An epidural steroid injection (ESI) can relieve the pain of inflamed spine nerves caused by disc herniation or spinal stenosis. It is minimally invasive and can help to reduce neck, back, and leg discomfort. The epidural area, which is a fat-filled space between the bone (and the protective sac of spinal nerves), is where medicines are administered. Some pain relief can last for many days, others may last for years. The goal of pain relief is to make it easier for you to resume your daily activities.
What are epidural injections of steroids?
The epidural corticosteroid injectors place medication directly around pinched nerves. The epidural area is located between the spine’s bones, discs, nerves and spinal cord. This is the area where disc tissue can burst and cause inflammation and pressure around spinal nerves.
What are epidural corticosteroid shots used for?
An epidural steroid injection is used to treat back problems such as lumbar radiculopathy (slipped disc), spinal stenosis and sciatica. Corticosteroids can reduce inflammation and pain in the epidural area.
What is the procedure for epidural corticosteroid shots?
An epidural injection of steroids works by injecting a strong anti-inflammatory at the nerve impingement site in the spine. There are many options for injected medication, including steroid injections, local anesthetics and saline. Each individual’s needs will vary in their volume and concentration.
Three possible routes for epidural injections of epidural in the lumbosacral back may be available:
- caudal
- Interlaminar (also known by translaminar)
- Transforaminal
Your doctor will decide which method is best for your case based on your history and any previous spinal surgery.
- Caudal injections are the simplest way to access the epidural spaces. However, they can be very specific. If multiple areas of the spine need to be accessed or if there are post-surgical complications, this can be a useful option.
- A translaminar or interlaminar injection delivers the medication directly into an epidural space at the affected area. It can be targeted on one side or the whole body and can treat multiple levels.
- A transforaminal infusion delivers the medication to an area near the area where the affected nerve root exits from the spine. It is then compressed by a disc herniation. It is the most common approach to an epidural injectable.
How often do you need epidural steroid injections for pain?
The recommended frequency of epidural steroids injections is three to six times per calendar year. Injections may be given several weeks apart in the case of a new disk herniation to ensure quick and complete resolution. Injections are usually given every three to six weeks for chronic conditions.
How long does an epidural for back pain last?
If a patient with a new disc shearing responds favorably, epidural steroid injections are able to permanently relieve pain. The desired effect duration for patients suffering from chronic pain or recurrent disk herniations is three to six months or longer.
What are the risks from epidural steroid injections
Any procedure that involves needles can lead to infection, bleeding, and nerve damage. Properly performed, the risks are negligible and the benefits often outweigh the risks.
The following are contraindications when epidural steroid injections can be performed:
- Anticoagulation and bleeding disorders
- medication allergies (rare)
- Localized infection or systemic infection can occur in the same area.
What are the side effects from epidural steroid injections
Some common side effects include mild pain at the injection site, temporary worsening and flushing, insomnia, and increased blood sugar. These symptoms usually resolve in one to three days. The headache is another less common side effect.
Are there any preparations? What can I eat prior to and after the epidural injection of steroids?
Specific instructions will be provided by your doctor. They will differ depending on whether you are at a facility with epidurals (lumbar, cervical, or thoracic). Fasting guidelines are not prohibitive as the procedure is often done with local anesthetic.
Is anesthesia available? Are epidural steroids painful?
An injection of local anesthetic into the skin is used to numb the area where the epidural is then placed. Although mild discomfort may occur, patients should not feel any severe pain.
How long will I be required to lay flat on my stomach while or after the procedure?
The procedure may take between 10 and 20 mins. If possible, the patient will be required to lie down in order to allow fluoroscopy (Xray guidance). After a short monitoring period, you are able to sit, stand, or walk as usual.
Who can perform epidural steroid injections
Many doctors can perform epidural steroids injections, including pain management physicians, interventional radiologists, and physiatrists. They are all trained to safely perform this procedure.
Who is a candidate for the job?
