Herniated L5/S1, sciatic pain, what should I do?
August 2, 2010 11:56 AM   Subscribe

I was rear-ended 9 months ago and now have a herniated L5/S1 with associated issues (sciatica, back pain). My doctor wants me to get an epidural injection of corticosteroids. Is this really my best option?

YANAD, but:

I was rear-ended while at a standstill by someone going 40-50 mph. This resulted in a herniated disc at L5/S1. It's apparently pressing on the nerve that goes down my left leg, giving me sciatica. Doc has also thrown around another term, spondylolisthesis, which apparently adds another layer of complication.

I have tried physical therapy and chiropractors and have been to two different orthopedists (reason was that I moved across the country 6 months ago). At this point I'm surprised that after 9 months I'm still in such bad pain. It's not as bad as it has been, but still enough to be annoying and very uncomfortable at times.

From what I have read about corticosteroids, they merely block the pain receptors so that you don't hurt anymore but don't really fix the problem.

Have you had a similar injury and had this procedure done? If so, what was your experience and would you do it again? If this doesn't work, what other options do I have?
posted by buckaroo_benzai to Health & Fitness (24 answers total) 3 users marked this as a favorite
A family member of mine got this treatment, and it led to a huge improvement. The orthopedic surgeon bluntly said that surgery simply was not advanced enough to fix the problem she was having, and that the injection --- if it was inserted correctly --- offered the most hope of relief. The big "if" was whether the injection would hit the right spot, since it was based somewhat on conjecture informed by x-rays.

It was extremely effective. Almost a year later, her symptoms are vastly improved. The experience of getting the shot was painless ... it sounds bad but isn't.
posted by jayder at 12:10 PM on August 2, 2010

A friend of mine herniated a disc recently - she lives downstairs from me, so I spent a fair amount of time hanging out, helping her get her lunch, supervising while she went on (doctor-recommended) little walks around the flat, etc.

She got the injection. Two, I think, several weeks apart, and they have done wonders. She's also done the physical therapy thing. The way it was explained to her - and she's a nurse practitioner, so she also talked to all her NP and MD colleagues - was that the shot block some of the pain, yes, but also helps reduce the inflammation. She got the first shot within a month of being diagnosed. She is back to work, is walking around normally, can sit in normal positions for normal amounts of time, etc. The only thing she can't do yet is Morris dancing, which involves a lot of jumping around. She's back to doing the less-jumpy waltzes and such.
posted by rtha at 12:24 PM on August 2, 2010

If you think you need surgery because that will 'fix the problem', trust me, you want to do everything you can to avoid surgery. It is not the first resort. It can make the problem worse instead of better. Try the injection!!
posted by treehorn+bunny at 12:27 PM on August 2, 2010

I had a herniated disk there. I waited nine months. I did shots. I ended up getting surgery. Three years later, I have permanent nerve damage. Plus scar tissue from the surgery grew in a way that caused something awful called arachnoiditis.

Back doctors of all kinds love those shots. That's how they make money. They help some people. Especially people who don't have bad problems and who don't wait a long time to get them fixed.

Having said all that, I do not think anecdotal evidence can really help you.

I am forwarding you a part of an e-mail I sent someone the other day about this issue. I think you should get a surgical evaluation, asap. Sorry if the tone seems weird. I was writing to an older person.

Me-mail me if you've got questions. I've been through it all.
At this point, I suggest getting a surgical evaluation. Not because you should get surgery or because you should push for surgery. In fact, I strongly advise against surgery unless two surgeons agree that surgery is the only way to treat your problem. If the first surgeon says you need surgery, get a second consult. You want to be dead certain before you get back surgery because the chances are good that 1) it won't work and 2) scar tissue will grow back in a way that will cause you new problems.

I say get a surgical evaluation because there are really only two interventions to treat back problems: injections and surgery. If you do need surgery, the sooner you have it done, the better your chances for recovery. And you won't waste time with the shots and physical therapy.

Surgeons aren't going to tell you that you need surgery if you don't. They get enough business from people who do need surgery, they won't try to convince people to get surgery who don't need it. They can look at your MRI and see things that doctors who treat back pain cannot immediately see. Most back doctors just read MRI reports, they don't actually examine at the MRI films like surgeons do.

Only a surgeon knows if surgery could help in your case. If a surgeon says you don't need surgery and to try injections and/or PT, then you can be confident that those methods might give you some relief.
posted by vincele at 12:28 PM on August 2, 2010

My girlfriend suffered debilitating pain from a herniated disc for quite some time, but found no relief from cortisone shots. What did work was a Microdiscectomy.
posted by mgkk at 12:30 PM on August 2, 2010

From what I have read about corticosteroids, they merely block the pain receptors so that you don't hurt anymore but don't really fix the problem.

