How many times is epidural given before surgery is considered?

Posted by tacitsentinel @tacitsentinel, Jun 27 7:01pm

Healthy 38M 5'8 165lbs. I had a lumbar injury at work in November 2020. First worker's comp doc did x-rays and I had physical therapy for 1.5 months that didn't help. MRI was requested after the first month of PT. MRI was ignored and I was discharged with permanent ongoing work restrictions of >10lbs lifting and limited bending. WC doc lied in her notes that I refused to attend pain management that she never recommended. She also tried to play the 'ol dirty card and blamed my back injury on dysautonomia, which my primary care doc had been treating me for for nearly a year before the back injury. He shot back with a letter that said that the dysautonomia has no bearing whatsoever on musculoskeletal injury or healing and that they need to treat my back injury separately.

Took me 4 months to get a spine specialist/ortho surgeon. His notes:

"Mild sciatic list. Forward flexion extension is limited. Straight leg raise testing reproduces back and buttock pain bilaterally. No pain with range of motion of his hips. Good strength in all muscle groups from L1-S1. No sensory deficits. MRI scan is reviewed with lumbar spine advanced degenerative changes noted at L4-5 with disc space narrowing. Did not see any evidence of any nerve compression at that level. The other levels are well-maintained. There is some edema in the endplates. Thoracolumbar spine reveals mild tenderness to palpation. Discussed treatment options with him today. He has not had improvement with physical therapy. He does have advanced changes noted at L4-5 that represent exacerbation of an underlying degenerative condition through his work injury. I recommend bilateral L4-5 transforaminal injections Continue his previous work restrictions. Diagnosis: Lumbar Radiculopathy."

He also added his own restrictions for alternating standing/sitting due to the tingling, pain and alternating numbness in my legs (e.g. sometimes a whole foot will turn number just by standing in place for a few minutes). I'm in a state where even if you have some degeneration, if your workplace duties exacerbate it, the law requires for it to be treated as a full-on injury. My lawyer has also stated that the employer is responsible.

I had those bilateral injections on 6/18. For about 3 days, the stabbing lumbar pain and tingling/sciatica down both legs went away. Incidentally, the odd bladder malfunction/bowel motility symptoms and lightheadedness from the 'dysautonomia' since December 2019 also went away for those 3 days. On 6/21, the stabbing lumbar pain came back, the sciatica and tingling came back down to the toes of both feet and my bladder/bowels started acting up again. My lightheadedness returned. We know that dysautonomia in and of itself is a set of symptoms, not a medical condition or disease specifically. The bladder and bowel pain feel like they are coming directly from my lumbar as some kind of referred pain.

So now it has been 7 months to this day since my back injury. The outside half (meaning separated by the tibia) of the full length of my calves have been numb on both legs 24/7 since November 2020. The epidural had no effect on them and dermatome maps show the L4-5 as responsible for that numb area on both legs. In addition, apparently the L5-S1 affects the bladder/bowels based on nerve charts. I obviously have some sort of nerve damage going on in my legs.

I go back to the doc in the morning for follow-up. Will he order more epidurals given that it only lasted for 3 days or will surgery be recommended at this point?

Surgery is not always the answer have you tried physical therapy you may want to give it a try once they go in you may still have the pain you have now my pain did not start until I had surgery my leg went numb my left foot would not move so they had to operate it was a complete success but after about six months the pain started coming back it turned out that my body had scarred badly so more mri and more surgery they found that the nerves and skirts tissue could not be separated so my journey began you can find the rest of the story on This sight I am not up to telling it again take care and I do hope you find the answer you need

REPLY
@bear338

Surgery is not always the answer have you tried physical therapy you may want to give it a try once they go in you may still have the pain you have now my pain did not start until I had surgery my leg went numb my left foot would not move so they had to operate it was a complete success but after about six months the pain started coming back it turned out that my body had scarred badly so more mri and more surgery they found that the nerves and skirts tissue could not be separated so my journey began you can find the rest of the story on This sight I am not up to telling it again take care and I do hope you find the answer you need

Jump to this post

I had 1.5 months of physical therapy that didn't do anything. I had bilaterial (double) steroid injections in the left and right L4-5. Helped for the 3 days and the crushing pain came back again. At 38 years old, I have the back of probably a 55-60 year old, but only in the L4-5 area. The other areas are well-maintained. Got another round of epidurals scheduled.