ESI is a treatment that may be of benefit to patients suffering from pain in their neck, arm or leg (sciatica). These conditions are especially beneficial:
- Spinal Stenosis: This is when the spinal canal or nerve root canal narrows. It can lead to back and leg pain, particularly when you are walking.
- Spondylolisthesis refers to a weakness or fracture of the upper and lower sides of a vertebra. When the vertebra slides forward, it can cause pain by compressing the nerve roots.
- Herniated disc: The gel-like material in the disc can burst through a weak spot in the wall (annulus) or bulge. This material can cause pain, irritation, and swelling when it comes in contact to a spinal nerve.
- Degenerative disc is a breakdown or aging in the intervertebral Disc, resulting in the collapse of the disc space and tears within the annulus. It can also lead to the growth of bone spurs.
- Sciatica refers to pain that runs along the sciatic canal from the buttocks down to the legs. It’s usually caused by compression at the 5th or 1st lumbar spine nerves.
Some patients have found ESI helpful in treating painful inflammatory conditions. ESI can be used to help diagnose if surgery may be necessary to relieve the pain from a herniated disc. If symptoms are not controlled by rehabilitative exercises or if the pain is too severe, epidurals may be used to ease the pain so that patients can continue with their physical therapy.
ESI should never be performed on anyone who has bleeding issues or is suffering from an infection. Injecting patients with diabetes may temporarily raise blood sugar levels. The injection may temporarily raise blood pressure and eyepressure in patients suffering from glaucoma. This should be discussed with your doctor. Talk to your doctor if it seems that you may be pregnant. Fluoroscopy xrays could be dangerous to your baby.
Who does the procedure?
The following physicians can perform epidural steroids injections: radiologists (PM&R), neurologists, radiologists, anesthesiologists (anesthesiologists), and surgeons.
What happens prior to treatment?
Your medical history and imaging data will be reviewed by the doctor performing the procedure to determine the best method for you. This appointment is your opportunity to ask any questions.
Patients who are taking blood-thinning medications (Coumadin and Plavix, for example) should discontinue them. It is possible to discontinue taking blood thinning medication (Coumadin, Plavix, etc.) several days prior to the ESI. Talk with all your doctors about medications, including the one that prescribed them and the one who will inject it.
The procedure can usually be performed in an outpatient clinic using xray fluoroscopy. It is a good idea to arrange to have someone drive your vehicle to and from the center on the day you receive the injection.
What happens during treatment
The procedure will require you to sign consent forms, to list all medications that you are currently using, and to indicate if you have any allergies. The procedure will take approximately 15 to 45 minutes. There will be a recovery period.
The goal is to get the medication as close and painlessly as possible. The type and extent of your condition will determine the type of injection. The doctor will decide which type of injection is most likely for the best results.
Step 1: Prepare the patient
The patient lies flat on the x-ray table. The local anesthetic used to numb treatment areas is very mild so that the patient feels as comfortable as possible. The physician will provide feedback by keeping the patient awake and aware throughout the procedure. The center may offer a low dose of Valium or Versed as an oral sedative.
Step 2: Insert your needle
An x-ray fluoroscopy is used to direct a hollow needle into the epidural area. Fluoroscopy is a way for doctors to monitor the needle’s progress on an xray monitor. This allows them to ensure that the needle goes in the correct place. While some discomfort is normal, patients often feel pressure more than pain.
There are many types of ESIs.
- Cervical ESI (neck). The needle entry site is on the neck, at the top of the opening for the nerve roots and just outside the epidural space (Fig. 2). Contrast dye can be injected to confirm that the medication is flowing.
- Cervical ESI injection
- Figure 2. Figure 2. The needle is inserted at the side of your neck to reach the neuralforamen, which delivers the steroid medication green to the area where the inflamed neuro root exits the spine.
- Lumbar ESI, low back The needle entry site for the nerve canal is located slightly behind the middle line of the back. Contrast dye can be injected to confirm that the medication flows.
