Epidural Steroid Injections (ESI)
The epidural space is the outermost space found in the brain and spine In the spine, it contains many structures including the spinal nerve roots as they leave the spinal cord and spinal canal to enter the body. The spinal nerve roots are a common location of injury and pain resulting from compression and inflammation.
An epidural steroid injection is designed to treat the pain and symptoms of spinal nerve root inflammation and compression. The goal of an ESI is to place anti-inflammatory medications (steroids) around the affected nerves to help reduce pain and inflammation. These injections may be used to treat several conditions associated with inflammation of the nerves, including radiculopathies, degenerative disc disease, herniated discs and spinal stenosis.
An epidural steroid injection for spinal nerve pain is different than the epidural given for the pain of child birth. An epidural during child birth provides only anesthetic (numbing) medications continuously through a catheter placed into the epidural space, providing pain relief during labor. No steroids or other anti-inflammatories are given with this type of epidural. Once this epidural is removed after the birth of the child, the pain reducing (anesthetic) benefits end shortly thereafter.
Your physician will talk with you about your symptoms and perform a thorough physical examination to determine the source of your pain. Imaging, such as x-rays and MRI, can help to assist in this diagnosis, if needed. Symptoms of a pinched nerve in your neck include pain in the neck and possibly pain/numbness radiating down your arm(s). Symptoms of a pinched nerve in your lower back include pain in the low back and possibly pain/numbness radiating down your leg(s). Symptoms may be described as sharp, aching, electrical, burning, numbness, tingling, etc. If the nerve compression is severe, it may result in weakness of the arms or legs.During your appointment in the office, your doctor will discuss the reasons he feels that your pain is related to the spinal nerves.
There are a few recommended criteria to be considered a good candidate for an ESI. Usually, patients should have failed to improve with appropriate conservative measures, such as anti-inflammatory medications, physical therapy, chiropractic care, massage, etc. Prior to being considered a candidate for an ESI, most patients will need some form of imaging (x-ray, MRI, etc.) to correlate with history and exam findings. Epidural injections tend to have the best results with spinal nerve compression and spinal nerve root irritation.
The procedure does involve placing a needle through the skin, so you may feel some mild discomfort. Local anesthetic is used to numb the skin and lessen the pain associated with skin puncture. If you wish, mild IV sedation and pain medication may be given prior to the injection to make you as comfortable as possible (discuss with your doctor). During the injection, as the needle tip gets closer to the epidural space and the painful nerves, it is possible that you will feel a reproduction of your typical arm or leg pain. This is quite common. If this should happen, just let the physician know and he will carefully reposition the needle to a different spot within the epidural space. Most patients tolerate this procedure without significant discomfort.
This varies with each patient. During the injection, a steroid medication and an anesthetic medication are injected into the epidural space. Many patients get some immediate relief due to the anesthetic medication, which partially numbs the nerves and surrounding painful structures. Unfortunately, this pain relief is often temporary, as the effects of the anesthetic usually last only a few hours. The steroid medication is a strong anti-inflammatory used to treat inflammation. Unlike anesthetics medications, steroids often do not work immediately, as reducing inflammation takes time. It can take 2-3 days until steroids start to provide some pain relief. Steroids reach their maximum benefit between 7-14 days.
Epidural injections can provide great pain relief for some spine conditions, but provide minimal or no relief for other spine conditions. If most of your pain is coming from the spinal nerves in the back or neck, there is a good chance that the epidural injection will help a significant portion of your pain. If you have other conditions, such as arthritis, contributing to your pain, then the ESI may only provide relief for a portion of your pain. Most patients receiving epidural injections do not experience 100% pain relief, since they often have other sources of pain in their spines than just nerve inflammation. The goal of the ESI is to reduce pain enough so that you can become more functional. Often, after pain is reduced, starting a therapeutic exercise program or physical therapy can help prolong the pain reducing response of the injection.
