Three months since the second injection:
Hello Dr Bland,
It's quite some time since I've updated you on my progress, so I thought that this three months' period would be appropriate. My reaction to the second injection has been, on the whole, much better than that of the first injection. However, at this three months' period, I am starting to experience some mild symptoms returning: occasional numbness (mainly in the thumb) whilst sleeping or especially, when cycling. Nevertheless, the symptoms are tolerable and that is why I haven't contacted you for a while.
It is my intention to make an appointment with you in about three months from now, as I have been coming every six months since the symptoms began. Would you find this acceptable?
I have two further questions:
Does the effectiveness of the injections increase the more that one receives them and how many would be the acceptable number to have in both a one year period and overall? I ask this as I am very enthusiastic to try and avoid surgery if possible.
Thank you.
Hello Dr Bland,
Many thanks you for your reply.
I think that I will soon contact your office to make an appointment to see you in early July, which will be approximately six months since the last appointment. If you then recommend that a third injection would be appropriate, the time scale since the second injection would again be six months. As I said in my previous e-mail, my symptoms are relatively mild at the moment, so this period of time should be suitable.
Kind regards.
If you tell me your appointment preferences in terms of day and time I will book something for July as we are almost booking to the end of June now and we also have holidays to consider. JB
Hello Dr Bland,
Thanks for the offer but I have already contacted your office and they have given me an appointment for the 26th June.
Kind regards.
That's a bit odd as they are not really supposed to hand out review EMG appointments for my patients without asking me and I would have deliberately delayed it into July and set up the appointment as being delayed for clinical reasons. I'll find out what they have done and why next time I am in the office. It's possible that my office manager might have read this thread on the web and was just trying to be helpful:-) JB
Hello Dr Bland,
I'm quite happy to wait until July for the appointment if it's more convenient for you. Will you be personally letting me know of any change of date (or not) through this forum, or will I hear by letter or otherwise?
Kind regards.
Hello Dr Bland,
Many thanks for your help in sorting the appointment out.
Kind regards.
Thanks for the update. You can see the difference in the two injection responses in your subjective severity scores - 1.82 before the first injection 2.0 after it, compared to 2.27 before the second injection, 1.0 after it. The scores of course range from 1=no symptoms to 5=maximum symptoms. You are welcome to come back and see me anytime of course - though at present I am struggling with the waiting list a little and routine booking are about 6-7 weeks ahead so bear that in mind.
A colleague and I have just been looking at the outcomes of second injections compared to first ones in the same hand and the preliminary analysis suggests that the second time around ones are, on average, slightly more successful. However, this data is subject to an innate bias in that patients who respond poorly to their first injection are probably less likely to try a second one and the people who have a second injection are therefore a selected group who have already shown an ability to respond well to steroids. At least we can say however that there is no obvious 'tailing off' of effectiveness in the second injection.
This raises the obvious question of whether we should actually try second injections in people who have not responded to the first one - no answer at the moment.
There is no evidence based answer to how many and how often either I am afraid. My working rule of thumb is not more than once every 6 months but that is not absolute. As long as patients understand that we are are in a sense experimenting I am also prepared to continue injections until the patient gets tired of them, so long as the nerve conduction results do not indicate progressive deterioration of median nerve function.
One other thing you might like to think about is that we do not know whether it is better to re-inject as soon as the symptoms start to recur or whether it is better to wait until they become a nuisance again. If you want to re-inject now as an experiment I would bend the 6 month rule but it will take an awful lot of people in the same position making the choice to inject or wait to give us the beginnings of evidence on which to actually make a recommendation. JB