Spinal Injections

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34 Comments

  • Sylvia Wierick

    Reply Reply August 26, 2011

    Dr. Best,
    I am a member of your website. I wrote you with a question on August 19th, I believe and have not received an answer. My understanding from your website is that I would have an answer by now. Are you on vacation or what?
    Thank you for a response.

    • Dr. George Best

      Reply Reply August 26, 2011

      Hi Sylvia,

      Actually, I received your email on August 22 and sent you a detailed response the same day. Perhaps it went to your spam box (for future reference, please add info@sciaticaselfcare.com to your address book / approved senders list). The short version of my response is that I requested you send me information regarding the findings of any imaging you’ve had done to allow me to better assess what’s happening with you and give you more specific advice. Please email me what information you have and we’ll go from there.

      Dr. Best

  • mkraju

    Reply Reply September 18, 2011

    i have a sciatica and numbness.is it advisable to have an steroid injection or to go to surgery?

    • Dr. George Best

      Reply Reply September 19, 2011

      It depends on the underlying cause of your symptoms. In the event of a full disc rupture, a severe disc herniation, and/or severe narrowing of the bone canals from degenerative bone spurring, surgery may be needed. In most other cases without these severe underlying causes, surgery is not needed and the symptoms will gradually improve with the self-treatment methods on this website, with or without some additional help from spinal injections, medication, or physical therapy.

      Dr. Best

  • Peter Adamack

    Reply Reply January 12, 2012

    Hi Dr B

    I am 63 and have had sciatica for the past two years. Usually flairs up in November as the Golf season is over. 7 months (March to October).

    I have spoken to my Doctor and he has mentioned that injections can be beneficial. I do not want to have surgery if possible.

    I have been doing the exercises you have recommended, improvements are very slow.

    What do you think about Inversion tables? and can they make things worse?

    Lastly, I had a hip replacement 7 years ago, All is ok with range of motion, and I have no pain, except that I have developed a problem where I can walk about a mile, then my hip starts to ache (have to sit down for 10 minutes or so). I read the surgeons report on my operation and it states that while operating the sciatic nerve was placed to one side ( I guess it means that they were careful) could this have anything to do with my walking ache? or even Sciatica.

    Thank you in advance

    Peter A

    • Dr. George Best

      Reply Reply January 13, 2012

      Hello Peter,

      You didn’t say what if any diagnostic procedures have been done to evaluate the cause of your sciatica. Since it comes on after golf season, rather than during, it may be primarily muscle referral pain from the piriformis and/or gluteus minimus muscles rather than true sciatic nerve irritation. Muscles tend to stay looser while you’re more active, so they may be knotting up after golf season because you’re not moving around as much. If that’s the case, stretching and massage will probably be helpful.

      Inversion tables are usually helpful, but they can irritate symptoms when there is severe pain and inflammation present. If your symptoms are relatively tolrable, inversion is probably worth a try – just start slowly doing just a few minutes at a shallow downward angle at first.

      The hip ache you described probably is muscular since the other common cause of that type of symptoms is arthritis, but that’s not an issue with a joint replacement. Since it is a little difficult to get a good stretch where it is needed with a replaced joint, massage from either a massage therapist, or simply finding sore spots and rubbing them with firm pressure yourself will probably help.

      Good luck!

      Dr. Best

  • peaarlina brown

    Reply Reply January 14, 2012

    After viewing the video I did not see the website indicated to be shown at the bottom of the video. ow can it be located?

  • Peter A

    Reply Reply January 15, 2012

    Dr Best, Thanks for the return information.

    Referring to my last note, If my problem is (muscle) and not (nerve) after Golf seasons ends would it be fair to say that exercises for muscle problems is the best solution? This past summer my problem did not effect my Golf swing only when the season was over (4 – 6 weeks later).
    I do have serious pain that runs down my leg, is this not Sciatica? (especially just below my knee). There are times when I have a hard time walking, also does your body tilt to one side if the problem is muscle related?
    I was a bit skeptical initially regarding the (mackenzie) exercise, I thought it was a waste of time to simply lay on the floor. Then I tried it I could stay on my elbows for about 10 – 15 seconds, then I had to lower myself to the floor. (there was serious pain) again would this happen if I had a muscle problem?

    Thank you again in advance for your help.

    Peter A

    • Dr. George Best

      Reply Reply January 16, 2012

      Hi Peter,

      Golf would tend to really irritate a nerve compression problem such as from a herniated disc and it would cause increased symptoms while playing golf, not several weeks after you stopped playing. On the other hand, trigger points in the muscles will tend to be better with activitiy because they get more circulation. When you become less active, you don’t get as much circulation through the muscles and the trigger points will tend to become more active symptom generators.

