Argh, my nucleus pulposus

March 12, 2009 3:42 PM

How does a ruptured disk benefit from an epidural?

I suffered a ruptured disc at the L5-S1 last week, and I've been talking to my doctors and a neurosurgeon about treatment options. I understand how surgery works, but how do non-surgical options repair the damage?

I know that steroids help by reducing swelling, but it seems like a short term treatment of the symptom, rather than addressing the real problem. If the disc is ruptured, though, how will steroids provide long-term benefit? It seems like the pulposus would essentially just be drawn back into the disc, but not addressing the rupture.

posted by boo_radley to health & fitness (12 comments total)

I had a ruptured disc at L5-S1 last summer. I was told that they like to try the steroid injection as a more conservative treatment before surgery. They had a very hard time getting the needle to the right spot for me and I didn't get any relief from it. But, they said sometimes the steroids will reduce the inflammation enough that things will calm down and the disc material will be reabsorbed. I did end up having a discectomy and had good results.
posted by sulaine at 3:54 PM on March 12

As I understand it, something like a caudal epidural steroid injection is a pain management technique. It does not fix the ruptured disk.

I had a suit following one of these, and this is what I recall. Basically, the process would go something like this: an IV will be placed in your forearm while you are in the prone position. You will be monitored with with EKG, blood pressure cuff, and pulse oximetry. You would be put under conscious sedation with something like Versed and Fentanyl. Probably a nasal cannula would be placed to maintain appropriate oxygen saturation. Once under sedation, the caudal canal would be anesthetized with Lidocaine. The epidural will be inserted under fluoroscopic guidance in the epidural space. A dye will be injected to see how far it goes. The caudal canal will be injected with Marcaine with Celeston. The epidural needle is then removed and hopefully completely intact.

The whole point of this being to provide symptomatic pain relief for the injured back, not to heal it.
posted by dios at 3:56 PM on March 12

Because sulaine has had it done, she probably can tell you a lot more about it then I can!
posted by dios at 3:58 PM on March 12

You are not put under general anesthesia for the epidural. You do get an IV and some sort of sedative. They numb the lower back with local anesthesia, then they insert the needle and use x-rays to determine when the needle is the correct spot to inject the steroids. The whole thing from walking into the waiting room to leaving was maybe 1.5 hours.
posted by sulaine at 4:05 PM on March 12

Thanks for the details and descriptions, I appreciate them. sulaine, was the epidural described as purely palliative or did your doctor recommend it as a cure for your back injury?
posted by boo_radley at 4:16 PM on March 12

I had this procedure a couple of years ago. I had it done twice. The doctors recommended three times. I got discouraged when after two treatments two months in a row I was still in pain and didn't go back for the third. But then, a month after the second treatment I realized I wasn't in pain and my left leg and foot were no longer numb. Two years later I am occasionally stiff but other than that am pain free. I hope it works for you too, that is a miserable feeling to have that constant pain.
posted by meeshell at 5:18 PM on March 12

My doctor recommended it as a cure. And I have heard numerous stories of people that have had disc issues who were helped/cured by the steroid injections. My disc was totally ruptured, with the disc material mostly squished out and all in the spinal column. I had severe pain in my back, butt, legs and severe numbness in my foot and calf. The doc that did my injection said that she had a hard time even guiding the needle into the right spot. They had to start all over twice. I gave it one full week after the injection then I started calling everyday saying I had had no change. Feel free to memail if you want more info/thoughts.
posted by sulaine at 6:00 PM on March 12

I have had three back operations at the L4-L5 level with the third being a fusion. Along the way I had two epidurals. My expectation was that it was for both pain management and a lesser component of potential long-term relief. Mine was done by a doctor who specializes in pain management if that is any indication. My surgeon did not do the epidurals (his partner did). Just like a birthing mother gets an epidural to block the pain during childbirth. Depending on what is pushing on the nerve, it may reduce the inflamation enough to be a long term "cure".

My first operation, done when I was 15 lasted 25 years. I played ice hockey, basketball, softball and whatever I wanted to do after a recovery period. The second one lasted only 3 years. The fusion has been awesome for over 5 years. No residual issues.

