Mary Watson can smile again, now that

cooled RFA has relieved her chronic

back pain. Her story starts on page 2.

Managing PainVolume Seven | Spring 2011

Inside

& more

2468

Walking Tall

Finding Relief from CRPS

A MILD Change for Pain Relief

Finding the Source of Muscleand Nerve Pain

A newsletter on treating chronic pain from Cleveland Clinic’s Department of Pain Management

Ms. Watson was examined by Teresa E. Dews, MD, who specializes in pain management treatments at Cleveland Clinic’s Hillcrest Hospital in Mayfield Heights, Ohio.

“Even though Mary had been diagnosed with spinal stenosis years ago, the symptoms she was experiencing when I examined her were not consistent with that condition,” says Dr. Dews. “I found that the source of Mary’s chronic back pain was arthritis, which had developed in the joints of her spine.”

Arthritis in the spine’s joints often develops because of the body’s aging process, a prior injury or an inherited disease. Ms. Watson’s pain usually began in the middle of her lower back, and would often travel to her pelvis and shoot down to her legs and toes.

Turning to advanced therapiesConservative treatments such as pain or anti-inflammatory medications, epidural injections and physical therapy may relieve chronic back pain for only a few days or weeks. What’s more, these traditional treatments may stop working altogether for many patients.

That’s why pain management physicians are increasingly turning to advanced therapies such as cooled radiofrequency ablation (RFA). This new treatment has been shown to significantly reduce the intensity of certain chronic back pain conditions. Moreover, cooled RFA provides long-lasting pain relief.

Cooled RFA is a minimally invasive procedure that uses radiofrequency energy – a high-frequency electrical current – to generate safe levels of heat, which destroys or ablates nerves that send pain signals to the brain. Destroying the nerves blocks signals to the brain, which significantly reduces or eliminates the pain sensation.

“In my practice, most patients experience pain relief greater than 50 percent after receiving cooled RFA therapy,” says Dr. Dews. “Many patients also experience chronic pain relief for six to nine months or up to a year.”

Ms. Watson underwent the cooled RFA treatment about a year ago and has been mostly pain free ever since.

“Before I was treated, I felt as if I didn’t have much to look forward to in my life because it was being controlled by my chronic pain,” she reflects. “After receiving my treatment from Dr. Dews, I can do a lot more. Sometimes when I do too much, I can get some pain below my knee. But as Dr. Dews told me, when that happens, all I have to do is prop up my feet and forget about running the vacuum cleaner. I let my husband do it.”

How cooled RFA worksDuring the cooled RFA procedure, the patient is given a mild sedative to relax, but remains awake. A local anesthetic is applied to numb the area in the patient’s back where the physician inserts a needle.

Using X-ray, the physician carefully guides the needle to the exact location of the nerves that are sending pain signals to the brain. Through the needle, the physician inserts a probe that delivers the high-frequency electrical current. Water flows through the probe to keep it cool, which enhances the treatment and prevents heat damage to surrounding tissues. The procedure takes about 30 minutes.

“After the procedure, the patient returns home and can resume normal activities the next day,” says Dr. Dews.

“The patient usually begins to feel pain relief in about a week or two.”

Dr. Dews requires her patients to undergo physical therapy, which can enhance long-term relief of chronic pain. Many patients are able to reduce their consumption of pain and anti-inflammatory medications.

“Although cooled RFA treatment is effective, it’s important for patients to be motivated to participate in their pain management treatment plan, to have reasonable expectations and to remain as physically active as possible,” Dr. Dews says.

Cooled RFA treatment is not appropriate for everyone. Determining whether a patient is a good candidate for this therapy will depend on a physician’s physical examination of the patient, as well as a series of diagnostic tests and other factors.

Mary L. Watson could hardly walk when she was diagnosed in 2003 with spinal stenosis, a condition in which the spinal canal narrows and compresses the nerves, causing chronic pain.

“I had surgery for my spinal stenosis and I was fine for about a year, but the pain came back,” says Ms. Watson, who owns and operates a print shop in Clarion, Pennsylvania. “My doctor told me there were no other treatments.”

That left Ms. Watson with no choice but to deal with her chronic pain, which progressively worsened over time.

“I golfed for years, but had to give that up because the pain got so bad,” she says. “On a scale of 1 to 10, my pain was a 10-plus just about every day. That’s how bad it was.”

Making the callIn 2009, Ms. Watson heard from a family friend who had received successful treatment at Cleveland Clinic’s Department of Pain Management for a chronic pain condition.

“I decided to call and see what they could offer. When I went to my first appointment, I knew they were going to help me,” recalls Ms. Watson. “They sit down and talk to you and they explain all of your treatment options.”

Teresa E. Dews, MD

32

Mary L. Watson

Walking Tall Advanced minimally invasive procedure uses radio waves to provide chronic back pain relief that lasts longer than traditional treatments

Chronic Pain Support Group Meets Monthly

The Chronic Pain Support Group meets the

third Monday of each month from 2 to 4 p.m.

at Hillcrest Medical Office Building I, Suite 214,

6803 Mayfield Road, Mayfield Heights.

Nurse Manager Lennie Gandolf, RN,

moderates the support group sessions.

More Info

For more information, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

Ms. Watson was examined by Teresa E. Dews, MD, who specializes in pain management treatments at Cleveland Clinic’s Hillcrest Hospital in Mayfield Heights, Ohio.

“Even though Mary had been diagnosed with spinal stenosis years ago, the symptoms she was experiencing when I examined her were not consistent with that condition,” says Dr. Dews. “I found that the source of Mary’s chronic back pain was arthritis, which had developed in the joints of her spine.”

Arthritis in the spine’s joints often develops because of the body’s aging process, a prior injury or an inherited disease. Ms. Watson’s pain usually began in the middle of her lower back, and would often travel to her pelvis and shoot down to her legs and toes.

Turning to advanced therapiesConservative treatments such as pain or anti-inflammatory medications, epidural injections and physical therapy may relieve chronic back pain for only a few days or weeks. What’s more, these traditional treatments may stop working altogether for many patients.

