Why Steroid Injections Don't Help?

[energyofhope]

I have always wondered why I don't get benefit from selective nerve blocks or epidural steroid injections. At best, the results are absolutely neutral, with no reaction whatsoever. But at worst, when they've hit the problem spot head on, I go into a terrible long lasting flare-up. When the flare-up subsides, my symptoms return to the same intensity levels as before the injection. So, the injections either don't help, or make things worse, no benefit...

Has anyone else experienced the same pattern? If so, have your doctors ever given you a good explanation for this (opposite) result. It would be good to figure out if this points at a specific kind of pathology.

I suspect that something that chronically irritatates/inflames nerves is responsible, but then I've read that many people with this diagnosis get benefit from the injections, so I don't know. Any ideas?

[mmglobal]

A couple of possible reasons may be:

1. The pain is coming from somewhere else and the injectant is being applied to the wrong area.

2. The injection is being performed in the right area, but the injectant is unable to get to the inflammation site because it is blocked by scar tissue, for some reason flows elsewhere or the injection somehow 'missed'.

3. The injectant may get to the area needed and may reduce inflammation, but the pain generators are so profound that they are not significantly impacted by the injection. (like when an amputee percieves pain in an foot that no longer exists.) Permanent nerve damage causing phantom pain?

[energyofhope]

The enigma is more along the lines of a bad reaction to the steroid. (There is no such reaction to a local anasthetic of equal volume) What type of pathology results in this response?

Does steroid take a longer time to be absorbed by the body while other substances are absorbed faster? Is this responsible for extra pressure (maybe more so in the presence of a lot of scar tissue) Just a hypothesis...

Mark, can you please bring it up with the doctor community when you have a chance?

[Katie]

I've had the same reaction, unfortunately. The first couple helped a tiny bit, the rest did nothing or made things worse. All the doctor said was that it works for some and not others.

I refused to have any more, including those that would be guided by imaging. I didn't want an more steroids 'floating around' in there.

[energyofhope]

I refused to have more injections as well. I am not a masochist.

[mmglobal]

I had 8 ESI's in my lumbar spine. After 6 with one doc over several years, with (I think) 4 yeilding good results, I had another by a different doc. It made me WAY worse. When I explained what had happened to the first doc, he said, "I'll bet that he had to stop and back up, didn't he?" He was absolutely right... the needle ran into bone and he backed up and went again.

I've observerd > 50 discograms now. Some doctors are able to get the needles where they want them to go with smooth and accurate movemens. Others are herkey jerkey and bump into things, back up, do it again, and again, take the needles all the way out... try again and again. That's one reason why use of versed is popular... the patients won't remember that.

The difference from one needle jockey to the next is dramatic. Having said all this, I'm not suggesting that this relates to eOh's case. It's just another possibility for why ESI's sometimes make things worse.

Mark

[Keano16]

Another problem is that some of doctors do not use flouroscopic (or similar) guidance.

[mmglobal]

Yes, the flouro is thought to be very important. I've seen many (including doctors) who go so far as to suggest it's malpractice to do it without flouro.

The first pain doc I described had been doing injections since before flouroscopes were still made out of stone. He did the injections with me laying on my side on an exam table in his office. The billing for the ESI was an insignificant add-on to an office visit. He gently gets the needle where he wants it without flouro, I belive, with way better results than the average doc with flouro.

The doctor who caused all the pain with his less accurate technique in spite of using guidance needed to have me in a prodecure room (OR) with all the extra equipment. The ESI gets billed out as if it was surgery with facilities fees and a ton of extras. Instead of a $200 injection done as part of an office visit, it's a $3000 gotcha.

I agree flouro is better, but it doesn't make up for poor technique. Just like I'd rather have a good fusion than a poorly done ADR; a well done open discectomy than poorly done endoscopic procedure, etc... ; I'll take the old guy without flouro if he's that good. (unfortunately, as patients, we only find this by dumb luck. I don't think there is a good way to evaluate this in advance. "Are you good?" will not yield a useful reply.)

Mark

[Keano16]

The point is - find a professional and modern doctor...

Then he can do it even without a flouro

[energyofhope]

I've had almost 20 injections with 6 different (presumably very good) doctors at UCLA, UCSF, Stanford, Derby and a few other places. Three quarters of them were done with CT guidance. From my experience the results are independent of who did them and are pretty much the same (as I have described) None could explain why people like me (and they know of others like me) get negative reactions. I am very dubious that all 6 managed to hit the bone or otherwise fell short of optimum technique. Statistically, it is simply very unlikely. Interestingly, I've had neutral or positive results with oral or intravenous steroids. What I and others like me experience is a local reaction to the steroid mixture. What is different in us that makes us react like this? Scar tissue? Nerve damage? Reaction to preservatives in steroid mix? Steroid contact with the nerves? The volume effect? I think this deserves to be studied, but I don't think it is. This is the unanswered question.