REPLY
@tacitsentinel

I had 1.5 months of physical therapy that didn't do anything. I had bilaterial (double) steroid injections in the left and right L4-5. Helped for the 3 days and the crushing pain came back again. At 38 years old, I have the back of probably a 55-60 year old, but only in the L4-5 area. The other areas are well-maintained. Got another round of epidurals scheduled.

Jump to this post

I have had five more surgeries sense that one that did all of this it is scar tissue that has caused the pain the scar and the nerve could not be separated that is why I have had a pump for over 21 years and it worked I always had some pain but it wasn’t like it is now it’s like the last 21 years never happened I am waiting to see a new doctor and hope that he will get things back the way they were the sixth can’t get here fast enough for me but if you are having most of your symptoms with L5 L4 then a pump may help you like it did me the test is not very hard you would be surprised at what it does thank you for taking to me it’s not easy to keep myself on track with all this pain going through my legs and back but maybe I could help someone else a little I hope that you find what really works for you. This is the scar from where they keep replacing my pump every five to six years

REPLY

@tacitsentinel I'm sorry you are going through these spine issues. I am a Mayo spine surgery patient and I wanted to make you aware of some things in your post that caught my attention.

Because you had resolution of your bladder/bowel issues with a spinal epidural injection, those should be investigated as possibly being spine related. Those issues can be caused by cervical spinal cord compression. If you have not had MRI imaging of your complete spine, you wouldn't be able to rule that out as a secondary problem or know if it is related to your recent injury. The injection works by reducing inflammation and takes pressure off the injured area temporarily, and this can be considered as a diagnostic procedure. I did have issues emptying my bladder because of cervical spinal cord compression at C5/C6. You could also have spinal cord compression at the lower end of your spine too. The symptoms of cord compression are harder to pin point because when the whole spinal cord is compressed, you don't know specifically what part of it is affected. The dermatome map is very specific for nerve issues that arise from the nerve roots between the vertebrae. When you have a collapsing disc, that space between the vertebrae (the foramen) gets smaller and if is is also affected by inflammation, extruded disc material or bony growth, the space where the nerves exit gets compromised and can press on a nerve passing through the space.

I also had leg pain, and pain all over my body caused by cord compression in my neck. This is referred pain that is known as “funicular pain”. Here are links to medical literature and cases of funicular pain.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111492/
https://neupsykey.com/neurologic-evaluation-of-the-cervical-spine/
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-03299-x
https://www.hopkinsmedicine.org/health/conditions-and-diseases/myelopathy
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-03299-x
This is an excerpt of a Spine Health link that explains "funicular pain".

“Funicular pain is another type of spinal cord-related pain and may occur when the cord’s ascending tracts—the spinothalmic or posterior column tracts—become compressed or irritated. Funicular pain tends to present as an achy, throbbing, or cold feeling in one of the limbs, such as a leg, or in the trunk of the body. It can also feel electric shock-like and similar to radicular pain (sciatica) going down the leg. Sometimes funicular pain is experienced when the neck is flexed forward, known as Lhermitte’s phenomenon, and results in a searing pain that can travel down the spine and/or into the arms or legs.4”
https://www.spine-health.com/conditions/neck-pain/types-neck-pain
That was my experience too and it was missed by 5 surgeons who evaluated me, and none would help because they didn't understand the problem or why I has all these crazy seemingly “unrelated” symptoms. You should share this with your attorney and get another opinion with a surgeon who understands funicular pain. You can't trust medical opinions that were selected and paid for by your employer because they were hired to discredit you. You don't have to keep doing spine injections. They will not solve the problem and often are used to postpone potential surgery. Injecting steroids into the spine is not FDA approved, although many doctors do this.

