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Back pain, leg weakness after labor epidural

Discussion in 'Anesthesiology' started by pd4emergence, Jun 21, 2008.

  1. pd4emergence

    pd4emergence Man or Muppet?
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    I was on call the other night and get called to L and D to see a lady with severe back pain and increasing unilateral leg weakness. Lady is a 30 something year old, second baby, who had an epidural for delivey which was d/c'ed about 24 hours prior. Epidural had worked well and had resolved totally per the patient. She said she had some back pain at the epidural site but over the past few hours this had intensified and that her left leg was numb and weak. On exam she was tearful, epidural site with some bruising and she was very tender not only at the site but above and below the site. Left leg had both extensor and flexor weakness but exam seemed limited by effort because of pain. She also had a sensory deficit to cold over the anterior and medial aspect of her thigh and to her whole foot. I looked back at her chart and it had been a moderately difficult epidural with two attempts, the first with a right sided paresthesia and frank blood in the catheter. Normal labs. Only pushed for about 10 minutes, no birth canal instrumentation. I sent her for a stat lumbar MRI which was totally normal, no hematoma, no disc abnormalities. Now what?
     
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  3. Noyac

    Noyac ASA Member
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    Not sure what to do but I think a neurology consult with an EMG would be a good start. THis may give the location of the injury, ie: nerve root or elsewhere.
     
  4. SleepIsGood

    SleepIsGood Support the ASA !
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    MRI is negative?

    I say still watch pt closely. See if any new focal deficits occur.

    Put lidoderm 5% patch on back where the site of epidural is. Start Lyrica 75mg qd (titrate to effect).

    Possible nerve injury, so get the Neuro consult. Neuro will likely tell you to start Vitamin B1 for remyelination.
     
  5. Arch Guillotti

    Arch Guillotti Senior Member
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    Meralgia Paresthetica maybe?
     
  6. Planktonmd

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    Many times sacral plexus injury or sciatic nerve injury could happen during labor because of extreme flexion of the patient's hips during the delivery, and because the patient has an epidural in place the symptoms don't appear until later.
    OB nurses and doctors don't realize that it's possible to push a woman's thighs way more than her normal range under epidural anesthesia and they forget that she won't even know if they are hurting her because she is numb.
    In my experience this happens more frequently when the epidural anesthesia is too dense and the patient is totally numb.
    Most of the times it's just stretch injury and it does resolve in a few weeks.
     
  7. huktonfonix

    huktonfonix board certified!
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    the sad thing is that the OB will probably try to blame the whole thing on the epidural and likely the patient will too. I agree with plank on this one. It sounds like nerve stretch/compression from baby since it seems like mostly sciatic distribution covered initially by the epidural. Any bowel/bladder deficits?
     
  8. Intubate

    Intubate ASA Member
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    meralgia paresthetica is sensory only in the anterolateral thigh.

    you have to get a neuro consult.

    don't accept blame.
     
  9. lobelsteve

    lobelsteve SDN Lifetime Donor
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    EMG does not show injury until minimum of 7 days (3 weeks for board questions).
     
  10. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Meralgia paresthetica is a peripheral nerve injury of the lateral femoral cutaneous nerve that only has a sensory component over the anterolateral thigh. The nerve is often compressed and suffers a neuropraxic injury at the inguinal ligament.
     
  11. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Pregabalin does not bind to plasma proteins. The apparent volume of distribution of pregabalin following oral administration is approximately 0.5 L/kg. Pregabalin is a substrate for system L transporter which is responsible for the transport of large amino acids across the blood brain barrier. Although there are no data in humans, pregabalin has been shown to cross the blood brain barrier in mice, rats, and monkeys. In addition, pregabalin has been shown to cross the placenta in rats and is present in the milk of
    lactating rats.

    I know the kid ain't a rat, but if she is breast feeding- don't do it.
     
  12. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I agree. The obturator nerve is also commonly affected- but this lady sound like L4-L5 are the primarily affected roots.

    Call Neuro or PMR, and get PT involved early.
     
