Frequently Asked Questions

John De Angelis, M.D.

I recently had a consultation by a spine surgeon for back pain. He discovered a ruptured disk. He advised epidural blocks. Does the epidural injection make the pain and the ruptured disc go away?

A ruptured disc can cause nerve inflammation, nerve swelling and severe pain. Epidural injections counteract these effects and frequently, but not always render the pain and disability inactive. The ruptured portion of the disc, however, remains the same, but without the pain and disability. Your surgeon is doing everything he can in an effort to avoid back surgery. He is conservative. That’s good.

I have been diagnosed as having shingles of my eye. I have severe pain and swelling resulting in the closing of the affected eye. Oral medications have not been helpful. What can be done to control the pain and swelling?

Shingles of the eye, herpes zoster, is caused by the same virus responsible for chicken pox. It can be extremely painful with burning, throbbing and itching. Inflammation, blisters, scabs, and swelling frequently occur. An effective treatment (Stellate ganglion block) is used for resistant cases. The procedure temporarily anesthetizes a related bundle of nerves in the neck. The procedure is often dramatically successful in reducing pain, swelling and inflammation.

My primary care doctor has referred me to a pain doctor for 3 epidurals for my low back pain. What is magic about the number 3 or why do I need 3 injections?

One epidural injection is sometimes all one needs to relieve 100% of the pain. If this occurs, then a 2nd and a 3rd is usually not necessary. If there is any pain left after the first and/or the 2nd epidural another epidural is a wise option. If there is significant pain following the 3rd, then other low back structures should be investigated as possible sources of pain and if discovered then treated.

Is it possible that my chronic headaches are caused by structures in my neck? If the answer is yes, then is there a method that can be used to find and treat the responsible area?

The neck (facet) joint is one of the many causes of headache. Neither the presence nor the absence of MRI changes confirms the diagnosis. The diagnosis can only be made by diagnostic injections. While you are experiencing headache, an anesthetic is placed near the joint’s nerve. If the headache is absent or near absent following the injection, the headache is, for the most part, caused by facet joints.

I have had several cortisone injections in the small joints in my neck and my low back but never obtain relief for more then 2 or 3 weeks. Is there any drug or procedure that gives a long term benefit?

Spine surgeons have known for years that these injections of medications into the facet joints of the neck or low back do not give long term benefit. Before any facet joint treatment is performed, one must make certain that the facet or facets are the reason for the pain. Once diagnosed the most successful treatment is termed radiofrequency. This procedure usually gives 6 to 12 months of pain relief. The radiofrequency is usually repeated when the nerves regenerate (regrow) and become active once more.

My primary care doctor advised me to have my epidural injection performed by a physician who uses fluoroscopy. Why?

Neck epidural injections performed without the use of fluoroscopy (Continuous X-Ray), misses the target or area of pain in 50% of the cases. Epidural injections in area other than the neck miss the target in 30 to 40% of the cases when fluoroscopy is not used. If the procedure is done without fluoroscopy and does not work, it may not have worked because the intended area of pain was not reached by the medication.

I was referred to a pain medicine doctor for epidural spinal injections. The doctor would not perform the injections because I had an active infection. Why?

Ideally, spinal injections should not be done for patients with any potential infection. Spinal cord infections have occurred when epidural injections were performed in the presence of infections in areas far removed from the infection site. There are always exceptions.

After a complete physical examination and X-rays, I was informed that my low back pain was caused by the sacroiliac joint. How can I be sure that my pain is in fact coming from my sacroiliac joint?

The physical examination and X-ray will not and can not determine whether or not back or thigh pain is caused by the sacroiliac joint. The diagnosis of sacroiliac pain can only be made by using X-Ray guided diagnostic injections. If the injections block or eliminate the majority of the existing back or thigh pain, the pain is coming from the sacroiliac joint. If most of the pain remains following the injection, then the pain is not due to the sacroiliac joint.

I asked to be “knocked out” for a spinal injection. Why was this request refused?

The doctor can not see the spinal nerves during X-ray guided needle insertion. When awake, needle contact with a nerve which has not been bathed in anesthetic causes the patient to experience an “electric shock.” This alerts the doctor not to insert the needle any further. If the patient is “knocked out,” needle contact with the nerve would not be noticed by the patient, no warning would be given to the doctor and the needle could be inserted into the nerve and do damage.

During a recent extensive medical examination a ruptured disc was discovered in my low back. I have no problems with my back or lower extremities. What should I do?

Twenty four percent of a group of patients without back pain or lower extremity symptoms had MRI evidence of a ruptured disc. These patients did not need any treatment because the ruptured disc produced no problems. If you have a ruptured disc and your doctor determines that there are no problems as a result of this finding, it is best left alone.

I have low back pain with a herniated disk. Should I have surgery?

The ruptured disc may or may not be responsible for your pain. There are several back structures capable of producing very similar back pain. These structures include the disc, small joints (facet joints), the sacroiliac joint, ligaments, fascia and muscles. The ruptured disc can be treated if it is determined that it is the cause of your pain. If tests reveal the disc not to be at fault then other structures can be investigated.

I am a male and 76-years old. My low back pain extends down my thigh to my calf. My pain occurs only after I start walking and stops when I rest. The MRI of my low back is abnormal. Are these symptoms related to the abnormal MRI findings?

Your symptoms sound more like poor blood circulation rather than a low back problem. The lack of blood circulation (vascular insufficiency) is characterized by calf pain after walking with a quick relief after you stop walking. In vascular insufficiency there is often an inability to feel the foot pulse on the painful side.

Since my lung surgery 8 months ago I have had persistent and severe pain at the surgery site. A complete evaluation did not reveal tumor recurrence, nerve damage or other causes. Medications have not helped. What can I do?

A promising treatment with a low potential for danger is the injection of Botox into the painful areas. This procedure has been used successfully to deaden the nerve endings which are responsible for the pain perception.

I have been told that I have sciatica. What can be done for the condition?

Sciatica is a term used to describe pain going from the low back into the buttocks and down the backside of the thigh and leg. The pain is caused by irritation of a spinal nerve. Disc herniaion (rupture or extruson) is the most common cause. To find the actual cause one must do diagnostic tests. Once the cause of the sciatica is determined, the appropriate treatment for the specific diagnosis should be initiated.

Why did my doctor put me on an antidepressant drug when I my problem was a pain disorder?

Some antidepressants have pain relieving properties as well as anti-depressant activity. Amitriptyline commonly known as Elavil is one of the oldest of the antidepressant agents used in the treatment of some types of pain. This category of drug can be used for pain with or without depression.

Can pain cause psychological problems or distress?

The answer to the question is yes. A recent study discovered that psychological distress vanished following a pain treatment procedure which completely relieved the patient’s pain. No psychological therapy was used. The study concluded that the psychological distress exhibited by these patients was a consequence of the chronic pain.

What is spinal stenosis of the low back?

Spinal stenosis is a narrowing of the bony spinal tunnels or canals that are occupied by the spinal cord and its nerves. The narrowing produces nerve pressure, irritation and pain with motion in the close-fitting canal. The bathing of the spinal cord and its nerves with injected medication is often helpful. In severe and debilitating cases surgery may be necessary.

I had been free of back pain for 8 years following my lumbar herniated disc surgery. Pain has returned to the same area. How can the pain come back after the disc was removed?

The surgery was successful in that your pain was alleviated. Your pain may or may not be due to another disc. There are several other causes of pain which cause the same pain as does a protruding or ruptured disc. Two examples are small joints which connect the vertebra to each other and the sacroiliac joint.

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