      The severity of the pain does not indicate the source of the problem. Muscle referral pain can be just as painful as nerve compression and can poduce symptoms that are essentially identical to sciatic nerve irritation (true sciatica). Tilting (bending to one side or having the appearance that one leg is longer than the other) needs to be distinguished from a sideways shift (where it looks like the upper body has been slid sideways on the lower body). Tilting can be caused by any kind of uneven muscle contraction. Sideways shifting is usually associated with a an acutely inflamed disc herniation.

      When the McKenzie extension exercise immediately causes a lot of pain that is mostly in the low back, this is a sign of spinal arthritis as the exercise pushes joint surfaces closer together and arthritic joints are often inflamed. If it causes increased symptoms down the leg, this is a sign of degenerative arthritic changes at the back part of the spine (bone spurs, synovial cysts, ligament thickening, and/or associated swelling)narrowing the spinal canals. This type of problem has different reactions to activity in different people. In some cases, activity (like golf) improves symptoms and inactivity increases symptoms. In other cases, or even at other times for the same person, it is the other way around. Even when there are underlying issues with degenerative arthritis, muscles are often signficant symptom generators and things like stretching and massage are usually helpful even though they don’t alter the arthritic problems at all.

      Dr. Best

  • Thomas W. Yale

    Reply Reply January 18, 2012

    Dr. Best,

    I couldn’t pass up the opportunity to express my gratitude for educating me on the subject of sciatica. I have either inflammation or herniation of the disk between my L4 and L5 vertebrae for which I am receiving treatment from a chiropractor, am performing the exercise to push the disk forward away from the sciatic nerve, and am applying ice packs to reduce the inflammation/herniation. Thanks to you, what was excruciating pain weeks ago has diminished to persistent but milder discomfort. I avoid all anti-inflammatory drugs and have firmer grounds on which to refuse unnecessary, expensive—and risky—surgery. I now understand that, as there is no “cure”, and even when I have completely recovered from my affliction, I will nevertheless perform the exercise as a preventative measure.

    Thank you so much.

    Sincerely,

    Thomas W. Yale

    • Dr. George Best

      Reply Reply January 19, 2012

      You’re welcome, Thomas. I’m glad that you’ve found my information helpful.

      Good luck for continued recovery.

      Dr. Best

  • Peter

    Reply Reply January 19, 2012

    Hi Dr Best, and thanks again for getting back to me.

    In you last note you mentioned diagnostic procedures (do you mean MRI or CT).

    I seem to be in a position where I am not 100% sure as to wheather my problem is nerve or muscle.
    I tried the sitting in a chair and lifting my leg (no pain) so I figure it has to be muscle.

    I have also been given advice that an MRI is needed only if surgery is necessary do you agree?

    Recently, I seem to have pain directly on my knee cap (nerve I guess) but it can be quite painfull.

    I really want to get to the bottom of what it is I have. I am probably wasting my time if I don’t know. I may be headed in the wrong direction altogether. I will do whatever is necessary (exercise or whatever) Does this make sense to you.
    Is there a foulproof way to determine if it really is Sciatica? or just a muscle spasm? or arthritis?
    It is very frustrating not knowing what direction to go.

    Once again, thanks for your help.

    Peter A.

    • Dr. George Best

      Reply Reply January 19, 2012

      Hello Peter,

      MRI is preferable to CT for image quality but if you’ve had any kind of metal implantation in your body (joint replacement, surgical staples, etc.), you have to do CT instead (because the magnetic field of an MRI machine is so powerful that it can literally rip metal implants out of the body and at the very least make having an MRI extremely painful). If someone is improving consistently, even if it is slowly, I don’t think an MRI or CT is necessary, but when someone is not improving, diagnostic imaging is an important tool to figure out why someone is not improving. To say that MRI is needed only if surgery is necessary misses the point – you don’t really know whether surgery is necessary (the definition of which can vary greatly) without taking steps to diagnose the problem, such as doing an MRI when a patient is not improving in a reasonable amount of time.