That’s why pain management physicians are increasingly turning to advanced therapies such as cooled radiofrequency ablation (RFA). This new treatment has been shown to significantly reduce the intensity of certain chronic back pain conditions. Moreover, cooled RFA provides long-lasting pain relief.

Cooled RFA is a minimally invasive procedure that uses radiofrequency energy – a high-frequency electrical current – to generate safe levels of heat, which destroys or ablates nerves that send pain signals to the brain. Destroying the nerves blocks signals to the brain, which significantly reduces or eliminates the pain sensation.

“In my practice, most patients experience pain relief greater than 50 percent after receiving cooled RFA therapy,” says Dr. Dews. “Many patients also experience chronic pain relief for six to nine months or up to a year.”

Ms. Watson underwent the cooled RFA treatment about a year ago and has been mostly pain free ever since.

“Before I was treated, I felt as if I didn’t have much to look forward to in my life because it was being controlled by my chronic pain,” she reflects. “After receiving my treatment from Dr. Dews, I can do a lot more. Sometimes when I do too much, I can get some pain below my knee. But as Dr. Dews told me, when that happens, all I have to do is prop up my feet and forget about running the vacuum cleaner. I let my husband do it.”

How cooled RFA worksDuring the cooled RFA procedure, the patient is given a mild sedative to relax, but remains awake. A local anesthetic is applied to numb the area in the patient’s back where the physician inserts a needle.

Using X-ray, the physician carefully guides the needle to the exact location of the nerves that are sending pain signals to the brain. Through the needle, the physician inserts a probe that delivers the high-frequency electrical current. Water flows through the probe to keep it cool, which enhances the treatment and prevents heat damage to surrounding tissues. The procedure takes about 30 minutes.

“After the procedure, the patient returns home and can resume normal activities the next day,” says Dr. Dews.

“The patient usually begins to feel pain relief in about a week or two.”

Dr. Dews requires her patients to undergo physical therapy, which can enhance long-term relief of chronic pain. Many patients are able to reduce their consumption of pain and anti-inflammatory medications.

“Although cooled RFA treatment is effective, it’s important for patients to be motivated to participate in their pain management treatment plan, to have reasonable expectations and to remain as physically active as possible,” Dr. Dews says.

Cooled RFA treatment is not appropriate for everyone. Determining whether a patient is a good candidate for this therapy will depend on a physician’s physical examination of the patient, as well as a series of diagnostic tests and other factors.

Mary L. Watson could hardly walk when she was diagnosed in 2003 with spinal stenosis, a condition in which the spinal canal narrows and compresses the nerves, causing chronic pain.

“I had surgery for my spinal stenosis and I was fine for about a year, but the pain came back,” says Ms. Watson, who owns and operates a print shop in Clarion, Pennsylvania. “My doctor told me there were no other treatments.”

That left Ms. Watson with no choice but to deal with her chronic pain, which progressively worsened over time.

“I golfed for years, but had to give that up because the pain got so bad,” she says. “On a scale of 1 to 10, my pain was a 10-plus just about every day. That’s how bad it was.”

Making the callIn 2009, Ms. Watson heard from a family friend who had received successful treatment at Cleveland Clinic’s Department of Pain Management for a chronic pain condition.

“I decided to call and see what they could offer. When I went to my first appointment, I knew they were going to help me,” recalls Ms. Watson. “They sit down and talk to you and they explain all of your treatment options.”

Teresa E. Dews, MD

32

Mary L. Watson

Walking Tall Advanced minimally invasive procedure uses radio waves to provide chronic back pain relief that lasts longer than traditional treatments

Chronic Pain Support Group Meets Monthly

The Chronic Pain Support Group meets the

third Monday of each month from 2 to 4 p.m.

at Hillcrest Medical Office Building I, Suite 214,

6803 Mayfield Road, Mayfield Heights.

Nurse Manager Lennie Gandolf, RN,

moderates the support group sessions.

More Info

For more information, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

Such was the case for Benjamin. When he turned 15, CRPS struck him with constant pain in his left leg and foot, especially after he had sat for hours playing video games. The unrelenting pain became worse and forced Benjamin to leave school, confining him to his home where he was tutored. His friends would visit him, but it was difficult for them to understand what he was going through.

“Depression was very common for me. I would have breakdowns,” says Benjamin. “If it weren’t for my parents, I wouldn’t have been able to survive.”

Difficult to detectBecause there is no definitive test for CRPS, it can be challenging for physicians to diagnose in some patients who initially may not have many of the classic CRPS symptoms such as severe or unexplainable burning pain, skin color changes and skin texture changes. Before arriving at Cleveland Clinic, Benjamin met with several physicians and underwent many tests, but they could not determine what was causing the pain. A diagnosis can be made based only on a physical exam, the patient’s medical history and symptoms. However, some CRPS symptoms are not unique and mimic other chronic pain conditions.

For example, after Benjamin was referred to Cleveland Clinic, neurological specialists suspected he had piriformis syndrome, a rare neuromuscular disorder. The syndrome occurs when the piriformis muscle in the buttocks compresses or irritates the sciatic nerve, the largest nerve in the body. When this muscle squeezes the sciatic nerve, it causes frequent pain in the buttocks. The pain usually travels down the leg and often worsens when the patient sits, as in Benjamin’s case.

To treat his piriformis condition, Benjamin underwent a surgical procedure, which reduced the pain. About six months after the surgery, however, the pain returned and became worse.

“Following the surgery, Benjamin began to manifest the classic symptoms of CRPS. His skin on his left leg was cooler than his right leg,” says Dr. Cheng. “The skin on his leg also changed dramatically to a purplish color, which is another classic symptom.”

Blocking the painDr. Cheng recommended that Benjamin receive a spinal cord stimulator (SCS), a relatively new but increasingly popular treatment method that reduces chronic pain by 50 percent to 80 percent in many patients.

The stimulator is a small, implantable device that generates electrical impulses, which diminish or block pain signals transmitted from the spinal cord to the brain. Instead of pain, patients feel a gentle, tingling sensation.

“Experience has shown that SCS can be effective for many qualified patients who have CRPS,” explains Dr. Cheng.

