Epidural Steroid Injections

How do these injections work?
During these injections the steroid medication is deposited around the irritated nerve roots and the inflamed tissue surrounding these structures. The swelling around the nerve roots is due to a herniated disc, osteoarthritic changes, spinal stenosis or a mechanical injury. Usually a very minute amount of inflammation is enough to create significant symptoms. The MRI studies may not necessary correlate with the clinical symptoms a patient is experiencing.

A series of three injections are usually performed, although the number is variable, based on the total amount of steroid medication received over a period of twelve months and the individual response to each injection. Based on the clinical presentation these injections can be given via a transforaminal (a lateral opening of the spine) or translaminar (a posterior opening of the spine.) Most frequently these injections are given in the lumbar or cervical spine, although rarely the thoracic spine may be involved as well. Approximately 70 % of the patients with leg or arm pain will improve after these injections, provided that they are seen within a reasonable amount of time from the onset of the symptoms. Those patients with midline pain tend to be less responsive.

For certain patients who have scar tissue formation due to previous surgery, a catheter is used to break down this tissue or a medication (hyaluronidase and/or hypertonic saline) is injected for the same purpose. This will allow the steroid medication to reach the affected nerve roots and provide relief of pain. This procedure is called an "epidural lysis of adhesions" and is used primarily for patients who failed simpler modalities. A caudal (tail bone) approach may be chosen for those patients presenting with lumbar symptoms.

For those patients with scar tissue and persistent pain, a more aggressive approach consists of lysis of adhesions via a catheter connected to a portable camera. This is called epiduroscopy and offers a direct visualization of the epidural space.

What to expect during the procedure?
For optimal outcome, this procedure needs to be performed under fluoroscopic (X-ray) guidance. The patient lies on the stomach. The appropriate area is prepped with an antiseptic solution and then a local anesthetic is used to numb the skin. A light sedative can be administered as well. Under direct X-ray visualization the needle is introduced towards the target area. The correct location is determined based on clinical presentation and MRI studies. A mild, temporary discomfort may be perceived at the time of the injection. A contrast material may be used to increase the accuracy of the procedure and to ascertain that the medications are delivered right at the intended target. A mixture of local anesthetic with steroids will be injected through the needle.

After the injection the patient will keep a diary of the pain level so a decision can be made regarding the next therapeutic step. A mild local discomfort may persist at the site of the injection for a day or two. Usually the improvement occurs within a few days after the injection. Some of the patients may fail to get better and further reassessment by the physician may be needed. Not all patients are alike, and each treatment needs to be tailored individually, based on clinical and radiological findings.

On the day of the procedure, the patient needs to be accompanied by a designated driver since after the procedure temporary residual numbness may be perceived. Our staff will provide further discharge instructions before the patient leaves the surgical area. The following day a nurse will call the patient and the outcome will be reassessed. A follow up appointment will be set up in two to three weeks after the procedure with one of the physicians or nurse practitioners.