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Epidural Steroid Injection Problem
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flatcake posted:
New here. Looks like a great place for getting good advice. A little background. After years of acupuncture, massage, chiropractics, hypnosis, physical therapy, etc, with no relief, I started 15 months ago down the path of Western Medicine for chronic low back pain. First step was MRI, showed ?large bulge in L5/S1 disk with severe impingement to S1 nerve root?. Also ?moderate bulge in L2 disk, impinging nerve?. L3 & L4 have degenerated. OTC pain meds don?t touch the pain. I had big hang-ups about narcotic pain meds long-term, but all 5 specialty docs I?ve seen for this say it?s not advisable to operate for my condition. So now I?ve gotten over my hang-up about opioids. The main thing I?ve tried to do is fiercely protect my tolerance, because I know there?s really no ceiling to the tolerance one can get from long-term opioid use, and I?ll need tolerance room down the line. For the last year I?ve been taking only enough to tamp the pain down by about 60-75%, because in the past I?ve had a known history for a high pain tolerance (old climbing buddies used to comment on my high pain tolerance all the time after my various injuries), so I can easily deal with the 25% of the pain that?s left after medicating. I have free license with my doc to take more and tamp it down by 95%, but I don?t because I know as the years go by I?ll need the room on the meds. Anyway, it?s been recommended several times that I try an epidural steroid injection. My gut feel was not to do it. I finally caved last week and had one done. Biggest mistake of my life!! Wish I could go back in time and get back to the way I was. Wondering if anyone else has had this experience with these things: I was pumped full fentanyl and versed on the procedure table, doc said I wouldn?t feel anything during the injection. Completely wrong. On the 1-10 pain scale it was way over the top. I screamed like a baby with a bullhorn. Doc was surprised that I felt anything at all. In recovery/observation room I couldn?t sit without excruciating pain, once home I couldn?t sit or lay down without extreme pain. 6 hours after procedure I went into spasm and hollered uncontrollably for over 3 minutes in a twisted heap. Could not get on top of the pain. My regular prescription is for 4 Norco 10s per day, but I usually take ? every 4 hours and deal with whatever pain is leftover after that (again, trying to stave off tolerance). After procedure I was taking 1 Norco 10 every 3 hours along with Skelaxin, and it wouldn?t even touch the pain. Doc said to ramp up to 2 Norcos every 3 hours in the short-term. This would tamp it down to about an 8 on the pain scale. For me ?8? is the pain-point where I can?t understand what?s being said to me, and can?t speak, my breathing is very deep and controlled, and I see spots. Anyway, it?s now 6 days later, and sitting and laying down are excruciating, and I?m doing 20 milligrams of hydrocodone (2 Norcos) every 3 hours, and this takes it down to about a 5 on the scale now. Bye-bye to my lack of tolerance, I?m sure. Anyone else out there ever experience this after an epidural steroid injection? This doc came HIGHLY recommended by my PCP and others. Also, I feel I need to go to timed release meds, get something stronger than hydrocodone, but don?t tolerate Oxycontin or MS Contin (morphine). Both make me REALLY depressed, agitated, angry, and these 3 traits are usually the opposite of my personality. Anyone else out there who has Hydrocodone work for them (but Oxy or Morphine not work) have suggestions on a timed release to try? Opana maybe? Or Methadose? Any advice is welcome. Thanks.
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corlaw responded:
I am sorry to hear of your experience, I had one Mon afternoon and was sedated, they used profol and after the IV went in and med I woke up walking down the hall with guidance from nurse, did you just get local anesthetic, I would have went with the knockout option like I did, sorry to hear about your pain.... I also do not loike the oxycodone ie percocet because it made me sedated and did nothing for the pain not sure why but I have always tolerated morphine, not much problem.... just was not enough for me.
 
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cweinbl responded:
Hi "Flatcake." Sorry to hear about your epidural nightmare. It is indeed unusual. I have a few observations:

1. It is never wise to take less medication than recommended ("1/2 of a Norco). Such dosages are rarely effective; nor will it last as long as necessary.

2. Any chronic pain patient here would jump for joy with a pain reduction of "60-75%." "95%" is unheard-of here. If you can obtain that level of pain reduction, even temporarily, then you are indeed the luckiest of us all. The last time I had a pain reduction of 95% was 40 years ago, when I was 17.