  13. Jeff05

    Jeff05 Senior Member
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    you have ruled out compression by hematoma or abscess (too early anyway) with MRI.

    i would have NEURO come by and write up a consult. make sure they document involvement of multiple spinal nerves (deficits in dorsi and plantar- flextion). i would ask the consultant to state whether the injury is likely due to epidural catheter (single level) or labor - and to document.

    this is likely a plexopathy caused by fetal head. it will resolve by itself.

    i would not give lyrica. but, would encourage immediate physical therapy to prevent disuse atrophy.

    maybe the pain guys can comment on potential for development of CRPS II after this type of neural insult.
     
  14. passgas

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    This neuropathy too low (sacral nerve) to be caused by epidural needle or catheter, so probably stretch injury from position and/or baby.

    Curious RE. which agent was used: Was it chloroprocaine with EDTA preservative? That may explain many of the symptoms.
     
  15. ucsfgaspain

    ucsfgaspain ASA Member
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    Get neurology to document NCS study now. People are right that nerve injury etc. will not show up until a few days later. But that's not the point of the early NCS. The issue is that you want to document that there was no prior injury before a needle was placed in her back. That's what the NCS EMG is for. I would get neuro in on this if I were you.

    Extensor and Flexor weakness and sensory deficits all argue for more than one nerve route involved. You've got L4, L5 and S1 and probably L3 going on. The sensory deficity to the entire foot argues against a peripheral nerve injury like the obturator nerve.

    Honestly, I don't think neurontin or pregabalin (basically a ploy to try to extend the patent of gabapentin) is contraindicated just b/c she's breast feeding. Dude. if she's hurting like a motherf*cker she ain't breast feeding her kid. Don't leave the woman thrashing around. The longer her pain is uncontrolled the longer she's going to hate you and want to sue you. I'd hit her with everything. None of the drugs we give will alter the porgression or ability to diagnosis what she's got. If she's got nerve injury, it's done. I'd hit her with narcs, NSAIDs, AED's. The works.

    Gabapentin, narcs, etc. have all been extensively given to pregnant and breast feeding patients. Dude the chronic pain population still procreates. This woman needs syptom control so worrying about potential toxicity to the kiddies is like farting in the wind. It don't mean squat.

    In terms of CRPS. You can't tell until she starts developing symptomsi.e. look for the allodynia. If she gets that aggressive interventions should probably be done. Refer her to your best pain guy. Would I do anything interventional now...hell no...try to get a diagnosis before trying to stick more needles in her. I don't have a working diagnosis that makes sense. From what you told me I would have thought it was a hematoma for sure.

    It sounds like multiple nerve roots and this makes me scared. You know a lumbar plexopathy shouldn't give her intense back pain either. So I'm worried that you've got something brewing. What, I don't know...no way that there was an intrathecal placement of the catheter? I only ask b/c this kind of sounds like a bad case of neurtoxicity due to local (Like when they had the microcatheters with continuous spinals.) Sorry couldn't be of more help.

    Finally, I see these things frequent enough in my pain practice. This is my word of warning. It's tempting to just blow this off. We as anesthesiologists aren't the poster children for continuity of care. But you should hover over this woman like a mother hen. Go the full nine on this woman, that's how you show her that you care and so she doesn't go looking for Joe Schmoe lawyer to take you to town. Best of luck.
     
