Epidurals are a miracle technology

https://worksinprogress.co/issue/the-wonder-of-epidurals/

by karakoram • 1 month ago

90 90 1 month ago

Male scheduled for my 3rd epidural with steroids next week for on-going spinal stenosis, relieves pain for a few days, then back to pain.

Will go for minimally invasive micro laminectomy next, tired of treating symptoms and not the root cause.

In that procedure surgeon will remove parts of lower vertebrae that is pinching the nerve bundle, nerves that progress down each leg.

Success rates of better than 70%, it's a gamble. But willing to accept that rather than end up on addictive pain pills for life.

3 to 6 months recovery period before active lifestyle again, cannot risk disturbing the "fix". Giving up flip turns in lap swimming for quite a while. Supplemental covers the other 20% that medicare won't pay.

Cash paying patients suffer $35k to $45 K for the procedure.

Medicare pony's up only about $6,500, which the surgeon must accept, no extra cash changes hands.

Supplemental covers the 20% that medicare will not pay.

brookside• 29 days ago

(While it's clear you've done a ton of your own research for your own case.)

Steve Kerr's advice after his own back surgery complications (albeit microdiscectomy, not a laminectomy) make me hesitant:

"If you're listening out there, if you have a back problem, stay away from surgery... Rehab, rehab, rehab. Don't let anybody get in there."

vitally3643• 29 days ago

This kind of comment is only marginally better than "well, I asked ChatGPT and...."

You acknowledge the parent commenter knows more than you, but you decide it's somehow helpful to post contradictory information anyway sourced from someone else who also likely knows more than you.

ortusdux• 29 days ago

I helped a friend through a microdiscectomy, and it could not have gone better. Laparoscopic procedure, short recovery, lifechanging reduction in symptoms. The biggest hurdle was that their insurance required PT/rehab prior to authorization, even though all the experts involved agreed that it would not help.

amluto• 29 days ago

The heuristic I found when researching this a few years ago was slightly more nuanced than your quote: back surgery is very likely the wrong solution for back pain.

But if you have nerve problems caused by an issue with your spine, you probably want to address them before they become worse or irreversible, and back surgery may end up being the only option.

WarmWash• 29 days ago

Honestly surgeons should be paid hourly like technicians. $800/hr or something like that. For a 2 hour procedure, $1600. Another $5k for facility and support staff. Looks like medicare is on point...

notnaut• 29 days ago

Medicare for all fixes a lot of the problems with the US health system!

Broken_Hippo2• 29 days ago

I'm with you until I remember how expensive medical school plus internship is in the US. If doctors cannot pay back their student loans, it doesn't matter. The majority of folks in medical school have family that can support them now - not fixing education will make this even worse.

Don't get me wrong. I support state-sponsored health care, especially after moving from the US to Norway over a decade ago. Just the peace of mind not having to worry so much about financial ruin because of health issues relieves so much stress - even stress related to just keeping yourself healthy is less (If I get hurt while jogging, it isn't a big issue, for example) But fixing the US system is bigger than just payments or insurance for all. Gotta fix things like education costs, the burden of unpaid internships, and things like that, too. I wish it weren't such a complicated problem and I wish there were the political desire to do such a thing.

ak217• 29 days ago

Good surgeons are a bit like major airline pilots. They have more pricing power than you think.

complianceowll• 29 days ago

I understand everyone has different beliefs, and personally, I fall extremely short of what I should be, but I just took some time to pray for you and your procedure. I really hope the root cause is fully resolved.

rythmshifter• 29 days ago

My mother had this surgery and advised me to never have it done due to complications

thelastgallon3• 29 days ago

Go for surgery if you have neurological symptoms (loss of sensation, motor function, etc). If its pain, try your best to avoid surgery and find the right physiotherapist to help you be pain free. Spine surgery is risky and there is a risk of cascading failures.