“When the SCS reduces chronic pain by at least 50 percent, and ideally by 80 percent, it helps patients tolerate physical therapy, which is particularly important to maintain the functionality of the arms and legs. In addition, SCS can help patients reduce their intake of medications, which in turn reduces side effects. These positive results can help patients improve their quality of life.”

Before implantation, patients undergo both a psychological evaluation and an external stimulator trial for about seven days to determine whether the stimulation reduces their pain by at least 50 percent.

After a successful trial, the battery-powered SCS is implanted underneath the patient’s skin. Using X-ray guidance, the physician places the SCS electrode wire within the spinal cord’s epidural space. Patients are able to increase or decrease the electrical stimulation when needed, which can provide long-term pain relief.

“What the SCS did for me is that it kept my everyday pain – the pain that I had constantly for four years – almost to no pain at all,” says Benjamin. “To be freed from my pain was a huge relief for me.”

With his pain well under control, Benjamin plans to continue to work on his craft as a writer and search for a publisher who will print his books.

Benjamin Broestl, 19, of North Royalton, Ohio, is an aspiring novelist who has already written three fictional works about horror, the paranormal or things that cannot be explained by science. Ironically, for nearly four years, Benjamin lived with a complicated chronic pain syndrome that cannot be completely explained by medical science.

Last spring, Benjamin was given the diagnosis of Complex Regional Pain Syndrome (CRPS), a debilitating condition generally caused by a nerve disorder that is sometimes followed by an injury. Typically, the pain originates in the patient’s arms or legs.

In the U.S., CRPS afflicts up to 1.2 million people a year, and occurs predominantly in women between the ages of 30 and 50. Every year, Cleveland Clinic’s Department of Pain Management treats more than 50 new CRPS patients.

“CRPS is a devastating condition for many patients, and it can occur in any age group, including children,” says pain management specialist Jianguo Cheng, MD, PhD. “In many cases, a very small lesion, an injury or surgery can cause or lead to this condition. And in circumstances we do not quite understand, CRPS can occur in some patients who have not experienced an injury, lesion or surgery.”

54

Benjamin Broestl

Finding ReliefSpinal cord stimulation provides effective treatment for a young patient who suffered a four-year bout of CRPS

Jianguo Cheng, MD, PhD Symptoms of Complex Regional Pain Syndrome

Symptoms of Complex Regional Pain Syndrome

(CRPS) typically appear in the arms or legs,

but can occur in any part of the body. In many

cases, CRPS may follow surgery or an injury

such as a sprain or fracture.

The classic CRPS symptoms are:

• Severe or unexplainable burning pain

• A high sensitivity to touch

• Skin color that becomes blotchy, purple,

pale or red

• Skin temperature that may be warmer

or cooler compared with other limbs

• Skin texture that may become shiny and thin,

and sometimes excessively sweaty

• Changes in nail and hair growth patterns

• Brittle nails

• Difficulty moving the affected part of the body

More InfoTo make an appointment, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

Such was the case for Benjamin. When he turned 15, CRPS struck him with constant pain in his left leg and foot, especially after he had sat for hours playing video games. The unrelenting pain became worse and forced Benjamin to leave school, confining him to his home where he was tutored. His friends would visit him, but it was difficult for them to understand what he was going through.

“Depression was very common for me. I would have breakdowns,” says Benjamin. “If it weren’t for my parents, I wouldn’t have been able to survive.”

Difficult to detectBecause there is no definitive test for CRPS, it can be challenging for physicians to diagnose in some patients who initially may not have many of the classic CRPS symptoms such as severe or unexplainable burning pain, skin color changes and skin texture changes. Before arriving at Cleveland Clinic, Benjamin met with several physicians and underwent many tests, but they could not determine what was causing the pain. A diagnosis can be made based only on a physical exam, the patient’s medical history and symptoms. However, some CRPS symptoms are not unique and mimic other chronic pain conditions.

For example, after Benjamin was referred to Cleveland Clinic, neurological specialists suspected he had piriformis syndrome, a rare neuromuscular disorder. The syndrome occurs when the piriformis muscle in the buttocks compresses or irritates the sciatic nerve, the largest nerve in the body. When this muscle squeezes the sciatic nerve, it causes frequent pain in the buttocks. The pain usually travels down the leg and often worsens when the patient sits, as in Benjamin’s case.

To treat his piriformis condition, Benjamin underwent a surgical procedure, which reduced the pain. About six months after the surgery, however, the pain returned and became worse.

“Following the surgery, Benjamin began to manifest the classic symptoms of CRPS. His skin on his left leg was cooler than his right leg,” says Dr. Cheng. “The skin on his leg also changed dramatically to a purplish color, which is another classic symptom.”

Blocking the painDr. Cheng recommended that Benjamin receive a spinal cord stimulator (SCS), a relatively new but increasingly popular treatment method that reduces chronic pain by 50 percent to 80 percent in many patients.

The stimulator is a small, implantable device that generates electrical impulses, which diminish or block pain signals transmitted from the spinal cord to the brain. Instead of pain, patients feel a gentle, tingling sensation.

“Experience has shown that SCS can be effective for many qualified patients who have CRPS,” explains Dr. Cheng.

“When the SCS reduces chronic pain by at least 50 percent, and ideally by 80 percent, it helps patients tolerate physical therapy, which is particularly important to maintain the functionality of the arms and legs. In addition, SCS can help patients reduce their intake of medications, which in turn reduces side effects. These positive results can help patients improve their quality of life.”

Before implantation, patients undergo both a psychological evaluation and an external stimulator trial for about seven days to determine whether the stimulation reduces their pain by at least 50 percent.

After a successful trial, the battery-powered SCS is implanted underneath the patient’s skin. Using X-ray guidance, the physician places the SCS electrode wire within the spinal cord’s epidural space. Patients are able to increase or decrease the electrical stimulation when needed, which can provide long-term pain relief.

“What the SCS did for me is that it kept my everyday pain – the pain that I had constantly for four years – almost to no pain at all,” says Benjamin. “To be freed from my pain was a huge relief for me.”

