Facial edema and injection site swelling after series of 3

[dc2md]

Hey guys. A friend of mine in Ohio underwent a series of 3 cervical IL ESIs. Her pain is 90% better and she's thrilled with the results, but she asked me about the extreme facial swelling she has (more than when she was pregnant). She also says she has a softball-sized swelling at her injection site (though I'm sure she's exaggerating the size).

I've never seen these side effects in a patient, but that's likely b/c we don't do series of 3 where I train, and of course I don't always see the follow-ups b/c go to another rotation.

Has anyone had experience with this? The facial swelling is likely the blocking of COX-1 & 2 in the renal collecting ducts causing Na and K+ retention (and therefore fluid)....like NSAIDs can do. But how long does this last? And what would cause injection site swelling so much. Seems like she would've seen more systemic problems if it was the steroid or contrast. Any thoughts? Thanks

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[lobelsteve]

Injection site swelling can be an abscess forming, or deposition in the tissues dorsal to the spine.
Facial swelling is a side effect of most steroids.

Get a CBC/ESR and if + MRI C-spine.
If no other complaints, can employ tincture of time.

Tell your friends to call you BEFORE they undergo unnecessary care (series of 3).

 

[Ligament]

Great question. This happens in about 1% of my patients. The facial edema is nothing to worry about. The abcess in her back IS a worry! She should get evaluated immediately.

 

[SSdoc33]

the most likely scenario is that the yahoo who did the injection either used a crapload of steroid each time, super high volumes of injectate, or both. agreed that the posterior swelling is an issue, but if it truly was the size of a softball, and an abscess, it would definitely hurt.

 

[dc2md]

Tell your friends to call you BEFORE they undergo unnecessary care (series of 3).

I know. I tried to talk her out of the series...but I'm just a lowly resident and he's a guy with a sign outside. How can I compete with that? 🙂


Turns out the softball-sized swelling is more like an enduration with a softball-sized circumference. No redness, pain, or fever.

 

[Tenesma]

where do i start??? the fact that anybody does a series of 3 is beyond me at this point in time...

 

[Dr. Ice]

where do i start??? the fact that anybody does a series of 3 is beyond me at this point in time...

Amen..but its still done like crazy and I see it all the freakin time.

 

[clubdeac]

So I'm not answering the original post but just wanted to add that it's one of my biggest pet peeves when patients say, "why am I only getting one epidural, my last doc gave me three?" or "yeah it always takes three before I get any relief, when are you going to reschedule me" and I hear this crap daily. Half the time my brain is turned off so I don't explode from all the crazy crap I hear.... "it's my L4/5 disk that hurts", i have degenerative disc dx, I've got 4 blown disks".... and it goes on and on. Ahhhhh 😱

 

[PMR 4 MSK]

I'd be willing to bet that if you read the procedure reports, you'd see each of the three injections used a larger than normal dose of steroids. Some people experience minor swelling after an injection, and something like this could be due to mega doses. I see it from guys in my town who set everyone up for 3 epidurals before they walk through the door for their first appt.

 

[Dr. Ice]

So I'm not answering the original post but just wanted to add that it's one of my biggest pet peeves when patients say, "why am I only getting one epidural, my last doc gave me three?" or "yeah it always takes three before I get any relief, when are you going to reschedule me" and I hear this crap daily. Half the time my brain is turned off so I don't explode from all the crazy crap I hear.... "it's my L4/5 disk that hurts", i have degenerative disc dx, I've got 4 blown disks".... and it goes on and on. Ahhhhh 😱

Ditto..makes my bp go way up! Its unfortunate that we picked the field of medicine with the most con artists, unethical jackwagons, criminals and just plain bad doctors. Its no wonder that people roll their eyes when I tell them Im a "pain doc"

 

[PMR 4 MSK]

Sometimes, just to be an @$$, when a new patient tells me the etiology of their pain is "I have bulging discs" I tell them so does everyone their age. The blank stares of uncomprehension entertains me.

I bet upwards of 50% of my new patient referrals are because someone ordered an MRI of the L-Spine, the radiologists said there were "bulging disks" and either A) they sent the patient to a spine surgeon who wisely said no surgery, go to a pain doc, or B) they send them expecting a LESI for the bulges. Seriously, I get copies of MRI reports with the referral records where they circle the "bulging disc" phrase in the report and handwrite - "Refer to pain for injection." Now the patient comes in expecting a LESI then and there. They are not expecting a full H&P and choices or recommendations. They are focused on a shot.

 

[Tenesma]

PMR

while I share your frustration - and I suspect most of us see a few consults like this each day, I do have a different point of view.

if you have a PCP that you trust, that you have seen for a few years, and you have horrible back pain, and you are told that you have "bulging discs" and to see DR XYZ for some shots to fix the discs... and you have no medical knowledge, of course you will come into an appointment with certain expectations.

I try to train my PCPs that MRIs are only helpful to rule out fracture, infection, cancer and imminent neurologic compromise, and that if patients have back pain and haven't responded to certain key conservative steps, then to refer them to me for an evaluataion.... those patients tends to be easier to deal with.

