Lumbar epidural steroid injection
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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An epidural injection is typically used to help with chronic low back and/or leg pain due to sciatica. While the effects of the injection tend to be temporary - providing relief from pain for one week up to one year - an epidural can be very beneficial for patients during an episode of severe back pain.
It can provide pain relief to the point that a patient can progress with a rehabilitation program.
An epidural is effective in significantly reducing pain for approximately 50% of patients.
An epidural is an injection that delivers steroids directly into the epidural space in the spine.
The epidural space is the space between the dura and the vertebral wall and is filled with fat and small blood vessels. It is located just outside the dural sac. The dural sac surrounds the nerve roots and cerebrospinal fluid.
There are often inflammatory factors and other substances that generate pain, such as substance P or cytokines, that are associated with a lumbar disc herniation, and this inflammation causes nerve root irritation and swelling.
Steroids (corticosteroids) have been shown to reduce inflammation by inhibiting the production of substances that cause inflammation. An epidural steroid injection can be highly effective because it delivers the medication directly to the site of inflammation.
Lumbar epidural steroid injections are recommended in certain conditions such as lumbar disc herniation, degenerative disc disease, and lumbar spinal stenosis—all of which can cause severe acute or chronic low back pain and/or leg pain. For these and other conditions that can cause chronic pain, an epidural steroid injection may be an effective non-surgical treatment option.
An epidural steroid injection usually takes between 15 and 30 minutes to perform. The patient may have the procedure while lying flat or sitting up. Prior to the epidural injection, the skin is numbed with lidocaine, a local anesthetic.
Many types of physicians can be qualified to perform an epidural steroid injection, including an anesthesiologist, rheumatologist, radiologist, neurologist, physiatrist, and surgeon. Both diagnostic ultrasound as well as fluoroscopy may be used for guidance.
Once the needle is in the exact position, the epidural steroid solution is injected. Following the injection, the patient is usually monitored for 15 to 20 minutes before being discharged to go home.
Sedatives are rarely necessary. Patients are usually asked to rest on the day of the epidural steroid injection. Normal activities may typically be resumed the following day.
Patients will find that the benefits of an epidural steroid injection include a reduction in pain, primarily in leg pain. Patients seem to have a better response when the epidural steroid injections are accompanied by an organized therapeutic exercise program.
An epidural steroid injection is generally successful in relieving pain in approximately 50% of patients. If a patient does not experience any back pain or leg pain relief from the first epidural injection, further injections will probably not be beneficial. However, if there is some improvement in back pain or leg pain, one to two additional epidural steroid injections may be recommended.
As with any invasive medical procedures, there are potential risks associated with lumbar epidural steroid injections. Generally, however, there are few risks associated with epidural steroid injections and they tend to be rare. Risks may include:
•Infection. Minor infections occur in 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
•Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
•Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or secondarily from infection or bleeding.
•Dural puncture ("wet tap"). A dural puncture occurs in 0.5% of injections. It may cause a headache that usually gets better within a few days. Although rare, a blood patch may be necessary to alleviate the headache.
Paralysis is not a risk since there is no spinal cord in the region of the epidural steroid injection.
In addition to risks from the injection, there are also potential risks and side effects from the steroid medication. These side effects from an epidural steroid injection tend to be rare. Side effects from steroids are more common when taken daily for several months. Risks and side effects may include:
• High blood sugar
• Stomach ulcers
• Avascular necrosis (dead bone) in the hips
• Facial flushing
• Metallic taste in the mouth
• Increased appetite
Lumbar epidural steroid injections should not be performed on patients who have a local or systemic bacterial infection, are pregnant, or have bleeding problems. Epidural steroid injections should also not be performed on patients whose pain is from a tumor or infection, and if suspected, an MRI scan should be done prior to the injection to exclude these conditions.
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