain reliever) and antipyretic (fever reducer) properties. Nortriptyline (Pamelor) is both a tricyclic antidepressant, and is also used to treat neuropathic or nerve pain. Gabapentin (Neurontin) that was working so well for you is used as an anticonvulsant (to treat seizure), and also for treatment of neuropathic pain.
13. Question: I was playing football and I threw out my back. I did 4 weeks of PT and the pain is somewhat better, but I still get sharp pain in my left butt and it is very painful to sit for more than 10 minutes. My ortho doctor examined me, looked at X-rays of my spine and she said that the pain is in my SI joint and that I should see you for an injection. Don’t you always get an MRI before you give an epidural?
Answer: An epidural injection refers to introduction of medication (usually steroid) to the surface of the nerve. MRI or CT scan is often obtained to determine which nerve roots may be “pinched” or inflamed, and to determine the optimal target for the injection. The sacroiliac (SI) joint is the joint between the sacrum and the iliac bone, is lined by cartilage, and connected by fibrous ligament. The nerve roots send tiny braches to the joint. They are often not seen on CT or MRI. X-ray study alone will suffice if the diagnosis is back strain. However, there is suspicion for other risk factors such as fracture, infection, or tumor, then more advanced imaging studies may be considered.
14. Question: I am presently in Triple-A baseball and my ambition is to make it to the Major League. I ruptured a disc in my back and my doctor wants me to get a steroid injection. Won’t it make me fail a drug test and ruin my career?
Answer: There are different types of steroids. Corticosteroids have anti-inflammatory properties, are commonly used for joint and spinal injections. Their medical use is legitimate and will not get you in trouble. What you are concerned about are the anabolic steroids. These are structurally similar to the male hormone testosterone, and are illegally used by some athletes to build up muscles and enhance performance; better known as doping. Anabolic steroids have serious long term risks to your health.
15. Question: My doctor recommended epidural steroid injection because I have a herniated disc which is pinching my nerve and giving me terrible leg pain. Why wouldn’t they do an ablation?
Answer: Epidural steroid injection is more appropriate for your pinched nerve. Radiofrequency ablation (RFA), also called rhizotomy, is the use of an electric current to heat a portion of a nerve to block the transmission of pain signals. It is commonly used to treat some types of arthritic chronic pain in the spine, knee, and hip. Cardiac specialists also use ablation to block certain areas of the heart from generating and transmitting abnormal heart rhythm such as atrial fibrillation.
16. Question: I often hear you say that laughter is the best medicine. Can you explain what you mean?
Answer: There is an abundance of scientific evidence that laughter increases the release of endorphins (endogenous morphine) in the brain. They are part of nature’s mechanism for coping with pain and stress. By decreasing the heart rate and blood pressure and relaxing the muscles, laughter can reduce your stress level, boost the immune system, and be beneficial to the overall psychological and physical well-being. Some of the benefits derived can be long-term. [MORE INFORMATION].
17. Question: It is interesting that laughter can make my pain better. Are there other things that I can do to increase my natural endorphin level that does not involve taking medication?
Answer: Laughter is the best medicine. Other activities that have been shown to boost the release of endorphins in the brain and decrease pain and stress include exercising, yoga, meditation, and singing. Complementary therapies such as acupuncture, and massage have been shown to trigger the release of endorphins.
18. Question: I hurt my back 2 months ago and the pain was traveling from my back to my leg, and the foot was numb. My doctor said that I had a herniated disc. She gave me an exercise program to do at home. The pain was gone in 3 weeks and I was back to normal. How did the exercise make the disc go back inside?
Answer: When a disc herniates, the central gel-like nucleus pushes out the weakened outer fibrous ring known as the annulus. It can sometimes rupture through the annulus. A herniated disc may affect the nearby nerve root in 2 ways. First is by mechanical compression, secondly chemical irritation by inflammatory substances that are released by the nucleus. The herniated disc does not actually work its way back in, but over time, it shrinks as it loses water and is absorbed by the inflammatory chemicals. It can take several weeks or months for the process to complete. When this happens, the limb pain and other symptoms of a “pinched nerve” also called radiculopathy, often improve or resolve. This is one major reason why, more often than not, conservative management is warranted before surgical consideration for the treatment of a disc herniation.
19. Question: My dad was helping me to replace the flat tire in my car 6 months ago and he felt a pop in his back. He had excruciating pain down to his left leg and he could barely lift the foot which was also numb. I drove him to the ER and the doctor said that he had a foot drop. They put an intravenous and gave him steroid through it. He had MRI of the spine and the doctor said that there was a large herniation. Dad was admitted to the hospital, and the spine surgeon was consulted. He had surgery the following day. His pain went away almost immediately, but he still has some numbness. He completed 3 weeks of PT and he has regained some strength in the foot, but not complete. The surgeon explained it but dad does not remember why he went for surgery and did not try epidural injection first. Can you enlighten me about the reason?