What I can't stand are the # of patients who come to my practice for "stenosis" because their report at one level mentions "mild foraminal stenosis)... and then, after I tell them that they have no stenosis (based on my review of their imaging), they think I am an idiot because clearly their PCP and the radiologist know what they are talking about.

 

[Dr. Ice]

Sometimes, just to be an @$$, when a new patient tells me the etiology of their pain is "I have bulging discs" I tell them so does everyone their age. The blank stares of uncomprehension entertains me.

I bet upwards of 50% of my new patient referrals are because someone ordered an MRI of the L-Spine, the radiologists said there were "bulging disks" and either A) they sent the patient to a spine surgeon who wisely said no surgery, go to a pain doc, or B) they send them expecting a LESI for the bulges. Seriously, I get copies of MRI reports with the referral records where they circle the "bulging disc" phrase in the report and handwrite - "Refer to pain for injection." Now the patient comes in expecting a LESI then and there. They are not expecting a full H&P and choices or recommendations. They are focused on a shot.

Why do you feel like an ass? I tell all my patients that. Mainly because someone has made them feel like a freak telling them that "something horrible is wrong with their spine." I feel the need to tell these people that they are not dealing with anything uncommon..so I tell them that they are dealing with a normal aging spine and that their pain may be related to muscular issues as well.

My favorite is the 17 year old who comes in with his concerned parents because his PCP told him he "does not have a normal 17 year old spine" just because there may be some mild dessication on imaging. Now I have to totally undo the mental damage that has already been done. Those visits wind up being 45 minutes filled with blank stares and disbelief. So annoying...

 

[Tenesma]

whenever I review an MRI, my first sentence always is "your spine looks quite good actually"... I pause for dramatic effect and measure their response... when patients brighten up and look optimistic - those are the ones that will do well and respond to most treatments... when the patient slumps into the chair and gives me an irritated look, that is the one I will try to avoid using any interventions on - purely anecdotal...

 

[knoxdoc]

whenever I review an MRI, my first sentence always is "your spine looks quite good actually"...

Hilarious - that is pretty much verbatim for me when I walk in the room....then I look at the MRI to see if I'm right.

 

[PMR 4 MSK]

When asked by patients why they have XYZ findings on their MRI, I find myself quite frequently telling patients "Because your spine is no longer 18 years old."

I agree it helps to tell people "Your spine looks pretty good" while sometimes throwing in, "For a spine that's not 18 anymore." It avoids telling people their spine looks the way it does simply because they are old.

 

[Dr. Ice]

Hilarious - that is pretty much verbatim for me when I walk in the room....then I look at the MRI to see if I'm right.

haha..same here!

 

[dc2md]

whenever I review an MRI, my first sentence always is "your spine looks quite good actually"... I pause for dramatic effect and measure their response... when patients brighten up and look optimistic - those are the ones that will do well and respond to most treatments... when the patient slumps into the chair and gives me an irritated look, that is the one I will try to avoid using any interventions on - purely anecdotal...

When asked by patients why they have XYZ findings on their MRI, I find myself quite frequently telling patients "Because your spine is no longer 18 years old."

I agree it helps to tell people "Your spine looks pretty good" while sometimes throwing in, "For a spine that's not 18 anymore." It avoids telling people their spine looks the way it does simply because they are old.

Very clever. I think I'm gonna steal those ideas. Thanks

 

[clubdeac]

Hilarious - that is pretty much verbatim for me when I walk in the room....then I look at the MRI to see if I'm right.

I say the same thing at least 5x a day. Just the other day I had a 40 y/o mildly obese woman come in who had herniated a disk 5 years back. Leg pain resolved with ESIs but back pain persisted. She came in with a new herniation with radicular pain down the other leg. She told me she was so depressed and thinking of going on disability for her DDD b/c a doctor had told her that she had a degenerative process that would only get worse with time. I couldn't believe it. What a horrible self fulfilling prophecy to tell someone! I promptly took the opportunity to tell her he was completely wrong and that her leg pain would most likely improve with ESIs and her back pain could improve as well with some dedicated core conditioning. By the end tears were streaming down her face in disbelief. She said she hadn't felt that much hope or relief since her initial dx 5 yrs ago. Now lets just hope I'm right...

 

[Ligament]

whenever I review an MRI, my first sentence always is "your spine looks quite good actually"... I pause for dramatic effect and measure their response... when patients brighten up and look optimistic - those are the ones that will do well and respond to most treatments... when the patient slumps into the chair and gives me an irritated look, that is the one I will try to avoid using any interventions on - purely anecdotal...

I have scientifically studied this and it is very, very true.

 

[Tenesma]

clubdeac.... please tell me you realize that any patient who goes from wishing disability on herself one moment to believing in miracles the next - is going to have some serious issues....

 

[clubdeac]

clubdeac.... please tell me you realize that any patient who goes from wishing disability on herself one moment to believing in miracles the next - is going to have some serious issues....

Yeah I realize that. I probably sounded a bit naive and idealistic. My point was that patients who get told a specific dx with a hopeless outcome really don't have a chance and most often embrace and become what they've been told - a self fulfilling prophecy. Although I believe she did have genuine tears of relief, I realize it's gonna take a lot of work. At least the first step's been taken to counter the lie she's been living. I guess....