Podcast 43 - Epidural Steroid Injections

Transcription

Dr. Chad Edwards: This is Doctor Chad Edwards and you are listening to podcast number 43 of Against the Grain.

 

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Announcer: Welcome to Against the Grain Podcast with Doctor Chad Edwards, where he challenges the status quo when it comes to medicine. We get into hot topics in the medical field with real stories from real patients, to help you on your way to a healthy lifestyle. Get ready, because we’re about to go against the grain.

 

Marshall Morris: Hello, hello. This is Marshall Morris, and today I am joined by Doctor Chad Edwards, who believes that 80% of medical recommendations are crap, technically speaking here. He is the author of Revolutionize Your Health with Customized Supplements. He served in the U.S. army. He graduated from medical school at Oklahoma State University. He’s the founder of revolutionhealth.org and Against the Grain podcast. Doctor Edwards, how are you doing today?
Dr. Edwards: It is Friday, I’m excited to be here. I’ve got a good weekend coming up, I’m getting right to move. Things are good.
Marshall: I love to hear that. What are we talking about today in terms of the hot topic?
Dr. Edwards: Today we are going to talk about the topic that actually came up at a talk that I was doing this morning. We’re going to talk about epidural steroid injections.

 

Marshall: Epidural steroids. ESIs?

Dr. Edwards: ESIs, that’s right.

 

Marshall: Okay, cool. Walk me through it. Why is this a hot topic?

 

Dr. Edwards: Patients — a common dogma for patients with low back pain, they’ve got pain problems, this kind of stuff, they are going to go to their doctor, they might get the MRI, they’ll get sent either a spine surgeon or something like that, reviewed other their surgical candidate if they don’t want surgery, there’s a whole host of different ways that — they go to pain management and they’ll say, “You know what, let’s start with some ESIs. Let’s start with an epidural steroid injection. Ultimately, what we’re talking here is back pain but epidural steroid injection is one of the ways that the pain management world will use to treat back pain.

 

Marshall: Okay. So the underlying problem that maybe affects a bunch of our listeners is back pain.
Dr. Edwards: Exactly.

 

Marshall: Okay. Let’s get into it. What is the dogma? Break it down for me.

 

Dr. Edwards: The thought is that inflammation is the cause of a lot of pain. I can’t disagree with that totally, but in this case, what we see is ligament and tendon damage as the source of these many people’s problems. The concept though is that you’ve got an inflamed nerve root. You’ve got something wrong with your back. You’ve got a herniated disc, you’ve got something, you’ve got this nerve coming out of your back. We are going to go in there and we’re going to reduce your inflammation. We’re going to do that by doing an injection with lidocaine and with steroids. It’s usually something like triamcinolone or Kenalog, and we’re going to inject that into your spine, into your back. That will numb it up a little bit, because of the lidocaine, and it will reduce the inflammation because the steroids are anti-inflammatory. The idea is that we’re going to temporarily reduce your symptoms by giving you these steroids and lidocaine.

Marshall: Quick question from my third-grade mind here. How does lidocaine or what is lidocaine?

Dr. Edwards: Lidocaine is an anesthetic. If you’re going to go get a cavity field, they’re going to give you something like lidocaine, marcaine, one of those anesthetics, local anesthetics that numbs up the tissue right around it.

Marshall: That’s what people will do to reduce inflammation and make you kind of mask the pain a little bit. Is that right? Is that accurate or what?

 

Dr. Edwards: The lidocaine is just for the pain, that’s it. It doesn’t affect the inflammation. The inflammation is being affected by the steroids.

Many patients will go in and they might get a lot of improvement, and what I — generally when patients get benefit, they’ll come to me and they’ll say, “I had three or four or five or how many they’ve had. They’ll help the whole lot upfront and now they’re just not helping me that much anymore. Sometimes they will continue to help, sometimes they don’t help at all.” There’s a whole spectrum on how much it helps.

My issue though, we’ve talked about Tulsa prolotherapy many times. We’ve talked about the underlying cause of pain, and patients with back pain. We’ve done podcasts on MRIs. We’ve done podcasts on low back pain. You can go back on reference in the early numbers some of those podcasts, I hear are a little more about them but the ligaments and tendons as the underlying pathology, not so much chronic information, but the steroids, my issue with them is, the main thing about them is that they are actually necrotic to the tissues. Necrosis means that it destroys. It kills the tissue. Instead of having this ligament or tendon or these connective tissues that are thick, a millimeter thick, I’m just pulling a number. Instead of having a millimeter thick after you get a steroid, they may only be like 0.9 millimeters thick. So they’re not as thick as they were before. It’s not stronger. It’s not healed. It’s not thicker. It’s not better. So why are we doing this?