    #14 ucsfgaspain, Jun 21, 2008
    Last edited: Jun 21, 2008
  16. pd4emergence

    pd4emergence Man or Muppet?
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    Great discussion. Let me keep the story going. It is about 1 am by this time. MRI negative was negative. If the sun would have been up I would have gotten our neuro guys to come. It wasn't so I tried to start her on some NSAIDS (which she refused because of GI issues), I ended up starting her on some po lortab, IV PRN morphine, and some flexeril. At this point I was thinking she probably had a large compression or stretch injury to her lumbar plexus and that there was nothing that the neuro guys were going to do before the am. After some pain meds her back pain was better and I told her I would be back in the a.m but if things got worse to tell her nurse and I would come see her again. I saw her about 6 the next morning and her weakness was totally resolved, she had been up to the bathroom without much difficulty. She did say that her anterior thigh had some numbness but was much better than the night before and seemed to be resolving also. I arranged for my partner who originally put the epidural in to see her later that day to make sure she had no residual neuro deficits. I again told her to tell her nurse to let us know if things got any worse. I probably could have went ahead and asked for a neuro consult but I felt that it may not be needed (our neurologists don't seem to add much when consulted). So that's the way I left it that morning. That afternoon my partner calls me and tells me that her leg is now pretty much the way it was when I first examined her the night before (weak, numb and all she can do is wiggle her toes). I say well f**k. He did get neurology involved. They MRI'ed her head and got a CT of her pelvis to make sure a hematoma was not there pressing on the lumbar plexus, both of these were negative. Per neuro, she had a normal neuro exam, with intact reflexes, except for her left leg which was weak, numb but with normal reflexes. EMG and conduction studies were ordered but it was going to be the next afternoon before they would be done. PT was consulted. We finally got the nerve conduction studies and EMG studies which were totally normal.
     
  17. pd4emergence

    pd4emergence Man or Muppet?
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    No chloroprocaine.
     
  18. Gimlet

    Gimlet Cardiac Anesthesiologist
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    conversion
     
  19. xyzdoc

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    A consult from Psychiatry may help find out the issues.
     
  20. militarymd

    militarymd SDN Angel
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    I hate ob anesthesia
     
  21. Planktonmd

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    You keep mentioning the lumbar plexus, isolated Lumbar plexus injury shouldn't give you the complete numbness of the foot that you mentioned.
    This is either an isolated sacral plexus injury (L4-S3) or most likely a combination of sacro-lumbar plexus injury due to severe stretch during delivery.
    The transient improvement of symptoms might be due to the NSAID and I suggest a short course of steroids.
    As I said previously she will get better in a few weeks.
     
  22. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    Word.
     
  23. pd4emergence

    pd4emergence Man or Muppet?
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    She had normal conduction studies and had normal equal reflexes on the affected side. This would have been a large distribution for it to be a stretch injury probably L2 or so to S2or S3. I think the defect was supratentorial the whole time (either conscious or subconscious). The neurologist doing the conduction studies agreed.
     
  24. pd4emergence

    pd4emergence Man or Muppet?
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    I agree. Fortunately, we were able to leave it with the ob and the neurologist.
     
  25. pd4emergence

    pd4emergence Man or Muppet?
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    This should have been the title of this thread.
     
  26. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Oh, a stress injury, I thought it was a stretch injury.
    Have neuro follow-up in 3 weeks.

    If happy baby, happy home- OK.
    Still post-partum depression is likely to spring from this.
    Have psych see her in house, then follow up weekly for PPD.
     
  27. coprolalia

    coprolalia Bored Certified
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    Be careful about liberally applying the Psych consult. This may play poorly in front of a jury.

    -copro
     
  28. urge

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    How about some steroids?- pain guys, do they help?
    Repeat emg in a two or three weeks. You already ruled out the stuff you can fix. I wouldn't call psychiatry just yet. I would let it play and if the repeat emg is normal and she is still symptomatic, then I would consult them.

    Why would anyone use lyrica when neurontin is cheap? Is it that much different?
     
  29. ucsfgaspain

    ucsfgaspain ASA Member
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    I don't see anything wrong with hitting her with a little steroid. Do a prednisone taper see if there is a large inflammatory component. Of course if she's got psych issues you may exacerbate her depression:scared:. It's pretty funny to me how we are all infatuated with the newest drugs. Pregabalin is quicker to titrate but in a woman like this I'd have no problem blasting her with neurontin. Sedating the hell out of her may be helpful actually especially if there is a large supratentorial component.

    I also would be very wary of labelling her nutz. ( You can think it privately...but don't leave a trail of this thought yet in the medical chart) Be the nice doctor and listen to her complaints and treat them seriously cuz if it turns out that she does have a real injury, you want to come out smelling like roses. If psych is going to get involved have the neurologist make that call. In that way you are seperated from the consult...therefore you remain objective and look like you just tried to do the best thing for this patient.

