An epidural steroid injection (ESI), which is minimally invasive, can be used to relieve pain in the neck, arm and legs caused by spinal stenosis, disc herniation, or spinal stenosis. The epidural space is the fat-filled area between bone and protective sac for the spinal nerves. The pain relief can last several days, or even years. It is important to reduce pain so you can resume your normal activities and follow a physical therapy program.
What are epidural steroids injections?
An epidural corticosteroid injection places medication directly around pinched nerves as they exit the spine in the epidural space. The epidural space lies between the spinal cord and nerves, between the discs and bones of the spine. This is where disc tissue can protrude and cause pressure or inflammation around spinal nerves.
What is the purpose of epidural corticosteroid injections?
The most common use of epidural steroids is to treat back pain due to a herniated disc, lumbar radioculopathy, spine stenosis, or sciatica. Corticosteroids, which are powerful anti-inflammatory medications, can be injected into the epidural space to reduce inflammation around an irritated neuron that causes back or leg pain and discomfort.
How does epidural corticosteroid injections work?
The epidural steroid injections deliver a powerful anti-inflammatory to nerve impingement sites in the spine. The injections may contain steroid, local anesthetics, or saline. They can also vary in volume and concentration depending on the individual.
There are three routes that can be used to administer epidural injections in lumbosacral spinal.
- caudal
- Interlaminar (also called translaminar).
- Transforaminal
Based on your condition and any previous spine surgery, your physician will determine which method is best for you.
- The caudal injection, while the most straightforward way to access the epidural area, is also the most specific. This can be helpful if multiple parts of the spine are involved, or if other options are not possible.
- Interlaminar or translaminar injections deliver the medication directly to the epidural space at affected levels. They can target one side or both and can treat multiple levels simultaneously.
- Transforaminal injections deliver the medication to the affected area of the nerve root. This is done by compressing the disc. This is the first option for epidural injections.
How often can you receive epidural steroids injections?
It is recommended that epidural steroid injections be given up to three to six time per year. If a disc herniation is a new one, the injections can be administered several weeks apart to achieve quick and complete relief. It is not uncommon for chronic conditions to go longer than three to six months between injections.
How long can epidural injections for back pain last?
Patients with new disc herniations who are responsive to epidural steroids injections may experience permanent relief of their pain. Patients with chronic pain and recurrent disc herniations should expect to see an effect for three to six months.
What are the potential risks associated with epidural steroids injections?
There are risks associated with any procedure that involves a needle, including bleeding, infection and nerve injury. If performed correctly, the risks of any of these are minimal and often outweighed by the potential benefits of the procedure.
There are some contraindications to epidural steroids injections.
- Anticoagulation or bleeding disorders
- medication allergies (rare)
- Systemic infection or localized infections in the vicinity
What side effects can epidural steroids injections have?
Side effects that are common include slight injection site pain, flushing, insomnia and temporary worsening or aggravation of usual pain. These side effects are usually temporary and disappear within one to three working days. Headache is a less common side effect.
Do I need to prepare? Do I need to eat before or after an epidural steroid injection?
Specific instructions will be given by your doctor. These will depend on the facility and the type of epidural (lumbar or thoracic, cervical). Fasting is not a problem since the procedure is typically performed under local anesthesia.
What is the use of anesthesia? Is epidural steroid injection painful?
The epidural needle is placed and a local anesthetic is administered to the skin. The procedure is not painful and may cause mild discomfort.
Do I need to be flat on my stomach during and after the procedure?
The procedure takes between 10 and 20 minutes. Patients will need to lie down if they are able to receive fluoroscopy (X-ray guidance). After a brief monitoring period, you will be able to stand and walk again as normal.
Who does epidural steroids injections?
There are three types of epidural steroid injections: pain management doctors, physiatrists, and interventional radiologists. All of them are qualified to safely perform the procedure.
Who are the candidates?
ESI may be beneficial for patients with neck, arm, leg, or low back pain (sciatica). These conditions are particularly suitable for ESI:
- Spinal stenosis is a narrowing of the spine canal and nerve root canal that can cause leg and back pain, especially when walking.
- Spondylolisthesis is a weakness or fracture that occurs between the upper and bottom facets of a vertebra. The nerve roots can be compressed if the vertebra moves forward.
- Herniated disc: This is when the gel-like substance within the disc can burst or rupture through the weaker area of the surrounding wall (annulus). When this material comes into contact with a spinal cord, it can cause irritation, pain, swelling, and nerve damage.
- Degenerative disc: The process of aging or breaking down of the intervertebral disk causing disc space collapse, tears in the annulus and the growth of bone spurs.
- Sciatica is a condition that causes pain along the sciatic nerve, in the buttocks, and down the legs. It is often caused by compression of either the 1st or 5th lumbar spinal nerves.
Some patients have found ESI to be helpful in the treatment and prevention of painful inflammatory conditions. ESI can help to determine if surgery is necessary for the pain caused by a herniated disk. Epidurals are used to relieve pain that interferes with rehabilitation exercises.
ESI should not be performed on patients with bleeding or infection. Patients with diabetes may experience a slight increase in blood sugar. Patients with glaucoma may experience a temporary increase in blood pressure and eye pressure. Talk to your doctor about this. Tell your doctor if you suspect you might be pregnant. Fluoroscopy xrays can be dangerous for the baby.
Who is responsible for the procedure?
Epidural steroid injections can be performed by physiatrists, radiologists, surgeons, anesthesiologists and neurologists.
What happens before treatment?
To determine the best way to inject the needles, the doctor will review your medical history and any imaging studies. You are welcome to ask questions during this appointment.
