So, we all love to refer chronic backpaineurs to ortho or neuro or pain management or whomever for epidural steroid injections for sciatica.  It offers people something besides pain meds and boring physical therapy but not so radical as surgery.  We’d love to believe that they work and help people – ideally keeping them out of the ER for their chronic problem.  The providers that do them also love to believe that they work – pts would be happy and the money they make from doing a relatively simple and safe procedure (the exception is the risk of fungal meningitis due to contamination of the drug) is awesome!   Of course that financial motivation is going to drive doing the procedure.

Now a pretty big study out of the Annals of Internal Medicine shows that in all likelihood, these injections don’t work.   They may provide short term relief but offer no significant long term benefit.  Now, some providers might like this since it means they can do repeat injections on patients when the first one wears off but I don’t see it that way.   I see the whole thing as a big scam.  And let me tell you, many doctors out there are in on this sort of thing.  All the money in medicine these days is on procedures so everyone wants a piece of this pie.  You make diddly squat using your brain in medicine and all in using your hands.  Human nature cannot avoid this lure so doctors do procedures – often of unclear or unproven benefit to patients who are often desperate for relief from their problem – be it chronic back pain or prostate cancer or whatever.  Insurance companies are pressured to cover these things and when docs all opt to be out of network, the company pays them BIG TIME  – often ridiculous amounts. Payments of near 100K for a routine, non-emergent multilevel back surgery are not uncommon.  Of course an injection pays much less but it’s simple!  It takes three seconds!  Do 20 of them in a day and CHA-CHING!

Until we change the way we reimburse for medical services and start to value the brain as much as the hands, this will never stop. We’ll just move on to the next cash cow.

Here’s a consult for all you vets out there. First let me tell you that I have an appointment to take my dog to the vet tomorrow but thought I’d get some opinions.
History is a 9 y/o F spayed Tibetan with one day of biting and scratching at her posterior and dragging her butt on the ground. Very uncomfortable appearing. No GI symptoms or urinary problems. Here’s the pic

I’m not a huge fan of testicular pain.  In general, the vast majority of the time, I can never really figure out what is causing it. Of course you rule out the bad (but rare) stuff like testicular torsion or cancer but with the exception of a hydrocoele, I can rarely tell exactly what the cause is.

The other day, a guy came in with this complaint. He looked normal enough and did not appear to be ill at all.  The pain started about 5 days ago and he seemed like he considered it more of an irritation.  So it was with immense dismay that when I peered under his gown I saw that his scrotum was about 5 sizes bigger than it should, it was deeply red and had boggy, peeling skin on it!

I immediately went from “OK, order the sonogram, check the urine, blah, blah, blah, to HOLY CRAP, call a surgeon, start some antibiotics!!!’

The guy had Fornier’s Gangrene and went rapidly to the OR where most of the skin off his testicles, perineum, and lower abdominal wall were excised.  Luckily, he is still alive.