Dr. Roach

Dr. Keith Roach

DEAR DR. ROACH: I am an 86-year-old male in relatively good health. I developed pain in my lower back, buttocks and upper legs that started a couple of months ago. It is particularly painful in the morning when I arise and subsides some as I work through the pain and get going through my day.
My primary care doctor sent me to a physical therapist who diagnosed me with spinal stenosis and scheduled a 12-session physical therapy routine. My primary doctor also prescribed tizanidine, a muscle relaxer, but the side effects of it concern me.
Can you give me any advice on a course of treatment, preferably without drugs, that will help eliminate the pain? — W.C.
ANSWER: The most common cause of spinal stenosis in an older person is due to spondylosis, or degenerative osteoarthritis of the spine. Due to bone spurs, loss of disc height and other changes in the spine, the spinal cord and the neural foramina can get small enough that the nerve tissue gets compressed.
When a nerve gets compressed, there are three major types of changes that a person notices. Numbness often starts before pain, and weakness is generally a finding once the nerve compression is severe. Progressive weakness is considered an emergency with spinal stenosis. I have seen a person go from normal strength to permanent weakness in just a few days. Fortunately, this is not common in spinal stenosis due to arthritis.
There are three types of treatments for spinal stenosis: medications, physical therapy and surgery. Anti-inflammatories are commonly used and have provided benefits for many people. My experience with muscle relaxers is that they are beneficial for a week or so at the cost of some sedation, but the effectiveness tends to wear off. I mostly use them at night for short-term use when symptoms are particularly bad. I try to avoid opiates, but other types of pain medicines are sometimes beneficial.
Physical therapy is the mainstay of conservative treatment. It has been shown to improve function and reduce pain. To maintain benefits after your physical therapy course is complete, continue with the modalities (such as exercises and stretching) that are recommended by your therapist.
Surgery should only be considered when symptoms cannot be managed with conservative therapy or in people with progressive symptoms, especially neurological deficits like weakness, bladder issues or bowel symptoms.
DEAR DR. ROACH: Would metformin be a good idea for a 74-year-old person who was diagnosed as prediabetic and has a blood sugar of 110 mg/dL? I have diabetes on my mother’s side. — Anon.
ANSWER: In the diabetes prevention program study, metformin was found to prevent or at least delay the onset of diabetes. The study only included people of average weight or higher; the small subgroup of people with Type 2 diabetes who are of lower than average weight may not benefit from metformin.
In my practice, I prefer lifestyle changes for most patients, as there are many benefits that go beyond diabetes, but I absolutely do prescribe metformin, in addition to lifestyle changes, for some at-risk patients to prevent overt diabetes.
Metformin does have its risks. It should not be used in people with chronic kidney disease. It also causes diarrhea and stomach upset in many people, but this tends to lessen with time or when using the slow-release formulation.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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