Everyone responds differently to the injection. Prior to your injection, your physician will assess your individual condition and the chances of success of the injection. A good response to the injection will be at least 3 months of good pain relief. It is possible that the injection will provide relief lasting much longer than 3 months. However, it is also possible that the injection will not provide much relief at all. The only way to truly know how effective an epidural injection will be is to wait and see.
The number of injections performed depends on your spine condition and your response to the injection. You will be seen back in clinic about 2 weeks after your ESI to assess your response (this is the time it takes for steroids to reach maximum effectiveness). The decision to do more injections will be based off your response to the first injection.
If you have a great response to the first ESI (>80% pain reduction), then there is no need to have a second injection immediately. ESIs can always be repeated inthe future if the same pain should return.
If you have had 80% improvement, but 20% improvement in your pain following your first ESI, a second injection may provide some “additive” benefit. A subset of patients require two injections to see benefits of the injection. You can discuss the possibility of a second injection at your 2 week follow up visit.
If you had minimal improvement with ESI (20% pain reduction), then your doctor will re-evaluate your condition to determine the next step in the treatment plan.
Due to the side effects of steroids, it is recommended that you get no more than 4 ESIs per calendar year. At most, three injections can be performed in a 6 month period.
If the ESI does not help your pain, then the doctor will re-evaluate you at your follow up appointment. Some people require more than one injection to get adequate pain relief. However, no pain relief from an ESI could also mean that your pain is coming from a different source in your neck or back. If this is the case, then a different type of injection may help your pain. It is important to know that these injections do not change your spine anatomy. If you have a large herniated disc or severe arthritis/spinal stenosis, the injection may not provide significant long lasting benefit.
Will I eventually need surgery for my spine condition?
The goal of our clinic is to prevent surgical intervention, if possible. There are a few reasons to have surgery on your neck or back. These reasons are:
Sudden numbness in the genital area (saddle anesthesia)
Sudden loss of bowel and/or bladder control.
Severe pain that you cannot tolerate and pain that is not helped with conservative treatments (medications, physical therapy,
chiropractic care, injections, etc.)
If you should ever develop any sudden weakness, saddle anesthesia or loss of bowel/bladder control, you should call your doctor immediately. If you cannot reach your doctor, you need to go to the emergency room immediately to get evaluated.
No, for your safety. You have the option to have mild IV sedation and pain medication through an IV prior to the procedure, however, you cannot be put under general anesthesia for this injection. Your feedback is critical to the safety of the ESI. As the needle approaches the epidural space, it is possible that the needle will come close to the spinal nerves. If this should happen, you may feel some discomfort traveling down your arm or leg. We rely on you to tell us this information, so that we can adjust the needle to another location. If you are put under general anesthesia, there is an increased risk of nerve damage from the needle. If you do not wish to have any IV pain medication, then you may take a pain pill prior to the procedure with a sip of water.
Epidural steroid injections are not performed in our office. They are performed in an ambulatory surgery center with the use of fluoroscopic (live x-ray) guidance. X-ray guidance is critical to ensure that the injection is placed in the correct location. You will usually arrive at the surgery center about 20-30 minutes prior to your appointment to get set up for the procedure. If you are going to get IV sedation or pain medication with your injection, you will be asked to not eat food for 4-6 hours prior to your procedure or drink any liquids for 2 hours prior to your procedure. The decision to get sedation or pain medication is always optional. The total duration of the procedure usually takes about 10-15 minutes. Your doctor will discuss this procedure more in detail during your office visit prior to the injection. If you got any IV medication during the procedure, you will be required to have a responsible adult driver to get you home. If you do not have a driver, then you will not be able to get any IV medication. Typically, you will be seen in the office about 2 weeks after the injection to assess the response of the steroid injection.
Generally speaking, this procedure is very safe. However, as with any procedure, there are risks, side effects, and the possibility of complications. Some of these common risks are listed below.
Pain:The injection site may be sore after the injection, due to the needle passing through painful tissue. Usually, any increase in pain is temporary. In most cases, very little discomfort is felt by the patient.