Don't completely trust any anesthesiologist (pain management) or neurosurgeon (for surgery) or chiropractor or random folks advice to do yoga/stretch. Spend quite a bit of time understanding the anatomy, read up on everything and maybe you will find the right set of exercises to help relieve pain. Troubleshooting disk/spine/nerve issues is very hard and most doctors don't have any time to investigate it deeply. They just look at MRI. There are lots of people with the same problems showing up on MRI, but they are pain free.

wiz21c• 29 days ago

why "not" yoga/stretch ? I understand it may not be the right thing for every kind of pain but the way it is usually presented (your body needs movement) sounds convincing. (I don't practice yoga but taichi)

causality02• 29 days ago

I have to cautiously agree with you, with the caveat that many physios don't seem to know what they're doing either and the effectiveness of therapy can differ wildly based on which therapist and what regimen they use. Speaking as someone with a herniated disc that went through a discectomy which re-herniated immediately following surgery. Frankly I've only just now started getting relief by reducing the amount of weight pushing on the disc by way of treatment with semaglutide. Could've saved myself thousands of dollars in medical costs and rehab if I'd just done this a year ago.

thelastgallon3• 29 days ago

I don't understand the downvotes. If you have any counterpoints, please do share so I can learn instead of downvoting.

DivingForGold2• 29 days ago

Have already tried chiropractic, PT, several back exercises daily for a year or more, got recommended by 2 customers to a doc who is a specialist in radio ablation of the sensory nerves in the lower spinal region (medicare requires 2 epidurals 2 weeks apart before they would approve the RA). The RA worked great for less than a year, had another RA, worked for several months. 1 month ago had my 3rd RA, after that is when the pain got rather serious, follows the sciatic nerve across the buttocks and down each leg to the foot. Lately it alternates from each side, several days on one side, then several days on the other side.

I have not requested serious pain pills, applying clove oil (eugenol) mixed with benzocaine all over the lower back and buttocks, (lidocaine 5% is useless) wait 10 to 15 min, then can arise in morning from bed for a day's work, yet nagging pain most of day. I refuse OTC NSAID's as they can damage the heart over time. My spinal X-ray looks like an F1 racetrack. Doc says scoliosis, yet no one in my family has this genetically. At some point it just get's so frustrating you start to realize that surgery may be the only way out. Spoke to an 80 year old once who said he had the procedure, they had him up and walking the hospital floors after he awoke from the anesthesia, let him go home next day (I guess his was uncomplicated and straightforward).

nchmy2• 29 days ago

Friend, as many others are saying, you should try to avoid surgery as much as possible.

Check out moveu.com - it's cheap (and free to start if you want for their drip marketing to send you a coupon code) and full of excellent information, videos, community etc for fixing yourself. I have no affiliation - just a happy user.

Many people have been able to fix situations that the butchers (surgeons) assured them they could only treat with surgery. And there's many more who have had spinal surgery who say they're now stuck for life with a terrible situation.

Findecanor• 29 days ago

I've woken up from surgery with an epidural that had a leak. That wasn't fun.

It made it emotionally difficult to get surgery again.

lrasinen• 27 days ago

Got knee surgery with an epidural that leaked. The surgery itself went fine but the headache and nausea afterwards were absolutely brutal.

Roark662• 29 days ago

It was surprising to see incidence of death by cesarean is almost 13 per 100k. It is commonly thought as the safest way and half of all births in my country are via cesarean.

photonios• 29 days ago

In what country do you live? I've had children in two European countries, in both it was common knowledge that natural birth is safer then cesarean and doctors/hospital strongly prefer it.

farhaven• 29 days ago

doctors/hospital strongly prefer it.

Seems to depend a lot on the hospital. We (partner is pregnant with a high risk pregnancy) were at a level 1 prenatal care center in Germany a few weeks ago where they very much insisted that in her and the child's condition, a c-section is pretty much her only option.

We're now in a different, also level 1, prenatal care center, also in Germany (though a different state), where the prevailing medical opinion is "natural birth should work perfectly fine for you. We're not ruling out a c-section in case things go sideways, but natural birth is very much our preferred option in your case."

The first center seems to be quite keen on using as many cases as possible for training their staff in c-sections, even where it's not strictly necessary/beneficial. At least that's what we've heard from other parents in similar situations.

Roark662• 22 days ago

Poland. Both children my sister had were cesarean.

There were no complications at all, but both were as the doc put it "large" so my sister was given a choice.