The leg pain you are having can be spine related. It isn't always a nerve problem in the legs and compression anywhere along the nerve path from the spine to the leg can produce the symptoms.

I also wanted to mention the light headedness you described. That can be caused by a cervical spine problem. I did experience dizziness and vertigo when I had muscle spasms before my spine surgery. I had spinal cord compression at C5/C6 and spams that twisted or tilted the vertebrae and caused dizziness and headaches. There are arteries that pass through the sides of the cervical vertebrae on their way to the brain, and if you stretch these or kink them when vertebrae get twisted or tilted and it stays that way, it alters the blood flow to the brain. The spasms also effectively made the spinal canal smaller om my compressed spinal cord and caused issues with an uneven gait and difficulty emptying my bladder.

Since your case is complicated by the referred pain, you need a surgeon who understands funicular pain. I suggest using the medical literature and saying you think your case might be like this and ask the doctor. You will find out if they understand it by dong this. A spinal deformity expert would be a good expert for another opinion. You should search for the best surgeon you can find right now for another opinion so you will be ready with a good surgeon on your case if you proceed to surgery. Don't just settle for one opinion because it took so long to get there. It's a big decision and there may be different surgical approaches and you would need to understand your choices.

I did have a spinal deformity neurosurgery expert for my surgeon who was also trained in orthopedic spine. If you have any instability or slipping of vertebrae over each other at your injured lumbar area, you would need this type of surgeon. Here is a patient story like that from my surgeon and also my story. Let me know if I can offer more assistance, and please check back so we know how you are doing.
https://sharing.mayoclinic.org/2017/07/26/spinal-surgery-saves-teen-swimmers-mobility/
https://sharing.mayoclinic.org/2019/01/09/using-the-art-of-medicine-to-overcome-fear-of-surgery/

REPLY
@jenniferhunter

@tacitsentinel I'm sorry you are going through these spine issues. I am a Mayo spine surgery patient and I wanted to make you aware of some things in your post that caught my attention.

Because you had resolution of your bladder/bowel issues with a spinal epidural injection, those should be investigated as possibly being spine related. Those issues can be caused by cervical spinal cord compression. If you have not had MRI imaging of your complete spine, you wouldn't be able to rule that out as a secondary problem or know if it is related to your recent injury. The injection works by reducing inflammation and takes pressure off the injured area temporarily, and this can be considered as a diagnostic procedure. I did have issues emptying my bladder because of cervical spinal cord compression at C5/C6. You could also have spinal cord compression at the lower end of your spine too. The symptoms of cord compression are harder to pin point because when the whole spinal cord is compressed, you don't know specifically what part of it is affected. The dermatome map is very specific for nerve issues that arise from the nerve roots between the vertebrae. When you have a collapsing disc, that space between the vertebrae (the foramen) gets smaller and if is is also affected by inflammation, extruded disc material or bony growth, the space where the nerves exit gets compromised and can press on a nerve passing through the space.

I also had leg pain, and pain all over my body caused by cord compression in my neck. This is referred pain that is known as “funicular pain”. Here are links to medical literature and cases of funicular pain.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111492/
https://neupsykey.com/neurologic-evaluation-of-the-cervical-spine/
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-03299-x
https://www.hopkinsmedicine.org/health/conditions-and-diseases/myelopathy
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-03299-x
This is an excerpt of a Spine Health link that explains "funicular pain".

“Funicular pain is another type of spinal cord-related pain and may occur when the cord’s ascending tracts—the spinothalmic or posterior column tracts—become compressed or irritated. Funicular pain tends to present as an achy, throbbing, or cold feeling in one of the limbs, such as a leg, or in the trunk of the body. It can also feel electric shock-like and similar to radicular pain (sciatica) going down the leg. Sometimes funicular pain is experienced when the neck is flexed forward, known as Lhermitte’s phenomenon, and results in a searing pain that can travel down the spine and/or into the arms or legs.4”
https://www.spine-health.com/conditions/neck-pain/types-neck-pain
That was my experience too and it was missed by 5 surgeons who evaluated me, and none would help because they didn't understand the problem or why I has all these crazy seemingly “unrelated” symptoms. You should share this with your attorney and get another opinion with a surgeon who understands funicular pain. You can't trust medical opinions that were selected and paid for by your employer because they were hired to discredit you. You don't have to keep doing spine injections. They will not solve the problem and often are used to postpone potential surgery. Injecting steroids into the spine is not FDA approved, although many doctors do this.

