Following the procedure, outpatients are monitored for 20 to 30 minutes and discharged home with standard post-conscious sedation orders that include instructions to avoid driving for the remainder of the day. Postdischarge instructions should include back rest with no strenuous physical activity for 3 days to minimize risk of postprocedural disc herniation. Efficacy of the procedure is dependent not only on the technical aspects of the procedure but also on strict postprocedural guidelines that will allow healing within the disc and avoidance of reinjury. Many practitioners give a preprinted instruction sheet with "dos and don'ts" and exercise instructions to patients after treatment.
Patients should be counseled that they may experience an increase in typical symptoms for 1 to 7 days after the procedure, with transient local discomfort at the entry site(s). Pain can be managed with local ice at the injection site and nonsteroidal anti-inflammatory analgesics as needed. Patients with more severe pain or patients accustomed to narcotics may require narcotic analgesics as well. Most patients will return to their preprocedure pain level within the first week. A fitted lumbar corset may be prescribed at the discretion of the treating physician, to be worn during waking hours for the first few weeks after the procedure. The patient should be instructed to call if fever develops or if a flare-up occurs that does not resolve after the first week.
Symptomatic improvement usually begins in 1 to 2 weeks after treatment, and symptoms continue to improve gradually over time for as long as 6 to 9 months. Activity restrictions generally include the admonition to rest for 1 to 3 days after the procedure. Vertical sitting should be limited to 30 to 40 minutes for the first 2 weeks, then increased as tolerated; prolonged vertical sitting should be avoided. Lift ing restrictions are generally imposed at 1 to 10 pounds for the first 2 weeks, then 25 to 50 pounds for the first 3 months.
Return to work varies for individual patients and their type of work. Most patients can return to sedentary work 2 to 5 days after the procedure, though they should be instructed not to sit in one position for more than 30 to 40 minutes at a time in the first few weeks. Patients should not return to heavy work or lifting before week 8 and should engage in some individualized and progressive work hardening before return. In week 2, patients should be encouraged to begin exercise with walking only and to begin stretching exercises. Walking and stretching are encouraged for the remainder of the recovery period to maintain flexibility and promote healing. Jarring axial loads (Stairmaster, running, rowing, aerobics) should be avoided. Patients who are slow to recover or need more detailed instruction may be referred for a formal physical therapy program for back stabilization at 6 weeks. Athletic pursuits can be resumed in month 4 depending on tolerance of increased activity. Golf and tennis may require special instruction.
In appropriately selected patients, results are fairly consistent. Published data in peer-reviewed journals are sparse, and no placebo or sham trial exists at present.22-29 Multiple citations report very similar results including several retrospective multicenter analyses, a few published prospective clinical trials, and a case-control study that compared IDEA outcome with that for nontreated patients denied insurance coverage for the procedure. All trials generally reported a roughly 65-70% response rate measured as a decrease in subjective pain (Visual Analog Scale) with a measurable decrease in analgesic use and measurable functional improvement (SF-36 scales) measured at 3, 6, 12, and 24 months after the procedure.
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