How many injections are “too much”?

[painfree23]

I have patients ask me all the time , “can I keep doing these ESIs every 3-6 months for the rest of my life”? If they are like 80…my answer is always yes. I always struggle with how to answer the 40 or 50 year olds that get 80% relief for 3 months from an esi to treat their radicular symptoms from a disc or multilevel stenosis. Any tips?

Thanks

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[callmeanesthesia]

Just tell them eventually they will likely progress to the point of needing surgery (or in the case of a herniation eventually it will likely get better) and the goal is to delay surgery as long as possible.

If you’re not sure where the risk/benefit line lies, discuss with them long term risks of steroids and have them see a surgeon you trust to find out what surgery would involve.

 

[SpineandWine]

Related to that. How often does one do stacked injections- for example, patient gets 50% relief, would you schedule another for additional relief?

 

[SSdoc33]

sigh

 

[pmrmd]

Too much: More than 40mg per injection, more than 200mg per year, more than 400mg over three years (triamcinolone equivalents) IIRC

The effects of dex on adrenals is no fleeting it has to be a different number if using only that.

 

[willabeast]

Related to that. How often does one do stacked injections- for example, patient gets 50% relief, would you schedule another for additional relief?

Depends on how well the dye hit the target. If a technically good injection, doubt another one soon after will do anything other than increase risks. If a mediocre dye study first injection, might be worth another try with a different technique. For example - caudal ESI gives 50% relief L5S1 herniation. Try a S1 TF to see if any better result. Which does not really answer your question. IMHO stacked injections are not useful.

 

[RoloTomassi]

Agree with above. If at 50% and patient wants a second, I'll almost always do different approach and steroid

 

[Ducttape]

"only if you need them and they continue to help. the pain may change over time. it may become more manageable, in which case you dont need injections. it may get worse, then you should see a surgeon to see if there are surgical options, though there are a lot of risks with surgery."