3. Do not worry about "tolerance." If you become tolerant to the highest safe dosage of a narcotic (and it can take years to reach that level), you only need to rotate to a different narcotic temporarily. After a few months, you can return to the original narcotic and it will be effective again. Tolerance should never be a major issue for a chronic pain patient.

4. We all react differently to the same drug. If Oxycodone is not the best medication for you, don't be discouraged. There are a dozen alternatives.

5. I understand that you obtain good results with Norco (Hydrocodone). However, most chronic pain patients respond better to a long-acting pain medication. If you don't like Oxycodone (Oxycontin), or morphine (Avinza, Kadian),then ask your doctor about other long-acting drugs, such as Fentanyl Transdermal.

6. Most chronic pain patients should ask their doctor about using an anti-depressant, to inhibit the reuptake of Seratonin. I don't recall you mentioning that. And, if you have sciatica, you could also benefit from an anti-convulsant (Neurontin, Lyrica, etc.)
 
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flatcake responded:
I appreciate your thoughtful reply, cweinbl. I see from your final signature line that you have a very complex pain situation, and I'm sorry to hear that, but I can tell you speak from experience. I know comparatively speaking I'm new to Chronic Pain Management, and it was very comforting to read your comments about tolerance. Until just a few days ago I had an unusually over-careful philosophy about this, partly due to my own misconceptions and partly due to reading horror stories about recreational users and their tolerance -- but of course recreational use has nothing to do with pain management. Due to my misconceptions, and after hearing from several people like you, I realize now I have been purposefully under-medicating for no reason.

You mentioned anti-depressants. I haven't been prescribed any yet, although I did complain to my doctor about insomnia from the Hydrocodone, and he precribed Trazodone. The doc said it's an old-school anti-depressant from the 60s, but he said these days they generally only prescribe it for insomnia. I'll ask my doc about anti-depressants a little more.

For those on this board I feel bad for them that a pain reduction of 65-75% would be considered good. Sometimes for me, that remaining 25-35% of the pain that the meds don't always touch is like an all-consuming core-deep evil presence that reverberates down to my very soul, killing all abilities for creative thinking and concentration, and uncontrollably contorting my usual facial expression and voice tone. It scares me to think what it's going to be like if that remaining percentage of pain grows from its current level.

Anyway, now it's 11 days after the injection, and I feel that I've almost returned to the same place I was prior to the procedure. VERY HAPPY ABOUT THAT! I realize now it's not a bad place to be compared to what was happening.

Thanks again for the info. Here's hoping you are finding some kind of relief.
 
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cweinbl responded:
Hi "Flatcake." FYI, Trazadone IS an anti-depressant, albeit an old one (Tricyclic). I have used it for years. I take it at HS (bed time) because it helps me sleep. Anti-depressants can help relieve chronic pain because they inhibit the reuptake of serum Seratonin, one of the body's natural pain-fighting chemicals in your bloodstream. So, if you're already using Trazadone, then you have accomplished that part of comprehensive pain management treatment.
 
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flatcake responded:
"Anti-depressants can help relieve chronic pain because they inhibit the reuptake of serum Seratonin,"

That's very interesting, thanks for the info. Prior to going into official Pain Management 3 months ago, I had been seeing a Physiatrist for 12 months (rehabilitation doc, not to be confused, of course, with a Psychiatrist! ), then had been talking with my regular PCP about this for a few years prior, and no one has ever mentioned this aspect about anti-depressants. One thing I do know, the Physiatrist who first prescribed Trazodone about 8 months ago said there is no dependence, no withdrawal if discontinued suddenly. I say BS to that. I ran out right before leaving to visit relatives over the Holidays, figured I'd skip it for 7 days and refill on return. By day 4 I went into classic SEVERE depression symptoms, which I have no experience with, and couldn't figure out what was wrong with me. One of the most unpleasant physiological experiences I've ever had, just wanted to stay in bed with the covers pulled up to my eyes and I'd never been a depressed person before. Got the Trazodone refilled by day 8 and was almost immediately a new man. So...for me anyway, Trazodone causes dependence. After those withdrawal symptoms I have a new understanding of what people go through who are clinically depressed. I didn't really understand it before.

