Epidural steroid injection (ESI)

Overview

Epidural steroid injections (ESI) are a common method of treating inflammation associated with back pain, leg pain related to lower back pain or neck related arm pain. In these cases, the pain is caused by an increase in pressure locally on the spinal nerves that causes pain as the nerves travel down or out of the spine.

An epidural steroid injection (ESI) is a minimally invasive procedure that is used in practice to help relieve neck, arm, leg and back pain caused by pressure on spinal nerves due an inflammatory process in and around the spine such as disc herniation, spinal stenosis or trauma. With an Epidural injection (ESI), the medicine is delivered directly to the epidural space, which is an area between the bone and spinal nerves. The goal of the treatment is to reduce pain to such an extent which will allow you to endure a physical therapy program.

What is the epidural space?

The spinal cord and its nerves and bones is covered by a protective layer called the dura. The space that surrounds this protective layer is called the epidural space.

Why do I have pain in the epidural space?

The bones that make up your spine are called vertebrae. Vertebrae are divided by soft discs that protect the vertebrae, allowing for motion and bending and keep them together. If one or more of the discs or back bones are damaged, they cause the surrounding tissues, including spinal nerves, to become painful and inflamed. Damage to the disc or back bone can be caused by trauma, spinal stenosis, arthritis or disc herniation.

How do I know if my pain is from the epidural space?

If you have back pain that tends to travel to either your neck, arms or legs, you probably have nerve root inflammation. If it is associated with numbness or a tingling sensation, then the area around your spinal nerves is inflamed (epidural space).

What is an epidural steroid injection (ESI)

Simply put, an epidural shot is a way to deliver pain medication in a quick and effective manner. The medicine is injected into an area consisting mostly of fat (called the epidural space), which surrounds and protects the bone and nerves in your spine.

The injection contains a corticosteroid (an anti-inflammatory) and an anesthetic (a painkiller and numbing agent). When injected, the drugs are delivered to an area between your nerves and backbones. The anti-inflammatory medications help to reduce the inflammation in the area and also flush away harmful proteins and deposits, thereby reducing pain. The combination of a pain killer and anti-inflammatory allows for pain relief from a few to days to a couple of years. This can allow for your spinal condition to improve with either an exercise program or physical therapy.

Epidural injections are mainly used for radicular pain where simpler and more conventional methods have not improved the condition. It is important to know that the pain relief can be short lived although some people can get lasting pain relief from these injections. EPI is usually combined with other treatments such as physiotherapy and rehabilitative exercise programs.

What are steroids?

Steroids is a general name given for glucocorticoids. It is a man-made, synthetic drug that is in its form and function similar to cortisol. Cortisol is a hormone that we naturally release in our bodies in response to stress. It’s function is to reduce pain and inflammation and are used to treat a variety of painful and inflammatory conditions.

Are you a candidate for epidural spinal injection (EPI)?

Other treatment options will be discussed with you before your doctor will go ahead with injections. You and your doctor both ill have to agree and your consent will need to be obtained.

In general, patients with either pain in the lower back, leg, neck or arms may benefit from EPI. Patients with certain conditions may also find EPI beneficial such as spinal stenosis, spondylolisthesis, herniated disc, degenerative disc or sciatica. EPI has been proved to have astounding beneficial outcomes for many patients in the treatment of painful inflammatory conditions. In many conditions, epidural injections can be beneficial in the sense that it reduced the pain enough for the patient to enter rehabilitative programs.

Who will perform the procedure?

Physicians that administer epidural injections include surgeons, anesthesiologists, neurologists and radiologists.

What are the possible risks?

Potential risks include bleeding, infection, spinal headache, allergic reaction and nerve damage.

Side effects from the steroids may include temporary weight gain, water retention, hot flushes, insomnia, elevated blood sugar and mood swings. Patients may also experience limb weakness or numbness, but this should resolve within 8 hours after the procedure.

Before the procedure

You will meet the doctor that will perform the procedure and he/she will review the risks and benefits of the procedure. The doctor will also discuss possible side effects of the procedure such as infection, bleeding, spinal headache, temporary limb weakness or numbness. Your doctor will explain the procedure to you and will tell you in a step-by-step fashion what will happen.

The physician who will perform the procedure will review your medical history and obtain information regarding your previous surgeries, previous complications that you might have had with anesthesia, other medical conditions such as bleeding disorders, cancer, infections, diabetes or glaucoma. They will also request previous imaging studies that you might have received such as x-rays or CT scans.

You should also prepare some questions and concerns that you might have to ask during this time. Patients on certain medications such as blood thinners may be required to stop them several days before the procedure and a few days after.

2 weeks before the procedure

Let your physician know if you have any bleeding disorders or if you are on any blood thinners like aspirin, warfarin(Coumadin®), heparin, clopidogrel (plavix®), enoxaparin(Lovenox®) or NSAIDS (ibuprofen, naproxen, nabumetone,dicolfenac, etodolac, indomethacin, oxaprozin or ketoprofen). These medications may increase your risk of bleeding complications during or after the procedure.

The day of the procedure

Usually, you will be fully awake during the procedure and sedation is only occasionally used. If you have diabetes, you will need to contact your physician regarding the management before and during the procedure. It is important that you continue to take all of your medications as you normally would. You need to make sure that the doctor doing the procedure is aware of all of the medications.

During the procedure

You will have to sign consent form, list all of your current medications and all of your known allergies. You will also fill in a check list asking questions about recent symptoms such as fever, weight loss, nausea, fatigue, loss of appetite, couching or pain. After all of the necessary documents are provided, you will be moved to the waiting room. The procedure will then take place in a dedicated area accompanied by trained staff to assist the doctor. Often an x-ray machine will be used to allow for accurate injection.

Your blood pressure and pulse will be monitored before, during and after the procedure. You will be positioned with facing down and exposing your back.

The skin around the injection site will then be cleaned with an antiseptic solution which can feel very cold.

Your doctor will then warn you of a small needle prick during which he/she will inject a local anesthetic agent that will numb your skin and surrounding tissues. This will allow for the procedure to be pain free. Please note that even though you won’t feel pain, sensations such as touch and pressure will still be present. The doctor will then guide a needle to the epidural space with the help of an x-ray machine to allow for accurate positioning, where the injection will be made. You may feel some pressure or tightness while the doctor injects the medication. Please inform the doctor of any pain or discomfort during the procedure.

The procedure usually takes 15-45 minutes.

After the procedure

You will be monitored after the procedure and then you will be allowed to go home. It is very important that someone drives you home. Usually patients resume their normal activity by the next day and apart from mild pain at the injection site, patients should not experience any other pain or side effects. It is important not to expect immediate results and allow some time for the injection to work. This may take a few days. You should schedule a follow-up appointment with your doctor to address any concerns that you may have and also to document efficacy of the procedure.

How long can I expect pain relief?

The duration of pain relief will be different in every case. It usually depends on the severity of inflammation and the type of condition you have. Injections can bring pain relief for several weeks or months after which further treatment or another injection is needed. Other times, a single injection is sufficient enough and brings long-term pain relief.

Treatment options for arm or leg pain is best achieved through a combination of injection in conjunction with graded rehabilitative exercise. Individual programs may include a cortisone shot, regenerative medicine, PRP injection, PRP treatment or stem cell therapy which boosts the body’s natural ability to heal.

If your pain does not resolve after a brief period, contact us so that we may help diagnose the problem and treat the underlying cause. Do not let pain persist or else it may become chronic.