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Hi Dr Saghafi, Last nine months, I am having pain

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Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 828 Questions

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Posted on Sat, 2 Feb 2019 in General Health
Question: Hi Dr Saghafi,
Last nine months, I am having pain in my right butt , ham string and calf. MRI showed moderate central canal stenosis at the L4-L5 level due to a new small broad central disc protrusion and moderate to severe bilateral facet hypertrophy. I tried two epidural injections - one at L4 L5 and one at L5 S1 plus L4 L5. No improvement. I am scheduled for early March for EMG/NCV test. I am thinking of a cortisone shot for piriformis syndrome next week.
1) What are your thoughts?
2)Are there any more risk with this injection vs epidural I took?
3)I am taking 5 hour flight 3 days after the injection. Is that OK ?
4) My spine doctor says he does these injections also. Is that normal?
Thanks.
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Follow up: Dr. Dariush Saghafi 0 minute later
Hi Dr Saghafi,
Last nine months, I am having pain in my right butt , ham string and calf. MRI showed moderate central canal stenosis at the L4-L5 level due to a new small broad central disc protrusion and moderate to severe bilateral facet hypertrophy. I tried two epidural injections - one at L4 L5 and one at L5 S1 plus L4 L5. No improvement. I am scheduled for early March for EMG/NCV test. I am thinking of a cortisone shot for piriformis syndrome next week.
1) What are your thoughts?
2)Are there any more risk with this injection vs epidural I took?
3)I am taking 5 hour flight 3 days after the injection. Is that OK ?
4) My spine doctor says he does these injections also. Is that normal?
Thanks.
default
Follow up: Dr. Dariush Saghafi 56 minutes later
One more information. My spine doctor says he will do this injection with ultra sound guidance. Is that the best way?
default
Follow up: Dr. Dariush Saghafi 0 minute later
One more information. My spine doctor says he will do this injection with ultra sound guidance. Is that the best way?
doctor
Answered by Dr. Dariush Saghafi 20 hours later
Brief Answer:
Buttock pain

Detailed Answer:
Good morning and welcome back to the forum. I've reviewed your past and present questions of both myself and colleagues and wish to thank you once again as always for another opportunity to clarify information and opinions for you on your condition.

I understand you have gone ahead and done the epidural shots which have not given any relief to the buttock pain you are experiencing on the right side that radiates downward into the leg. I also understand there is a small broad central disc protrusion with moderate to severe bilateral facet hypertrophy (degenerative arthritic changes). You are considering a cortisone shot for pain relief for the diagnosis of piriformis syndrome.

1. What are your thoughts?

>>> As you'll recall from our last discussion I believe that chemical injection with steroids is appropriate as a stop gap measure when pain and discomfort are so intense that normal activities of daily living are interfered with and quality of life begins to deteriorate. And so to that extent shots are good. That being said, I also believe there is a very fine line between recognizing exactly when this point occurs and when more conservative approaches still have a chance to confer relief and should be tried so that external chemical shots (cortisone as an example) do not come into direct tissue contact which can cause problems if done too frequently. The problem in this latter statement is that nobody quite knows what "too frequently" means, however, in my opinion the use of injections in the form of cortisone/marcaine or epidurals, or facet injections, etc. is a slippery slope which both doctors and patients can tumble on. And so my overall thought is that injections should be reserved for situations where nothing else seems to be helping and a person's quality of life and functionality are decreasing without any benefit to any of the other regimens being tried (i.e. exercise, NSAID's, massotherapy, stretching exercises, TENS, IFC).

2) Are there any more risk with this injection vs epidural I took?

>>>> I believe the cortisone injection is technically a much easier procedure to perform and to some extent is likely more comfortable to most patients since it is given into the belly of a muscle or into a region of the body that is different from "penetrating the back" from behind and going into the spinal canal region where more points of painful contact on entry exist. Otherwise, risks of chemicals that are used is going to be roughly the same. As explained above I'm not entirely keen on using steroid injections in general due to their deleterious effects that occur as a result of DIRECT TISSUE CONTACT. And although it's not exactly known what all the toxicities are associated with these injections the vehicles used to prepare and mix these shots can cause weakening and laxity (if done to excess) of tendons, ligaments, and cartilage which then, can feed into a viscious cycle of even more pain to increased mechanical forces resulting in an area that may have compromised connective tissue tensile strength. Again, I emphasize that your particular case is not to that level but there's that SLIPPERY SLOPE.

