Procedure

Pain Control Procedures

Epidural Steroid Injections

Background:

For over 50 years epidural steroid injections (ESIs) have been used to treat pain originating in the spine (“spine pain”), usually neck pain extending into the shoulders or arms, or low back pain with associated hip, thigh, or leg pain. Today, ESIs have become an important part of non-surgical management of spine pain. An ESI can help relieve spine pain, often allowing a patient to progress with a rehabilitation program and to resume some normal activities. ESIs work by delivering steroids directly to inflamed, pain-generating spine areas, decreasing the inflammation (irritation and swelling) that may be causing the pain.

What is an ESI?

An ESI is an injection that delivers steroids and/or anesthetic medicines directly into the epidural space, which is inside the spine, but just outside the dural sac that contains the spinal cord and nerves. The epidural space contains nerves, but not the spinal cord. There are substances in this space that cause nerve inflammation, leading to pain. Steroids reduce this inflammation. An ESI works because it delivers medication directly to the inflamed area.

When is an ESI typically recommended?

In general, ESIs are used to help provide pain relief. Several common conditions can cause severe acute or chronic spine pain:

• Disc herniation
• Degenerative Disc Disease
• Spinal Stenosis

For these and other conditions that can cause pain, an ESI is an effective non-surgical treatment option.

Describe the ESI procedure:

An ESI usually takes 15-30 minutes. You will lie flat on your stomach on an x-ray table or CT table. Using fluoroscopy or Cat Scan guidance, the physician guides a needle through your skin toward the epidural space, confirms its location by injection of x-ray contrast, and then injects the medication. Afterwards, you will be monitored for 15-20 minutes and then allowed to go home. Sedation is available if you are anxious or uncomfortable, but you must have someone else to give you a ride home. You should rest the remainder of the day after the injection, but can resume activities the next day, still obeying any restrictions that your spine doctors have given.

What are the benefits?

The main benefit of the ESI series is a reduction in pain. ESIs relieve pain for 50-75% of patients. If you do not get pain relief from the first injection, further injections may still help. Also, other types of injections, such as nerve root or facet blocks, may be tried depending on your pain and the way your spine looks on MRIs, CTs, or x-rays.

What are the potential risks and side effects?

As with all invasive medical procedures, there are risks associated with ESIs, but these are few and they are very uncommon. They are as follows:

• Infection. Minor infections occur in 1-2% of patients.
• Bleeding. Bleeding is rare.
• Nerve Damage. While extremely rare, nerve damage can occur directly from the needle, or from infection or bleeding.
• Dural Puncture. Occurs in 0.5% of patients. It may cause a spinal headache that usually gets better within a few days.
• Paralysis. Not a risk.

Temporary leg weakness involving one or both sides may result from effects of an anesthetic medication, if administered for low back ESIs. The risk is greater if a dural puncture occurs or if you have had prior surgery. If you have had prior surgery, you also may notice delayed lower extremity numbness or weakness.

There are very rare side effects from the steroid medication:

• A temporary decrease in resistance to fight infection
• High blood sugar, particularly if you have diabetes
• Stomach ulcers
• Severe arthritis of the hips
• Increased blood pressure
• Transient flushing
• Increased appetite

ESIs should not be performed if you have an infection or a bleeding problem, or are pregnant (since x-rays are used). Occasionally, an MRI scan may be needed prior to the ESI to rule out certain conditions. Injections may be done, but with extreme caution, for patients with allergies to the injected solution, serious medical problems (such as congestive heart failure or uncontrolled diabetes) and those who are taking aspirin or other blood thinning drugs (Ticlid, Plavix, for example).

How frequently can epidural steroid injections be performed?

There is no research that gives a definite answer to this question. It is reasonable to perform up to 3 injections per series, with series separated by at least 3 months. A series of 3 injections is not always necessary. If 1 or 2 injections lessen your spine pain, some physicians may prefer to save the 3rd injection for any recurrence of spine pain. Most physicians believe that a series of 3 injections provides the best chance for lasting relief.

SPECIAL INSTRUCTIONS:

• Notify the radiologist and nurse if you are allergic to x-ray dye or steroids.
• Begin a clear liquid diet 4 hours before your procedure.
• You must not drive after the procedure because of the effects of sedation. Please arrange for a ride home.
• Please bring your spine MRI and CT scans with you, if you have them.

Radiology Associates of Bennington also provides other pain control procedures, including facet and median branch blocks, joint injections, and nerve root blocks. For more information on our additional pain control procedures, please refer to the Radiology Info Website.