    **** like this is why I hate OB. Bad stuff happens in OB...and when you have to deal with B.S. it justs pisses me off. I also had a conversion disorder as well. F*ing pt. suddenly becomes unresponsive during a c/s. All vitals were stable but the b*tch wouldn't respond at all to her husband or to me. I ended up inducing and putting her to sleep just to cover my bases. Ended up with a psych consult and man was I pissed! Needless increase in morbidity and mortality. There are easier ways woman...to get a push present for your hubby!
     
  30. pd4emergence

    pd4emergence Man or Muppet?
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    We pretty much told her it would get better and made sure she had close follow up with her OB and neurologist. The OB in this case was going to be seeing her a day or two after discharge and he pretty much thought she was bullsh*tin the whole time. The neurologist was sure that there was no peripheral nerve injury and did not want to start her on anything. She was going to see him a week after discharge. I agree that the psych consult will be their call not ours, either way her symptoms and exam do not correlate but they do correlate with the fact that it wasn't the epidural. F'in OB.
     
  31. Tenesma

    Tenesma Senior Member
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    uscfgaspain - you use steroids as a way to diagnose an inflammatory component??? is that what they teach at UCSF?
     
  32. urge

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    Please discuss steroids. I'm far from being a pain guy but I wonder if the say mechanism is involved as when we do steroid epidurals.
     
  33. Planktonmd

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    Primary physicians prescribe steroids left and right for things like: bronchitis, bad cold......
    We give steroids for simple things like preventing nausea and vomiting...
    So if you suspect a mechanical trauma to a plexus causing perineural edema it doesn't hurt to give a few days of steroids (IMHO).
     
  34. ucsfgaspain

    ucsfgaspain ASA Member
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    Do I use it to diagnose inflammatory component. Uhh...no. But if she responded to NSAIDs and is screaming in pain. Why not put her on a steroid taper for as short while? Dude, as we all know mental masturbation is used to try to figure out the pathways of pain. We've tried to find a magic bullet for pain and we don't have it. Neurogenic versus nociceptive. NMDA receptors, mu receotirs. YOu can try to be cute with pain and try to tailor your pharmacologic and interventions to patients. We all do that. But honestly in my experience, in then end what do you do with REAL chronic pain patients? You throw everything but the kitchen sink at them to try to temper their pain down.

    In this acute setting, I would throw everything at her. Why? Cuz it won't chance the fact that if she really does have nerve root injury...damage is done...can't do much about it anyways.


    Tenesma, not sure if you are an anesthesiologist. But do you know how we treat PONV in the OR? 8 mg of decadron. It gives me a little bit of the heebie jeebies as a Pain guy since I think we treat steroids a little bit more cautiously. But for this woman screaming in pain. I've got no problems in giving her a medrol dose pack.

    Oooops. I just saw your post Plank. I just basically reiterated everyhting you said. BTW were you internal medicine trained? Cuz you definitely seem to have the breadth and depth of general medical knowledge. I just wonder cuz I have a lot of buddies...that went through IM and then gas. They seem to have a more comprehensive view of things. CCM guys do too. Us pain guys...not so much.

    Take a look at some of our internal medicine buddies. They hand those things out like candy. Peace
     
    #33 ucsfgaspain, Jun 23, 2008
    Last edited: Jun 23, 2008
  35. ucsfgaspain

    ucsfgaspain ASA Member
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    Urge,

    So we really don't know how epidural steroids work. We have some ideas. People talk about the DRG(dorsal root ganglion) as being the site of action. Who really knows. The general thought is that you have chronic inflammation of a compressed nerve root and steroids temper down that inflammation. You know pople will get off on various molecular pathways etc. But in the end no one really knows. Sh+t if we knew the true pathways of pain, we'd have defeated pain a long time ago and I'd be out of part of my job (that's why I do OR as well...the more options you have, the better)

    We do transforaminal injections b/c we think that we are delivering the drug more anteriorly and thus closer to the DRG is more benefitial. (I happen to believe that TF ESI do help more often). When we do epidurals up on the floor. Who the hell knows where the steroid is going. If you watch the dye spread under fluoroscopy when doing an epidural. I'm amazed at how well we do with our epidurals in the OR! To be truly midline without fluroscopy is a feat and to get great bilateral spread is also amazing to me without the aid of fluoroscopy. If they've got a little rotational scoliosis...good luck.