InitialLastName• 29 days ago

I wonder how much of that is selection bias? In my (admittedly limited) experiences around the labor and delivery process, c-sections were (apart from when requested) advised for high-risk pregnancies and as a recourse for something having gone wrong in the L/D process. One could reasonably expect that both of those situations would indicate a higher risk for mortality from surgery.

Note that per Wikipedia [0], death by abdominal surgery in general in High-HDI countries is on the order of 100-1000/100k.

[0] https://en.wikipedia.org/wiki/Perioperative_mortality

clark_dent• 29 days ago

I think this is going to depend strongly on population. Average age of the mother, width of the pelvic canal, and similar are going to vary widely with culture, race and country.

wl5• 29 days ago

There's selection bias. High risk deliveries tend to start at or convert to cesarian at the first sign of trouble.

empath75• 29 days ago

We had 3 kids, one with an epidural and induced labor and the other 2 were natural child birth, no medication at all, and my wife much preferred the natural child birth -- all of them at at a hospital "birthing center", with a five minute walk to an OR if needed. She was more present emotionally at birth, we were able to walk out of the hospital with our baby a few hours later. She was practically bedridden for a week after the induced labor with the epidural.

Obviously, I'm only a spectator, but the overall experience seemed way less traumatic and stressful for her with the natural child birth, working with midwives and nurses rather than doctors.

wahern• 29 days ago

The first birth is invariably the most difficult (longer, more painful), and the most difficult to recover from regardless of epidural. You can't at all compare the experience of a second birth without an epidural to the first birth with an epidural.

Also, it can be difficult for women to remember the finer details of the pain because the hormones after birth specifically function to cause a kind of amnesia. (The hormonal effect on memory isn't unique to pregnancy or women, it's just rarely so pronounced as at child birth.)

We've had two kids, the first my wife had an epidural (after rejecting it twice before expressly demanding one unprompted), the second without. The first birth lasted, IIRC, over 20 hours at the hospital (not counting initial time spent at home), and we had long conversations with various maternity nurses and our doula about women's experience with child birth. The hospital's nurses were on strike so our nurses were from around the country with experience with all different kinds of hospitals and populations.

KaiserPro2• 29 days ago

Its hard to measure, but for the UK at least, and depending where you are, you try natural, then if shit goes wrong you graduate to ceasarian.

So it would be interesting to see the elective vs crash ceasarian rate.

stivatron• 29 days ago

Here in Argentina the nurses discourage you to seek it, then they blame the anesthesiologist is not available. We have had 2 with cesarian and one friend was in so much pain that she had to ask for a cesarian too.

mef51• 29 days ago

I've heard a few times now that giving birth while lying on the back is a relatively modern invention and that for most of history women adopted squatting or leaning forward positions.[1] And that the back position is actually much more painful. How much does laying on the back increase the pain to the point where an epidural is necessary? Is it still necessary in the other positions?

disclaimer: I know nothing about this

[1] https://www.bbc.com/future/article/20260401-women-were-never...

eblume• 29 days ago

When you've been given an epidural, you are generally required to be in a bed. (This doesn't answer your question, but I think it is relevant.)

chrismorgan3• 29 days ago

My wife works at a leading private maternity hospital in India. I can’t yet report from personal experience, but my wife says that epidurals are normal procedure, and per the hospital’s published statistics, about 90% choosing to give birth propped up or squatting (this figure excludes C-sections, water births, and complicated cases), which implies not being in a bed for at least the last part.

jvvw• 29 days ago

Anecdotally from personal experience (gave birth to one child on back, the other in a squatting position, didn't have an epidural for either), the pain didn't depend on position - very painful both times! But pushing felt much much easier squatting than on my back.

The hospital only had two rooms suitably equipped for giving birth in a squatting position, so I was lucky to get one second time.

economistbob• 29 days ago

Interesting to find out that the contents of epidurals are not standardized across facilities. If that is the case, then how can one definitely opine on the safety of them when the contents are locally designed cocktails?

wl5• 29 days ago

It's not as if people are pushing random drugs into epidurals. There's a small number of drugs that are commonly used and the differences come down to selecting the classes of drugs to be used, the particular drugs from those classes, and the dosing. There's no one right answer. In other words, it's just like the rest of anesthesia.

advisedwang2• 29 days ago

how can one definitely opine on the safety of them

Because the statistics still include all those variations. The variations are also not that huge, and are also independently studied.