By the way, have you tried Gabapentin for your sciatica? I had painful sciatica symptoms along with the chronic low back pain when I first started seeing the Rehab Doc -- physiatrist -- a year ago. He prescribed Gabapentin and it worked great. He also showed me several stretches I wasn't aware of (thought I generally knew a lot about that, but apparently not) and after using the stretches for a few weeks I was able to make the sciatica symptoms completely go away 100%. Prior to the stretches though, I had great sciatica relief from Gabapentin while getting no sciatica relief from opioids. My 2 cents. But my guess is you probably already know about Gabapentin.

Thanks for the further info about anti-depressents. It really helps since I'm fairly green on the whole pain management thing.
 
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cweinbl responded:
Hi "Flatcake." I'm with you the Trazadone. While not in the same call as a narcotic, one can develop a dependence to it. I would certainly have trouble falling asleep without it. But, dependence is never a problem unless you run out. As I mentioned earlier, Trazadone (Deseryl) is one of the old Tricyclic anti-depressants, with more side effects than newer drugs. Many people today use Cymbalta. Not only will it inhibit the reuptake of Seratonin, it also appears to have some benefit for inflammation-related pain. But for the purpose of maintaining serum Seratonin, almost any old anti-depressant will do (and the old ones are dirt cheap).

Yes, I know how Gabapentin (Neurontin) works. I used it for a few years. It can help to reduce neuropathic pain. In the same class (anti-convulsants), Lyrica (Pregbalin) is newer and appears to have fewer side effects. Neurontin is less expensive. Combined with an anti-depressant and a long-acting narcotic, this "cocktail" of drugs can be a formidable weapon in managing chronic pain.
 
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annette030 responded:
This older antidepressant is often prescribed to help patients sleep. The newer SSRIs often do not make a patient sleepy at all.

I looked Trazedone up to make sure I remembered right, it is not listed in my drug book as a tricyclic, but as a serotonin reuptake inhibitor/antagonist. My doctor told me many years ago when I tried it that it was different from the tricyclics, which mediate serotonin, norepinephrine and dopamine.

Made me a total zombie, I did not take it for very long. Other people react differently to it than I did.

I always start out with the older, cheaper, generic drugs, then if I get side effects that don't go away, I try one of the other drugs. If you don't happen to be one of the people who gets side effects from a particular drug, you can save tons of money over the years. I have rarely really needed the newer non-generic drugs. I don't take any now.

Take care, Annette
 
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Ted723 responded:
Hi All...OK...brand new and seeing 1st neurologist tomorrow, 2/12/10...Getting THREE opinions before anyone cuts me open.

DDD, two ruptured discs L5-S1 is the worst of the two I guess (PCP's words), "severe" spinal stenosis is written on the MRI report. I have viewed the MRI CD on my PC and even I can see the innards (if you will) of my discs "flowing" outta their casings. Report also states "Severe nerve root compression". Sciatica is very bad on left side top to bottom and then jumps to right leg occasionally. Have also had a few "can't feel my leg" episodes (including no feeling when I touch leg with my hands). Also have bladder/bowel "issues" as of past week....and that's all I care to discuss about THAT.

Reading all of you is both helpful AND scaring the crap outta me. Original injury was 30 years ago and I refused surgery then due to fears of repeated surgeries...and Charles...reading YOUR signature does nothing to change my fears of multiple surgeries. I have "thrown out my back" many, many times in 30 years, but this one looks like "it". Over the decades I have tried it all---from acupuncture to TENS units, to traction to PT for months on end. Snowstorm in Dec. '09 and I shoulda known better.....Anyway I am taking Perc's (5/325---they accomplish very little re: sciatica) and I am on an anti-depressant due to depression (many years dealing with THAT issue). I also have 4 stents (2 in heart & 1 in each side of my groin). I have my own pharmacy for goodness sake....

I wanted to introduce myself now as I anticipate being a regular....I do have a basic question, though. I KNOW it's different for each case and each type of surgery, but what is an "average" recovery time to get back to my desk job? I own my own business with a partner and want to have SOME idea...any help?....Any reply would be greatly appreciated. Next surgical consult is 2/26/10 with what I have been told is one of the "best in New England", by both patients and other doc's...A close friend used him 5-6 years ago and is absolutely fine these days. HE says "Oh, a week or so and you'll be back to work"....I am missing about 1-2 days a week NOW...PRE-surgery, so I am doubtful of his prediction. I have fallen many times as the left leg says "uh-uh, no way" and down I go. I also have days where it feels like I've NEVER injured my back...100% pain-free, so I KNOW those discs are moving all over the place in there.

