Earliest Reference to "Series of 3" Epidural Injections?

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Aether2000

algosdoc
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So far, this is the earliest reference I could locate:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1708522/?page=1

The article is from 1925- a caudal canal approach that used 20 ml of 1% novacaine (procaine) followed by 50-80 ml of saline or petrolatum. Remember this preceded the discovery of corticosteroids by 12 years and the clinical use of corticosteroids by nearly 22 years.

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Thank you for this.
 
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It's unreal how several local practices still do this as standard of care regardless of outcome on first esi. Routinely scheduled for series 3 of identical injection. Zero relief on first 2, lets do the same thing again! 95% relief on first esi? Need 2 more.... brilliant


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"Insanity is doing the same thing over and over again and expecting different results".

(fyi this cannot be attributed to Albert Einstein...)
 
if you are over 65, and a practicing orthopedist, i think it is a rule to perform 3 steroid injections before referring over to me (knees, GTB, subacromial, etc). thought process hasnt really changed much
 
I am sure there is some reason doctors use three injections. It may be due to religious reasons, because of three naked men, or some other reason. Below are the meanings of three-

Number 3 is the number of good fortune.Number 3

The Pythagoreans taught that the number three was the first true number.

Three is the first number that forms a geometrical figure – the triangle.

Three was considered the number of harmony, wisdom and understanding.

Three is the number of time: Past Present Future; Birth Life Death; Beginning Middle End

Three is the number of the divine.

Three is a sacred number in many religions.

In ritual many actions are preformed three times.

Three is the Number of Magic

We are all familiar with the expression “third time lucky”.

In fairy tales three is often the magical number.

Heroes and heroines are often offered three choices or three tests. They overcome difficulties on the third try.

In Zoroastrianism there are three ethical principles: Humata, Hukhta, Huveshta- to think good to speak good to act good


Muslim Divorce

Under Muslim law a man can divorce his wife by repeating the phrase “I divorce thee” three times.


Utopian City

Plato divided his Utopian city into three populations: Laborers – Guardians (warriors) – Philosophers (rulers)

The Borromeam Rings

The three Borromeam Rings are three rings that are interlocked.

If any single ring is removed, the two remaining rings will fall apart.

This has been used as a symbol of “strength in unity” for centuries in many parts of the world.

The symbol of the three rings that are interlocked is also known as “The Tripod of Life”. Christians may use “The Tripod of Life” to symbolize the Trinity; Father, Son and Holy Spirit.

Nobel Peace Prize

On the Nobel Peace Prize Medal there is engraved a picture of three naked men. The inscription reads: Pro pace et fraternitate gentium, translated ” For the peace and brotherhood of men”. The medal was designed by Gustav Vigeland.

Valknut

Valknut-SymbolThe symbol of three interlocked triangles is called Valknut.

It was used in Viking times as a symbol for the slain dead.

Valknut is associated with the Norse god Odin.

The Vikings believed Odin would protect the dead warriors who died in his name. They believed they would spend their afterlife in Valhalla belonging to Odin.

The name means “Knot of the Slain”.

Primary Colors

cosmicenergy250Only three primary colors are needed to mix most other colors; red, yellow and blue.

Lies

According to Benjamin Disraeli (British Prime Minister, 1804-1881) there are three degrees of lies: Lies – Damned Lies – Statistics

Anniversary

In the Western world, leather traditionally marks the third year anniversary.

The Triple Goddess

Triple GoddessThe Triple Moon/The Triple Goddess. It shows her three aspects as maiden, mother and crone. Often used by Wicca.

3 Empress Rider WaiteAstrology and the Tarot


Gemini is the third astrological sign of the Zodiac. (May 21 – June 21) Number three is the number of Jupiter.

Number three is lucky for Sagittarius.

In the Tarot, three is the card of the Empress.

The Empress stands for creation and growth. Reserved it warns of inaction.



The Shamrock

Shamrock crossThe Shamrock, the three-leaf clover, is a symbol of Ireland.

Saint Patrick taught Christianity in Ireland. He used the three-leaf cover to explain the concept of the Holy Trinity (The Father, Son and Holy Ghost) in Christianity.

Saint Patrick died March 17, 461.

March 17 is celebrated as his feast day and named Saint Patrick’s Day.

leprechaunThe Leprechaun – Three Wishes In Irish Folklore there is a saying;

If you catch a Leprechaun and set him free, the Leprechaun will grant you three wishes.



Petals of the Iris Flower

iris 3 pedalsThe iris flower was a symbol of power in ancient Egypt.

It was often placed on scepters of rulers and kings. The three large petals of the iris flower symbolize:

Faith – Wisdom – Courage

The iris flower is named after the Greek messenger goddess, Iris. She was also seen as the rainbow. Iris flowers were planted on the graves of women.

The ancient Greeks believed that the goddess Iris would lead the dead women to the Underworld.

Picture from Botanical Magazine, 1792

The Troika

Troika OrlowskiThe word “troika” is a Russian word for threesome, triplet or trio.

A Troika is three-horse harnessed sledge.

Troika is also the name of a traditional Russian dance. The dancers dance in groups of three.

A Troika also means a committee consisting of three members.

During the rule of Stalin, the Troika was used to speed up the prosecutions of people accused of political crimes.

In that meaning a Troika consisted of three judges and replaced the normal legal system.

Lithograph (1819) artist: Aleksander Orlowski. The Hermitage Museum, St. Petersburg, Russia

Three Grains

An old superstition from Britain states that it is lucky to find three whole grains in a loaf of bread.