[mmglobal]

Just an interesting side note. In the OR, I've seen graphic examples of why some people experience no radicular pain with profound disc herniation and exiting nerve root compression, while others experience severe pain with seemingly minor pathology. What the surgeon pointed out is something like, "here... look at this nerve. you see the way it's all clean and red. this has almost no insulating fat layer around it. this person can have a minor disc herniation that may not even be compressing the nerve root, but the chemical irritation gets right to the nerve." Then on another surgery he pointed out the exact opposite... "see the way the nerve is surrounded by an insulating layer of fat?"

[Keano16]

This can also occur when source of pain is disc itself (discogenic back pain). No nerve root compression is visible, all looks great but patients often are not capable of making a few steps!

[energyofhope]

Just got back from a P/T eval of my S/I joints. They pulled and pushed and pressed on my pelvis and twisted on it - no problem found. No problem with the hips either. Thank God, at least these parts of my body are not broken.

[Katie]

It's great that you are able to narrow it down. In regards to the steroid injections and your question about why they don't work, can you tell me if you have had odd reactions to other medications as well?

I wondered if there is that correlation with me. I cannot take many pain killers...Fentanyl, Lyrica, Oxycodin, etc. As my husband described it...they make me do the funky chicken. On the floor, almost incoherent and vomiting with the Fentanyl, and almost as bad with others.

I have put it down to the theory that red-heads metabolize drugs differently, proven in a recent study, I think.

Just a thought...even if you don't have blatantly red hair, you can have the genes for it and thus the same reactions.

[energyofhope]

Katie,

I am very sorry to hear about how your body reacts to different meds and about your allergies - this is terrible! I feel for you!

I generally don't suffer from allergies. However, my body dislikes the detergent they like to use for hospital linen - something I discovered after one of my surgeries - I broke out into hives and they said I had contact dermatitis. This is the first (and only) allergy I know about at this time - to hospital linen. This is not to say there are no others, just no others I know about at this time.

Like you, I can't tolerate Lyrica and Neurontin, but not because of an unusual reaction. I am very sensitive to the known side effects - these drugs make me into a mental retard - I lose all short term memory, have problems thinking and talking. And, these drugs don't do much for my pain anyway. With the opiods, which help me the most I must say, (Oxycodone, Hydrocodone) in high doses, I develop a very strong body-wide itch that will keep me from sleeping at night. My docs have told me this is an infrequent but well known neuro-psychiatric side effect. People who don't get high on narcotics tend to itch. I'd rather be high So, I manage this side-effect by trying not to take these meds in the evening or at night.

I agree with you that we are given one size fits all solutions in medicine, while people are very different biologically and physiologically. Subtle genetic variations play a huge difference. Medicine should be highly personalized with drugs, procedures and devices tailor made for each of us. I believe, this is the future, but it is not here yet, and I doubt I will see it in my life time.

[Katie]

Your posts are full of wisdom and foresight, and I really enjoy hearing from you. It really sucks (for lack of a better word) to be 'special', doesn't it.

[JKDE302]

Originally Posted by energyofhope

I have always wondered why I don't get benefit from selective nerve blocks or epidural steroid injections. At best, the results are absolutely neutral, with no reaction whatsoever. But at worst, when they've hit the problem spot head on, I go into a terrible long lasting flare-up. When the flare-up subsides, my symptoms return to the same intensity levels as before the injection. So, the injections either don't help, or make things worse, no benefit...

Has anyone else experienced the same pattern? If so, have your doctors ever given you a good explanation for this (opposite) result. It would be good to figure out if this points at a specific kind of pathology.

I suspect that something that chronically irritatates/inflames nerves is responsible, but then I've read that many people with this diagnosis get benefit from the injections, so I don't know. Any ideas?

That is 100% the same way i felt....

[jessmith07]

that's funny to hear that there's someone else out there that gets itchy from narcotics...I thought I was the only one!

[energyofhope]

I've always suspected there are others like me... now I know this is so for a fact. Thank you all for replying!

[dridobits]

Hi Energy and welcome, I'm not sure I met you before. I found your post interesting. I get better response from oral prednisone than injections. I am wondering if the injection doesn't get to the right place. One of the docs that's injected me has done a decent job, the other a village idiot.

You mentioned "I suspect that something that chronically irritatates/inflames nerves is responsible"....well this is true when there is a chemically sensitive disc. That's my big problem....that's why they are doing a front and back fusion on me as it's the best way to get rid of the disc completely. I hadn't heard of anything beyond that being an irritant. Chemically sensitive discs are also known as "low pressure" discs.

[energyofhope]

Yes, I agree about the disks being a possible culprit for some people. In my case though, I no longer have organic disks left - mine are Prodiscs and bone from fusion. So, I am thinking more along the lines of a possible cyst or scar tissue causing this chronic nerve irritation. It's a mystery, really...