    COnsequently, I don't apologize for spotty blocks. Sh+t happens. The only way I can guarantee an epidural working 100% of the time. Is through fluroscopy.

    You know those old farts..that roll in with some ortho nightmare of a problem. ANd you've got them and you've basically performed accupuncture as you hit a wall of bone trying to get the goddamn spinal in. Before you contemplate taking a 14 guage thuoy needle and coring through the bone to get to the intrathecal space (believe me I have), try fluoro. With fluoro...any trained (or for that matter, untrained monkey can hit that Sh+t) under fluoro. Have your ortho dude, shoot a quick shot with the patient prone. And throw your spinal in prone, use the plain 0.5% bupiviciane. Good to go.
     
    #34 ucsfgaspain, Jun 23, 2008
    Last edited: Jun 23, 2008
  36. Planktonmd

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    Yes, I did a full residency in internal medicine before anesthesia.
    It comes in handy sometimes, but sometimes you catch yourself using the flea mentality when you shouldn't :)
     
  37. lobelsteve

    lobelsteve SDN Lifetime Donor
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    And if she gets a GI bleed because of the Prednisone, or AVN- then what?
    I'm not seeing tie your hands together, but I'd much rather her get some Ultram and Lyrica +/- hydrocodone instead of steroids.

    2 cents from a PMR Pain guy.
     
  38. Planktonmd

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    What percentage of your patients who receive steroids (including epidural steroids) get GI bleeds or avascular necrosis?
    Tramadol is not a benign drug and it causes more addiction than you might imagine it also causes severe withdrawal symptoms after even a few days of use.
    Pregabalin is a class of medications that we know very little about, not enough data on how it affects the newborn of a nursing mom and it's being pushed down our throats by aggressive marketing.
    Hydrocodone causes addiction and and also passes in the breast milk.
    There is no such a thing as benign medications.
     
  39. Tenesma

    Tenesma Senior Member
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    1) ucsfgaspain: you wrote: "Do a prednisone taper see if there is a large inflammatory component." - If you use steroids because that is part of your armamentarium of throwing the kitchen sink at a pain patient, then fine (even though i think that is a bit old fashioned without much sophistication, but maybe that is the standard of care in your neighborhood... If you use steroids as a diagnostic process then that makes no sense whatsoever...

    2) i did anesthesia - what does decadron IV for PONV have to do with treating pain with steroids? ...

    3) EMG/NCS is pointless unless you are trying to establish a baseline

    4) waxing and waning weakness is not a true neurologic emergency - if anything it usually implies supra-tentorial process or that she was guarding because of pain...

    5) numbness over her whole foot makes no sense...

    6) i am glad i don't do OB anesthesia all the time - we used to see variants of this case all the time and usually by post-delivery day 2 the symptoms would regress... and without blinking an eye the OB residents/fellows/attendings ALWAYS blamed the epidural... once they even blamed the epidural, and it turned out the patient never had an epidural.
     
  40. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I do not prescribe oral steroids. No role for any of my patients.
    As far as a hospitalized patient with a difficult delivery and enough stress to cause some type of neurological or psychological symptoms, the last thing I'd do is provide a medication that has the potential to keep her in the hospital much longer. Tramadol over a week will not cause addiction, lyrica is not known to have immediate and profiound sequela- but after a PMR residency seeing all the crap that happens from OB to the ICU- I have seen half a dozen patients die, bleed out, or lose hips from a Medrol dose pak- so it bothers me that other docs throw them around without any known inflammatory focus occurring.