3)I am taking 5 hour flight 3 days after the injection. Is that OK ?

>>>> Not only is that OK...but I wish you'd take me with you if you're going somewhere warm and comfortable! LOL! I think it's fine to travel after the injection since the whole purpose to getting these treatments and procedures is so you can live a normally balanced life without terrible pain. It's a good test of fire so to speak as well to help you decide as to how much value the injection may have for you. Just as you discovered that the 2 epidural injections didn't really give you the relief you were looking for so too may you wish to gauge the steroid shot. Some people get marvelous relief from the procedure but there are many instanceds where the shot does not work but in my opinion, that's because the ROOT OF THE PROBLEM has not been addressed and so the "bandaid" just doesn't turn out to be big enough or robust enough for the amount of pathology involved.

4) My spine doctor says he does these injections also. Is that normal?

>>> If by "normal" you are asking whether this type of procedure is part of the typical arsenal of tools a spine doctor has to treat patients then, I would agree that he SHOULD know and be comfortable with these shots....so yes, I think it is "normal" for him to tell you that he is capable of doing these shots.

5. My spine doctor says he will do this injection with ultrasound guidance. Is that the best way?

>>>> Well, here we may get into a bit of a difference of opinion professionally because although doing image guided deposition of injections certainly SOUNDS much better than blind site application....in MY OPINION...for what you're talking about (steroid shot into piriformis muscle?" I'd expect him to be able to do it without the added cost and expense of a piece of equipment. But again, this is a tricky question to answer because it really depends on the skill and knowledge of the injector as to whether or not using U/S vs. blind is really superior. There is a study that looked at the comparison between blind injection of steroids for carpal tunnel syndrome vs. U/S guided deposition and the results were actually indistinct for long term results between the 2 techniques. There may have been a slight advantage of U/S guidance in the short term effect of pain relief compared to blind placement....but in the long term the overall reduction in pain and improvement in function were the same with and without the added technology.

"Comparing the effectiveness of ultrasound-guided versus blind steroid injection in the treatment of severe carpal tunnel syndrome"

https://www.ncbi.nlm.nih.gov/pubmed/0000

You may also find the following article interessting in its opinions though it is lay and not medical journal based...but it raises some good points.

The Pros and Cons of Ultrasound-Guided Injections
The procedure offers greater accuracy but still draws debate

https://www.verywellhealth.com/ultrasound-guided-injections-0000


So I suppose under the circumstances where you are being injected by someone else...the "best way" is whichever way the operator feels they NEED TO go that gets the best job done for the patient with the least cost and discomfort/risk. In this case, I believe the piriformis muscle is a big enough target to find anatomically (especially for a spine specialist) that if it were me, I feel confident I could easily get a cortisone shot into the RED ZONE...so to speak.

Once again, the pleasure has been mine in answering your questions this morning and as always I hope your outcomes are healthy and pain free ones! If I've provided useful information could you do me the favor of CLOSING THIS QUERY with a 5 STAR rating and positive feedback?

53 minutes total time spent reviewing, researching, and analyzing the present query.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Dariush Saghafi 0 minute later
Brief Answer:
Buttock pain

Detailed Answer:
Good morning and welcome back to the forum. I've reviewed your past and present questions of both myself and colleagues and wish to thank you once again as always for another opportunity to clarify information and opinions for you on your condition.

I understand you have gone ahead and done the epidural shots which have not given any relief to the buttock pain you are experiencing on the right side that radiates downward into the leg. I also understand there is a small broad central disc protrusion with moderate to severe bilateral facet hypertrophy (degenerative arthritic changes). You are considering a cortisone shot for pain relief for the diagnosis of piriformis syndrome.

1. What are your thoughts?

>>> As you'll recall from our last discussion I believe that chemical injection with steroids is appropriate as a stop gap measure when pain and discomfort are so intense that normal activities of daily living are interfered with and quality of life begins to deteriorate. And so to that extent shots are good. That being said, I also believe there is a very fine line between recognizing exactly when this point occurs and when more conservative approaches still have a chance to confer relief and should be tried so that external chemical shots (cortisone as an example) do not come into direct tissue contact which can cause problems if done too frequently. The problem in this latter statement is that nobody quite knows what "too frequently" means, however, in my opinion the use of injections in the form of cortisone/marcaine or epidurals, or facet injections, etc. is a slippery slope which both doctors and patients can tumble on. And so my overall thought is that injections should be reserved for situations where nothing else seems to be helping and a person's quality of life and functionality are decreasing without any benefit to any of the other regimens being tried (i.e. exercise, NSAID's, massotherapy, stretching exercises, TENS, IFC).

