Epidural Steroid Injections

An epidural steroid is a medical procedure in which corticosteroid medication is injected into the epidural space. The epidural space is the area surrounding the spinal cord and nerves that pass through it. It is filled with fat and connective tissue, providing cushioning and protection to the spinal cord and nerves. By delivering corticosteroids directly into the space, the medication can help reduce inflammation and relieve pain and other symptoms associated with certain spinal conditions such as herniated discs or spinal stenosis.

Why do I need epidural steroid injections?

If you have intense pain in your legs and arms and it is coming from inflamed spinal nerves , epidural steroid injection may give you quick pain relief. The nerves can be pinched in and around the spinal column and can cause intense pain. The narrowing of the space around the spinal cord and nerves can cause inflammation. The pain is usually described as intense pressure, pinching, vice like, shooting, sharp, stabbing.

Common indications of epidural steroid injections

Herniated discs
Slipped vertebrae or spondylolisthesis
Bone spurs
Scarring around the nerves after spine surgeries
Joint cysts or facet cysts
Thickening of ligaments around the spinal cord as seen in aging

What are the risks of epidural steroid injections?

Since the epidural steroid injections are always done under the continuous guidance of an X ray machine, the risks are low. However some of the reported side effects are

Flushing is attributed to the injected steroids, which is a feeling of warmth around the face and chest. This usually will subside within 2-3 days
Sleeping problems
Anxiety
Menstrual issues
Water retention
In rare cases worsening of pain for 1-2 days

Serious complications are rare but can include

Allergic reactions
Infection
Bleeding /Hematoma
Nerve damage
Paralysis

What can I do before I opt for steroid injections ?

Some the strategies that can be tried before getting epidural steroid injections include

Over the counter inflammatory medications like motrin , aleve ( make sure you are not on blood thinners, and do not have kidney problems )
Physical therapy
Chiropractor
Nerve pain medications like Gabapentin ,Cymbalta , Lyrica
Exercising

Is there any testing required before epidural steroid injections?

It is not recommended to schedule anyone for epidural steroid injections before relevant imaging. Initial imaging usually includes X rays . Based on the X ray results clinicians usually decide about additional imaging required. The subsequent tests may include MRI, CT scans.

If you are on blood thinners or anticoagulants such as aspirin, plavix, warfarin, eliquis or xarelto you may need blood tests before epidural steroid injections.

Additionally the pain team will reach out to the prescribing team to make sure its safe to hold blood thinners before the procedures.

How do I get ready for epidural steroid injections?

Tips for getting ready

Limit eating or drinking for a certain amount of time before your procedure
You will be asked to stop anticoagulants or blood thinners before the procedure.
If you are choosing to get sedatives or anesthesia for your procedures you will be asked to bring someone to drive you.
Give yourself ample amount of time to reach the facility and be prepared to be at the facility for atleast an hour.

What happens during the procedure?

You will be asked to change into a gown
If you have chosen to get sedation for the procedure, you will need an intravenous line before the procedure
The procedure itself is only 5-10 minutes.
You will be asked to lay on a table on your abdomen
The monitors will be then applied including blood pressure and EKG
The back or neck will be cleaned with cold , cleaning solution
The area of the approach will be identified with X ray machine
The skin will be numbed with numbing medicine
The needle is then directed to the appropriate space under the guidance of X ray machine
Three ways the provider can get to the epidural space
Interlaminar : Lamina is the flat part of the spinal bones and this approach involves going in between two flat parts in the midline to access the space. This approach can be used to provide temporary relief for disk herniation, spinal stenosis and localized back pain.
Transforaminal : Foramina are the openings through which your nerves exit the spinal canal. With this approach it is possible to isolate a specific nerve in the spine which is causing you to have pain. Many times it can alleviate the pain that is originating from disc herniation and shooting to your legs . It can also be used to delineate if surgery at one level is indicated for you especially in cases where the cause of pain is not completely clear.
Caudal epidural : This involves going through the sacral hiatus , which is at the bottom of your sacrum and above tailbone. This is also midline and is usually done in patients who had spine surgery in the past and still are having nerve related pain.
The needle is confirmed to be in appropriate space using contrast
Then a combination of steroid and numbing medication is given
After the procedure your back will be cleaned again and you will be taken to the recovery area.

How painful is epidural steroid injection?

You may feel a little pinch when the clinician injects numbing medicine. After that you may or may not feel

Pressure
Tingling
Burning
Momentary pain

What are the side effects of epidural steroid injections?

You may experience mild discomfort for 2-3 days at injection site
If you have Hypertension or diabetes you may see a transient rise in blood pressure or blood sugar. This is usually transient and may last up to 48 hours after the injections
Steroids can cause increase in eye pressure for patients who have glaucoma

How long before it takes effect?

The numbing medicine will help you immediately , however it wears off in about 4 hours. Steroids can take up to 7-10 days for full effect.

What are the risks and possible complications of epidural injections?

In the hands of experienced clinicians and with use of modern equipment like X-ray machines the risk of complications is very low.

However reported side effects or complications include

Low blood pressure
Headaches
Infection
Bleeding
Hot flashes
Nerve damage
Loss of Bowel or bladder control
Weakening of bones

What to expect after lumbar epidural steroid injections?

Many people get temporary relief for 6 months – 1 year after epidural steroid injections. Some people may have no relief. Sometimes repeat injections are recommended to increase the chances of the steroid to work.

Studies have revealed that epidural can provide reliable pain relief for up to 6 months in many cases. However, every person is different and experiences pain differently, so your experience may vary.

Epidural steroid injections are most successful at providing temporary pain relief for radicular pain ( which is pain shooting down your leg, arms or chest wall) caused by a lumbar herniated disk and lumbar spinal stenosis. It’s important to remember that lumbar ESIs are not intended to cure back pain; their main goal is to provide pain relief. It is recommended as adjunct to other measures of treatment including but not limited to physical therapy and chiropractic therapy.

When should I call the pain management office?

You will be instructed to make a follow up appointment in 2 weeks. It is highly recommended to follow up regardless of whether the epidural helped or not as further course of treatment will be discussed in the follow up visit.

It is recommend to call the office immediately if you are

Feeling dizzy
Have uncontrolled pain that is not helped by motrin, tylenol or icepacks
You are experiencing fever
If you have increased weakness in legs or arms
Complete loss of bowel or bladder control