With his pain well under control, Benjamin plans to continue to work on his craft as a writer and search for a publisher who will print his books.

Benjamin Broestl, 19, of North Royalton, Ohio, is an aspiring novelist who has already written three fictional works about horror, the paranormal or things that cannot be explained by science. Ironically, for nearly four years, Benjamin lived with a complicated chronic pain syndrome that cannot be completely explained by medical science.

Last spring, Benjamin was given the diagnosis of Complex Regional Pain Syndrome (CRPS), a debilitating condition generally caused by a nerve disorder that is sometimes followed by an injury. Typically, the pain originates in the patient’s arms or legs.

In the U.S., CRPS afflicts up to 1.2 million people a year, and occurs predominantly in women between the ages of 30 and 50. Every year, Cleveland Clinic’s Department of Pain Management treats more than 50 new CRPS patients.

“CRPS is a devastating condition for many patients, and it can occur in any age group, including children,” says pain management specialist Jianguo Cheng, MD, PhD. “In many cases, a very small lesion, an injury or surgery can cause or lead to this condition. And in circumstances we do not quite understand, CRPS can occur in some patients who have not experienced an injury, lesion or surgery.”

54

Benjamin Broestl

Finding ReliefSpinal cord stimulation provides effective treatment for a young patient who suffered a four-year bout of CRPS

Jianguo Cheng, MD, PhD Symptoms of Complex Regional Pain Syndrome

Symptoms of Complex Regional Pain Syndrome

(CRPS) typically appear in the arms or legs,

but can occur in any part of the body. In many

cases, CRPS may follow surgery or an injury

such as a sprain or fracture.

The classic CRPS symptoms are:

• Severe or unexplainable burning pain

• A high sensitivity to touch

• Skin color that becomes blotchy, purple,

pale or red

• Skin temperature that may be warmer

or cooler compared with other limbs

• Skin texture that may become shiny and thin,

and sometimes excessively sweaty

• Changes in nail and hair growth patterns

• Brittle nails

• Difficulty moving the affected part of the body

More InfoTo make an appointment, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

How LSS causes chronic painWith the aging population, 1.2 million people suffer from pain secondary to spinal stenosis every year. Lumbar spinal stenosis (LSS) develops when the ligaments and bones outside the spinal canal thicken, which causes the spinal canal to narrow in the lower back. This narrowing compresses and interferes with the blood supply and the nerve tissues, which triggers pain or numbness in the lower back, buttocks, legs, feet and toes and limits these patients’ functional activities, especially walking and standing for any length of time, says Nagy A. Mekhail, MD, PhD, of Cleveland Clinic’s Department of Pain Management.

“In addition to causing daily chronic pain, spinal stenosis limits patients in what they can do in their everyday lives,” explains Dr. Mekhail. “For example, lumbar spinal stenosis can trigger pain in some patients who simply walk to the mailbox. Other patients may be standing in the kitchen preparing a meal for about 10 or 15 minutes and they need to sit down in order to relieve the pain.”

Conservative treatments such as medication regimens, physical therapy and epidural injections provide most LSS patients with temporary pain relief, but some patients may develop side effects or they may stop responding to these therapies. Although invasive surgical procedures exist for LSS, treatment results tend to diminish over time.

76

The MILD treatment provides an option for patients who no longer respond to conservative treatments, or who cannot tolerate or choose not to undergo traditional invasive operations, says Dr. Mekhail.

How mild it isMILD is a minimally invasive procedure. While a patient is under sedation, a local anesthetic is applied to the area of the spine where the physician inserts a thin, hollow needle, or cannula. Through the cannula, another surgical instrument is inserted that enables the physician to take out small pieces of the ligaments and, sometimes, tiny pieces of bone. A special X-ray view and injection contrast material in the epidural space allow the physician to see the spinal canal region and control the surgical instruments. Once the soft tissue or bone pieces are removed, the spinal canal widens as evidenced by the spread of the contrast material. Widening the spinal canal decompresses the nerves, which relieves the chronic pain.

The surgical instruments are removed and a bandage covers the small incision. Following the procedure, the patient returns home and resumes normal activities the next day. Usually, the patient will begin to feel pain relief within the first few days after the procedure.

“What is just as important is that patients must follow up with a regular physical therapy program, which can help them correct posture issues and improve their muscle functionality as well as their circulation,” says Dr. Mekhail.

“We can show them how to do daily exercises in their homes that can be good for the back and for their general health.”

Even though the MILD procedure is relatively new, Dr. Mekhail says it has a very good safety record. To date, about 5,000 patients have been treated with the MILD procedure and have shown no serious adverse effects.

“Overall, with no major device- or procedure-related complications, the MILD procedure compares favorably with reports of both simple and complex surgical decompression procedures,” says Dr. Mekhail.

Research continuesNevertheless, Dr. Mekhail continues to pursue his research on the MILD procedure and its outcomes.

For example, he will serve as the lead physician in a randomized, controlled research study that will compare patients who receive MILD treatment with patients who receive a series of epidural injections and physical therapy. The national trial is expected to recruit an estimated 250 patients who have been diagnosed with symptomatic lumbar spinal stenosis at one or two levels. The stenosis has to be secondary to thickening of the ligaments inside the lumbar spinal canal. Half of the patients will receive the MILD treatment and the other half will receive a series of epidural injections and physical therapy over six months.

A MILD Change for Pain ReliefMinimally invasive lumbar decompression procedure offers a new treatment option for chronic pain patients with lumbar spinal stenosis

Nagy Mekhail, MD, PhD

After years of suffering with chronic pain due to lumbar (back) spinal stenosis, Leanne Bly and Judith McKinney are virtually pain free, thanks to a new, advanced procedure known as minimally invasive lumbar decompression (MILD).

Leanne Bly loves working as a volunteer tour guide at the Columbus (Ohio) Museum of Art. She also enjoys

traveling, especially when it means seeing her grandchildren on the West Coast. Now, she looks forward to these activities even more because she no longer feels the chronic pain that usually started in her buttocks and traveled down her legs when she stood for 30 minutes or walked a couple hundred feet.