 

Marshall: You go talk to, say physicians in general, it’s not maybe inherent or one physician or another one type of specialty or another, it’s just this thought process that steroids and lidocaine will solve the underlying root when really you’re adjusting the symptoms, maybe not what’s causing the symptoms. Is that accurate?
Dr. Edwards: That’s exactly right.

Marshall: Why do you think there’s this widespread illusion or understanding that this is how we treat low back pain or any kind of pain in this world?

 

Dr. Edwards: Zig Ziglar tells us a story. I think I’ve told this story before but for those that have never heard this story before, Zig Ziglar tells a story about he wanted a ham one time. He brought it home to his wife and the first thing she did was cut the end of the ham and stick it in the pot and go to roast it. And he’s said, “Why did you cut the end of the ham?” She said, “I don’t know, my mum always did and I guess we need to call her.” They called mum and said, “Why did you cut the end of the hem because that’s what she’s doing. She just wasted part of my ham.” She said, “I don’t know, that’s what grandma always did.” They’re like, “Let’s get grandma on the phone.” They get grandma on the phone and they said, “Grandma, we’re cutting the end of this ham and you always did that. Why did you do that?” She said, “I don’t know why you’re doing it, but my pen was too small. [laughter] The point of that story is that that was what was passed on. It’s just that’s what you do. You have this, that’s what you do. When you are not a subject-matter expert, and as a family physician, I was not a subject-matter expert in low back pain. If someone had low back pain, and I couldn’t fix them with my standard stuff, I would send them to someone else. A subject-matter expert would say, “I’m the one you send people to. There is no one else to send me to, at least not in regard to this.” Not being the subject-matter expert, I see what my colleagues are doing and I’m going to do that. In fact, you may — our listeners are maybe aware of the term ‘standard of care’. What’s the standard of care for treating a cold? What’s the standard of care for this?

Standard of care simply means all of the other physicians in your area or most of the other physicians in your area what are they doing? It’s peer pressure. It’s the classic, if your mom asking you, “If all your friends jumped off the bridge, would you jump off the bridge?”

In this case the answer is yes, because that’s what the standard of care means. When you think about it, it’s really kind of ridiculous. I understand why they do it and why there is a standard of care. If you are outside the standard of care, it’s not necessarily a bad thing but you better know what you’re doing. You better know that you’re safe because the medical board does this to protect patients. As long you are working in the interest of your patient and you’re doing something that’s not harmful, you don’t necessarily have to do the same thing that all your colleagues are doing especially when it’s backed by evidence, because what if one of your colleagues are wrong? In some cases, that’s the way it is.

Epidural steroid injections, when I as a family doc would send — if you came to me with low back pain, I had a few things that I would do. In fact when I was at Fort Bragg North Carolina, we had a back class. I would send the patient to the back class. In physical therapy, the physical therapists ran a class once a week, once a month, I don’t remember how frequent, but I remember going to this class as part of my residency and they were having to sit there and listen to how low back pain came up and here are some exercise that you can do. It was not a bad idea and they were able to help some people but it wasn’t fixing ligament and tendon problems. I would argue that it didn’t fix that, maybe it was a low back pain, although I can’t help strengthen the back a little bit.

If I couldn’t fix you with that then I’m going to go and get an MRI, and depending on what that shows, then I’m going to send you to another big surgeon. Even if your MRI is normal, at some point I’m going to be like, I don’t have anything else for you so I’ll either send you to pain management or an orthopedic surgeon. So I had. That’s what everybody else did I want to be as smart as that guy so that’s what I’m going to do without really thinking through what is it that I’m doing.

 

Marshall: Sure the process of it.

 

Dr. Edwards: Right.

 

Marshall: For these ESIs, what is — in terms of the treatment and just the nature of it? How does that go? What is typically the healing process for that or what is functionally happening with ESIs?

 

Dr. Edwards: Yes. Basically you go into your doctor, they say we’re going to do an ESI, basically they’re going to do an injection into your spine, into what’s called the epidural space. That just has to do with the spinal not cord but the spinal canal and the lining of the spinal cord these things called the meninges and there’s a space called the epidural space. It’s outside the dura, one of the meninges. And there’s this little space and we’ll stick a needle in there and we’ll inject these solutions, the steroids and the lidocaine into this space and it will kind of diffuse through there, numb that space up and be anti-inflammatory, reduce inflammation. Again some patients get really good benefit from that first for a period time. Some patients do not.