Eh? Where'd you read that?

I have no idea if that is your best option; that's something your doctor would know. But either you misunderstood what you read or you're reading the wrong sites and getting bad info because that's not what corticosteroids do. That's actually a better simplified description of what narcotic painkillers like codeine do.

Corticosteroids are very strong anti inflammatories. Some of them are extremely strong anti inflammatories. They help by relieving inflammation.
posted by Justinian at 12:31 PM on August 2, 2010

Justinian is right-- they are anti-inflammatories. They reduce swelling and can make the bulge disappear in some people.

If you've had sciatica for nine months, you need to get a second opinion from a surgeon. Surgery can make a mess of things, but so can waiting when you need surgery.
posted by vincele at 12:35 PM on August 2, 2010

Thanks for the information so far. I have a consult tomorrow with the doctor who is scheduled to do the injection. I'm still not sure if I want to do it, it seems like a temporary fix and while it would be nice to possibly be pain-free for a while I would rather do something that will fix or manage the problem long term (not necessarily surgery). My main concern is that I don't want it to get worse, which thankfully, it hasn't... but I do enjoy strenuous physical activity and want to make sure I'm not messing myself up further... it would be nice to get back to light weight training and rock climbing one day...

My primary doctor is an orthopedic surgeon, and he is the one who is recommending the injection. I will try to find another orthopedic surgeon to get a second opinion. I find it curious (worrying?) that he is basing all of this basically on the MRI, x-ray, and bone scan reports that another doctor wrote up. He himself has never seen the actual images (they were done under the care of another doctor on the east coast, and now I'm in California... I told him I could get him copies of the images, but he said that was not necessary... seems odd to not go to the direct evidence, but I'm not a doctor).
posted by buckaroo_benzai at 12:53 PM on August 2, 2010

I had L5S1 surgery in 1999. I remember coming to and immediately noticing no pain -- and it wasn't a "hey I feel it but I don't care" thing. I had pain from the incision, from the catheter, from the breathing tube stuff, but I didn't have that shearing pain from the disc. Recuperation was uneventful and on schedule according to what my doctor said was reasonable (I was out of work for 6 weeks, then back part time for 4 weeks.) I did physical therapy 3 days a week until I went back to work, then 1 - 2 days a week for maybe another 4 weeks. Today I'll get a twinge once in a while, but it has not affected my ability to do what I want in anyway. Well, except for that one time when it acted up real bad the night before my wedding. But overall I'm really happy with the decision I made to have surgery immediately.

My dearest friend had the exact same surgery in 1998. It happened after trying the shot thing 2 or 3 times. She did not receive lasting or strong enough relief for her symptoms, and combined with a long commute, she ended up in an emergency operation situation over the holidays. She's had little to no problems since the surgery (including a no problem pregnancy & epidural), but she has always said she wish she'd skipped the shots.
posted by macadamiaranch at 1:13 PM on August 2, 2010

I was in your accident 53 years ago. Let me say one thing right up front. There is no cure. There is only relief from the side-effects of the damage. I have opted out of surgery for all of these years because it also comes with side-effects. A really good Ortho will always suggest conservative treatment first. Corticosteroid injections are not always helpful and are not always painless. That said, they are a very good first option for treatment. IANAD, but it is my opinion that, since it has been nine months, any damage that could have been fixed by surgery has already happened and is not going to get significantly worse. Start with conservative treatment and move on as necessary.

While injections are great for relieving the inflammation, they can involve pain for the first day or two afterward. Ask for pain medication and plan to be on your back for a day or two, just in case.

I have seven blown discs. I find great relief by using an inversion table. I do not (and would not recommend that you) extend it past 45 degrees beyond level. At that point I get great relief and can feel the difference for several days at a time. This is something to discuss with your Ortho before trying it out.
posted by Old Geezer at 1:20 PM on August 2, 2010

I guess my main concern is: are the injections putting me on a long road to nowhere so that I'll have to keep getting them for the rest of my life, or is there a chance that 1 or 2 of them will fix the issue? (I will definitely ask the doc tomorrow, but it helps to know what other people's experiences have been... I'm also a bit skeptical of most MDs)

Sorry if I seem so scatterbrained. This is scaring the shit out of me. I almost fainted in my cubicle earlier today just reading about the injections, and the possible side effects, etc (and I'm NOT the type of person to get queasy and faint, ever).

I am a very active person and this has all really been quite a blow to me. Right now I am at the point where it doesn't hurt too bad, and doesn't really prevent me from being able to do a lot of stuff (I went hiking 4.7 miles with 3,200 ft of gain (9.4 mi round trip) on Saturday and my back and leg pain is at the level of "constant moderate annoyance" right now).