Ms. Bly’s MILD procedure was performed about two weeks before a trip to Australia. She enjoyed her vacation even more because she was pain free.

“I flew to Hawaii from Atlanta, and then I flew to Australia, where I snorkeled in the Great Barrier Reef and walked in the Australian bush with an aboriginal guide for five hours,” says Ms. Bly, a retired computer and math tutor who lives in Columbus. “I was able to do all of that without any pain, so I was pretty happy.”

For Ms. McKinney, chronic pain is no longer slowing down her demanding schedule as the owner of a maintenance facility company in Port Clinton, Ohio. Throughout her busy day, she used to feel the pain shoot into the balls of her feet and down to her toes while she walked. She also felt a non-stop burning sensation in her feet.

“The MILD procedure was like magic,” says Ms. McKinney. “I left a little tender from the procedure, but within a day I felt better, and the day after that I felt even better. Now, for the first time in many years, I am essentially pain free.” She can now walk for two miles and stand for more than an hour.

Leanne Bly

Judith McKinney

More InfoFor more information, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

How LSS causes chronic painWith the aging population, 1.2 million people suffer from pain secondary to spinal stenosis every year. Lumbar spinal stenosis (LSS) develops when the ligaments and bones outside the spinal canal thicken, which causes the spinal canal to narrow in the lower back. This narrowing compresses and interferes with the blood supply and the nerve tissues, which triggers pain or numbness in the lower back, buttocks, legs, feet and toes and limits these patients’ functional activities, especially walking and standing for any length of time, says Nagy A. Mekhail, MD, PhD, of Cleveland Clinic’s Department of Pain Management.

“In addition to causing daily chronic pain, spinal stenosis limits patients in what they can do in their everyday lives,” explains Dr. Mekhail. “For example, lumbar spinal stenosis can trigger pain in some patients who simply walk to the mailbox. Other patients may be standing in the kitchen preparing a meal for about 10 or 15 minutes and they need to sit down in order to relieve the pain.”

Conservative treatments such as medication regimens, physical therapy and epidural injections provide most LSS patients with temporary pain relief, but some patients may develop side effects or they may stop responding to these therapies. Although invasive surgical procedures exist for LSS, treatment results tend to diminish over time.

76

The MILD treatment provides an option for patients who no longer respond to conservative treatments, or who cannot tolerate or choose not to undergo traditional invasive operations, says Dr. Mekhail.

How mild it isMILD is a minimally invasive procedure. While a patient is under sedation, a local anesthetic is applied to the area of the spine where the physician inserts a thin, hollow needle, or cannula. Through the cannula, another surgical instrument is inserted that enables the physician to take out small pieces of the ligaments and, sometimes, tiny pieces of bone. A special X-ray view and injection contrast material in the epidural space allow the physician to see the spinal canal region and control the surgical instruments. Once the soft tissue or bone pieces are removed, the spinal canal widens as evidenced by the spread of the contrast material. Widening the spinal canal decompresses the nerves, which relieves the chronic pain.

The surgical instruments are removed and a bandage covers the small incision. Following the procedure, the patient returns home and resumes normal activities the next day. Usually, the patient will begin to feel pain relief within the first few days after the procedure.

“What is just as important is that patients must follow up with a regular physical therapy program, which can help them correct posture issues and improve their muscle functionality as well as their circulation,” says Dr. Mekhail.

“We can show them how to do daily exercises in their homes that can be good for the back and for their general health.”

Even though the MILD procedure is relatively new, Dr. Mekhail says it has a very good safety record. To date, about 5,000 patients have been treated with the MILD procedure and have shown no serious adverse effects.

“Overall, with no major device- or procedure-related complications, the MILD procedure compares favorably with reports of both simple and complex surgical decompression procedures,” says Dr. Mekhail.

Research continuesNevertheless, Dr. Mekhail continues to pursue his research on the MILD procedure and its outcomes.

For example, he will serve as the lead physician in a randomized, controlled research study that will compare patients who receive MILD treatment with patients who receive a series of epidural injections and physical therapy. The national trial is expected to recruit an estimated 250 patients who have been diagnosed with symptomatic lumbar spinal stenosis at one or two levels. The stenosis has to be secondary to thickening of the ligaments inside the lumbar spinal canal. Half of the patients will receive the MILD treatment and the other half will receive a series of epidural injections and physical therapy over six months.

A MILD Change for Pain ReliefMinimally invasive lumbar decompression procedure offers a new treatment option for chronic pain patients with lumbar spinal stenosis

Nagy Mekhail, MD, PhD

After years of suffering with chronic pain due to lumbar (back) spinal stenosis, Leanne Bly and Judith McKinney are virtually pain free, thanks to a new, advanced procedure known as minimally invasive lumbar decompression (MILD).

Leanne Bly loves working as a volunteer tour guide at the Columbus (Ohio) Museum of Art. She also enjoys

traveling, especially when it means seeing her grandchildren on the West Coast. Now, she looks forward to these activities even more because she no longer feels the chronic pain that usually started in her buttocks and traveled down her legs when she stood for 30 minutes or walked a couple hundred feet.

Ms. Bly’s MILD procedure was performed about two weeks before a trip to Australia. She enjoyed her vacation even more because she was pain free.

“I flew to Hawaii from Atlanta, and then I flew to Australia, where I snorkeled in the Great Barrier Reef and walked in the Australian bush with an aboriginal guide for five hours,” says Ms. Bly, a retired computer and math tutor who lives in Columbus. “I was able to do all of that without any pain, so I was pretty happy.”

For Ms. McKinney, chronic pain is no longer slowing down her demanding schedule as the owner of a maintenance facility company in Port Clinton, Ohio. Throughout her busy day, she used to feel the pain shoot into the balls of her feet and down to her toes while she walked. She also felt a non-stop burning sensation in her feet.

“The MILD procedure was like magic,” says Ms. McKinney. “I left a little tender from the procedure, but within a day I felt better, and the day after that I felt even better. Now, for the first time in many years, I am essentially pain free.” She can now walk for two miles and stand for more than an hour.