      Now, don’t tell anyone I told you what I’m about to tell you because it’s the best-kept secret in health care and if anyone finds out I’m letting the cat out of the bag, my life could be in danger (just kidding – sort of!): Nothing in health care is really foolproof and while doctors would like you to believe that diagnosis is always scientific and definitive, that’s just not so. In fact, just because you find something on an MRI or other diagnostic test does not necessarily mean that is the cause of the symptoms. Diagnosis is really a best-guess that is based on all of the available information. In most instances there are multiple possible causes, and in some cases the symptoms may be a result of more than one thing. So, you start with treating the most obvious or most likely issues and modify treatment or run additional tests if needed, depending on the results. In the case of sciatica symptoms you can run neurodiagnostic tests to see if the nerve is involved. But even then that only narrows it down to a nerve issue – you have to look at other things to try to determine the cause of the nerve issue since nerves don’t just get inflamed for no reason. Xrays will tell you if there is arthritis, but in many cases arthritis (even severe arthritis) is asymptomatic, so just because there is arthritis present, it doesn’t mean it the cause of the symptoms (this is true of disc problems as well). In many cases treatment winds up being the ultimate diagnostic test – if you treat for arthritis and things get better, then the assumption is made that the problem was arthritis. If things don’t get better, you look for something else. And if all treatment measures fail and the doctors can’t figure out what’s wrong with you, then there is only one possible diagnosis – it’s all in your mind (because after all, doctors know everything and if they can’t figure out what’s wrong with you, there’s obviously nothing actually wrong with you and you must be imagining it)!

      My purpose in telling you this is let you know what to expect and to encourage you to try to be patient with the process. You might very well go down the wrong path for a while and get delayed in finding a solution. The good news is that most of the things you might try won’t do any lasting harm, so even if they don’t do much to help you, they won’t do much to hurt you either. I know it is frustrating to have to take a trial and error approach, but unfortunately that’s just the way it is in a lot of cases.

      What I can tell you is that in my 20 years or so of practice most of the cases I’ve seen appear to at least have a muscular component, even when there are other problems present, so you can’t go too far wrong addressing the muscle problems regardless of whatever other treatment you do.

      Good luck!

      Dr. Best

  • Peter A

    Reply Reply January 19, 2012

    Dr Best,

    Thank you for your recent, timely response. (Very Impressed)

    This problem is much more complex than expected. I think that I now have a much better understanding of what is going on. I will try to be patient and do whatever is necessary.
    When my situation is resolved, I’ll be in touch.

    Once again thank you for your help,

    ps, I will keep your secret.

    regards,

    Peter A

  • Mike Ellis

    Reply Reply February 2, 2012

    Succinct but informative videos, good job. Thanks.

  • Lilia González Burunat

    Reply Reply February 25, 2012

    Dr. Best soy una persona que tengo 66 años y afortunadamente tengo buena salud y camino todos los días y hago una rutina de estiramientos durante 40 mins diariamente. Fui operada de mi columna hace 33 años de la 4ta y 5ta vertebra lumbar por un desgaste de disco en el cual se me implanto hueso de mi cadera. A partir de ese momento siempre he tenido que hacer ejercicio pues amanezco con dolores todos los días y el ejercicio me hace sentir bien, Tengo la pierna izquierda mas corta que la derecha desde que nací 3cms. Hace tres meses mi quiropractico me recomendo que me le pusiera a mi zapato izquierdo un aumento de dos centimetros para ayudarme a compensar el desgaste que mi columna puede seguir sufriendo por los años y me dijo que esto me iba a ayudar y que el cambio en mi estructura osea iba a a doler un poco pero con el tiempo me sentiría mejor. Desde entonces todos mis zapatos hasta mis tenis tienen, el aumento sin embargo me empezo a doler el ciatico de la pierna derecha y trato de hacer mas estiramiento y masajes y lo que me lo quita es el paracetamol pero lo tengo que tomar todos los días, eso no importa pues se que no tiene grandes efectos secundarios pero al leerlo a usted quiciera saber que más puedo hacer y si estoy en lo correcto. Mil gracias Lilia González

  • Howard

    Reply Reply August 28, 2012

    I HAVE L4 PERTRUDING SLIGHTLY FORWARD AND TO THE RIGHT.ALSO A BONE SPUR AT SAME LOCATION.WHAT EXERCISES SHOULD I DO TO BRING VERTEBRAE BACK TO NORMAL.POSITION .

    • Dr. George Best

      Reply Reply August 28, 2012

      If the vertebra (not the disc) is shifted forward, this is a condition known as spondylolisthesis (which is Latin for “spine slippage”). There are two main underlying causes. One is a defect in the part of the vertebra between the neural arch and the vertebral body which produces a separation between the front and the back part of the vertebra. The other is degenerative arthritis in the spinal joints that causes thickening of the bone on the joint surfaces that displaces the vertebra forward. Neither cause can really be corrected by exercise, but further slippage in the first type can be minimized by keeping the abdominal muscles strong (with exercises like crunches). In the case of spondylolisthesis caused by degenerative arthritis, there is limited progression of the slippage, so exercises are primarily directed at stretching tight muscles for symptom control (knee to chest stretches and rolling face down across an exercise ball are two commonly-prescribed exercises for this purpose).

