by Stewart B. Segal, MD
GETTING TO THE POINT
by Stewart B. Segal, MD
In response to my good friend Gary’s question, injecting steroids (potent anti-inflammatories) directly into the back often helps alleviate the pain from disc disease and spinal stenosis.
In the past, doctors would treat inflammatory illnesses (see Friday, January 14, 2011 article) with oral medication. An anti-inflammatory medication, such as ibuprofen, naproxen or even a steroid, was swallowed, making its first stop in your stomach. The medicine was then absorbed into the blood stream (systemic), passed through the entire body, processed by the kidneys, all to treat your left 5th finger. While it was the best approach we had, it was like taking out an atomic bomb to kill an ant. Don’t get me wrong. Ibuprofen and naproxen are excellent medications when used appropriately. Steroids have an undeserved, bad reputation. Steroids are powerful medications capable of doing great good but also capable of being harmful when used inappropriately. If everything hurts and is inflamed, then the oral route makes sense. For well localized pain and inflammation, the oral route does not make sense.
Today, we have a host of new options. Modern technology and research have created highly effective topical anti-inflammatory medications. Now, if I need to treat your left 5th finger, I can prescribe Voltaren Gel which is applied to the affected area four times a day. The medicine works at the point of inflammation and pain. While six percent is absorbed into your blood stream, it is far less than an oral dose.
Let’s get back to the treatment of the back. Topical medications do not work on the back. Since topical agents don’t work, the physician is left with high doses of oral medications or getting to the point of pain by injecting directly into the back. Specialists, having determined what the source of the back pain is, can inject a steroidal anti-inflammatory right on the source of the pain, avoiding systemic absorption. If the source of the pain is a pinched nerve, the injection is placed into the epidural space (space lining the nerve). If the pain is in the joints of the spine, the injection is placed into the intra-articular joints or facets.
The fact that a specialist can accurately place a medication into a 2–3 mm space using only radiologic images and his gifted hands is somewhat miraculous. Any one epidural or facet injection has a relatively high failure rate but a series of three over many weeks is most often successful. In my community, there is an incredibly gifted physiatrist, Dr David Schneider, who performs these procedures. His skills and success rate is amazing.
Getting to the point, I am a big fan of treating topically, at the source of the problem!