You might as well ask how we can talk about the risk/safety of general anesthesia, given that different hospitals and even different anesthesiologists use different drugs.

rocqua• 29 days ago

There's a very strong podcast series about the common failure of Epidurals: "The retrievals" season 2, by serial productions. I found it rather eye-opening. The series includes reporting on a conference of the Society for Obstetric Anesthesia and Perinatology (SOAP) where the professionals in this field also found it eye opening. (mostly episode 2)

I don't bring this up to say that actually Epidurals suck, just to bring attention to the fact that they can fail, and that the system has historically handled such failure really poorly, and that the system itself isn't very well aware of this issue. This isn't just opinion from some podcast, but also admitted by the professionals working within this field.

It's also something valuable to be aware of when you or your partner is planning to have an epidural, because there is real space (and even a need) for advocacy for the patient when an epidural fails and the woman giving birth is in excruciating pain.

wl5• 29 days ago

The problem that The Retrievals deals with is epidurals failing during cesarians, which, they're quick to emphasize, is painful, open abdominal surgery. The not-so-simple solution is to convert to general anesthesia (anesthetic gas, IV propofol, etc). This isn't without its risks to the mother and the child, so there's reluctance on the part of anesthesiologists to go that route if there's other options. The result is unnecessary birth trauma.

atrus• 29 days ago

This isn't without its risks to the mother and the child
The result is unnecessary birth trauma.

Not trying to be snarky, but which is it? This is definitely a situation in which having a midwife there to advocate for you is an absolute plus.

chhxdjsj• 29 days ago

anesthesiologist here, I really fear a dodgy epidural being used for caesarean section surgical anaesthesia, and if there is any hint that an epidural isnt perfect I pull it out and do a spinal anaesthetic (as long as I have time eg. If the baby can wait long enough). Its a big call which needs to be made quickly. I have a theory that modern epidural medication mix has been dropped to be so low concentration of active drug that it is harder to differentiate a good epidural from a patchy one, and as a result people are topping up patchy epidurals and then running into problems with pain during surgery.

Fire-Dragon-DoL2• 29 days ago

I was shocked to discover that if a woman gets an epidural, it stops producing oxytocin that mitigates the pain for the baby (and mom).

That sounds absolutely horrible for that little creature. Yet I am a man, so I really am not allowed to speak on the matter and I absolutely let my wife decide entirely on the matter by herself (we had absolutely no time for an epidural, my wife delivered both kids way too fast)

adyer07• 29 days ago

I looked for a source for this, and found the opposite:

Newborn oxytocin levels were higher in the umbilical artery vs. umbilical vein, and both were higher than maternal plasma levels, implying substantial fetal oxytocin production in labour. Newborn oxytocin levels were not further elevated following maternal intrapartum synthetic oxytocin, suggesting that synthetic oxytocin at clinical doses does not cross from mother to fetus.

In other words, the fetus makes its own oxytocin during labor. It does not come from the mother.

[1] https://link.springer.com/article/10.1186/s12884-022-05221-w

kshahkshah• 29 days ago

HARD disagree. Watch “the business of being born”. We’ve turned a fairly routine extremely biologically conserved process into this insanely traumatic experience.

jamesboehmer• 29 days ago

Why don't you go ahead and give birth then, tell us all about your experience.

pjerem• 29 days ago

I'm 99% sure you are a men.

InsideOutSanta• 29 days ago

I rather think the problem is that births are inherently traumatic (a whole-ass little human coming out of your crotch isn't exactly all fun and games; there's a reason similar imagery is a common trope in horror movies), and we haven't put nearly enough effort into making them less so.

BrandoElFollito3• 29 days ago

Birth in humans is not a "extremely biologically conserved process". Women bodies are not ready for the size of head of the baby.

Compare this to cows or horses - where the baby is of sizeable size, but goes statistically smoothly.