      Dr. Best

  • Rosy

    Reply Reply January 12, 2013

    I am a certified massage therapist in US. What is required to be a massage therapist in Puerto Rico?

    • Dr. George Best

      Reply Reply January 12, 2013

      Well, Puerto Rico is actually a U.S. territory, but to my knowledge licensure for massage therapy for any state/territory is done through the state/territory board of health, or in some cases there may be a separate board of massage therapy. For Puerto Rico, I found the following information:

      The Puerto Rico Department of Health (www.salud.gov.pr) handles the certification of all health professionals, including nurses, dentists, pharmacists, veterinarians, undertakers, etc. To obtain more information contact The Office of Regulation and Certification of Health Professionals at (787) 723-2885 or 725-7506, (787) 725-8161 or (787) 725-8121.

      Good luck!

  • Howard

    Reply Reply January 23, 2013

    Dr. best,Hope you can help. I have grade 1 spondylolithesis, left ridiculopathy of L4-Ll5, and severe central canal stenosis .Also have disc bulges of L4-L5 flattening the thecal sacs on all. I had 1 ESI so far.Followed up with therapy and have started exercising at gym( limited). was great for about 2 months.Started getting pain again down back of both legs 1/2 way down.Continue doing stretching exercises, but have pain all day.would say pain level averages 5-6.No pain while sitting.What would you suggest.They tell me because of the severity of the stenosis, I will ultimately need surgery,not only to open up spinal canal, but to stabilize L4- L5. Should be absolutely fine after rehab of 3-6months.What are your thoughts? Thank you.Seen all of your related videos and gained a lot of knowledge.

    • Dr. George Best

      Reply Reply January 24, 2013

      Hello Howard,

      Central canal stenosis can be caused by different things and the cause makes a big difference as to what the best treatment options are. If the stenosis is mostly due to disc bulging, exercises and anti-inflammatory measures (cold packs, medication, etc.) will often be sufficient to manage the issue, but surgery is sometimes needed. If it’s congenital (you were born with a narrower canal than normal) and/or due to degenerative bone and ligament thickening, symptoms can sometimes be controlled for a while with exercises and anti-inflammatory medication, but surgery is usually needed eventually to trim away the excess bone, ligament, and other tissue.

      With regards to the spondylolisthesis, a grade 1 is usually quite stable, and when found in adults, it’s highly unlikely to progress to the point where it would need stabilization. It kind of sounds to me like the doctor may be trying to justify an “open” surgery when you would probably do just as well with a “minimally invasive” procedure. If you do wind up needing to consider surgery, I’d recommend at least getting an opinion from a surgeon who does minimally invasive (done through small incisions using a scope) to see if that is an option in your case. If you are a candidate for minimally invasive, the recovery is a lot faster and there are much fewer issues with post surgical scar-tissue.

      One of my big pet peeves with spine surgeons is when they give unrealistic expectations to people to talk them into surgery. It’s very unusual for anyone to be “absolutely fine” after open spine surgery – EVER, let alone 3 to 6 months. Most are better than before the surgery (some are the same or worse), but almost everyone still has some residual symptoms to varying degrees that last for the rest of their lives. People who have minimally invasive surgery seem to fare considerably better overall, but it’s far from perfect. Surgery may be necessary in some cases to get lasting symptom improvement, but it rarely returns them back to completely normal. My rule of thumb for deciding whether to have surgery is to ask yourself whether or not you can tolerate the symptoms as they are. If the answer is yes, I would not go for the surgery. If the answer is no and you have exhausted the other potential treatment options, then it’s time to go forward with the surgery.

      With regards to self-treatment, since you have no pain when sitting, my guess is that you would do best using the flexion (forward bending) position for the MxKenzie exercises, at least at first. I’d recommend investing in an exercise ball for doing the flexion exercise if you don’t already have one and use that position for a minute or so at a time several times per day. If you have some combination of disc bulging and degenerative bone stenosis, you may actually need to use both flexion and extension exercises, or start out with flexion and periodically add in some extension, so test the various positions on a regular basis and do whatever centralizes/relieves symptoms. Cold packs will help reduce inflammatory swelling, so as long as you are having symptoms, I suggest using them for 15 minutes or so at least a few times per day.

      If you have further questions, let me know.

      Good luck!