    The last time we discussed oral steroids on the pain forum: http://forums.studentdoctor.net/showthread.php?t=515139&highlight=oral+steroids
     
  41. ucsfgaspain

    ucsfgaspain ASA Member
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    Tenesma,

    I understand your point of view. And I have stated you can try to be elegant with pain and try to use Occam's razor priniciples in your diagnosis and treatment. But dude...we live in the U.S. where there are more lawyers than engineers. B/c of this and b/c not everyone lives in a MICRA state where we limit damages for pain and suffering, I would throw everything but the kitchen sink at her.

    What is the downside of short course of steroids? If she don't respond quickly, stop it. Sure you can quiver in your pants about AVN and GI bleeds but honestly, I think that if you are worrying about this, then man I don't know how you can be in anesthesia. There are a lot more REAL risks in what we do in the OR everyday from other things.

    You are right, chances are that her symptoms are a supratentorial. BUT when a young healthy woman is sitting in front of a jury crying about the intense pain she had from the mean...uncaring anesthesiologist, I know what I would do to make me feel and look better. I'd be the caring anesthesiologist that did everything to make the patient feel better.

    Different strokes for different folks. Who do you think the patient is going to believe? Some nameless face..who came in and did their epidural and then disappeared into the wind. Or are they going to believe their OB? The doc that delivered their precious bundle of joy? To be cavalier about this patient b/c ....there is no f*ing way my epidural did anything...is just inviting legal trouble. You will get away with it most of the time. But when you don't and have to defend yourself even froma frivoulous lawsuit, you'll be happy that you did a little hand holding for the few cases that these things occur on.

    Peace.
     
  42. ucsfgaspain

    ucsfgaspain ASA Member
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    Lobelsteve,

    That's cool that you don't use oral steroids. I don't use it much. Mostly for patients that it's worked in the past and they don't want steroid delivered to the epidural space or if someone is terminal and has bony mets. But....

    Do you know how many times oral steroids are used in the U.S? I'm not sure of the exact number but like I said other physicians hand it out like candy. For instance, I went to the allergist and got allergy tested. I started getting urticarial lesions from the skin testing that started shooting up to to past my armpit. Guess what they offered me? Antihistamines, po steroids. I took the antihistamines ...told them no thanks about the po steroids and made sure I grabbed a little vial of epi. Why? Cuz steroids ain't going to kick in...at least not in time enough before I anaphylax and die. Now I know about the risks of steroids and deferred...but 99.999% of the time, the patient would have take the oral steroids prescribed by the allergist.

    AS a pain guy, how many of your referrals have gotten medrol dose packs for their lumbar radiculopathy before you get to see them? How many of your IM/ FP/ even spine surgeons prescribe steroids for their lumbar radiculopathy? Consequently, why don't we see an FDA warning (black box) about medrol dose packs so that no one uses them. SH+t we see it for droperidol for N/V. I know that the risks are very real about steroids and all the things you described. But they are rare.

    Would I stay up at nite and worry about a medrol dose pack causing a delayed discharge. Uhhh not in your life. Do my internal medicine colleagues worry about it when they discharge their patients on them for asthma, lumbar radiculopathy, etc. etc.? Nope.

    Weigh the risks and benefits, and make the decision yourself. I think that I'd give the steroid, you don't. Coolness. Agree to disagree. No harm no foul.

    Peace.
     
  43. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    What makes you think that oral steroids are more harmful than 40-80 mg Depomedrol you inject in the epidural space and other locations everyday?
    How about NSAID's then?
    Did you stop prescribing NSAID's because they are known to cause gastritis, ulcer and GI bleeds more frequently than steroids?
    I have seen disastrous GI bleeds caused by NSAID's but everyone keeps prescribing them, are they all negligent?
    One more thing: I did not say that Tramadol over one week causes addiction I said it causes very annoying withdrawal symptoms: Muscle pain, anxiety, insomnia and general unhappiness, ask your patients how they felt after a short course of Tramadol.
    The bottom line: I know that you practice pain management and I am not here to infringe on your line of work but I have to remind you that we deal with a different subset of patients and under different circumstance.
     

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