Bruising at the site of injection
Infection:Rare. The skin is cleaned thoroughly prior to the injection to minimize this risk. Everything is done under sterile technique.
Bleeding:Usually any bleeding stops spontaneously. To minimize any bleeding risk, we ask that you stop all blood thinning medications prior to the procedure.
Nerve Damage, Seizures, Paralysis, Death:Exceedingly rare complications.
Steroid medications have several possible side effects. The systemic side effects associated with steroids are typically less with steroid injections than steroid pills. Typical side effects of steroids can include indigestion, upset stomach, nausea, increased appetite, trouble sleeping, increased anxiety/restlessness, heart racing and occasionally headache. If you have a history of diabetes, steroids may cause a temporary increase in your blood sugar readings. If you use insulin to treat your diabetes, you may need to temporarily adjust the dose of the medications. Some of the risks of injected steroids include bone and cartilage damage, skin atrophy, hypopigmentation, and the weakening/rupture of the muscle where injection is given. To ensure safety, the number of steroid injections performed in a particular joint or location is limited to about 4 injections per year.
Stop all aspirin based products and non-steroidal anti-inflammatory (NSAIDs) medications for 5 days prior to your injection. Examples of NSAIDs include Ibuprofen (Advil, Motrin), Naproxyn (Aleve, Naprosyn, Anaprox), Indocin (Indomethacin), Lodine (Etodolac), Relafen (Nabumetone), Daypro (Oxaprozin), Meloxicam (Mobic), Diclofenac (Voltaren, Arthrotec), etc. Celebrex, although a NSAID, does not need to be stopped. If you have any question if a medication you are taking needs to be stopped, please ask your doctor.
Stop fish oil and Vitamin E supplements for 5 days prior to your injection.
Stop all blood thinning medication, including warfarin (Coumadin), pradaxa, debigatran, argatroban, plavix, etc. for 5-7 days prior to the injection. You may need to get permission from your prescribing doctor prior to getting off of these medications prior your injection to ensure that it is safe to stop these medications.
You should take all of your other medications, such as your blood pressure medications, with a small amount of water prior to your injection.
Do not eat for 4-6 hours prior to your injection.
Do not drink for 2 hours prior to your injection.
You may be required to have lab work or an EKG prior to your procedure. Discuss this with your pain physician.
For your safety, it is recommended that you have a responsible adult to drive you home after your injection. If you cannot get a driver to bring you home, you must tell your treating physician. If you do not have a driver, then you will not be able to have IV pain medication or sedation. Failure to have a driver may result in the cancellation of your procedure.
Your activity level after your injection should be at the following levels:
Day of Injection:We recommend no new activities. You should take it easy the day of the procedure. You can still perform regular everyday activities on this day.
Day 2:Up to 50% of your usual activity level.
Day 3:Activity is unrestricted as tolerated.
You may take pain medications, except for aspirin and NSAIDs, immediately after your injection.
You may resume all aspirin, NSAID and blood thinning medications the night of your injection or the following morning.
You may use ice compresses over the injection site – 20 minutes on, then 20 minutes off. Repeat this cycle as required. If using a gel pack, make sure a towel or piece of cloth is placed between the cold pack and the skin. Do not apply the cold packs to the numb areas following injection.
You may eat and drink after your injection is completed.
You may shower immediately, but please avoid swimming or baths/Jacuzzis/hot tubs for the first 2 days after the procedure, to reduce the risk of infection.
Should you develop fever, chills, drainage, excessive swelling or redness at the injection site, bladder or bowel dysfunction, or change in sensation or muscle strength, please contact our office immediately. If you cannot reach your physician, please present to the nearest emergency room.
If you experience a post-procedure headache, please contact our office. For the first 24 hours, lie down as much as possible. You can take Tylenol, up to 3 grams per day in doses of 1 gram every 8 hours. Drink plenty of fluids in the form of caffeinated beverages. The caffeine will often minimize the headache substantially. If you continue with headaches after 24 hours following the procedure, please contact our office.