Epidurals

[ceejay]

Ny surgeon suggested epidurals for my herniated
disks Currently on hydrocodone and Lyrica
After that is no longer effective he is looking at
disk replacement for 2 and fusion for one level

I am wondering what kind of experiences have people on the board had with epidurals What I
have read indicates is that they work for some and not for others and they do not work for ever

Can I go back to meds after epiduralsf

"

[Slackwater]

Originally posted by ceejay:
Ny surgeon suggested epidurals for my herniated
disks Currently on hydrocodone and Lyrica
After that is no longer effective he is looking at
disk replacement for 2 and fusion for one level

I am wondering what kind of experiences have people on the board had with epidurals What I
have read indicates is that they work for some and not for others and they do not work for ever

Can I go back to meds after epiduralsf

<span class="ev_code_BLUE">Please seek the advice of your surgeon(s) before relying on web-postings from people like me.</span>

I had an ESI (SNRB?), specifically a Transforaminal ESI. There was possibly a gradual easing of leg spasm activity; hard to quantify. I assumed it was a magic wand; I had to continue muscle relaxants. May I suggest ESI is a transition step I believe several surgeons will try ESI before committing to surgery. My recall is I can go back in again X more times in a twelve month period. Med.literature Supports & Refutes ESI as a step to take before having surgery, Decompression, Fusion or ADR - TDR.

My limited recall is reading something about slightly more effect in radicular pain compared to chronic low back pain (CLBP).


Four (4) references are listed below. Sample sizes in the first two (2) references below are small, so please again ask the surgeon(s). The most analytical document on all medical literature reports is the last doc.

~~~~~~~~~~~~
~~~~~~~~~~~~

References from reading material @ UCSF School of Medicine, 4/16/2008 7:00 a.m., Grand Rounds
C-130, 9:00 a.m. Topic: Non-operative approaches to spinal disorders<UL TYPE=SQUARE>(Ref: 1)

J Bone Joint Surg Am. 2000;82:1589. (Link to full text PDF)

The Effect of Nerve-Root Injections on the Need for Operative Treatment of Lumbar Radicular Pain :
A Prospective, Randomized, Controlled, Double-Blind Study
K. Daniel Riew, Yuming Yin, Louis Gilula, Keith H. Bridwell, Lawrence G. Lenke, Carl Lauryssen and Kari Goette

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
(Ref 2)
J Bone Joint Surg Am. 2006;88:1722-1725. doi:10.2106/JBJS.E.00278 Link to full text PDF

Nerve Root Blocks in the Treatment of Lumbar Radicular Pain.
A Minimum Five-Year Follow-Up
K. Daniel Riew, Jong-Beom Park, Yong-Sun Cho, Louis Gilula, Alpesh Patel, Lawrence G. Lenke and Keith H. Bridwell

Discussion
As a direct result of our study, we are now more confident about recommending lumbar nerve-root blocks as a first step prior to operative intervention in patients with lumbar radiculopathy due to a herniated nucleus pulposus or spinal stenosis.

We believe that the injections were effective in relieving symptoms for long enough that patients in whom the pain would have resolved naturally were able to avoid surgery in the meantime. Surgical intervention is not without substantial risks. An operation that had achieved similar results at five years postoperatively, such that the patient thought that no additional treatment was needed, would have been considered successful.

Given that many of our patients achieved this goal without surgical intervention, we believe that this study demonstrated the efficacy of injections to help otherwise excellent operative candidates to avoid surgery.[/list]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

PubMed.gov quick look, also on my hard disc here,


(Ref 3)
Spine J. 2005 Mar-Apr;5(2):191-201. PMID: 15749619

Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy

McLain RF, Kapural L, Mekhail NA.
The Cleveland Clinic Spine Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA

BACKGROUND CONTEXT:
Epidural steroid injection (ESI) is one of the most common nonsurgical interventions prescribed for back and leg pain symptoms. Although the use of ESI is widespread, proof of efficacy among the broad population of low back pain patients is lacking and use is predicated to a great extent on the cost and morbidity of the perceived "next step" in many patient's care-surgery.

PURPOSE:
To review the relative indications and clinical features that predict success with ESI therapy, and to provide a physiological rationale to guide clinical decision-making.

STUDY DESIGN/SETTING:
Review of literature and clinical experience.

RESULTS:
Clinical studies have alternately supported and refuted the efficacy of ESI in the treatment of patients with back and leg pain. Steroid medications do benefit some patients with radicular pain, but the benefit is often limited in duration, making efficacy difficult to prove over time. Steroids appear to speed the rate of recovery and return to function, however, allowing patients to reduce medication levels and increase activity while awaiting the natural improvement expected in most spinal disorders. Fluoroscopic verification of needle placement, with contrast injection, greatly improves steroid delivery while reducing risks. Although it is assumed that the benefit of steroids is related to their effect on inflammation, that remains unproven, and it is possible that benefit is gained through an unrecognized action.

