Dear Dr. Roach: For months, I’ve been suffering with severe lower-back pain while standing. It radiates down my leg, into my buttocks. Several weeks of physical therapy wasn’t helpful, and I can’t take many medications because I have atrial fibrillation. An MRI showed arthritis in my spine, but also schwannomas on the nerve sheaths. What information do you have on schwannomas of the spine?
Dear D.B.: The Schwann cell, in the peripheral nervous system, makes myelin sheaths, a protective coating around the nerve necessary for electrical impulses to travel.
Tumors of these cells are called schwannomas. Often, they are found in the nerve connected to the ear, affecting the sense of balance. They also arise in the nerves leaving the spine. They can occur in anyone, but when there are multiple tumors, the physician should consider schwannomatosis, a condition related to neurofibromatosis. These tumors are generally benign, although there is a rare malignant variety, called a malignant nerve sheath tumor. Due to their location, they can cause pressure on the nerve, which leads to symptoms of pain and sometimes weakness.
It sounds like you have at least two possible reasons for your symptoms, and only an expert reading of your MRI may be able to tell whether the pain is being caused by the schwannomas or because the arthritis is putting pressure on the nerve. (Radiation of pain into the buttock is strong evidence that the pain is due to nerve compression.) While physical therapy almost always is the best initial treatment for most back pain, this is one case where seeing a surgeon soon is important. The MRI is not definitive for schwannoma, so a biopsy may be needed to confirm the diagnosis. Many experts would recommend surgery for confirmation as well as to relieve the pressure on the nerve in order to stop the pain. Radiation therapy sometimes is used to treat pain in people who cannot have surgery.
Dear Dr. Roach: You recently had a column where you did not recommend alprazolam (Xanax) as a long-term sleep aid. What are the negative effects of using it that way?
Dear A.T.: Alprazolam is in the class of drugs called benzodiazepines, which includes Valium, Klonopin and Halcyon. They’re effective at getting people to sleep more quickly, and increase sleep time 30-60 minutes. Alprazolam is very short-acting (although there is a long-acting form now) and is not indicated for insomnia.
I don’t recommend benzodiazepines because they increase the rate of falls, especially in the elderly, because they can cause memory loss and because they can cause confusion and dependence.
I try to avoid prescribing sleeping medications, and most people with occasional difficulty sleeping do well with sleep hygiene advice: Having a regular sleep schedule, not trying to force sleep, avoiding alcohol and caffeine near bedtime and not using bright lights or computer screens before bed are part of this. If I do prescribe a sleep medication, I recommend using it no more than every other day and for no more than two weeks. People who need more than that, I refer to a sleep specialist.
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