Medical question on Epidural

[merphie]

Any opinions on epidurlal steriod injection?

 

[Ralph]

For what purpose?

High dose corticosteroids are often given following severe spinal cord injuries---but they're given IV......not epidurally.

 

[merphie]

For what purpose?

High dose corticosteroids are often given following severe spinal cord injuries---but they're given IV......not epidurally.

Yes, my mother in law had a disk in her back. . . . I would say sliped. It was more exploded. They had to do back surgury and clean out fragments in the area. It was pinching her nerve.

She still has a lot of problems and she is going to have a 3rd Epidural injection. (That's what it's listed as, they are doing it with a sringe, not IV) The doctor is insisting on these injections before fusing her back. The shots make her worse.

 

[Ralph]

It's not common but it is one option for treating low back pain associated with such things as spinal stenosis,herniated discs, and degenerative disc disease.

The evidence supporting it is mixed. For treating ACUTE low back pain with sciatica epidural steroids were more likely to relieve pain than local injections were---but several months were needed before pain relief was seen.

It usually works in about 50% of the pts recieving it.

For CHRONIC low back pain--it doesn't seem to be any more effective than placebo.

Side effects are fairly rare---headache,fever,infection............

The biggest downside is they just hurt like hell.

 

[Chanileslie]

Okay, I have a few questions for you:

Has your mother undergone physical therapy in conjunction with the Epidurals?

Has your mother's pain decreased at all, even for a short time during any of the epidurals?

Has your mother discussed the increased pain aspects with her physician?

What level is the disc problem at? (lumbar, thoracic or cervical and which disc is being effected. Like it is very common for a disc to bulge or tear at L4-5 (lumbar between the bones 4 and 5). Thoracic disc bulges are uncommon.

Is your mother having other symptoms such as pain and tingling in her extremities? Does this decrease with the epidurals or increase?

Has she had a recent (post discectomy) MRI to show objective evidence of continued problems with the effected disc?

Epidurals are a very good pain relief technique for many people. But to be truely effective, they should be done in conjunction with physical therapy which will provide muscle strengthening to her back, so that she doesn't have future problems with the disk. If she is in more pain following the procedure (not just a few hours but days), this is probably not an effective procedure. She should ask her doctor exactly what benefits he feels she would gain from this procedure if she is having increased pain with the shots.

Back pain is awful and I feel for your mother. I hope she finds resolution.

 

[merphie]

Okay, I have a few questions for you:

Has your mother undergone physical therapy in conjunction with the Epidurals?

No, in fact she has almost been bed ridden.

Has your mother's pain decreased at all, even for a short time during any of the epidurals?

No, it's gotten worse and It's uncomfortable to sit. Sometimes even her left leg goes numb.

Has your mother discussed the increased pain aspects with her physician?

Yes, they insist on this path of treatment. They also have her on some anti-seizure medication. (would have to get the name of it)

What level is the disc problem at? (lumbar, thoracic or cervical and which disc is being effected. Like it is very common for a disc to bulge or tear at L4-5 (lumbar between the bones 4 and 5). Thoracic disc bulges are uncommon.

I believe it's lower back. I don't remember the name.

Is your mother having other symptoms such as pain and tingling in her extremities? Does this decrease with the epidurals or increase?

Yes, severe pain and tingling. Sometimes the entire left leg goes numb and it becomes difficult to walk. The last epidural she had didn't have an effect.

Has she had a recent (post discectomy) MRI to show objective evidence of continued problems with the effected disc?

I know they have done some scan recently and the doctor told her that there was some dense scar tissue. They also said he siatic (SP?) nerve was pinched to the point of damage. We believe some of the problem were caused by the long wait after injury caused by the insurance. (Workman's comp)

Epidurals are a very good pain relief technique for many people. But to be truely effective, they should be done in conjunction with physical therapy which will provide muscle strengthening to her back, so that she doesn't have future problems with the disk. If she is in more pain following the procedure (not just a few hours but days), this is probably not an effective procedure. She should ask her doctor exactly what benefits he feels she would gain from this procedure if she is having increased pain with the shots.

It maybe more due to the insurance althought the flat out rejected the last Epidural even though the doctor ordered it.

Back pain is awful and I feel for your mother. I hope she finds resolution.

So do i. It's a shame she has to suffer,.

 

[Dr. Imago]

I've seen many paravertebral blocks done in the OR. It's a procedure often performed by a pain management specialist (a subspecialty of anesthesiology). In fact, the hospital that I'm currently rotating at schedules around 5-10 every day. They are done under guided fluoroscopy targeting the region that is being painful based upon the symptoms.

The results do vary. Some people have immediate relief. Others get relief within hours to a day or two. Yet others get no relief at all. The length of the effect, likewise, can last from around week to a year or more, again, depending on the patient.