Leanne Bly

Judith McKinney

More InfoFor more information, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

Dr. Mekhail examines Judith McKinney during a follow-up appointment.

98

For patients who experience numbness and tingling, muscle weakness, spasms or pain in the limbs, neck or back, Cleveland Clinic’s Department of Pain Management offers electrodiagnostic testing to help find the cause.

Physical Medicine and Rehabilitation (PM&R) specialist Daniel J. Leizman, MD, and Pain Management specialist Hong Shen, MD, provide this service, which measures how well the muscles and nerves are functioning. The testing is performed in two parts:

• Nerve conduction studies measure the ability of specific nerves to transmit electrical impulses. Patients feel a small, brief electrical stimulus.

• Electromyography examines and measures electrical activity in different muscles. A very thin-gauge needle is inserted beneath the skin into these muscles, which may cause some temporary discomfort.

The results of this testing determine treatment and prognosis, which may involve a team that includes a board-certified PM&R physician such as Dr. Leizman. These specialists, also known as physiatrists, treat patients with spinal, musculoskeletal and neuro-logic disorders, including sports-related and occupational injuries.

Dr. Leizman sees patients at Cleveland Clinic’s main campus. Dr. Shen sees patients at Lutheran Hospital and Westlake Medical Office.

Finding the Source of Muscle and Nerve PainWhen patients’ symptoms warrant, electrodiagnostic testing can pinpoint the location and extent of the problem

Daniel J. Leizman, MD Hong Shen, MD

More InfoTo make an appointment, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

In Case of Pain, Call 216.444.PAIN

Your first step toward pain-free living starts with a phone call.

Call our appointment number today at 216.444.PAIN (7246) to see a pain specialist in or near your community. Schedulers are available 24/7.

Cleveland Clinic’s Department of Pain Management uses the latest diagnostic tools and delivers a wide range of traditional and innovative treatments for all types of chronic and recurrent pain conditions.

Multidisciplinary teams made up of pain management physicians, nurses, psychologists and therapists work together to treat patients at 22 locations throughout Ashtabula, Cuyahoga, Geauga, Lake, Lorain, Medina and Summit counties.

Speakers

For More Information

Our staff is available to speak to area community groups. To request a speaker, email us at painmanagement@ccf.org or call 216.448.0119.

For more information about any of the stories in this newsletter or for answers to your questions or concerns about pain management, please contact us at 800.392.3353 or visit us on the eb at clevelandclinic.org/painmanagement.

MedinaHospital

Cleveland ClinicBrunswick

TwinsburgPain Management

Center

Cleveland ClinicSolon

Cleveland ClinicWilloughby Hills

Cleveland ClinicBeachwood

Cleveland ClinicAvon Lake

LakewoodHospital

LutheranHospital

FairviewHospital

Cleveland ClinicStrongsville

Broadview HeightsPain Management

Center

MarymountHospital

HillcrestHospital

EuclidHospital

South PointeHospital

WestlakePain Management

Center

Cleveland ClinicChagrin Falls

Medina County

Cuyahoga County

Lorain County

Summit County

Lake CountyLake Erie

Geauga County

Ashtabula CountyMedical Center

Cleveland ClinicLorain

Cleveland ClinicElyria

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98

For patients who experience numbness and tingling, muscle weakness, spasms or pain in the limbs, neck or back, Cleveland Clinic’s Department of Pain Management offers electrodiagnostic testing to help find the cause.

Physical Medicine and Rehabilitation (PM&R) specialist Daniel J. Leizman, MD, and Pain Management specialist Hong Shen, MD, provide this service, which measures how well the muscles and nerves are functioning. The testing is performed in two parts:

• Nerve conduction studies measure the ability of specific nerves to transmit electrical impulses. Patients feel a small, brief electrical stimulus.

• Electromyography examines and measures electrical activity in different muscles. A very thin-gauge needle is inserted beneath the skin into these muscles, which may cause some temporary discomfort.

The results of this testing determine treatment and prognosis, which may involve a team that includes a board-certified PM&R physician such as Dr. Leizman. These specialists, also known as physiatrists, treat patients with spinal, musculoskeletal and neuro-logic disorders, including sports-related and occupational injuries.

Dr. Leizman sees patients at Cleveland Clinic’s main campus. Dr. Shen sees patients at Lutheran Hospital and Westlake Medical Office.

Finding the Source of Muscle and Nerve PainWhen patients’ symptoms warrant, electrodiagnostic testing can pinpoint the location and extent of the problem

Daniel J. Leizman, MD Hong Shen, MD

More InfoTo make an appointment, please call 216.444.PAIN (7246) or visit clevelandclinic.org/painmanagement.

In Case of Pain, Call 216.444.PAIN

Your first step toward pain-free living starts with a phone call.

Call our appointment number today at 216.444.PAIN (7246) to see a pain specialist in or near your community. Schedulers are available 24/7.

Cleveland Clinic’s Department of Pain Management uses the latest diagnostic tools and delivers a wide range of traditional and innovative treatments for all types of chronic and recurrent pain conditions.

Multidisciplinary teams made up of pain management physicians, nurses, psychologists and therapists work together to treat patients at 22 locations throughout Ashtabula, Cuyahoga, Geauga, Lake, Lorain, Medina and Summit counties.

Speakers

For More Information

Our staff is available to speak to area community groups. To request a speaker, email us at painmanagement@ccf.org or call 216.448.0119.

For more information about any of the stories in this newsletter or for answers to your questions or concerns about pain management, please contact us at 800.392.3353 or visit us on the eb at clevelandclinic.org/painmanagement.

MedinaHospital

Cleveland ClinicBrunswick

TwinsburgPain Management

Center

Cleveland ClinicSolon

Cleveland ClinicWilloughby Hills

Cleveland ClinicBeachwood

Cleveland ClinicAvon Lake

LakewoodHospital

LutheranHospital

FairviewHospital

Cleveland ClinicStrongsville

Broadview HeightsPain Management

Center

MarymountHospital

HillcrestHospital

EuclidHospital

South PointeHospital

WestlakePain Management

Center

Cleveland ClinicChagrin Falls

Medina County

Cuyahoga County

Lorain County

Summit County

Lake CountyLake Erie

Geauga County

Ashtabula CountyMedical Center

Cleveland ClinicLorain

Cleveland ClinicElyria

W

1110

Daniel J. Leizman, MDCleveland Clinic Physical Medicine and Rehabilitation specialist Daniel J. Leizman, MD, is now seeing patients at the main campus location. A graduate of Ohio State University College of Medicine in Columbus, Dr. Leizman served his physical medicine and rehabilitation residency at the Medical College of Wisconsin in Milwaukee.