If you find the right problem and treat it with the right solution, it’s going to work. The problem is that many patients that I see don’t have an epidural problem or they don’t have a nerve problem in the way that epidural injections would help. The second piece is that because these things are temporary. They don’t fix anything. We’re going to give you an epidural steroid injection. I’ve never heard a physician. Maybe there are some out there but I’ve never heard a physician tell a patient, “We’re going to give you three of these things and your back pain is going to be cured. You’re going to be done. You’re going to be good. You’re never going to need this again.” It’s not how it works. “We’re going to give you an injection and hopefully your pain gets better for a few weeks, a few months, maybe a year and then when it comes back come back and see us again we’ll do another epidural steroid injection.” You’re just giving injections to treat the pain. It’s not fixing the underlying solution.

 

Marshall: Sure. What I want to do is I want to take a quick break and when we come back talk a little bit about maybe an alternative to these ESIs and what you can do about it.

 

Dr. Edwards: Perfect. Let’s do it.

 

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Marshall: Okay. We are back. We’re joined today with Dr. Chad Edwards and we’re talking about epidural steroid injections and really what they mean and why they have become a standard but maybe not the best standard for a lot of patients or why maybe there’s other alternatives. Why don’t you walk us through Dr. Edwards maybe what patients are a good candidate for epidural steroid injections and why that isn’t just everybody that has pain?

 

Dr. Edwards: Yes sure. The first thing it’s not beneficial for everyone that has pain because these things have risks. One, we’re sticking a needle into the spine — into the spinal column. Two, we’re injecting steroids. Steroids are anti-inflammatory which I would argue is not the best thing for many of these kinds of pain patients.

 

Marshall: If you want to learn more about inflammation, we talked about that on one of the most recent episode.

 

Dr. Edwards: Yes exactly.

 

Marshall: It’s awesome.

 

Dr. Chad: Yes, good point. Then the other piece with this is the steroids, they suppress the immune system and they’re necrotic to the tissues. We don’t want to just throw steroids at everything under the sun. We want to heal and you can’t under chronic steroids. You’re not going to be optimally healthy. It’s just not going to happen. Who would be a good candidate for an epidural steroid injection? Common patients that would get this procedure would be patients that have pain in their neck, low back, arm or leg that or this sciatica type of pain. If you got sciatica, they may look at doing an epidural steroid injection and specific conditions that patients may have would include things like spinal stenosis. It’s where the canal of the spinal column — the cord basically, is compressed or narrowed. There’s not as much room there.

Spondylolysis, that’s where one vertebrae on top of the other, slides forward and that can cause a problem. That mainly happens in the L4, L5 this one little back region. Herniated discs, we’ve talked about herniated disks before. If you have a herniated disk, they may recommend an epidural steroid injection and then sciatica. Sciatica is really a catch all term for any pain that goes down the back of your leg almost. If they cannot treat that too, the sciatic nerve and a nerve root impingement from the spinal column then they may recommend an epidural steroid injection for that as well.

 

Marshall: Okay, so these are a few cases where it might be appropriate for epidural steroid injection. What are some of the cases where it might not be appropriate?

 

Dr. Edwards: Well anyone wanting to get better.

 

Marshall: Okay, walk me through that process.

[laughter]

 

Dr. Edwards: Again, one of our focuses with againstthegrainpodcast.com and at revolutionhealth.org, one of our primary process is to help patients get better. Get it to where you don’t need epidural steroid injections. Get it to where you don’t need repeated injections in your back and you don’t even need Tulsa prolotherapy. We’re going to strengthen these tissues. We did a podcast on MRI and how MRIs are a great way to get surgery if that’s what you want. We talked about how studies have been done showing a high incident finding or incident rates of abnormal findings on an MRI even when the patient had no previous pain and no injury. We can have abnormal MRIs in normal patients. How many patients are out there walking around with problems on their MRI that just never had an MRI but they don’t have pain.

I would argue that a lot of these conditions don’t need epidural steroid injections either. My blanket statement for this is, I would only recommend an epidural steroid injection when you failed Tulsa prolotherapy. If you failed PRP and or stem cell. When you haven’t gotten success with those things, then I would consider something like an epidural steroid injection that has much higher risks, much higher concerns, is a temporizing measure, doesn’t fix you, when you have no other options. That’s when I would recommend this.

 

Marshall: We’ve heard you talk about prolotherapy before. We have a couple of episodes on that. What it sounds like is prolotherapy is more of a treatment to fix the underlying problem and this epidural steroid injections is a way to mask or postpone addressing the problem. I’m sure there could be scenarios for needing to do that but with the non-invasive nature or maybe non-invasive isn’t the right word of Tulsa prolotherapy-

 

Dr. Edwards: –low risk.

 

Marshall: Low risk nature of prolotherapy. There really doesn’t seem like there’ll be any reasons why you shouldn’t try it at least because it’s not going to hurt you in the long term anyways.