      Dr. Best

  • Rich

    Reply Reply March 26, 2013

    Dr. George,
    There are at least 2 other injections I can think of that you didn’t mention:
    Facet injects, of which I’ve had several for supposed facet
    arthropathy but no relief; and Perispinal Etanercept (Enbrel) which
    I’m trying to learn more about. Please share your thoughts as I’ll do just about
    anything to avoid invasive procedures such as surgery.
    Thanks

    • Dr. George Best

      Reply Reply March 27, 2013

      Facet injections my be helpful in some cases of low back pain, but they’re pretty useless for sciatica in most cases.

      While perispinal etanercept is very effective in some cases, it is not yet widely available and studies on its overall effectiveness have had mixed results. It’s also currently “off-label” for the treatment of sciatica, meaning it is not yet FDA approved for this particular purpose, and therefore will probably not be covered by insurance. Despite the hype surrounding it, the way it works is supposedly by suppressing inflammation. While perispinal etanercept may or may not prove to be superior in effects and have fewer side-effects than cortisone injections in this regard, as with steroid injections, it probably will not help much in cases where there is significant direct nerve compression from protruding discs, degenerative bone and ligament thickening, etc., as opposed to symptoms coming primarily from the pressure of inflammatory swelling. One recent study has shown that the therapeutic effects of steroid injections are actually superior to perispinal etanercept (see: http://www.ncbi.nlm.nih.gov/pubmed/22508732), but more comparison studies may yield different results, so in my opinion, the jury is still out.

      Dr. Best

    • Lisa

      Reply Reply December 6, 2017

      No No No..do not let them do surgery. I’ve had 2 failed spine surgeries my scar is 15 inches long. I’m worse now than I was before the surgery. I can only walk from point A to point B..very off balance and wobbly. The pain from my lower spine radiates down my left leg all the way to my toes..ive done physical therapy 6 times..accupuncture..at least 15 injections..tens machine..ice..exercising..and still can’t walk without severe pain..i could no way walk 1/2 block..im so sorry I ever went under the knife..i break down and cry at least 10 times a day..i have no life whatsoever..pain management makes you feel like an addict..if i don’t get some kind of break soon..its not looking good..im highly allergic to steroids.so maybe that’s why they don’t work..dr keeps wanting me to get them..i told him NO I’m done..if anyone knows of anything I can do to get some kind of releif.please email me..i know exactly what everyone is going through..this is no joke..and I CAN’T TAKE THIS PAIN NO MORE..PLEASE HELP ME SOMEONE..

  • Susan Gautsch

    Reply Reply May 16, 2013

    Hi Dr. – do you have any information on something called Anti-TNF treatments for sciatica. There is a web sit for INR – Institute of Neurological Recovery. What does that injection do? Thank you

    • Dr. George Best

      Reply Reply May 16, 2013

      Anti-TNF is a relatively new means of treating inflammation. It works very well for some people, but is most likely to be effective in less severe cases of disc herniation in which inflammatory swelling is a significant symptom generator as opposed to more severe cases in which the protruding disc material itself is producing significant nerve compression. While it’s promoters claim it to be a superior new treatment for back pain and sciatica, the independent research so far has not supported that assertion. In fact, a recent study showed that the long-established treatment of steroid injections achieved statistically much better results overall than anti-TNF. Anti-TNF may have fewer side-effects than steroids, but it’s still a little soon to even say that with any certainty.

    • Lisa

      Reply Reply December 6, 2017

      Dr wants me to get implanted spine stimulator..i said no.saw to many bad review’s..pain meds barely take the edge off..im never completely out of pain unless i lay with a pillow between my legs.

    • Lisa

      Reply Reply December 6, 2017

      The only thing I got from injections was hair growing on my face and gained about 40 lbs. I had a severe reaction for about 3 weeks..i didn’t even know where i was..

  • Ronna Sittig

    Reply Reply November 27, 2017

    What do you think of “dry needling”?

    • Dr. George Best

      Reply Reply November 27, 2017

      Dry needling is a way of releasing trigger points and other soft tissue constrictions. It can be effective when the problem is primarily muscular or fascial (fascia is the tissue that covers and separates muscles and organs from each other). While some inidviduals get better results from dry needling than other soft tissue release methods (massage, stretching, foam rolling, etc.), in my opinion it is not a better method in general than other soft tissue techniques. The purpose and intent of dry needling is very different from spinal injections, which are used for delivering anti-inflammatory or pain blocking medication directly to the area of nerve irritation.

      Dr. Best

  • Lisa

    Reply Reply December 6, 2017

    Dr wants me to get implanted spine stimulator..i said no.saw to many bad review’s..pain meds barely take the edge off..im never completely out of pain unless i lay with a pillow between my legs.

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