Epidural Steroid Injections

An Epidural Steroid Injection (ESI) refers to the injection of corticosteroids and anesthetic solutions into the epidural space of the spine to treat irritated or compressed nerves. When a disk tears, the gelatinous nucleus contained inside the disk leaks out of a tear in the wall of the herniated disk and causes a localized inflammatory reaction. This creates swelling and pressure on the nearby nerve roots. The injection of steroids directly around the nerve roots near the disk herniation helps reduce this inflammation by decreasing swelling, separating adherent tissue, and washing away waste products. The reduced swelling is believed to allow for improved circulation and accelerate the healing process. Corticosteroids may also act like a local anesthetic and block the pain long enough to allow the body to begin the process of repairing itself. The effect may not be long lasting and differs from person to person. Most patients will receive good relief for several weeks or months after an injection. The pain reduction allows the patient to participate more fully in rehabilitation efforts, such as exercise and physical therapy.

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Several approaches for epidural injection are available, depending on the target and goal of treatment. A Selective Nerve Root ESI, otherwise known as a Transforaminal ESI, places the needle within a millimeter or two of the inflamed nerve root and has the additional advantage of "Hydro-Dissection" of the nerve root within the recess or canal that it travels through. This is currently thought to be the most potent technique, especially in the lumbar spine. Older techniques, such as the Intralaminar ESI or the Caudal approach, have their proponents, and can be useful for specific reasons. Previous surgery, especially fusion, may create challenges for perfect needle placement, due to bone and metallic hardware obstacles, epidural space scarring, and visualization of targets. The experienced interventionalist will select the best approach given the circumstances, and may combine several different needle placements at the same visit to better access a complex space or to better treat multiple nerve and disk issues.

How is an Epidural Steroid Injection administered?

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The patient is placed on a procedure table under a video X-Ray (Fluoroscopy) machine. The skin is sterilized and a local anesthetic is injected to numb the area. A needle then is advanced through the numb region to reach the epidural space. Contrast solution is used to confirm proper placement. The treatment solution containing anesthetic and steroid solution is then injected. Usually, the procedure takes about 5-10 minutes. The patient is monitored for 15-30 minutes and then may go home. We do not recommend that patients drive themselves home after the injection. Most experienced interventionalists agree that sedation is almost never needed due to the minimal amount of pain, small needle size, and relatively quick duration of the procedure.

Occasionally, a second or third injection may be recommended, depending on the results of the first injection. Most patients respond well to two injections. Occasionally more than three injections be justified within a three to six month period. Sometimes other solutions are added, such as Hyaluronidase to breakup scar tissue, or Ozone (much more common in Europe). When epidural injections are not helpful, a thorough search for other sources of pain is appropriate.

Risks of Epidural Steroid Injections

With any medical or surgical procedure, there are risks. In the case of epidural steroid injections, these risks are generally small and infrequent, and may include the following:
Temporary increase in pain or nerve irritation
Headache, which may last a few hours to a few days
Hot / flushed sensation in the face or chest
Excessive energy, sleeplessness, or irritability for several days
Itching, bruising, or rash
Light-headedness, which usually resolves in 15-30 minutes
Fluid retention or mild weight gain
Nerve or spinal cord compression from an expanding blood clot in the cervical region
Diabetics may experience elevated blood sugar for several days and dosage adjustments of diabetic medications may be necessary during those days.

General recommendations

Discontinue all blood thinners, such as
Coumadin, Aspirin, Plavix, and anti-inflammatory medication, for several days before the procedure. This decreases the likelihood that a blood clot could form causing spinal cord compression. These may be resumed after the injection.
Please ensure that transportation home is available following the procedure and allow approximately two hours in all for the procedure, which allows for 30 minutes or more of supervision in the waiting room following the procedure.
You may eat or drink your normal diet before and after the procedure, and resume normal activity afterwards.
Try to relax in the days & nights before your procedure. You will very likely find it minimally uncomfortable, easier than you expected, and very beneficial for your problem.