Another bread superstition says it if you take three loaves of bread out of the oven at one time, a death of someone you know will occur within a year.

Rosetta Stone

Rosetta StoneThe Three Languages of the Rosetta Stone The Rosetta Stone contains inscriptions in three languages: Demotic (Egyptian), Hieroglyphic and Classical Greek.

The Rosetta Stone helped reveal the secrets of Hieroglyphic writing. It is on display at the British Museum in London.

Dead Kings

Three English Kings have died in battle. 1. Harold II – October 14,1066 2. Richard the Lionheart – April 6, 1199 3. Richard III – August 22, 1485

Third President

Thomas Jefferson Presidential CoinThomas Jefferson was the third president of the United States. 1801 – 1809.

Jefferson was the principle author of the Declaration of Independence.

He owned many hundred slaves. Jefferson passed a law in 1807 to abolish slave trade.

He was strongly against the Bank of America saying that banking establishments are more dangerous than standing armies.

Animals

The octopus has three hearts. Camels have three eyelids. Cats have a third eyelid. It is called the haw.
 
I wonder....

here is a link to a pdf from 1972, from Analgesia and Anesthesiology.

http://journals.lww.com/anesthesia-...Clinic_II__lntradural_arid_Extradural.40.aspx

I extracted certain very interesting statements from this publication. to wit:

1. earliest reported use of epidural steroids:
The other approach to nonsurgical thesapy
seeks not to treat the etiologic mechanism itself but rather the radiculopathy which results. This was the approach of Lievre and associates,7 who in 1953 reported on the beneficial effect of hydrocortisone injected into the epidural space in 20 patients. Subsequently, others began to try this technic in selected cases. Cappios reviewed the early literature abroad and reported that good results were obtained in 67 percent of the first 80 of these cases. Later, in this country, Goebert and his coworkers9 at the Cleveland Clinic treated with peridural injections of procaine and hydrocortisone 113 patients with painful radiculopathies from
a variety of causes, obtaining good results im
72 percent. After first determining its safety in laboratory animals,lO this same group went on to record an improved success rate following the injection of 40 mg. of methylprednisolone and 40 mg. of procaine intrathecally.

2. possibly the first reported use of the dose of 80 mg depomedrol:
The patients
were divided into two equal groups alternately,
one group to receive 80 mg. of Depo-
MedroF epidurally and the other to receive a similar dose intrathecally.

3. First documentation that I can see where a specific number of injections were thought to be beneficial:
Only 3 patients in the epidural group (table 2), patients 1, 2, and 3, were afforded sustained and complete relief by a single injection, while 5 of the patients (numbers 4 to 81, who obtained complete relief, required 2, 3, and even 4 injections before the relief was sustained.
Thus an average of 2.25 injections was required when Depo-Medrol was given by the epidural route to provide prolonged complete relief.

4. the primary author was Dr. Winnie.

5. Read the article. it is fascinating. we really have not come that far. (in the question/answer, there is discussion about FDA indications, about psychological pretests, risk of infection, using sterile single use kits....)
 
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It's unreal how several local practices still do this as standard of care regardless of outcome on first esi. Routinely scheduled for series 3 of identical injection. Zero relief on first 2, lets do the same thing again! 95% relief on first esi? Need 2 more.... brilliant


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I have patients come in ALL of the time who, after an ESI that failed to yield any relief, tell me "doc my friend told me they had epidermals and the first two did nothing and it was the third or forth that did the trick".


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I have patients come in ALL of the time who, after an ESI that failed to yield any relief, tell me "doc my friend told me they had epidermals and the first two did nothing and it was the third or forth that did the trick".


Sent from my iPhone using SDN mobile app

I hear the same for time to time. Usually the performing physician is just doing midline L5-S1 ILESI very quickly, like 30 seconds.

Maybe some of the 2nd and 3rd times he goes paramedian by accident and some steroid reaches the right target.
 
Have patients that come in after having had two interlams and then say "the doctor told me he was gonna do something more involved for the third one..like come in from the side." See those all the time too...
 
It actually dates back to the legend of King Arthur:
"Three shall be the number thou shalt count, and the number of the counting shall be three. Four shalt thou not count, neither count thou two, excepting that thou then proceed to three. Five is right out."
--Monty Python and the Holy Grail
 
It actually dates back to the legend of King Arthur:
"Three shall be the number thou shalt count, and the number of the counting shall be three. Four shalt thou not count, neither count thou two, excepting that thou then proceed to three. Five is right out."
--Monty Python and the Holy Grail

:rofl:
Awesome!
 
The series of three seems to be the common rule in my area. Just about everyone I know in town does this and patients often show up to me having been referred for a "sseries of LESIs". I knew that some doctors did this but in my training which I just finished we certainly did not and I had no idea it would be so prevalent. I assume at some point there were some studies that suggest this was better, or this practice is just so widespread and easily adopted because you get to make more money?
 
The series of three seems to be the common rule in my area. Just about everyone I know in town does this and patients often show up to me having been referred for a "sseries of LESIs". I knew that some doctors did this but in my training which I just finished we certainly did not and I had no idea it would be so prevalent. I assume at some point there were some studies that suggest this was better, or this practice is just so widespread and easily adopted because you get to make more money?
 
I had originally thought due to a study that showed blind lesi only at correct level a third of the time-so do three. Very interesting to see these old studies
 
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