Requesting a second opinion

Before accepting a proposal for a treatment by a minimally invasive technique or a surgical intervention for chronic pain, ask yourself and your doctor the questions that will allow you to make up your mind.

Don't forget that it is unlikely that your doctor knows the precise origin of your pain, although he tells you he does. The probability of a correct diagnosis varies between 5% and 50%, depending on the pathology responsible for your pain. The only exception is a disc hernia. Only 20% of patients referred to our Pain Center have a correct diagnosis that truly explains their pain condition, when arriving for the first consultation. They have often been subjected to multiple spinal injections of steroids and sometimes even major spinal surgery without any improvement.

Ask your doctor what the precise indication for the injection treatment is, what will be injected, at which dose, and which structure the injection is directed towards. If an injection under CT is planned, remember that this technique is less precise than a fluoroscopic guided injection. It also exposes you to higher X-ray doses and is more expensive for your health insurance provider.

Ask about potential side effects and complications, and if the consequence of your treatment requires someone to accompany you. Don't forget that most radiologists proposing spinal injections do not make any pre-intervention consultations or post-treatment follow-ups.

Some lesser known facts that would help you make an informed decision:

Injection of steroids into the spinal canal for chronic low back pain is not an indication recognized by international scientific organizations. The products injected are not approved for spinal use by the medical authorities nor by the pharmaceutical companies that manufacture them. In case of complications, the doctor making the injection carries the total responsibility, and his insurance will not cover any damage.

Pain radiating to an arm or a leg indicates that there is a nerve being compressed in only 20% of cases. At least 80% of such radiations are referred pains provoked by pathologies in musculoskeletal structures such as facet joints and discs. Referred pain may be associated with decreased power, altered sensations and weak or absent reflexes, adding to the confusion. It is unwise to have steroids injected into your spinal canal or around a nerve root without a clear conception of a precise diagnosis. The MRI only gives reliable information in the case of a disc hernia, and even then, only if there is perfect agreement between the localization of the hernia on the MRI and the symptom distribution.

Arthritic changes on X-rays including CT and MRI are rarely significant in low back pain. Most patients with such changes do not have pain. Only 15% of arthritic joints as seen on X-rays produce pain. When your doctor proposes to inject steroids around your arthritic joints, there is thus an 85% probability the treatment will fail.

A reduction of the diameter of a spinal nerve root hole rarely provokes pain, but rather tingling sensations and occasionally sensory loss in the area supplied by that nerve root. There is therefore no indication to allow someone to inject steroids into a narrowed root hole for pain radiating into an arm or a leg, unless there is proof of the pain being radicular.

Less than 5% of facet joints displaying fluids on MRI are painful. There is therefore no reason to perform a steroid injection around or into congested facet joints because the likelihood of failure exceeds 95%.

Certain pain clinics and radiological services offer therapies that can be considered as experimental, e.g. are not recognized by international scientific organizations because they are poorly documented. These treatments are not reimbursed by your health insurance provider, and some may provoke serious complications. Among these therapies, several are offered for suspected disc pain with the aim of avoiding spinal surgery, such as intradiscal ozone and steroid injections, and percutaneous discectomies. There are numerous examples.

Worth remembering

• It is better to ask for a second opinion on the relevance of the proposed treatment (is it the most appropriate?) rather than facing a high risk of failure and potential complications, which may well result after an inappropriate procedure performed for an incorrect diagnosis.
• The chance of success cannot be greater than the precision of the diagnostic techniques used to decide on the indication for therapy.
• A 10% success rate for a therapy billed 1000 CHF costs CHF 10,000 to the health care system per success