 

Dr. Edwards: That’s exactly right. Again when you go back to that underlying thing, what are the risks? What are the benefits? C. Everett Koop, former surgeon general of the United States in the 1980’s said the nice thing about Tulsa prolotherapy if properly done is that it cannot do any harm. No one’s ever said that about an epidural steroid injection. No one has ever told a patient, “Don’t worry about it. This can’t do any harm.” And the head physician in the United States in the 1980s, just gave his stamp of approval on prolotherapy. Not just but with a statement like that, “This is risk?” “No risk.” What are you going to do? I mean it just makes no sense to me why someone wouldn’t consider prolotherapy. I had a good friend of mine came in for — he actually had a foot drop.

A foot drop means when you stand on your heels and you pull your toes up and kind of walk on your heels on his left foot. He was not able to stand on his heel and keep his toes up. Every time he tried to do that on just the one leg, his toe, his foot fell. He couldn’t – he lost strength in his lower extremity. He was concerned that he had nerve damage in his lower back and I believe he even got an MRI and it said there’s a little bit of concern for some nerve compression here. He thought that he had an issue that the only way he was going to get better was surgery. I told him, I said, “You can, you can consider that path. I’m not going to dissuade you from doing that, however, I would strongly recommend that you look at doing something like prolotherapy first. We’re not going to screw it up. We’re not going to make this worse. Maybe we can fix it.”

He said, “Okay, let’s do it.” He comes in. We do his injections. He stood up and said, “You know I do notice, I do feel like it feels definitely better,” but he still didn’t have that strength restored. I understand Tulsa prolotherapy fairly well and I told him, “You know this is going to take some time for this part to resolve. We’ll just have to watch closely and carefully. But I think we’ll have good success with this. Let’s just watch this and let’s see how you do.” He came back four weeks later for a follow-up injection and he didn’t really want to get injections because he was like, “Those things hurt. They weren’t comfortable.” But he was so excited about how well he was doing that he came back for another round and I said, “Okay, so how are we doing?” He was like, “It’s gone.” I said, “You have no more symptoms? Your foot is good.” He said, “No. I’m good.” So he stood up and he stood on the one leg, on his heel and he lifted his toe up and he was able to hold them up right there and I said, “Well then, we don’t need to do this. We don’t need to do another round.” He said, “We don’t need to?” And of course he was very excited that he had to get another round of prolotheraphy. I said, “No. Why would we do that? Your symptoms, the reason you came to me to begin with is because of this symptom. The symptom is gone, we’re done. We don’t have to do anything else.” And he actually told me, he said, “If it hadn’t been me and the fact that he knows me and trusts me, he never would have done it because he didn’t believe that injections in the area where we were doing them could fix this symptom. He didn’t believe it. And in Star Wars: The Empire Strikes Back, Luke is trying to raise the X-wing out of the Dagobah swamp and holding his hand out there and it kind of bubbles a little bit and he says, “I can’t do it. It’s too big.” And Yoda comes over and does it and lifts it up and sets it down. And Luke says, “I don’t believe it.” And Yoda says, “That is why you fail.” [laughs]

 

Marshall: Yes, exactly. So especially with this scenario and I’m sure other scenarios as well, was there a cost savings piece to prolotheraphy over going in and getting invasive surgery for that?

 

Dr. Edwards: Invasive surgery without question. Now the problem is that, of course, you know in my clinic we don’t take insurance but insurance doesn’t cover prolotheraphy. Even still, the procedure is so much less expensive than when you factor in co-pays, time off work, physical therapy, co-pays with physical therapy, prescriptions, prescription co-pays. Not even counting the risks and all those kind of things, it’s still most likely cheaper. But sometimes patients just have it in their head and they’ll say, “The surgery is covered. They’ll pay for my surgery. They won’t pay for prolotherapy. I’m going to do a surgery.” And I’m like, “Yes, but your co-pay on your surgeries is like $10,000 and I can save you thousands of dollars.” And they’re like, “Well, insurance will cover that.” I’ll be, “It’s Isodine. It’s ludicrous, or as we like to say, it’s bullcrap.

 

Marshall: It’s bullcrap. So, no — Dr. Edwards, I appreciate you sharing this with us today. Any closing thoughts about epidural steroid injections and alternatives to it?

 

Dr. Edwards: Yes. The first thing is look at the underlying cause of why are you having pain. Is there another solution? Prolotheraphy is fantastic. It’s safe. It’s beneficial. It’s cost effective. I would, without a question, recommend nearly every patient exhaust a course of prolotheraphy before I would recommend them getting an epidural steroid injection.

 

Marshall: Boom. Dr. Edwards. Thank you so much for joining us today.

 

Dr. Edwards: Thanks Marshall. See you next time.

 

Announcer: Thanks for listening to this week’s podcast with Dr. Chad Edwards. Tune in next week where we’ll be going against the grain.

 

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