Should I have a steroid jab in my spine for back pain?
Q I’VE SUFFERED from back trouble since I was 63. Then, at 72, it was diagnosed as central canal stenosis. At the time, I was told a caudal epidural might be beneficial but I didn’t pursue it. I am now 77 and my balance is worse. Should I have the epidural? Tony Woodward, Bingham, Notts. A Caudal epidural is another name for a steroid injection into the spinal canal, the channel through which the spinal cord runs. The treatment is used to ease lower back or lumbar problems such as radiculopathy (when a disc ruptures and presses on a nerve supplying the leg), or osteoarthritis in one of the facet joints (those that sit on either side of the vertebrae), which causes swelling and compression of a nerve.
another cause of lower back pain is spinal stenosis, which is what you have. With this condition the spinal canal becomes narrowed, typically as a result of osteoarthritis — the wear and tear of age. It’s more common in people over 60, with genetic factors and obesity playing a part.
as we age, the discs between the vertebrae deteriorate and bulge, and this in turn may alter the way the spine carries body weight, putting greater pressure on the facet joints, the buttresses that support either side of the spine. In response, the body’s repair mechanisms switch on, forming new bone, osteophytes, on the joints.
These boney lumps, together with the discs and the thickening of soft tissues, can encroach on nerves as they emerge from the spine. The spinal cord ends at about the level of your lower ribs — below this it is known as the cauda equina — and then branches to the left and right outside the spinal canal, forming the sciatic nerve, the main nerve supply to each leg.
The result is pain. This is the most common symptom (affecting 90 per cent of patients) either from compression of the nerves directly, or the same effect caused by an increase in pressure in the canal, reducing blood flow. There may be other neurological symptoms, too, including numbness or tingling affecting one or both legs (60 per cent of patients) and weakness (40 per cent of patients).
The symptoms may be worsened by walking or standing and are relieved by sitting or reclining. Balance can also be affected, mainly because the legs are weakened.
Spinal stenosis usually progresses slowly — your tenyear experience illustrates this — and in general, surgical treatment, to remove the osteophytes, for instance, is necessary only in the most serious progressive cases where the symptoms become intolerable.
With a caudal epidural, a steroid is injected into the lowest part of the spinal canal, through a space called the sacral hiatus, to help reduce the tissue swelling. However, potential hazards include the chance of infection.
Other treatments include simple painkillers, nonsteroidal antiinflammatory drugs in short courses and physiotherapy. But there are few, if any, large studies supporting any of these options.
despite this, I would opt for the epidural as it might make a considerable difference, and in good hands, the potential risk of infection is minimised. Q I WOULD like to have the flu jab, but when I was 20 (I am now 66) I reacted badly to it and fainted or collapsed, ending up in hospital for a day.
I do not know if this was to do with my general health — I was very thin and hadn’t eaten on the day — or some form of anaphylactic shock.
I believe that an egg-based chemical may have been in use at the time, and my system is intolerant to food containing gluten, wheat, milk, eggs and yeast. Symptoms include bloating, discomfort and poor sleep.
How can I check to see if the current vaccine will give me a similar reaction to that experienced nearly 50 years ago? Or should I just have it anyway? Robert Harris, Knebworth, Herts. A YOu are quite right to ask this question. Even today, flu vaccines are manufactured using an eggbased process — every dose is developed in an egg and contains traces of egg protein.
For this reason they may not be safe if administered to a person with an egg allergy. The worst case scenario is acute anaphylaxis, a lifethreatening allergic response.
The difficulty here is that we don’t know for certain what caused your collapse at the time. If it was accompanied by urticaria (or hives), a widespread itchy skin rash, it was probably an allergic reaction. Other signs of a more severe reaction would be swelling of the mouth and throat, and difficulty breathing.
However, you would probably remember if you’d had these symptoms (your food intolerances are not necessarily a confirmation of an allergy).
I suspect the most likely cause of your collapse — given that you don’t recall the reactions I describe — was a genuine fainting episode. Such events are not uncommon when people are given injections and are not due to an allergy.
For reasons that aren’t entirely clear, signals are sent from the brain down the vagus nerve to the heart, causing a sudden slowing of the heartbeat, followed by a drop in blood pressure.
Nevertheless, we should be cautious (not least because we shouldn’t rely on the memory of an event that happened more than 40 years ago).
It would be wise for you to check for egg allergy with both a skin test (in which a tiny amount of egg protein is put on the skin to observe for a localised reaction) and a blood test (to check for antibodies to fight egg protein).
This should be carried out at an allergy clinic — your GP could refer you.
If the tests are negative, I’d suggest having a flu vaccination in October, but taking an antihistamine tablet (for example, 4mg chlorpheniramine) one hour before the injection.
You should also remain at the GP surgery for 30 minutes following the injection.
If your allergy tests prove to be positive, then follow the advice of the allergy specialist.
It might be possible still to receive the flu vaccine, but possibly with more potent allergy suppressant cover, such as a shortcourse of an oral corticosteroid (for example, prednisolone).