2) Are there any more risk with this injection vs epidural I took?

>>>> I believe the cortisone injection is technically a much easier procedure to perform and to some extent is likely more comfortable to most patients since it is given into the belly of a muscle or into a region of the body that is different from "penetrating the back" from behind and going into the spinal canal region where more points of painful contact on entry exist. Otherwise, risks of chemicals that are used is going to be roughly the same. As explained above I'm not entirely keen on using steroid injections in general due to their deleterious effects that occur as a result of DIRECT TISSUE CONTACT. And although it's not exactly known what all the toxicities are associated with these injections the vehicles used to prepare and mix these shots can cause weakening and laxity (if done to excess) of tendons, ligaments, and cartilage which then, can feed into a viscious cycle of even more pain to increased mechanical forces resulting in an area that may have compromised connective tissue tensile strength. Again, I emphasize that your particular case is not to that level but there's that SLIPPERY SLOPE.

3)I am taking 5 hour flight 3 days after the injection. Is that OK ?

>>>> Not only is that OK...but I wish you'd take me with you if you're going somewhere warm and comfortable! LOL! I think it's fine to travel after the injection since the whole purpose to getting these treatments and procedures is so you can live a normally balanced life without terrible pain. It's a good test of fire so to speak as well to help you decide as to how much value the injection may have for you. Just as you discovered that the 2 epidural injections didn't really give you the relief you were looking for so too may you wish to gauge the steroid shot. Some people get marvelous relief from the procedure but there are many instanceds where the shot does not work but in my opinion, that's because the ROOT OF THE PROBLEM has not been addressed and so the "bandaid" just doesn't turn out to be big enough or robust enough for the amount of pathology involved.

4) My spine doctor says he does these injections also. Is that normal?

>>> If by "normal" you are asking whether this type of procedure is part of the typical arsenal of tools a spine doctor has to treat patients then, I would agree that he SHOULD know and be comfortable with these shots....so yes, I think it is "normal" for him to tell you that he is capable of doing these shots.

5. My spine doctor says he will do this injection with ultrasound guidance. Is that the best way?

>>>> Well, here we may get into a bit of a difference of opinion professionally because although doing image guided deposition of injections certainly SOUNDS much better than blind site application....in MY OPINION...for what you're talking about (steroid shot into piriformis muscle?" I'd expect him to be able to do it without the added cost and expense of a piece of equipment. But again, this is a tricky question to answer because it really depends on the skill and knowledge of the injector as to whether or not using U/S vs. blind is really superior. There is a study that looked at the comparison between blind injection of steroids for carpal tunnel syndrome vs. U/S guided deposition and the results were actually indistinct for long term results between the 2 techniques. There may have been a slight advantage of U/S guidance in the short term effect of pain relief compared to blind placement....but in the long term the overall reduction in pain and improvement in function were the same with and without the added technology.

"Comparing the effectiveness of ultrasound-guided versus blind steroid injection in the treatment of severe carpal tunnel syndrome"

https://www.ncbi.nlm.nih.gov/pubmed/0000

You may also find the following article interessting in its opinions though it is lay and not medical journal based...but it raises some good points.

The Pros and Cons of Ultrasound-Guided Injections
The procedure offers greater accuracy but still draws debate

https://www.verywellhealth.com/ultrasound-guided-injections-0000


So I suppose under the circumstances where you are being injected by someone else...the "best way" is whichever way the operator feels they NEED TO go that gets the best job done for the patient with the least cost and discomfort/risk. In this case, I believe the piriformis muscle is a big enough target to find anatomically (especially for a spine specialist) that if it were me, I feel confident I could easily get a cortisone shot into the RED ZONE...so to speak.

Once again, the pleasure has been mine in answering your questions this morning and as always I hope your outcomes are healthy and pain free ones! If I've provided useful information could you do me the favor of CLOSING THIS QUERY with a 5 STAR rating and positive feedback?

53 minutes total time spent reviewing, researching, and analyzing the present query.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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The User accepted the expert's answer

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