Epidural Steroid Injections
Epidural steroid injections (ESIs) are a frequently used treatment for certain acute and chronic pain conditions. Some common symptoms of conditions treated with ESIs are low back pain, neck pain, and pain radiating down an arm or leg. Pain arising from a spinal nerve root and traveling down an arm or leg is often referred to as "radicular pain ".
Radicular pain is caused by irritation or injury of the nerve root near or at the location of where the nerve separates from the spinal cord and exits the spinal canal. Pain is then perceived in the portion of the body that the nerve travels through. Typically, the pain is felt in the leg or the arm. Radiculopathy in the leg usually involves a lumbar or sacral nerve root. Radiculopathy in the arm usually involves a cervical or upper thoracic nerve root. In some conditions, more than one nerve root may be involved.
Some conditions commonly treated with Epidural Steroids include:
- Degenerative Disc Disease
- Postlaminectomy Pain Syndrome
- Spinal Stenosis
- Herniated Discs
The goal of the procedure is to place medication into the epidural space of the spine. This injection consists of a steroid and possibly a local anesthetic. The steroid works by decreasing inflammation around the nerve root. This usually takes 3-5 days, but may require longer to provide relief. Your physician may decide to use local anesthetic with the steroid to provide some immediate relief. The medicine then spreads throughout the epidural space, encompassing many other levels of the spine. The entire procedure usually takes less than fifteen minutes.
The most important and greatest success achieved with the use of epidural steroid injections (ESI) is the rapid relief of symptoms that allows patients to experience enough relief to become active again. With this help patients regain the ability to resume their normal daily activities.
Utah Epidural Steroid Injections
There are several techniques to place the medication into the epidural space. The type of pain and the anatomy of the spine will determine how the epidural space can be safely accessed. The different routes of access to the epidural space include:
- Interlaminar Injection: With this approach the needle enters the mid-line of your back. The medication is then injected and spreads to both sides of the spine.
- Transforaminal Injection: With this approach the needle is inserted into the side of the spine with the target site where the nerve root exits the bony portion of the spine (neural foramen). This approach is useful for a discrete nerve root pain or if the mid-line approach is not feasible for reasons such as the existence of scar tissue after surgery.
- Caudal Injection: after your skin is anesthetized, a needle enters the epidural space near your tailbone. This technique allows for a catheter to be placed (Racz catheter) and larger volumes of steroid and anesthetic to be delivered. The additional medication can be used to simultaneously affect more nerve roots in the inflamed area. Often, caudal ESIs are combined with another procedure called Lysis of Adhesions or the Racz procedure, which is used to treat epidural scarring. The evidence for caudal ESIs is similar to that of the transformational ESIs.
What Are Benefits Of Epidural Steroid Injections?
Epidural Steroid Injections are relatively painless and considered routine. Approximately 72% of patients experienced immediate pain relief in a 2007 research trial to evaluate the usefulness of a cervical interlaminar epidural steroid injection in patients with neck pain and cervical radiculopathy (Kwon 2007). If pain relief is only moderately achieved with the first injection, then another injection can be given in 2 weeks and may provide additional relief.
The use of multiple injections was studied by the Department of Anesthesiology and Intensive Care at the University of Pavia in Italy, and they concluded that therapy with multiple ESIs provide better control of chronic neck pain compared to that with a single injection (Pasqualucci 2007). Therefore, it is likely that your pain physician will recommend multiple ESIs. Often these procedures are done in sets of three.
ESI patients can expect to experience rapid relief of symptoms — enough relief to become active again. With treatment, patients are often able to resume their normal daily activities.
Another common complication of chronic pain is central sensitization. This is a development involving both the peripheral nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain. Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually, normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by a very light touch of the skin activate neurons in the spinal cord that normally only respond to painful stimuli. As a result, an input that would normally produce a harmless sensation now produces significant pain.
Epidural Steroid Injection Risks
ESIs are considered an appropriate non-surgical treatment for many patients who suffer from back and neck pain. Although ESIs are considered safe and the procedure is performed quite often, there are risks associated with the procedure. The major risks associated with this procedure involve bleeding, infection, post-dural puncture headache, and nerve damage.
The other risks of the ESIs may be directly related to the medications injected. Some of the potential side effects of corticosteroids include elevated blood sugars, weight gain, arthritis, stomach ulcers, and transient decrease in immune system function. All patients should consult their physician for a risk assessment for the procedure before receiving an ESI.
Patients with an allergy to any anesthetic, are on blood thinning medications, have an active infection or are pregnant should consult with their pain physician before receiving the procedure.
Outcomes Of Epidural Steroid Injections
The amount and duration of pain relief varies from person to person, and are dependent on many other factors including underlying pathology and activity level. Some experience relief that lasts for years while others' relief is short-term. It is important to discuss your response to epidural steroids with your physician in order to plan future treatment options.
The Department of Rehabilitation Medicine at the University of Washington conducted a study that compared the risks and efficacy between surgical alternatives versus lumbar ESIs. They concluded that "when weighing the surgical alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable non-surgical option in select patients."(Young 2007)
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