The leg pain you are having can be spine related. It isn't always a nerve problem in the legs and compression anywhere along the nerve path from the spine to the leg can produce the symptoms.

I also wanted to mention the light headedness you described. That can be caused by a cervical spine problem. I did experience dizziness and vertigo when I had muscle spasms before my spine surgery. I had spinal cord compression at C5/C6 and spams that twisted or tilted the vertebrae and caused dizziness and headaches. There are arteries that pass through the sides of the cervical vertebrae on their way to the brain, and if you stretch these or kink them when vertebrae get twisted or tilted and it stays that way, it alters the blood flow to the brain. The spasms also effectively made the spinal canal smaller om my compressed spinal cord and caused issues with an uneven gait and difficulty emptying my bladder.

Since your case is complicated by the referred pain, you need a surgeon who understands funicular pain. I suggest using the medical literature and saying you think your case might be like this and ask the doctor. You will find out if they understand it by dong this. A spinal deformity expert would be a good expert for another opinion. You should search for the best surgeon you can find right now for another opinion so you will be ready with a good surgeon on your case if you proceed to surgery. Don't just settle for one opinion because it took so long to get there. It's a big decision and there may be different surgical approaches and you would need to understand your choices.

I did have a spinal deformity neurosurgery expert for my surgeon who was also trained in orthopedic spine. If you have any instability or slipping of vertebrae over each other at your injured lumbar area, you would need this type of surgeon. Here is a patient story like that from my surgeon and also my story. Let me know if I can offer more assistance, and please check back so we know how you are doing.
https://sharing.mayoclinic.org/2017/07/26/spinal-surgery-saves-teen-swimmers-mobility/
https://sharing.mayoclinic.org/2019/01/09/using-the-art-of-medicine-to-overcome-fear-of-surgery/

Jump to this post

I wish I could get into mayo clinic. I tried but they would not let me come. Shattered my L4 3 yrs ago and have had neck fusion about 6 yrs before that. Neck is going bad now and back and leg pain. Bladder problems. Saw a new ortho Dr. He said he wouldn't touch my back now to muck wrong. Only way to treat pain is through injections. Epidural steroid, Si joint, and My RF'S.

REPLY
@suerc

I wish I could get into mayo clinic. I tried but they would not let me come. Shattered my L4 3 yrs ago and have had neck fusion about 6 yrs before that. Neck is going bad now and back and leg pain. Bladder problems. Saw a new ortho Dr. He said he wouldn't touch my back now to muck wrong. Only way to treat pain is through injections. Epidural steroid, Si joint, and My RF'S.

Jump to this post

@suerc I am so sorry you were denied coming to Mayo. Was that a long time ago? What department did you apply to? Has your spine status changed since then?

I think you should seek other opinions. Surgeons are often reluctant to operate on cases that they think may not be successful, and that is also determined by the skill of the surgeon, and you might get a different opinion from a surgeon who routinely takes difficult cases. I ran into that in the 2 years before I came to Mayo because surgeons convinced themselves that I had problems they could not fix. Coming to Mayo made all the difference for me.

If this is something you wanted to try again and ask for a review of your imaging, I can try to help. I don't work for Mayo, but I got into Mayo after 5 local surgeons refused to help me over a period of 2 years of trying. Can you share more details about your condition? Would your insurance cover Mayo if you were accepted?