So any "educated guesses" as to "back-to-work" period??? Thanks to all of you and you will ALL now be in my prayers each night for some relief for you all---and yes, me too of course

Ted
 
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cweinbl responded:
Hi Ted. Spine surgery is only 50% successful for pain relief (80% for improved function). Do your own research. There are millions of people walking around with failed spine surgery syndrome (including me). Be careful what you wish for.

The recovery depends upon the type of surgery, which you did not mention. Microdiscectomy. uses a 2" incision. But, there will still be torn muscle and tendons. If all goes well, you might be able to return to work in 7-10 days. Of course, there can be complications. I went back a week after my first discectomy and developed severe inflammation, which was just as painful as the surgery and it lasted two months.

The problem with a microdiscectomy. is that the small incision, restricted use of instruments and difficulty viewing the entire area means that there is much greater chance that pieces of extruded disc will remain. Those pieces can later recompress a nerve root, leading to exactly the same pain and more surgery.

The other option is to have a laminectomy. It uses a much larger incision and the recovery time is longer (more like six to eight weeks). But, with a laminectomy, the surgeon can see and reach all areas of your spine, reducing the chance of leaving a piece of extruded disc inside.

Everyone wants the least pain and the fastest recovery. Take it from someone who had four failed spine surgeries, when it comes to surgery, you want the best change for success, not the fastest recovery.

You should know that when you have pieces of a herniated disc surgically removed, there will be increased pressure on discs above and below the surgical area. That means you will have an increased chance of another disc herniation. In 1984, I had pieces of L5-S1 removed. Just four months later, L4-5 herniated. Back to the operating room for more surgery.

Finally, you said nothing about your pain management program. No one should have spine surgery until the dozens of non-invasive and minimally-invasive pain management treatments have failed. Have you tried a corset, brace, TENS, traction, acupuncture, biofeedback, physical therapy, kinesiotherapy, injection of steroids and anesthetics, non-steroidal anti-inflammatories, cortisone, rhyzotomy (radio frequency denervation), spinal cord stimulator, intrathecal infusion pump, off-label medications (anti-depressants, anti-convulsants), combination of long-acting pain medication with breakthrough meds, counseling, hypnosis and meditation? If not, you may wish to try these before going under the knife.

One more thing... spine surgery will create fibrosis (scar tissue). Scar tissue can impinge spinal nerve roots causing just as much pain as compression by extruded disc. Once you have scar tissue, there is almost nothing that can be done about it. It is considered unethical to surgically remove fibrosis because at least as much will grow back. We each grow scar tissue at our own rates. I must be a real winner, because my last myelogram resembled a road map of New Jersey, with scarring everywhere from L3 to S1.

You should also know that there is a world of difference between a Neurosurgeon, an orthopedic surgeon and a fellowship-trained spine surgeron. Having had all three types of surgeons operate on my spine, I've discovered that no one is better educated, trained and experienced with leading edge techniques than a spine surgeon who has completed a fellowship. If you insist upon surgery, I urge you to get at least two opinions from spine surgeons. You'll find them at or near teaching hospitals.

I'm not trying to talk you out of having surgery. I am only presenting some facts for your consideration. If you desire surgery for pain relief, you have a 50% chance of success. There is also a chance that your pain could become worse than ever before. This is not a decision to rush into quickly or lightly. I can't stand for more than 5 minutes or sit upright for more than 15-20 minutes.
 
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L4L5S1 responded:
Hi. I've tried it all. I had some luck with epidural injections, but methadone pills, (10mg, 4 pills, 3 times a day) I had fusion surgury wich alleviated the leg pain, caused by sciatic nerve being crushed, but lower back pain is constant. The methadone helps tremendously. Hope this helps.
 