I know it could be worse, but still... I'm confused, worried, and scared. I have never been in the hospital or had any major surgeries in my life. I think the worst medical procedure I've ever gone through is having my wisdom teeth taken out.
posted by buckaroo_benzai at 1:24 PM on August 2, 2010

Ive got L5S1 herniation and fractured cervical vert for about 10 years. Pain usually comes when I do something stupid off the couch. My best results have been from a) not sitting at a desk and b) Feldenkrais therapy. Its a bit cooky, but I swear it really works.

I'd hold off on the injections.
posted by H. Roark at 1:39 PM on August 2, 2010

I've had two of the shots, six months apart. The last one was two years ago now. The shots reduced swelling and pain. IANAD -- so this is second hand from my doctor. The reduced swelling helps allow the physical therapy to rebuild your supporting muscles without irritating the nerves. The shots are a good conservative start. If your pain progresses to numbness/tingling and weakness, that's a sign permanent nerve damage could be happening. Good luck.
posted by fhqwhgads at 1:39 PM on August 2, 2010


I posted this in a thread a few weeks ago about bursitis but it's more relevant here.

Now a 25 year old male, was a 23 year old male otherwise healthy. I suffered from escalating hip pain that I google-diagnosed as bursitis, or a repetitive stress/overuse injury. It turned out to be referred pain from sciatic nerve impingement. I had viciously herniated and burst discs at L4/L5 and L5/S1. This after an x-ray and MRI and much professional consultation with my GP and some orthopedic specialists.

The x-ray showed regular (i.e. consistent and healthy) vertebral spacing in my thoracic spine and reduced vertebral spacing between a few of the lumbar and sacral vertebrae. That's what prompted them to recommend an MRI, which I got same-day thanks to some wizardry on the part of my referring GP. The nerve impingement and disc damage was clear as day on the MRI.

The x-ray was ordered by my GP, interpreted by a radiologist and later sent for interpretation to 2 orthopedic specialists. I was glad to have specialists involved, if only because the GP's limited orthopedic knowledge made him understandably reluctant to give me quantitative information about the odds of improvement, cure, etc.

My treatment plan started conservatively, with NSAIDs and muscle relaxers. Those made sitting and lying down only marginally more comfortable. After that I went on a program of physical therapy and epidural steroid injections. I'm back to about 90% now, but that includes a daily or twice-daily stretching regimen I didn't do before. As far as I can tell the disc rupture/herniation was not the result of traumatic stress the way yours is.

I was told that in the long term, there is no discernible correlation between disc condition and back pain. Plenty of people have beat-up discs and no back pain. Other people are in constant pain and have beautiful-looking discs. Physical therapy has done wonders for me. The ESI treatments were instrumental in loosening me up enough to actually complete the PT that was assigned.

My posts are simply my own anecdotal experience with hip pain caused by a back injury. I also had occasional numbness and tingling in the toes on the side with the pain, which is something I don't think bursitis causes. Initially I wasn't sure if the numbness was related to my hip pain, or just a result of too much time outside during the cold winter.

tl;dr: ESI helped me loosen up and live day to day until PT and stretching took over and now I'm back at about 80-90%.
posted by KevCed at 1:46 PM on August 2, 2010

I had 3 ESI treatments, 2-3 months apart. Last one was more than a year ago. Things have steadily improved since the first treatment except when I get overly ambitious. Then it takes a few days of taking it easy to let the swelling in my back recede.
posted by KevCed at 1:47 PM on August 2, 2010

I think you may be scaring yourself unnecessarily over the steroid injections. Obviously no treatment for anything is risk-free. People die in awful ways from the most common of antibiotics taken for ear infections. That said, I'm not sure what it is about the injections which freaks you out. IMNSHO steroid injections aren't a big deal in the grand scheme of things.
posted by Justinian at 1:59 PM on August 2, 2010

I guess my main concern is: are the injections putting me on a long road to nowhere so that I'll have to keep getting them for the rest of my life, or is there a chance that 1 or 2 of them will fix the issue?

Have you ever taken oral steroids for back pain? It's like that, but they shoot them into the site of inflammation. Injecting them directly into the problem spot supposedly is more effective.

So they aren't putting you on a road to nowhere. They could reduce swelling, and that could allow your body to heal itself. That's what happens for a lot of people who get the shots. After a few shots, the problem corrects itself. It's not like painkillers, which just mask the pain. If you go ahead with the shots, and they don't work after a few sessions, then you should rethink your options.

The injections are the one intervention short of surgery that is on offer in the U.S., if that is where you are. The risks are minimal-- there are websites that claim otherwise but they are kind of nutty.

That's my objective opinion.