CONCLUSIONS:
Randomized, controlled trials are needed to conclusively identify those patients most likely to benefit from ESI, and when and for how long. Until then, epidural steroids provide a reasonable alternative to surgical intervention in selected patients with back and/or leg pain, whose symptoms are functionally limiting. When appropriate goals are established and proper patients are selected, sufficient short-term benefit has been documented to warrant continued use of this tool.

~~~~~~~~~~~~~~~~~~~~~~~


You may / may not want to read the next article full-text, long, with a critical scientfic view of the medical literature and it restates the need for Propsective, Randomized, Controlled Clinical Trials:

(Ref 4)

The Spine Journal
Volume 8, Issue 1, January-February 2008, Pages 45-55 Full-Text PDF

doi:10.1016/j.spinee.2007.09.009
Copyright © 2008 Elsevier Inc. All rights reserved.

Intervention Review Article

Evidence-informed management of chronic low back pain with epidural steroid injections

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



Slackwater

[Terry]

My epidurals did not work pre-ADR but have worked since. I believe it helped reduce pain after the surgery and helped in the healing process. I had the epidurals every three months after ADR surgery but have not had any since December and I seem to be doing much better.

Terry Newton

[Slackwater]

Originally posted by Terry:
My epidurals did not work pre-ADR but have worked since. I believe it helped reduce pain after the surgery and helped in the healing process. I had the epidurals every three months after ADR surgery but have not had any since December and I seem to be doing much better.

Terry Newton

Steroids increase protein synthesis within cells that can create tissues, especially muscle. OK, good result. The theory is good, in theory.

Steroids have side effects beyond the intended muscle - tissue build-up, sometimes skin response, rash, emotional, ... Suggest chronic off-label use is required to severe negative side effects. I need more steroid injections to get into the WWF (wordwide wrestling federation).

Take care,

slackwater



Link
The American Journal of Sports Medicine 32:534-542 (2004)
© 2004 American Orthopaedic Society for Sports Medicine

Current Concepts in Anabolic-Androgenic Steroids
Nick A. Evans, MD*
UCLA-Orthopaedic Hospital, Los Angeles, California

[OsteoRach]

just to clarify, your is doc suggesting an epidural 'steriod' injection?

steriods injections are designed to reduce inflammation to reduce pain (if the injection is in the right place and the cause of the pain if inflammatory in nature, as is the case in chemical radiculopathy or the acute stages of an injury). if there is a mechanical compression of the nerve root (actual disc matter) and inflammation has little to do with the pain then a steriod injection will not reduce the pain.

Epidural steriod injections are effectively the same as a steriod injection for a knee injury, an inhaler for asthma, or someone who is presecribed a systemic steriod for a systemic inflammatory condition.

The reason steriods are used sparingly is that they are potent at reducing bone mineral density and long term use can cause of osteoporosis / pathological fractures.

So, in the case of inflammatory pain that is not going away with more conservative measures (rest, ice, elevation, compression, drugs (non-steriodal anti inflammatory drugs - NSAIDS, e.g. voltaren, ibuprofen, naprogesic, diclofenac) then a steriod injection is indicated and if done properly can alleviate pain. Especailly as ~80% of disc herniations DO NOT require surgery and if you can get out of the 'acute' stages (over time the disc dehydrates and no longer irritates the nerves / and the inflammation calms down) and central sensitization you are halfway there...

Important to note is that steriod injections do not treat the cause as such. However, it is well known in medical circles that ALOT of people have disc prolapses / ddd and NEVER have back pain, and that the size of a herniation does not correlate with the degree of signs/symptoms. also important is that the only true indications for spinal surgery due to disc prolapse / ddd are progressive motor weakness or change in bowel/bladder habits. after this surgery is elective...when it comes to elective surgery it is usually due to deminishing quality of life following no less than six months aggressive conservative care.

terry, in your situation your preop chronic pain was probably due to mechanical pressure of the nerve roots / nociceptors hence the steriod injections not working. Afterwards however your pain was probably inflammatory in nature hence the steriod injections helping. my next question however would be what are you iritating to cause ongoing inflammation?

rachel

[cathydownunder]

Ceejay
To answer your specific questions....
Yes you can return to medications after an eidural if it's not effective. I don't know what the statistics are regarding outcomes but
from my experience my ESI did nothing once the initial local had worn off.

[Terry]

Originally posted by OsteoRach:
terry, in your situation your preop chronic pain was probably due to mechanical pressure of the nerve roots / nociceptors hence the steriod injections not working. Afterwards however your pain was probably inflammatory in nature hence the steriod injections helping. my next question however would be what are you iritating to cause ongoing inflammation?

rachel

I have not had any epidurals since December. I had them about every three months after my ADR surgery. By December that was one year, one month out of surgery. I am doing much better and don't believe I will be requiring any more epidurals. I understand the long-term effects so I would not want to continue going down this path. Thanks everyone for the concern but I am doing fine. One year and on May 4th six months, so 1 1/2 years since major spinal surgery in Germany . Life is good.

Terry Newton

[Harrison]

I understand the long-term effects so I would not want to continue going down this path.

Good for you! Patients, doctors and researchers are still learning about the biological ramifications...

[Terry]

Originally posted by Harrison:
<BLOCKQUOTE class="ip-ubbcode-quote"><div class="ip-ubbcode-quote-title">quote:</div><div class="ip-ubbcode-quote-content">I understand the long-term effects so I would not want to continue going down this path.

Good for you! Patients, doctors and researchers are still learning about the biological ramifications... </div></BLOCKQUOTE>

I hate taking a medication that is a steroid for any period of time. I have heard of the possible effects on bone for a long time. Even if that is not proven, I only have one life and I am getting older anyway. I don't want to be in chronic pain in to my elder years. Not how I am imagining my retirement. I'm saving like a mad man and would like to have some enjoyment then and be able to travel, not have a lot of money and leave behind a rich widow.

Terry Newton

[OsteoRach]

hi Terry,

good luck with your continuing recovery. one day sooner rather than later i would like to be able to start riding again, i love it. you remind me that here is life after this,

regards

rachel