KaiserPro2• 29 days ago

Husband of a UK doctor here.

first, childbirth is fucking dangerous. Its also unnecessarily painful. In terms of risk[1], the epidural is not the thing thats going to cause "morbidity", its the baby coming out breech or massive internal bleeding.

A non insignificant number of women literally tear themselves a new arsehole when delivering a baby. Yes elective caesarians can carry higher risks, but also might be required to actually deliver a live baby, or save the mother.

THe problem for the statisics is that there is a difference between elective caesarians and emergency once. If you group them together, then you're going to get a higher mortality/morbidity rate, because there’s a reason why it was an emergency

Personally I have no fucking clue why people wouldn't want an epidural. My wife didn't want one the second time because "she wanted to get home quicker" (by a fucking day) it turns out by her own words: "it was way way more painful without the epidural" bear in mind shes a fucking doctor, and a paediatric one at that.

[1] Women of African origin in the UK have worse outcomes in child birth, partly because of the lower uptake in pain relief.

EliRivers• 29 days ago

extremely biologically conserved process

This seems just plain wrong. It is not at all extremely biologically conserved.

Pregnancy and birth varies wildly across species. Not conserved. For primates, it's got problems; in humans, pregnancy is an absolute mess. The birth itself is historically one of the most dangerous things a woman can do, and remains not exactly a walk in the park even with the best of modern interventions.

Terr_• 29 days ago

Plus even if it were conserved--in the sense that all our relatives have settled on the same winning-strategy with little variation--there's still a naturalistic fallacy waiting in there.

Does the popularity of cancers as one ages mean we should just let people die because Nature Always Knows Best?

nikolay2• 29 days ago

... Except when they injure your spine, like with one of my friends. I'm not sure why women choose painless childbirth, which is not only potentially bad for them, but for their newborns as well. My wife gave birth to 3 children, two in the US, and doctors were shocked she didn't want them. Yes, it hurts. The moment your child is born, all pain is gone, and you're in the most beautiful state ever, and this creates even a stronger bond, knowing what you had to go through to bring a child to life! Men, women - we're all weaklings today. When I think about our ancestors and the sword-and-spear bloodbath battles they fought in to protect their families, we don't have such men and women anymore! Pain is an essential part of life. Chronic pain is a different story, of course.

biggc• 29 days ago

Suffering is not a virtue

nikolay2• 29 days ago

It surely is. Ascetism and stoicism are extinct virtues, maybe venerated only in Eastern Orthodox Christianity. Many of our holy fathers have suffered terrible torture and death, but they even welcomed it. That's why Orthodoxy is so hard to grasp in the West, where people damage their livers just to tame their headache a bit, let's say.

wl5• 29 days ago

There's a lot of people out there who blame their epidurals for lower back pain and the like, but the evidence for causality is not there.

readthenotes1• 29 days ago

Epidurals apparently also reduce the likelihood of birthgasm

slopdetector2• 29 days ago

Anecdata, but I spoke to a mom here who declined an epidural during childbirth by choice. Her son is a champion big wave surfer.

evil-olive2• 29 days ago

are you suggesting that epidural usage or not during childbirth is correlated in some way with athletic ability of the child, decades later?

slopdetector2• 29 days ago

The mother said it was a conscious decision to promote birthing a strong, resilient child, based on her belief on the matter. I have no view, but it's an interesting report, given that her kid truly is an athletic outlier.

recursivecaveat• 29 days ago

Given that 20-90% of people don't receive one across various modern countries, I think we have enough regular data. Otherwise like 80% of Germans would be champion athletes if a no-epidural birth really did that for you.

johnp314• 29 days ago

My wife had knee replacement surgery two weeks ago. She was given an epidural for the procedure and it worked well for her. Our two children were born back in 79 & 82 (20th century) and epidurals were available but only as some sort of last resort so she did not get them.

SpyCoder772• 29 days ago

I have no clue why I decided to read this, but I am glad I did. Good read.

SpyCoder772• 29 days ago

This is partly because there aren't enough anesthetists For those of you who didn't think this was a word (which was me 60 seconds ago) it is a word, and is technically correct as opposed to anesthesiologists

Epidurals are a miracle technology

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