In truth, I have no love for those injections. They gave me no relief. I had something like 11 of them, and I felt like I was pressured into it by a "prestigious" but really awful hospital.

You have been in pain for a long time, and you deserve to live without pain! I hope that you can find a way to do that and relax before your appointment tomorrow.

(My saga of back problems and disgust with the back problem industry won't do anyone any good.)
posted by vincele at 2:29 PM on August 2, 2010

My primary doctor is an orthopedic surgeon, and he is the one who is recommending the injection.

Not that researching is a bad idea, but I grew up with "Never encourage a reluctant surgeon" as an axiom (and an adage). If he's like most surgeons, he's be encouraging surgery quick as a wink if he thought it was the best solution, or even an okay solution.
posted by small_ruminant at 2:51 PM on August 2, 2010

Sorry- forgot to italicize the quote.
posted by small_ruminant at 2:52 PM on August 2, 2010

Sounds like you should try the shots. At a minimum, they'll provide relief for a couple months. At best, they'll provide relief forever.

If after a couple shots and a few months, your surgeon will probably recommend surgery, but I agree that encouraging a reluctant surgeon might not be the best plan.

Personally, I went straight to the micro-discectomy because two doctors recommended it, and said that while steroids would likely provide temporary relief, looking at the MRI, both concluded they were unlikely to fix the problem long-term. Especially with a skilled surgeon, surgical fixes are much less invasive than they were even five years ago, and the odds of having bad effects from the surgery are much lower.
posted by DaveP at 3:10 PM on August 2, 2010

I have a large herniation in the same place as you do. I've had it for years.

I've also had three rounds of facet injections of steroids spread out over the last two years. The first injection completely resolved my sciatic pain but did little for my back pain. The second injection helped (in conjunction with core strengthening and continual physical therapy) with the back pain for about eight months. My last injection was almost a year ago. I've had very minimal pain since then.

The steroid injections were great. I think they helped me quite a bit but I honestly believe that my continued success is primarily because of my commitment to core stabilization, strength training as directed by my PT, and keeping my weight down.

But that was my experience and I would have them again if the need arose. Your doctor will and should warn you that everyone's experience is different and it is hard to predict the outcome. Some people respond well to the steroids and some people do not.

Good luck. I hope you find some relief.
posted by teamnap at 3:37 PM on August 2, 2010

Even if it is determined that surgery will 100% cure you with no chance of failure, insurance protocols generally require trying all the other (cheaper) options first. So, trust your doctors, get multiple opinions, and jump through the hoops until you are adequately fixed.

But we don't have rationing in the US. Not at all.
posted by gjc at 6:06 PM on August 2, 2010

You will not be on a road to nowhere. You can always elect to try something different if the shots don't work or things seem to be dragging on with them. I think you are hoping there is some other simple solution for herniated discs that you can just take a shortcut to, but there isn't, you've been doing all the right things, and the pain's still there. Sometimes your pain circuits just get so used to being activated, they just need something to stop the pain cycle (all the inflammatory mediators that cascade upon themselves) and give them time to calm down. I believe this is the current thinking in the pain world about why injections like this work (though I am not in 'the pain world' myself!)

I had a bursitis in my shoulder and got two steroid injections about 6 months apart that really helped, basically cured it, and that was about 3 years ago, I haven't needed another one since (even though I still do the things that probably gave me the bursitis in the first place). Also, I am pretty wimpy when it comes to pain, and the injection did not bother me much. Maybe you are exaggerating what it will be like in your head. Getting my wisdom teeth out was SO much worse!!
posted by treehorn+bunny at 8:46 PM on August 2, 2010

From what I have read about corticosteroids, they merely block the pain receptors so that you don't hurt anymore but don't really fix the problem.

Are you sure about that? Steroids are anti-inflammatories, which means that they work by reducing the inflammation which may be causing the problem. There is often an anesthetic front loaded in the needle (so it goes in first) which will indeed "block the pain receptors"; but the majority of the work is done by the steroid. It will probably take a while to work, and it may not help with the pain. Then again, it may work right away and solve the problem for an extended period of time. The doc who did my lumbar injections said that he had patients whom it didn't help at all, and others who got pretty much complete relief. And there was no way of knowing who would fall into which group without actually trying it. If the problem isn't inflammation pressing on the nerves, the steroid injection won't help. It's highly unlikely that it will cause any further damage, though.

Unfortunately, there's no real way of knowing what's causing the problem, short of cutting you open. Which will open a whole new can of problems, not the least of which is Major Surgery and all of the ways it can go wrong.

Other treatment options? Physical therapy to strengthen your core muscles. Yoga/Pilates for flexibility with control. Trust me, you do not want surgery as a first solution. Save it until there are no other options.
posted by jlkr at 10:15 PM on August 2, 2010

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