Answer: Many herniated discs can shrink over time, and surgery can be avoided. However, there are certain “red flags” which are indications for thorough diagnostic workup and possible urgent surgery to prevent significant long-term neurological deficit. Given that your dad had a foot-drop, early surgery was a reasonable consideration. Aside from significant motor weakness, other “red flags” include loss of bladder or bowel control, numbness in the saddle area of the buttocks, and suspected spinal infection or malignant tumor. In these circumstances, surgery may be considered to prevent progressive or devastating neurological loss. As with any other condition, patient’s overall medical status, respiratory, cardiovascular, BP, immune system, and glucose control, are important factors that are taken into account in the surgical decision making process.
20. Question: My neurosurgeon removed a tumor from my brain a few weeks ago. Thank God, I am doing very well. He said that it was a benign meningioma. He was unable to remove all of it and he is going to send me to get radiation therapy. I thought that radiation was only used to treat cancers. Am I missing something?
Answer: I don’t think that you are missing something. Complete removal of a non-cancerous meningioma may not be wise or possible if the location is difficult to access, if it is encasing a major nerve, artery or vein, or is in close proximity to other vital structures in the brain. In such circumstances radiation therapy may be recommended after recovery from surgery. The goal is to utilize precisely focused beam of radiation to shrink the residual tumor and prevent or slow it from growing over time.
21. Question: I have been working in construction for more than 20 years. I get pain in my back off and on. I heard that the spine is similar to the frame of a house. I don’t get it. Could you explain it to me?
Answer: The spine consists of a number of bony structures called vertebrae which house and protect the spinal cord and nerve roots. When viewed in a transverse plane, the strong bony foundation in front is the cylindrical vertebral body. A pillar, called the pedicle extends backwards on either side and connects to the triangular roof, or lamina. The chimney represents the spinous process. A bony wing called the transverse process projects from each side of the pedicle and provides attachment for muscles which play a role in maintaining posture. Between the pedicle and the lamina, a pair of processes called the facets extend upwards and downwards. The vertebrae form a chain, and the vertebral bodies are cushioned by discs which have a central gel that acts as a shock absorber, and an outer ring of strong fibrous tissue. The synovial joints of the facets allow for various motions. The ligamentum flavum (yellow ligament) is the thick ceiling which connects adjacent laminae and also attaches to the facet joints. The spine has 3 primary functions. i. Protection of the spinal cord and nerve roots from the base of the skull to the tailbone. ii. Maintenance of Posture. iii. Facilitate Movements of the head, neck, back, and hips. Wear and tear, arthritis, or injury to any of the structures may cause back pain.
22. Question: I get pain, cramping and numbness in my legs when I walk. I have to lean on a cart when I go to the supermarket. The PA (Physician’s Assistant) said that I have narrowing of the spine, and that when I lean on the cart it opens it up and that’s why I get better. How does the bone open up?
Answer: In the overview of the anatomy, I explained that the spine houses and protects the spinal cord and nerve roots. Narrowing of the spine, is referred to as “spinal stenosis.” It is often caused by wear and tear, resulting in arthritis which involves most of the structures of the spine. The outer ring of the disc degenerates and bulges out. The central gel becomes dry, shrinks, and is less effective as a shock absorber. There is loss of bone mass and development of bone spurs in the vertebral bodies, and enlargement of the facet joints. The ligamentum flavum loses elastin fibers and its elasticity, and there is thickening and buckling of the collagen component into the spinal canal. The result is spinal stenosis with compression of the spinal cord and nerve roots. When you bend or lean forward, the ligamentum flavum unfolds, flattens out and there is less compression. That is what is responsible for the temporary relief of your symptoms which are collectively known as neurogenic claudication.
23. Question: My grandmother lives in Arizona. Her neurosurgeon said that she has spinal stenosis in her back and recommended laminectomy under general anesthesia. Her primary care would not clear her for anesthesia because she has heart and breathing problems. She can hardly walk and she really wants something to be done. Epidural steroid injections helped her for a couple of years but not anymore. Are there are other options?
Answer: Decompressive lumbar laminectomy involves removal of the lamina, ligamentum flavum, and thickened facet joint to take pressure off from the nerves. A fusion may be done as well if the spine is noted to be unstable from the primary athritis or expected to be so after an extensive decompression. Minimally invasive options that often do not require general anesthesia may be considered especially in cases where thickening of the ligamentum flavum is the predominant cause of the stenosis. i. Interspinous Spacer Procedure: A device is implanted between adjacent spinous processes to provide some flexion, and limit extension. This results in unfolding and flattening of the ligamentum flavum and relief of pressure on the nerves. ii. Minimally Invasive Lumbar Decompression (MILD): A less than 1 cm long incision is made, and with fluoroscopic guidance, a small tubular port is directed to the ligamentum flavum between the laminae. Special instruments are passed through the port to remove pieces of the ligament. Injection of contrast material in the spine during the procedure will give a good idea as to how well the canal has been decompressed.