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TrishaHindsville responded:
Hi Ted, I'm brand new here, too. A work injury has caused me to have had 2 elbow surgeries and 2 knee surgeries so far and I still have a complete knee replacement to look forward to. I also had my L5/S1 herniated disc surgery on April 23, 2009. (also from the same circumstances) My neurologist was supposed to be the best in my area, too. I had severe stenosis and sciatia as well. My pain kept getting worse through physical therapy, so my neurologist said it was time to operate. He put in a lot of hardware (a new plastic disc, metal rods, a metal plate, screws, etc.) and fused my back. He told me I should be back to work in about 4-6 weeks. Yeah, right!!!(BTW--you won't even be able to DRIVE before then.) I wasn't even off my walker in 12 weeks, and I haven't even been able to drive a car in over a year. My pain has gotten worse instead of better after the surgery. I've gone through two sets of Epidural Steroid Injections (with local only), but neither one helped do anything except lighten my wallet. And when I didn't get better in his timeframe, and my pain progressively got even worse over the next six months, my neurologist didn't know what else to do with me, so he "terminated" our professional relationship. What a guy!!!! I went back to my regular Family Physician (who I kept in the loop) and I have now been diagnosed with INTRACTABLE PAIN caused from my back injury/surgery! I now take 60 mg. of Morphine at 8 a.m. and another 60 mg. of Morphine at 8 p.m. (my mother wasn't even on this much morphine when she was dying of cancer 20 years ago). I also take Oxycodone 10 mg. every 3-4 hours, Gabapentin (neurontin) 1800 mg. per day, Citalopram 40 mg. each morning for depression, Klonopin 15 mg. per day for my panic attacks (since the surgery) and Trazadone 300 mg. at bedtime. I'm probably missing something, but I suffer with short-term memory loss now, too! I am currently looking for a Pain Management doctor. My "regular pain" is still 8-9 out of 10 EVERY DAY!! There is not a moment during the day that I'm not in excruciating pain, but each person is different and some breeze through the surgery.

Ted, I hope you are one to have a quick and pain-free recovery! Good luck! Trisha
 
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cweinbl responded:
Hi Trisha. I'm sorry about your pain. Join the club. I have a couple of observations. First, if I took 300 mg of Trazadone, I too would suffer short-term memory loss (and long-term and every other "term"). That's a ton of Trazadone in one shot. I'll bet you sleep well. I use 50 mg at bedtime. The same applies to Neurontin. 1,800 mg is a high dosage.

You should also know that there is a much stronger pain medication than your morphine. It's called Fentanyl (at least 80 times more potent). Fentanyl is best delivered as Fentanyl Transdermal, a patch that is changed every two or three days. It originally wiped out about 80% of my chronic pain (and I've tried virtually everything). If huge dosages of morphine leave you wanting, ask your doctor about Fentanyl.

Finally, spine surgery is only 50% successful for pain (80% for improved function). Unfortunately, spine surgeons (being the egotistical artists they perceive themselves to be) do not tell patients this. They suggest that you will be mostly pain free. That's a lot of BS. What's worse is that after your spine surgery fails (as it does at least half the time), you will deal with additional pain from fibrosis (scar tissue). All surgery creates scar tissue. The more invasive, the more scarring. And, some people (like me) grow scar tissue like it's going out of style. This leaves the spine surgery patient with even more pain than they had in the first place.

The lesson to be learned from this is that spine surgery is a bad option. The success rates are low. This should always remain a last resort option, after a patient has been through at least two comprehensive pain management programs and tried the dozens of non-invasive and minimally-invasive options (including the spinal cord stimulator and the intrathecal infusion pump).

Best of luck to you, Trisha. Don't forget to ask your doctor about Fentanyl.
 
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Vsplain replied to cweinbl's response:
back pain can be so debilitating. Look up Dr Vijay Vad MD, he has a total mind and body approac with Eastern and Western medicine. I have had epidural steroid injections......they should never feel like what you experienced. As a nurse I am guessing your nerves were hit directly and inflamed. I have only experienced this kind of pain with a nerve injury in my arm from a blood draw. They hit my nerve and damaged it. The searing pain lasted for 6 months while the nerve regenerted. My biggest savior for back pain(I have 3 buldging disc L3,4 and 5 and 3 buldging in cervical area of neck) is pilates and yoga. You can do this at home if you dont have a gym. It strengthens your core and the empowerment of pain relief is amaing, not to mention standing taller. I stay away from too much pain meds like you.They . They
 
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Vsplain replied to Vsplain's response:
sorry didnt finish response. So I also limit my meds and tolerate a bit. My other motto is keep moving. I walk everyday or bike to keep moving. I did just hear about transdermal epidural from Dr Vad. It sounds like it targets the specific area of sciatica and gives pain relief for months. I have access to a University hospital pain clinic. I do make sure only an attending physician does my proceedures.......no interns who are practicing. Good luck! May your pain subside to a baseline and may you find good relief. I keep the fith that there are great stem cell reseatch out there. Someday this way of regenerating nerves and rebuilding discs are my hope.


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