REPLY

Hi Jennifer. Not sure what to do. Not looking forward to back surgery at all. Overall I am doing well I would think. I have a nasty low back pain and pain going down my rt leg to knee. Pain Dr has been ordering RF'S every 6 mo. Epidural steroids into my L4 and SI joint injections. But still leaves me with some pain. Not as much but some. By the end of the day my tailbone is so sore to sit on. Also I had spinal stenosis in my neck about 8 yrs ago and the levels below are going bad.when i first shattered my L4 in a boating accident I saw a Dr while in the hospital for 4 days,then was referred to there neurological dept. Same that did neck surgery. When I got out the office for my apts would never let me see a Dr. Only a P.A. even though I asked. 5 months after I called the director and she was furious. She was my neck Dr. She got me in with on of the back Dr. Did Ct scans as I have a neurostimulator. I ALSO have RSD in both legs. This Dr recommended I have a 4 level fusion front and back as soon as possible. I think because they didn't get me in to see a Dr sooner. I told her my concerns with my RSD she said I'd would not bother it. I am not that comfortable. I wanted to look into less invasive if I needed surgery. My primary Dr and neurologist kept pushing. So because I can go to other Dr on my plan, my Dr that diagnosed my RSD sent me to another Back specialist . He gave me recommendations but didn't think I needed surgery yet. So he basically said my back was healed and said if I need anything down the line to let him know. So needless to say for the past 3 yrs to the date July 7th. I have been limping thru. Last summer I got out of bed one day and I could not even stand on my Rt leg. Low back and leg hurt so bad. To stand to go to the bathroom I had to take dilauded and ketamine . Was able to do a MRI because of a new stimulator implant. Between pain Dr and pain clinic they decided to do 1 SI joint injection and I think we did 2 epidural. Pain was gone for awhile but has come back. Not to the point where I can't walk. But it hurts. I was referred to a ortho back Dr who has been known to be very good. He does noninvasive and open back surgery. I guess at that time I was not looking for back surgery. Just answers. He said my leg and back hurt and go numb because in the boating accident I compressed my spine so the disc's are all squished together and I need to keep getting epidurals. In those to shrink them. He also said if I was his mother he would not recommend surgery. There is so much going on they could make it worse. I sent my records to mayo after my 1st 2 Dr and Mayo said they could not do anything more than my Dr here could. So I dont know what to do. I just sit here getting epidural after epidural and SI joint injections. And RF'S. And still always have some sort of leg pain. And tailbone pain.

REPLY
@suerc

Hi Jennifer. Not sure what to do. Not looking forward to back surgery at all. Overall I am doing well I would think. I have a nasty low back pain and pain going down my rt leg to knee. Pain Dr has been ordering RF'S every 6 mo. Epidural steroids into my L4 and SI joint injections. But still leaves me with some pain. Not as much but some. By the end of the day my tailbone is so sore to sit on. Also I had spinal stenosis in my neck about 8 yrs ago and the levels below are going bad.when i first shattered my L4 in a boating accident I saw a Dr while in the hospital for 4 days,then was referred to there neurological dept. Same that did neck surgery. When I got out the office for my apts would never let me see a Dr. Only a P.A. even though I asked. 5 months after I called the director and she was furious. She was my neck Dr. She got me in with on of the back Dr. Did Ct scans as I have a neurostimulator. I ALSO have RSD in both legs. This Dr recommended I have a 4 level fusion front and back as soon as possible. I think because they didn't get me in to see a Dr sooner. I told her my concerns with my RSD she said I'd would not bother it. I am not that comfortable. I wanted to look into less invasive if I needed surgery. My primary Dr and neurologist kept pushing. So because I can go to other Dr on my plan, my Dr that diagnosed my RSD sent me to another Back specialist . He gave me recommendations but didn't think I needed surgery yet. So he basically said my back was healed and said if I need anything down the line to let him know. So needless to say for the past 3 yrs to the date July 7th. I have been limping thru. Last summer I got out of bed one day and I could not even stand on my Rt leg. Low back and leg hurt so bad. To stand to go to the bathroom I had to take dilauded and ketamine . Was able to do a MRI because of a new stimulator implant. Between pain Dr and pain clinic they decided to do 1 SI joint injection and I think we did 2 epidural. Pain was gone for awhile but has come back. Not to the point where I can't walk. But it hurts. I was referred to a ortho back Dr who has been known to be very good. He does noninvasive and open back surgery. I guess at that time I was not looking for back surgery. Just answers. He said my leg and back hurt and go numb because in the boating accident I compressed my spine so the disc's are all squished together and I need to keep getting epidurals. In those to shrink them. He also said if I was his mother he would not recommend surgery. There is so much going on they could make it worse. I sent my records to mayo after my 1st 2 Dr and Mayo said they could not do anything more than my Dr here could. So I dont know what to do. I just sit here getting epidural after epidural and SI joint injections. And RF'S. And still always have some sort of leg pain. And tailbone pain.