Lumbar ESI injection
For low back or leg pain, an ESI injection is performed in the lumbar spine. To administer steroid medication (green), the needle is inserted into the epidural space from the back of the affected side.
Caudal ESI (tailbone). To reach the lowest spine nerves, the needle must be inserted in the sacral Hiatus (above the tailbone). Contrast dye can be injected to confirm that the medication is flowing.
Step 3: Inject medication
The anesthetic and corticosteroid medications can be injected into epidural spaces around nerve roots after the needle is properly positioned. The needle is then removed. The procedure is then repeated depending on the pain location. You may inject at one or more levels of the spine.
What happens after treatment?
Most patients are able to walk within minutes of the procedure. You can usually leave the center after being monitored for a few minutes. Temporary leg weakness or numbness is rare. A driver should take you home.
Most patients return to full activity the following day. You can reduce the pain around the injection site by applying ice or Tylenol. In the coming weeks, you may want to track your pain in a diary. The corticosteroid may cause a slight increase of pain, numbness or weakness after the numbing medicine has worn off. To document the success of the procedure and to address any questions or concerns regarding future treatment, patients are encouraged to schedule follow-up appointments with their treating physician.
What are the results?
Many patients report some pain relief with ESI. Patients who only experience mild pain relief may need to have one to two additional injections. These are usually performed in 1-4 week intervals to maximize the effect. Pain relief may last from weeks to years. To strengthen the back muscles, and prevent future pain episodes from happening, injections should be done in conjunction with physical therapy and/or home exercises.
What are the possible risks?
ESI can be used for non-surgical treatment. There are very few risks. Inserting the needle can cause spinal headaches, bleeding, an allergic reaction, paralysis, nerve damage, or paralysis. Side effects of corticosteroid steroids include weight gain and water retention. Hot flashes can also cause flushing (hot flushes), mood swings and insomnia. People with diabetes may experience elevated blood sugar levels. A mild feeling of numbness or weakness in the arm or leg affected by corticosteroid side effects usually subsides within eight hours. This is similar to facial numbness that occurs after dental treatment. Patients with chronic conditions, such as diabetes, heart disease, and rheumatoidarthitis should consult their physician to get a risk assessment.
Potential Benefits of Epidural Steroid injections
A majority of practitioners agree that epidural injections can be helpful in the treatment of acute episodes of leg and back pain. However, they are not always successful and the pain relief is usually temporary. In most cases, three injections can be given within a year if the initial one is effective.
The following benefits may be possible when steroid injections are administered in the lumbar epidural spaces:
- Nerve pain and inflammation can be reduced. Steroids lower the production and sensitivity of nerve fibers, which in turn reduces the pain signal generation.
- Limit oral medication. These injections may reduce the need for oral medication. Some of these medications can have side effects that may make it difficult to stop taking them.
- Continue or re engage in physical therapy. This injection can provide enough pain relief to allow the patient to continue with a rehabilitation physical therapy program.
- Postpone surgery. The use of lumbar epidural injections to relieve pain may allow you to postpone surgery. Physical therapy may also be an option.
An epidural injection can be administered in a variety of ways, depending on the patient’s condition, their needs and the preference and experience of the doctor.
Epidural Injection Approaches
This type of injection is effective in providing significant pain relief, both acute and long-term. The injection injects a strong antiinflammatory medication directly into the painful region near the spinal nerve(s). Any of the following methods can be used for an epidural injection:
- Transforaminal route. This technique allows the precise administration of the steroid solution in the epidural space near the area that is most likely to cause nerve irritation. This injection technique targets particular nerve roots to manage pain and inflammation.
- Interlaminar route. This technique involves inserting the needle from the back and depositing the medication into the epidural. This method is not as precise, because the medication is not placed near the target nerve roots. Additionally, the steroid solution can be spread freely within the epidural spaces.
- Caudal route. Although this is an easy approach, it doesn’t directly target the source of pain in the epidural area or around the nerves. While the caudal method is less effective, it is more reliable and safer. This can be used to control pain that is diffuse or widespread.