Relief For Arthritis Pain

Lumbar Epidural Steroid Injection For Low Back Pain

The spine has many diseases that result in painful inflammation of nerves, ligaments, and discs that may respond to epidural steroid injections. These conditions include disc herniations, spinal stenosis, and arthritis of the spine. Epidural injection provide relief from pain when there is inflammation. Disc herniations are commonly known to produce inflammation of the nerves due to spilling out noxious chemicals from the disc onto the nerve root, causing pain from the back to the hand or foot depending on the location of the disc herniation. The epidural space is an area behind the spinal cord and spinal fluid that the nerves cross through in order to leave the spine.

• What is an Epidural Steroid Injection (ESI)?

Epidural Steroid Injection is an injection of long lasting steroid ("cortisone") in the Epidural space - that is the area which surrounds the spinal cord and the nerves coming out of it. There are several types of epidural steroid injections (ESI) in pain management and these include:

1. Intralaminar Injection: In this approach the medication is injected between the lamina of two vertebrae directly posterior to the vertebrae. The combination of steroid and anesthetic is delivered into the epidural space in the midline and spreads to the nerve roots on both sides of the spine. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing radiculopathy.
2. Transforaminal Injection: In this procedure the medication is delivered on the side of the vertebra above the opening for the exiting nerve root. This approach treats one side at a time and is thought to be more specific. There is powerful evidence suggesting that transforminal ESIs are effective for short-term and moderate for long-term improvement in managing lumbar back pain.
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4. Caudal Injection: This technique allows for larger volumes of steroid and anesthetic to be delivered and is best used when patients have had spine surgery. The additional medication can be used to affect more nerve roots distributing to the inflamed area at the same time. The evidence for caudal ESIs is similar to that of the transformational ESIs.
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• What is the purpose of it?

• How long does the injection take?

The actual injection takes only a few minutes.

• What is actually injected?

The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (triamcinolone - Aristocort or methylprednisolone - Depo-medrol, Celestone-Soluspan).

• Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the Epidural needle. Also, the tissues in the midline have less nerve supply, so usually you feel strong pressure and not much pain. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

• Will I be "put out" for this procedure?

This procedure is done under local anesthesia or light sedation if requested. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance.

• How is the injection performed?

It is done either with the patient sitting up or on the side, or on your stomach. The patients are monitored with EKG, blood pressure cuff and blood oxygen monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out. After the injection, you are placed on your back or on your side.

• What should I expect after the injection?

Immediately after the injection, you may feel your legs slightly heavy and may be numb. Also, you may notice that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a "sore back" for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 3rd day or so.

• What should I do after the procedure?

You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you.

• Can I go back to work the next day?

You should be able to unless the procedure was complicated. Usually you will feel some back pain or have a "sore back" only.

• How long the effect of the medication last?

The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months.

• How many injections do I need to have?

If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. Similarly If the second injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a third injection.

• Can I have more than three injections?

In a six month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get nay further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

• Will the Epidural Steroid Injection help me?

It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have "radicular symptoms" (like sciatica) respond better to the injections than the patients who have only back pain. Similarly, the patients with a recent onset of pain may respond much better than the ones with a long standing pain. Also, the patients with back pain mainly due to bony abnormality may not respond adequately and require facet injections. Conditions of the back and neck commonly treated with epidurals include:

• degenerative disc disease
• spinal stenosis
• herniated discs
• sciatica
• radiculopathy / radiculitis

• What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain - which is temporary. The other risk involve spinal puncture with headaches, infection, bleeding inside the Epidural space with nerve damage, worsening of symptoms etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body's own natural production of cortisone etc.

• Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on a blood thinning medication (e.g. Coumadin, Plavix), or if you have an active infection going on, you should not have the injection.