title: Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review.
abstract: BACKGROUND
  Epidural steroid injections (ESI) in the lumbar spine are not effective over the long-term for resolving "surgical" lesions. Here, we present a patient with a massive L2-L3 lumbar disk herniation whose surgery was delayed for 4 months by multiple unnecessary ESI, resulting in a cauda equina syndrome.
  
  
  METHODS
  A 54-year-old male acutely developed increased low back and radiating left leg pain in October of 2014. In December of 2014, a magnetic resonance imaging (MRI) scan showed a massive central/left sided disk herniation at the L2-L3 level resulting in marked thecal sac and left L2 foraminal and L3 lateral recess root compression. Despite the marked degree of neural compression, pain management treated him with 3 ESI over the next 3 months.
  
  
  RESULTS
  At the end of April of 2015, he presented to spine surgeon with a cauda equina syndrome. When the new MRI scan confirmed the previously documented massive central-left sided L2-L3 disk herniation, the patient emergently underwent an L1-L3 laminectomy with central-left sided L2-L3 lateral/foraminal diskectomy. Postoperatively, the patient was neurologically intact.
  
  
  CONCLUSIONS
  Pain specialists performed multiple unnecessary lumbar ESI critically delaying spinal surgery for 4 months in this patient with a massive lumbar disk herniation who ultimately developed a cauda equina syndrome. Unfortunately, pain specialists (e.g., radiologists, anesthesiologists, and physiatrists), not specifically trained to perform neurological examinations or spinal surgery, are increasingly mismanaging spinal disease with ESI/variants. It is time for spine surgeons to speak out against this, and "take back" the care of patients with spinal surgical disease.
authors.affiliation: Department of Neuroscience (Neurosurgery), Winthrop University Hospital, Mineola, NY 11501, USA.
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Epstein
keywords: Cauda equina syndrome; epidural steroid injections/variants; lumbar disk herniation; massive discs; pain specialists; spinal surgeons; unnecessary delay