This type of procedure seems to work best for patients with radiculopathic pain (i.e., shooting pain, sometimes called "sciatica" when involving the lower lumbar spine) that is complicated by muscle spasm.

As far as "epidural" steroid injection, I'd imagine that negative outcomes may be related to improper placement of the steroid. Epidural injections, believe it or not, require quite a bit of skill for proper placement. The epidural space (which means literally "outside the dura", the most superficial layer of the covering of the spinal cord) is what's called a 'potential space', meaning that there normal is nothing there. To get a needle exactly in that space requires precise placement within a few millimeters. A skilled and well-practiced anesthesiologist, though, should be able to hit this space without any problems. Likewise, pain is very subjective and often times such procedures may not treat the true causes. Occassionally, this is used as a "band-aid" for a patient who may have been referred for spinal surgery, but for whatever reason is unwilling to go.

-TT

 

[Chanileslie]

No, in fact she has almost been bed ridden.



No, it's gotten worse and It's uncomfortable to sit. Sometimes even her left leg goes numb.



Yes, they insist on this path of treatment. They also have her on some anti-seizure medication. (would have to get the name of it)



I believe it's lower back. I don't remember the name.



Yes, severe pain and tingling. Sometimes the entire left leg goes numb and it becomes difficult to walk. The last epidural she had didn't have an effect.



I know they have done some scan recently and the doctor told her that there was some dense scar tissue. They also said he siatic (SP?) nerve was pinched to the point of damage. We believe some of the problem were caused by the long wait after injury caused by the insurance. (Workman's comp)



It maybe more due to the insurance althought the flat out rejected the last Epidural even though the doctor ordered it.



So do i. It's a shame she has to suffer,.

Well unfortunately, if it is scar tissue causing pressure on the nerve root, epidurals won't do a thing for her, not even palliative. And if she is unable to do physical therapy, the long term prognosis when it relates to epidurals is not very good. Also, if the nerve is severly damaged then epidurals would not be of benefit either.

Scar tissue can develope and it is one of the noted negative side effects of surgery and it can't be helped.

Now, without looking in depth at your mother-in-laws medical records, I can't tell you if it was the insurance companies fault for the long wait or not, but I can tell you if they denied the last epidural there is a good chance it is because she didn't get good results with the previous epidural and she is unable to attend PT in addition to the fact that it appears that her problem is scar tissue which an epidural will not relieve as an epidural works to relieve swelling related to disc bulges. I can't speak for other insurance companies, but we have to refer these type of cases to our Medical Directors who are physicians themselves for review before we can approve or deny this type of treatment.

Have you or another family member spoke with a case manager at the insurance company? You mother should (hopefully) have a nurse case manager overlooking her medical care to assure that is appropriate; unfortunately many insurance companies are turning away from this valuable resource. You might want to call and speak to the Case Manager as this is the person who is there to answer your medical questions.

Unfortunately, spines are a difficult area and can be problematic. The majority of disc problems will rectify themselves within 90 days without medical care, but many do not, and if there is compression of the nerve root for over 30 days there is the possibility of permanent damage. Surgery to remove the scar tissue may help this as from what you have written (and without review of the medical records) it sounds as if this may be a major source of the problem.

I hope everything goes well.

 

[merphie]

Well unfortunately, if it is scar tissue causing pressure on the nerve root, epidurals won't do a thing for her, not even palliative. And if she is unable to do physical therapy, the long term prognosis when it relates to epidurals is not very good. Also, if the nerve is severly damaged then epidurals would not be of benefit either.

Scar tissue can develope and it is one of the noted negative side effects of surgery and it can't be helped.

Now, without looking in depth at your mother-in-laws medical records, I can't tell you if it was the insurance companies fault for the long wait or not, but I can tell you if they denied the last epidural there is a good chance it is because she didn't get good results with the previous epidural and she is unable to attend PT in addition to the fact that it appears that her problem is scar tissue which an epidural will not relieve as an epidural works to relieve swelling related to disc bulges. I can't speak for other insurance companies, but we have to refer these type of cases to our Medical Directors who are physicians themselves for review before we can approve or deny this type of treatment.

Have you or another family member spoke with a case manager at the insurance company? You mother should (hopefully) have a nurse case manager overlooking her medical care to assure that is appropriate; unfortunately many insurance companies are turning away from this valuable resource. You might want to call and speak to the Case Manager as this is the person who is there to answer your medical questions.

Unfortunately, spines are a difficult area and can be problematic. The majority of disc problems will rectify themselves within 90 days without medical care, but many do not, and if there is compression of the nerve root for over 30 days there is the possibility of permanent damage. Surgery to remove the scar tissue may help this as from what you have written (and without review of the medical records) it sounds as if this may be a major source of the problem.