Patients who use blood thinners (Coumadin or Plavix) may need to stop taking them. You may have to stop taking the medication several days before your ESI. Talk to your doctor about any medication you are taking, as well as the doctor who will administer the injection.
The procedure is typically performed in an outpatient facility using x-ray fluoroscopy. You can arrange for someone to drive you to the center on the day of the injection.
What happens during treatment?
You will need to sign consent forms and list any medications you are currently taking. The procedure can take between 15 and 45 minutes. After that, there will be a recovery period. It is important to get the medication as close as possible to the nerve. The type of injection you choose depends on your condition, as well as whether or not you have had any previous surgery. The doctor will determine which type of injection is most likely to yield the best results.
Step 1: Prepare the patient
The patient lies down on an xray table. The local anesthetic is used for pain relief. To provide feedback to the doctor, the patient must remain awake and alert during injections. Based on the center, a low-dose oral sedative such as Valium and Versed may be offered.
Step 2: Insert the needle
The doctor uses an x-ray fluoroscopy to guide a hollow needle through skin between bony vertebrae and into the epidural space. Fluoroscopy allows the doctor to monitor the needle on an x-ray monitor in real time, making sure that it goes to the right place. Although some discomfort may occur, patients feel more pressure than pain.
There are many types of ESIs.
- Cervical ESI, neck. To reach the neural foramen, the needle entry point is located on the neck side. It is just above the opening of the nerve root. 2). To confirm the flow of medication, contrast dye is used.
- Cervical ESI injection
- Figure 2. Figure 2. An ESI injection into the cervical spine to relieve neck or arm pain. To deliver the steroid medication (green), the needle is inserted into the cervical spine from the side.
- Lumbar ESI (lower back). To reach the nerve canal, the needle entry site is located slightly above the midline of the back. To confirm the location of the medication, a contrast dye is administered.
Lumbar ESI injection
A lumbar spine injection to relieve low back or leg pain. To deliver the steroid medication (green), to the inflamed nerve root, the needle is inserted from behind the affected side.
Caudal ESI (tailbone). To reach the lowest spinal nerves, the needle is inserted into the sacral hiatus just above the tailbone. To confirm the flow of medication, a contrast dye is administered.
Step 3: Inject the medication
Once the needle has been correctly placed, the anesthetic medication and corticosteroid medications will be injected into the epidural area around the nerve roots. The needle is then taken out. The procedure can be repeated on the justify or right side depending on where your pain is located. It is possible to inject one or more spinal levels.
What happens next?
Most patients are able to walk immediately following the procedure. After a brief stay in the center, most patients can walk away. You should always be accompanied by someone to drive you home if there is any temporary weakness or numbness in your legs.
Patients can resume normal activities the next day. Ice and Tylenol may help to ease soreness around the injection site. It may be a good idea to keep track of your pain levels over the next few weeks using a journal. As the numbing medication wears off, you may feel a slight increase or numbness. After the procedure, patients should make an appointment to see their treating physician for a follow up appointment. This will allow them to verify the effectiveness of the treatment and discuss any future plans.
What were the results?
Many patients feel some pain relief from ESI. If you experience mild pain relief, two to three additional injections may be required, typically in intervals of 1-4 weeks. To achieve the full effects, these injections can be repeated. The duration of pain relief can vary, and may last for weeks or even years. To prevent future pain episodes, injections can be combined with physical therapy or home exercise programs.
What are the potential risks?
ESI has few risks and is recommended for certain patients. There are rare risks involved in inserting the needle. These include spinal headaches from a puncture, bleeding and infection. Nerve damage/paralysis is also possible (rare).
Side effects of corticosteroid may include weight gain, water retention and flushing (hot flashes), mood swings, insomnia, elevated blood sugar in diabetics, and elevations in blood sugar. The mild numbness and weakness in the affected leg or arm usually disappears within 8 hours. This is similar to facial numbness after dental work. For patients with chronic conditions such as heart disease, diabetes, or rheumatoidarthitis, it is a good idea to consult your physician.
Potential benefits of epidural steroid injections
An epidural injection is a good option for acute leg or back pain. The downsides to epidural injections include that they may not be always effective and that the pain relief can last anywhere from one week up to one year. If the first injection is successful, you may need to give up to three injections in a year.
Steroid injections can be administered in the lumbar epidural area and may provide the following benefits:
- Inflammation and nerve pain can be reduced. Steroids reduce the production of inflammatory chemicals, decrease nerve fibers’ sensitivity to pain and generate fewer pain signals.
- Limit oral medication. These injections can be used to reduce or eliminate pain. However, some oral medications may cause side effects if taken for a long time.
- Continue to engage in physical therapy or re-engage. The injection could provide enough pain relief for a patient to continue with a rehabilitative program of physical therapy.
- Postpone surgery. Postpone surgery if pain relief from lumbar epidural steroids injections is possible. If physical therapy is successful, it may be unnecessary.
There are many methods that can be used to administer epidural injections depending on the condition and patient’s needs.
Epidural Injection Approaches
This injection delivers a strong anti-inflammatory steroid medication directly to the pain area. It can provide significant and immediate pain relief. One of these approaches may be used to give an epidural injection:
- Transforaminal route : This technique allows for precise administration of the steroid solution to the epidural area, close to the nerve’s likely to be irritated. This technique injects specific nerve roots to reduce inflammation and pain.
- Interlaminar route : The needle is inserted at the back of your spine, and the medication is then deposited in the epidural area. This method is less precise as it doesn’t deposit medication near the target nerve root. Also, the steroid solution does not spread within the epidural area.
- Caudal route. This is a simple approach that can be used to treat pain. However, medication is not directed to the epidural space or around the nerves. Although it may not be as effective, the caudal approach is safer and more convenient. This may be a good option to manage widespread or diffuse pain.