Jeffrey R. Carlson, MD, MBA, CPE, FAAOS
I see many patients in the office who complain of lower back and leg pain. There may be several diagnoses to explain these symptoms, including bursitis, hip arthritis, tendonitis or, what most patients are concerned about, sciatic nerve pain. With these symptoms, it is important to do a thorough physical examination to guide the treatment plan. We don’t want to treat nerve pain like tendonitis, or the other way around. The treatments may be significantly different and wrong treatment may be ineffective for you, delaying your improvement and return to normal activities.
As the symptoms can be relatively similar, I sometimes use diagnostic injections to help refine the diagnosis. No, it’s not because I like giving my patients injections, although some of them may disagree! LOL! Diagnostic injections are a very important resource in my toolbox, because they can prove or disprove a diagnosis – meaning I can move forward with a treatment or choose another one better suited to your issue. Diagnostic injections will either improve a person’s pain dramatically, moderately or not at all, and that is the information I’m seeking.
Cortisone is used to decrease local inflammation, so a shot of this medication around a particular structure will decrease the inflammation and pain locally. As an example, an injection in the hip bursa will decrease the inflammation and pain in the hip bursa. An injection in the lumbar spine around a specific nerve (epidural steroid injection) will only affect the inflammation and pain coming from that particular nerve that irritated. It is logical then that an injection around the nerve in the back will not make hip bursitis or hip arthritis feel better. This is how an epidural steroid injection helps with the diagnosis of sciatica and can also be a treatment for the patient’s nerve pain.
A study from the University of Utah (Spine, 48 (13); p. 914-919; July 1, 2023) evaluated the effectiveness of epidural steroid injections on patients with pinched nerves. They performed epidural steroid injections on 59 patients with pinched nerves giving sciatica and found that 73% of the patients had greater than 50% of their pain relieved. Their evaluation also included an analysis of patient’s improvement after surgery (lumbar decompression and fusion). They found that those patients that had relief of their sciatic nerve pain in their leg after an epidural steroid injection, would go onto to have pain relief after surgery.
As the steroid injection only provides relief from inflammation, when the inflammation returns, so does the pain. This study tells us that patients can have surgery to have a permanent solution to their sciatic pain. Now, if the epidural steroid injection is effective, I will give my patients the option of continuing with a course of epidural steroid injections when the pain returns, but not closer together than every three months. The use of injectable and oral steroids is not recommended in doses more than once every three months, except in certain cases of severe autoimmune disease, for example. When the epidural injections don’t provide at least three months of relief, then it is time for surgery to fix the pain.
To make an appointment with Dr. Jeffrey Carlson, call Orthopaedic & Spine Center at 757-596-1900, or use our online scheduling tool.