I hope everything goes well.

The claim was filed under Workman's comp. They let her sit for 7 weeks with the initial injury before any treatment was scheduled.

The initially did the epidural before surgery and the experience was extremely painful. In fact, she had major pain side effect for some time after the first epidural.

They started delay tatics soon after. This included such things as referral to a doctor whom was out of their own network. After some time and quite a bit of pain, she seeked the council of an attorney to help cut through the mess.

After surgery, she was feeling much better and seemed positive. The doctor removed a lot of fragments of the disk and cleared the peices that were pinching the nerves. She did go to physical theory about 5 weeks after surgery. (I was corrected by my wife) She was scheduled for 6 weeks of physical theopy and half way through the radiating pain started again. She has never regained feeling in her leg. They did an ultra sound (Or something similar) that was supposed to help prevent scar tissue.

When she went back to the doctor, he said she had not improved and wanted to perform another Epidural. This had no effect on her condition. She had a MRI done and showed dense scar tissue in the area and he put her on oral medication called "neurotin" (SP?) 3 times a day. About the only thing it has done is caused her to sleep. They said the MRI was some sort of contrast MRI and they showed some bulging in numerous locations and degeneration in serveral others.

The case manager denied the epidural because they wanted more information. I can understand that position, but the pain should have been a consideration. No one is talking to each other and so here I seek more information.

This last epidural was done yesterday and the doctor said he wanted to get the drugs more toward the affected nerve. The L4 and L5 were ruptured.

Now she can't feel her left leg at all. She's in more pain than before. She's completely flat on her back with little or no movement. She feels that the pain is starting to radiate to her right side now as well. A burning sensation is how she describes it.

They have been hinting at having to do a second surgery that would completely fuse the L region of her back.

The family is at a complete loss and we don't know where to turn. The case manager seems to have little interest in anything. She has spoken to him only 3 times or so. He rarely returns phone calls.

 

[Dr. Imago]

Well unfortunately, if it is scar tissue causing pressure on the nerve root, epidurals won't do a thing for her, not even palliative. And if she is unable to do physical therapy, the long term prognosis when it relates to epidurals is not very good. Also, if the nerve is severly damaged then epidurals would not be of benefit either.

Scar tissue can develope and it is one of the noted negative side effects of surgery and it can't be helped.

Now, without looking in depth at your mother-in-laws medical records, I can't tell you if it was the insurance companies fault for the long wait or not, but I can tell you if they denied the last epidural there is a good chance it is because she didn't get good results with the previous epidural and she is unable to attend PT in addition to the fact that it appears that her problem is scar tissue which an epidural will not relieve as an epidural works to relieve swelling related to disc bulges. I can't speak for other insurance companies, but we have to refer these type of cases to our Medical Directors who are physicians themselves for review before we can approve or deny this type of treatment.

Have you or another family member spoke with a case manager at the insurance company? You mother should (hopefully) have a nurse case manager overlooking her medical care to assure that is appropriate; unfortunately many insurance companies are turning away from this valuable resource. You might want to call and speak to the Case Manager as this is the person who is there to answer your medical questions.

Unfortunately, spines are a difficult area and can be problematic. The majority of disc problems will rectify themselves within 90 days without medical care, but many do not, and if there is compression of the nerve root for over 30 days there is the possibility of permanent damage. Surgery to remove the scar tissue may help this as from what you have written (and without review of the medical records) it sounds as if this may be a major source of the problem.

I hope everything goes well.

Very nice post, Chanileslie.

-TT

 

[Chanileslie]

Merphie:

I can tell you from long experience of working in workman's comp, be proactive, be proactive, be proactive. If you call and you do not recieve a return phone call in 24 hours, call again, and again, and again. Claims examiners are often overwhelmed, which of course is not your or your mother-in-laws fault, but she has to deal with the results of that.

Also, it may be beneficial for your mother-in-law arrange to have a sit-down discussion with her physician to find out where he/she is going, what the expected outcome and to see if there is a curative treatment plan in place. Also, question in depth, the benefit of further epidurals considering the results from previous epidurals. Are they being performed at different levels? What is the expected gain? If the scar tissue is impinging on the nerve root, then what would be the effect of the epidurals? Do not be afraid to be aggressive and demand answers. If your mother-in-law does not feel comfortable doing this on her own, find out if a nurse case manager can attend with her or at least a family member or close friend.

Best of luck - it is not easy and it sounds as if your mother-in-law has a complicated back case at best, and she may have to learn to cope with chronic pain, which is difficult.

 

[Chanileslie]

Very nice post, Chanileslie.

-TT

Thank you.