Jump to this post

Jennifer if I could find a excellent Dr at mayo who does less invasive surgery that could give me a good opion I would checl out all my options

REPLY
@suerc

Jennifer if I could find a excellent Dr at mayo who does less invasive surgery that could give me a good opion I would checl out all my options

Jump to this post

@suerc I just found your post. I also want to let you know how to tag someone. To tag me, you would type @jenniferhunter in your post which would send me an e mail, so I would see it. I'm sorry I missed your earlier post. I know you have been through a lot.

If a surgeon was willing to help you, would you consider surgery? I know less invasive surgery sounds better, but also consider that the surgeon needs to be able to clearly see the area they are operating on, and sometimes minimally invasive surgery is not appropriate for the procedure that is needed. For a consult, you need a surgeon with advanced training and experience, and there are probably a lot of surgeons who don't want to operate on a case like yours for fear of failure. I'm not saying that to discourage you, but surgeons often cherry pick their cases so they will create higher success statistics for themselves.

If you do want to consider a consult at Mayo, first check that your health insurance is in network for Mayo.
If you would like get a second opinion from Mayo Clinic, you can find the contact information for the Minnesota, Arizona and Florida campuses here http://mayocl.in/1mtmR63.

When I originally contacted Mayo on their website, I received a call back form the neurosurgery department, and I requested that my records be sent in for review specifically to Dr. Jeremy Fogelson. The record review did not cost anything, and he accepted me as a patient. I also wrote him a letter that explained my symptoms and prior diagnosis from other surgeons, and also what they were missing. I had found medical research with a case like mine, and sent that in with my request. To make a request for review, you will need copies of all of your imaging and reports.
https://www.mayoclinic.org/biographies/fogelson-jeremy-l-m-d/bio-20055624
(There is also an appointment number listed on his profile if you prefer to call.)
https://sharing.mayoclinic.org/2019/01/09/using-the-art-of-medicine-to-overcome-fear-of-surgery/
https://sharing.mayoclinic.org/2017/07/26/spinal-surgery-saves-teen-swimmers-mobility/
Does this sound like a plan for you? Have I answered your questions?

REPLY
@suerc

Jennifer if I could find a excellent Dr at mayo who does less invasive surgery that could give me a good opion I would checl out all my options

Jump to this post

@jenniferhunter if I could find a Dr at Mayo that could give me a good option with all I have going on I would consider it

REPLY

You should also look at PT for your back issues before considering surgery. If you can find an osteopathic PT or one with that experience, it is better than the general PT offices. I have a hip that has bursitis and, finally, found that the combination of the shot to eliminate inflammation and then PT to strengthen muscles and improve flexibility was the trick. I have pirformis syndrome, so the stretches manage it very well, along with sciatica. I do have degeneration in my spine, but no pain there. I haven't had to go back for a shot in a couple of years.

REPLY
@marye2

You should also look at PT for your back issues before considering surgery. If you can find an osteopathic PT or one with that experience, it is better than the general PT offices. I have a hip that has bursitis and, finally, found that the combination of the shot to eliminate inflammation and then PT to strengthen muscles and improve flexibility was the trick. I have pirformis syndrome, so the stretches manage it very well, along with sciatica. I do have degeneration in my spine, but no pain there. I haven't had to go back for a shot in a couple of years.

Jump to this post

I have had about 10 yrs of PT due to RSD,Broken back, spinal stenosis. Ect…

REPLY
Please sign in or register to post a reply.