My opinion is to heal with steel. If indicated, get the operation. I do not see how an epidural will do anything other than delay the operation. YMMV
posted by JohnnyGunn at 7:27 PM on March 12

Epidural steroid injections reduce inflammation. This is good for pain relief, but one other thing that reducing inflammation can to is reduce the local pressure in the tissues surrounding the injury and allow greater fluid exchange within the damaged tissue. To me that's a little paradoxical, in that one of the things inflammation is supposed to do is increase blood flow to an injury. But if there is too much inflammation, the fluid exchange can't happen, the oxygen and other goodies don't flow freely, and healing is retarded. Or in the worst case, like in extremities, you get compartment syndrome, ischemia, dot dot dot. Way too much very not good.

I'm saying this as someone with a traumatically ruptured L4/5 disk that left me no feeling in my great toe, half of the sole of my foot, and a stretch up the outside of my shin. A year went by before I could seek medical help ($$). Eventually started 2 months of physical therapy, and things were getting better mobility-wise. But within about a month after the epidural in month 4, the numbness stopped and the feeling came back to the numb areas in my foot. That to me says the steroids help heal, not just relieve pain.

Now that I think about it, I tore the meniscus in my knee a few years back, and the only thing my doctor (really good, well-respected ortho in SF) prescribed was 16 Advil a day for 4 weeks. I was all better in week 5. Once again, I see these things as evidence that steroids are used for potential medical effect as well as palliative.

As for the procedure, you may be presented the option of local or general anesthesia. My doc said that he preferred that his patients get the general, because that improves his control over precise needle positioning because the lights are out - the patient's not gonna move at all. I hate generals, so I went local, it all went fine, easy to go home, and got to ask for a doggie bag with any leftover Versed after it was over.
posted by buzzv at 8:54 PM on March 12

[I'm an internist.] An ESI is done to reduce inflammation in the nerve root that is being compressed by the herniated disc (nucleus pulposis). It doesn't treat the disc per se, and in my community is only done if the disc is compressing the nerve root. An MRI report will usually describe this as "foraminal narrowing", where the foramen is the gap between the bones where the nerve exits.

As a rule of thumb for herniated disc pain, the pain resolves in 1/3 of people by 6 weeks, and in 2/3 by 6 months.
posted by neuron at 9:03 PM on March 12

I have severe herniation at L5-S1, L4-L5 and mild herniation at L3-L4. It was causing nerve impingement and sciatic-nerve issues relating to strength in my hamstrings, flexibility and severe pain in my hip.

As far as the MRI images show, there is no rupture. As part of the "conservative" approach they began with easing up on athletic activity and a course of different kinds/strengths of anti-inflammatories. I'm very active in cardio and weight lifting with many activities that weren't painful during, but definitely exacerbated (and possibly caused) my condition. That didn't really help so they decided to try ESI. Now a few weeks after the first ESI they decided to forgo the planned second/third treatments because I responded so well.

I'm into physiotherapy to strengthen front/rear core muscles (lumbar stabilizers) and to learn about ways to restore my previous level of activity without reinjuring. I feel 1000x better but it's been slow to get back to anything other than elliptical/swimming.

Basically the ESI breaks a feedback cycle where inflammation forces the nerve to rub against something that irritates it. This irritation causes inflammation and so forth. When the nerve is inflamed (some speculate this can be caused even by the fluid within the disc, if there is a rupture) it causes all kinds of pain and causes more inflammation. Sometimes NSAIDs are enough. Sometimes not. In my case the ESI made me worse for 2-3 days (as expected) because the additional fluid caused further impingement. Once the steroids kicked in I saw dramatic improvement in muscle function, pain and numbness.

My doctors (a GP, an orthopedist and two anesthesiologists at the pain clinic where I got my ESI) gave me stats that indicate there is little correlation between disc condition and pain. Plenty of athletes have crappy-looking discs and have no pain. Plenty of people have picture-perfect discs (whatever that means) and have chronic issues. There is a lot of individual variation in what makes herniated discs problematic and to what degree your symptoms will impair your life.

Best of luck.
posted by KevCed at 10:59 AM on March 13

A rather unusual update. I woke up this morning, and there was really little pain in my back and leg, perhaps a 2-3 on the scale. I can ambulate around without pain! I reported to my neuro's office, and they started me on a steroid blast, which may obviate the ESI.
posted by boo_radley at 10:31 PM on March 13