Epidural steroid injections
Spinal injections have been around for a while, sciatica (stemming from a herniated lumbar disc, it is pain in the sciatic nerve) associated with low back pain was the first issue to be treated with an epidural steroid injection in 1952 and in 1901, documented to treat low back pain was the use of a spinal injection. Today, for management of low back pain, an integral part of non-surgical treatments are the epidural steroid injections.
To release chronic leg and/or low back pain, typically an epidural injection is used. While the conclusion of the injection tend to be temporary, during an episode of experiencing severe pain in the back, an epidural could be very beneficial as it provides relief for up to one year. Importantly, with the progress of a rehabilitation program, the patient can obtain the pain relief that is sufficiently provided.
For approximately 50% of patients, an epidural can effectively reduce the pain significantly. The pain caused by inflammation can be decreased by the direct delivery of steroids to the painful area. It is thought that from the injection there is a flushing effect which helps “flush out” or remove, from around the structures, the pain causing inflammatory proteins.
What is an epidural?
Basically into the epidural space, steroids are delivered directly through an injection which is call an epidural. Sometimes the solution for flushing (either normal saline or lidocaine) is also used around the pain source area to help “flush out” proteins that are inflammatory.
Small blood vessels and fat fill the epidural space which is the space between the vertebral wall and the dura mater, a membrane. Just outside the dural sac is where it is located. Nerve roots are bathed in the cerebrospinal fluids which along with the nerve roots are surrounded by the dural sac.
There are often factors that are inflammatory and with other pain generating substances are associated with a herniated lumbar disc, where swelling and significant irritation to the nerve root is caused by the inflammation.
Inflammation is reduced by the use of steroids (corticosteroids) which inhibits the production of inflammation causing substances; directly to the inflammation site, the medication is highly effective as it is directly delivered to the location.
The typically epidural is recommended when?
Generally to provide relief from pain is when the epidural injections are typically used, enabling patients in rehabilitation to receive help with their progress. Individuals who feel more comfortable and have less pain are able to work on the generally active therapies. To achieve relief from lower back pain, rehabilitation is critical including aerobic conditioning with low impact, along with pain and strengthening exercises including stretching.
Several conditions that are common include lumbar spinal stenosis, degenerative disc disease and herniation of the lumbar disc which all cause chronic or severely acute leg and low back pain. A treatment option that is effective and requires no surgery is an epidural steroid injection and can be used for conditions that cause chronic pain.
How is performing the injection done?
Taking between fifteen and thirty minutes is the usual time needed for an epidural steroid injection. On their abdomen atop of an x-ray table the patient lies flat. Lidocaine, which is similar to what the dentist uses, is given to numb the skin prior to the injection.
Epidural injections are performed by many different physicians including surgeons, physiatrists, neurologists, radiologists and anesthesiologists. Toward the epidural space a needle is directed by the physician using a live x-ray, fluoroscopy for guidance. Without the use of fluoroscopy, controlled studies report that in 13 to 34% of the medication is misplaced from the epidural injections, which in turn makes using fluoroscopy a very important consideration when a needle needs to be guided into the epidural space.
The steroid solution is injected once the needle is in the exact position. Prior to being discharged to return home, for a time period of 15 to 20 minutes the patient is typically monitored following an injection.
For patient comfort and anxiety, sedation is available. However, as the procedure is not commonly uncomfortable, sedative are rarely necessary. Following the injection, a longer period of monitoring the patient is necessary if a sedative is used.
On the day of the injection of the epidural steroids, resting is typically asked of the patients. The following day, normal activities which include anything you were doing the prior week of the injection can be resumed.
The benefits are.
Primarily in leg pain, a reduction of the pain is the benefit of having an epidural steroid injection. When an organized therapeutic program for exercise is coupled with the injections, a better response is seen from the patients.
For approximately 50% of patients, relieving pain through an epidural is generally successful. Further injections will more than likely not be beneficial if the first injection did not give the patient any relief from the pain they were experiencing. However, a recommendation of one or two additional injections might be made if there is some improvement in pain.
What are potential side effects and risks?
With an injection in the lower back or lumbar of an epidural steroid, there are associated potential risks, as with any invasive medical procedure. However, the few associated risks generally tend to be rare with epidural injections. Included potential risks are:
• Bleeding. If underlying bleeding disorders are present in the patient, bleeding is more common, yet a rare complication.
• Infection. With injections, rare severe infections occur in 0.01 to 0.1% of the total number. Occurring in 1 to 2% of all injections is a minor infection.
• “Wet tap”. Occurring in 0.5% of injections is a dural puncture.
• Nerve damage. While it is ultimately rare to experience nerve damage, it can occur from needle trauma directly, or from bleeding or infection secondarily.
A spinal headache or post-dural puncture headache may be caused, however typically only last a few days. Although rare, to alleviate the headache a blood patch could be necessary.
With an epidural steroid injection, there is no risk of paralysis as there is no spinal cord in the region of the injection.
The steroid medication does have potential side effects and risks, in addition to the injection risks. Any of the epidural steroid injection side effects tend to be rare. Taken daily for several months is the more common way to be effected by steroid side effects. Side effects and risks include:
• Increased appetite
• Transient flushing
• Cataracts
• Avascular necrosis (severe arthritis of the hips)
• Stomach ulcers
• High blood sugar
• In immunity, a transient decrease
Lumbar injections of epidural steroids should not be performed on patients who have bleeding problems, are pregnant (using the fluoroscopy), or have either a systemic or local bacterial infection. Epidurals also should not be committed on patients whose pain is from an infection or a tumor, with a suspicion of such; to rule out the condition and prior to the injection an MRI scan should be done.
With extreme caution, injections may be done for patients who are taking antiplatelet drugs, such as Plavix, Ticlid and aspirin, have problems medically such as diabetes and congestive heart failure, or have allergies associated with the solution used for the injection.
An epidural injection of steroids can be performed how frequently?
For leg and/or low back pain, there is no dictating definitive research regarding the frequency for injections of epidural steroids. Per year, in general the performance of up to three injections is considered reasonable.
In the time period of two-week intervals is typically the way epidural injections are done. However, regarding whether or not performing a series of three injections is always necessary; in the medical community no general consensus has been formed. If the leg and/or low back pain is lessening from one or two injections, some physicians prefer to save for any potential back pain recurrences, the third injection to use later in the twelve-month period.