His specialty interests include spine care, musculoskeletal injuries, degenerative joint disease, sports medicine, exercise prescription, complementary and alternative medicine, wellness, electrodiagnostic testing (NCS/EMG), interventional pain management for neck and back pain, and impairment and disability evaluation.

To make an appointment with Dr. Leizman, please call 216.444.PAIN (7246) or 800.392.3353.

Englok Yap, MDCleveland Clinic Pain Management specialist Englok Yap, MD, is now seeing patients at Hillcrest and Beachwood pain management centers. A graduate of Jefferson Medical College in Philadelphia, Dr. Yap served his anesthesia residency and pain management fellowship at Cleveland Clinic.

His specialty interests include interventional pain management for back and neck pain, shingles, long-term pain following chest wall surgery, CRPS and musculoskeletal pain.

To make an appointment with Dr. Yap, please call 440.312.7246 (Hillcrest) or 216.839.3000 (Beachwood).

New Physician UpdatePain Management Locations

Cleveland Clinic Main Campus9500 Euclid Ave./C25Cleveland, OH 44195216.444.PAIN (7246)800.392.3353

Ashtabula County Medical Center2420 Lake Ave.Ashtabula, OH 44004440.997.6700John Hill, MD

Avon Lake Family Health Center450 Avon Belden RoadAvon Lake, OH 44012440.930.6800Philippe Berenger, MD

Beachwood Family Health and Surgery Center26900 Cedar RoadBeachwood, OH 44122216.839.3000Timothy Rhudy, MS, LACEnglok Yap, MD

Broadview Heights Pain Management Center2001 E. Royalton RoadBroadview Heights, OH 44147440.717.6125Samuel Samuel, MD

Brunswick Family Health Center3574 Center RoadBrunswick, OH 44212330.225.8886Sameh Yonan, MD

Chagrin Falls Family Health Center551 E. Washington St.Chagrin Falls, OH 44022440.893.9393Teresa Dews, MD

Elyria Family Health and Surgery Center303 Chestnut Commons DriveElyria, OH 44035440.366.9444Marc Soloman, MD

Euclid Hospital18901 Lake Shore Blvd.Euclid, OH 44119216.692.7543Pasha Saeed, MDWilliam Welches, DO, PhD

Fairview Hospital18099 Lorain Ave., Suite 404Cleveland, OH 44111216.476.7331Emad Daoud, MD, PhDGeorge Girgis, DOFady Nageeb, MD

Hillcrest Hospital6803 Mayfield Road, Suite 200Mayfield Heights, OH 44124440.312.7246Teresa Dews, MDRiad Laham, MDTimothy Rhudy, MS, LACEnglok Yap, MD

Lakewood Hospital14601 Detroit Ave., Suite 260Lakewood, OH 44107216.529.7246Fady Nageeb, MD

Lorain Family Health and Surgery Center5700 Cooper Foster Park RoadLorain, OH 44053440.204.7400Philippe Berenger, MDGeorge Girgis, DO

Lutheran Hospital1730 W. 25th St., Suite 4ACleveland, OH 44113216.363.2391Emad Daoud, MD, PhDHong Shen, MDMichael Stanton-Hicks, MD

Marymount Hospital12300 McCracken Road, Suite 259Garfield Heights, OH 44125216.587.8830Lokesh Ningegowda, MDSamuel Samuel, MDMarc Soloman, MD

Medina Hospital970 E. Washington St.Medina, OH 44256330.225.8886Paul Shin, MDSameh Yonan, MD

Solon Family Health Center29800 Bainbridge RoadSolon, OH 44139440.519.6925Timothy Rhudy, MS, LAC

South Pointe Hospital20000 Harvard Road, Building AWarrensville Heights, OH 44122216.491.6433Lokesh Ningegowda, MDPaul Shin, MDWilliam Welches, DO, PhD

Strongsville Family Health and Surgery Center16761 SouthPark CenterStrongsville, OH 44136440.878.2500Kenneth Grimm, DO

Twinsburg Pain Management Center2365 Edison Blvd., Suite 100Twinsburg, OH 44087330.888.4000Lokesh Ningegowda, MD

Westlake Pain Management Center850 Columbia Road, Suite 120Westlake, OH 44145440.835.8233Emad Daoud, MD, PhDHong Shen, MD

Willoughby Hills Family Health Center2570 SOM Center RoadWilloughby Hills, OH 44094440.943.2500Pasha Saeed, MDSameh Yonan, MD

To request an appointment with a Cleveland Clinic Pain Management specialist near you,

please call 216.444.PAIN (7246) or toll-free 800.392.3353.M. Barry Jones, MDCleveland Clinic Pain Management specialist M. Barry Jones, MD, is now seeing patients at the main campus and Shaker Pediatric Rehabilitation Center. A graduate of Robert W. Johnson Medical School, University of Medicine and Dentistry of New Jersey in Piscataway, Dr. Jones served his anesthesia residency at Washington University School of Medicine in St. Louis.

His specialty interests include acute and chronic pediatric pain, interventional pain management for back and neck pain, CRPS/RSD, neuropathic pain, chronic headache, musculoskeletal and abdominal pain syndromes, neoplasm and end-of-life related pain, medical hypnosis, mindfulness practices and integrative medicine.

To make an appointment with Dr. Jones, please call 216.444.PAIN (7246) or 800.392.3353.

1110

Daniel J. Leizman, MDCleveland Clinic Physical Medicine and Rehabilitation specialist Daniel J. Leizman, MD, is now seeing patients at the main campus location. A graduate of Ohio State University College of Medicine in Columbus, Dr. Leizman served his physical medicine and rehabilitation residency at the Medical College of Wisconsin in Milwaukee.

His specialty interests include spine care, musculoskeletal injuries, degenerative joint disease, sports medicine, exercise prescription, complementary and alternative medicine, wellness, electrodiagnostic testing (NCS/EMG), interventional pain management for neck and back pain, and impairment and disability evaluation.

To make an appointment with Dr. Leizman, please call 216.444.PAIN (7246) or 800.392.3353.

Englok Yap, MDCleveland Clinic Pain Management specialist Englok Yap, MD, is now seeing patients at Hillcrest and Beachwood pain management centers. A graduate of Jefferson Medical College in Philadelphia, Dr. Yap served his anesthesia residency and pain management fellowship at Cleveland Clinic.

His specialty interests include interventional pain management for back and neck pain, shingles, long-term pain following chest wall surgery, CRPS and musculoskeletal pain.

To make an appointment with Dr. Yap, please call 440.312.7246 (Hillcrest) or 216.839.3000 (Beachwood).

New Physician UpdatePain Management Locations

Cleveland Clinic Main Campus9500 Euclid Ave./C25Cleveland, OH 44195216.444.PAIN (7246)800.392.3353

Ashtabula County Medical Center2420 Lake Ave.Ashtabula, OH 44004440.997.6700John Hill, MD

Avon Lake Family Health Center450 Avon Belden RoadAvon Lake, OH 44012440.930.6800Philippe Berenger, MD

Beachwood Family Health and Surgery Center26900 Cedar RoadBeachwood, OH 44122216.839.3000Timothy Rhudy, MS, LACEnglok Yap, MD

Broadview Heights Pain Management Center2001 E. Royalton RoadBroadview Heights, OH 44147440.717.6125Samuel Samuel, MD

Brunswick Family Health Center3574 Center RoadBrunswick, OH 44212330.225.8886Sameh Yonan, MD

Chagrin Falls Family Health Center551 E. Washington St.Chagrin Falls, OH 44022440.893.9393Teresa Dews, MD

Elyria Family Health and Surgery Center303 Chestnut Commons DriveElyria, OH 44035440.366.9444Marc Soloman, MD

Euclid Hospital18901 Lake Shore Blvd.Euclid, OH 44119216.692.7543Pasha Saeed, MDWilliam Welches, DO, PhD

Fairview Hospital18099 Lorain Ave., Suite 404Cleveland, OH 44111216.476.7331Emad Daoud, MD, PhDGeorge Girgis, DOFady Nageeb, MD

Hillcrest Hospital6803 Mayfield Road, Suite 200Mayfield Heights, OH 44124440.312.7246Teresa Dews, MDRiad Laham, MDTimothy Rhudy, MS, LACEnglok Yap, MD

Lakewood Hospital14601 Detroit Ave., Suite 260Lakewood, OH 44107216.529.7246Fady Nageeb, MD

Lorain Family Health and Surgery Center5700 Cooper Foster Park RoadLorain, OH 44053440.204.7400Philippe Berenger, MDGeorge Girgis, DO

Lutheran Hospital1730 W. 25th St., Suite 4ACleveland, OH 44113216.363.2391Emad Daoud, MD, PhDHong Shen, MDMichael Stanton-Hicks, MD

Marymount Hospital12300 McCracken Road, Suite 259Garfield Heights, OH 44125216.587.8830Lokesh Ningegowda, MDSamuel Samuel, MDMarc Soloman, MD

Medina Hospital970 E. Washington St.Medina, OH 44256330.225.8886Paul Shin, MDSameh Yonan, MD

Solon Family Health Center29800 Bainbridge RoadSolon, OH 44139440.519.6925Timothy Rhudy, MS, LAC

South Pointe Hospital20000 Harvard Road, Building AWarrensville Heights, OH 44122216.491.6433Lokesh Ningegowda, MDPaul Shin, MDWilliam Welches, DO, PhD

Strongsville Family Health and Surgery Center16761 SouthPark CenterStrongsville, OH 44136440.878.2500Kenneth Grimm, DO

Twinsburg Pain Management Center2365 Edison Blvd., Suite 100Twinsburg, OH 44087330.888.4000Lokesh Ningegowda, MD

Westlake Pain Management Center850 Columbia Road, Suite 120Westlake, OH 44145440.835.8233Emad Daoud, MD, PhDHong Shen, MD

Willoughby Hills Family Health Center2570 SOM Center RoadWilloughby Hills, OH 44094440.943.2500Pasha Saeed, MDSameh Yonan, MD

To request an appointment with a Cleveland Clinic Pain Management specialist near you,

please call 216.444.PAIN (7246) or toll-free 800.392.3353.M. Barry Jones, MDCleveland Clinic Pain Management specialist M. Barry Jones, MD, is now seeing patients at the main campus and Shaker Pediatric Rehabilitation Center. A graduate of Robert W. Johnson Medical School, University of Medicine and Dentistry of New Jersey in Piscataway, Dr. Jones served his anesthesia residency at Washington University School of Medicine in St. Louis.

His specialty interests include acute and chronic pediatric pain, interventional pain management for back and neck pain, CRPS/RSD, neuropathic pain, chronic headache, musculoskeletal and abdominal pain syndromes, neoplasm and end-of-life related pain, medical hypnosis, mindfulness practices and integrative medicine.

To make an appointment with Dr. Jones, please call 216.444.PAIN (7246) or 800.392.3353.

Department of Pain ManagementThe Cleveland Clinic Foundation9500 Euclid Ave. / AC311Cleveland, Ohio 44195

Managing PainLesley A. Richard, Marketing Manager

This publication is for informational purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician’s medical assessment and medical judgment.

Cleveland Clinic is an independent, nonprofit, multi-specialty academic medical center. It is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,300 staffed beds, an education institute and a research institute.

© The Cleveland Clinic Foundation 2011

Managing PainVolume Seven | Spring 2011

Inside

& more

2468

Walking Tall

Finding Relief from CRPS

A MILD Change for Pain Relief

Finding the Source of Muscle and Nerve Pain