Epidural steroid injections (translaminar and transforaminal)

Epidural Steroid Injections (ESIs) are a common method of treating inflammation associated with low back related leg pain, or neck related arm pain. In both of these conditions, the spinal nerves become inflamed due to narrowing of the passages where the nerves travel as they pass down or out of the spine.

Narrowing of the spinal passages can occur from a variety of causes, including disc herniations, bone spurs, thickening of the ligaments in the spine, joint cysts, or even abnormal alignment of the vertebrae (‘slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the spinal sac and provides cushioning for the nerves and spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that can decrease pain and allow patients to improve function. Although steroids do not change the underlying condition, they can break the cycle of pain and inflammation and allow the body to compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself.

The procedure entails placing a thin needle into position using fluoroscopic (x-ray) guidance. Prior to the injection of steroid, contrast dye is used to confirm that the medication is traveling into the desired area. Often, local anesthetic is added along with the steroid to provide temporary pain relief.

Caudal epidural approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space.

Nerve block involves the needle is placed alongside the nerve as it exits the spine and medication is placed into the ‘nerve sleeve’. The medication then travels up the sleeve and into the epidural space from the side. This allows for a more concentrated delivery of steroid into one affected area (usually one segment and one side).

All three procedures are performed on an outpatient basis, and you can usually return to your pre-injection level of activities the following day. Some patients request mild sedation for the procedure, but many patients undergo the injection using only local anesthetic at the skin.

The steroid will usually begin working within 1-3 days, but in some cases it can take up to a week to feel the benefits. Although uncommon, some patients will experience an increase in their usual pain for several days following the procedure. The steroids are generally very well tolerated, however, some patients may experience side effects, including a ‘steroid flush’ (flushing of the face and chest that can last several days and can be accompanied by a feeling of warmth or even a low grade increase in temperature), anxiety, trouble sleeping, changes in menstrual cycle, or temporary water retention. These side effects are usually mild and will often resolve within a few days.

Epidural steroid injections have been performed for many decades, and are generally considered as a very safe and effective treatment for back and leg pain or neck and arm pain. Serious complications are rare, but could include allergic reaction, bleeding, infection, nerve damage, or paralysis. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is minimized. Overall, ESIs are usually very well tolerated and most patients do well.

Although not everyone obtains pain relief with ESIs, often the injections can provide you with improvement in pain and function that last several months or longer. If you get significant benefit, the injections can be safely repeated periodically to maintain the improvements. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects.

Facet Joint injections

Facet joints are located on the back (posterior) of the spine on each side where two adjacent vertebrae meet. The facet joints provide stability and permit the spine to bend and twist. The joint contains cartilage between bones and is surrounded by a sac-like capsule that is filled with synovial fluid (lubricating liquid that reduces the friction between bony surfaces with movement).

Why Get A Facet Joint Injection:

There are basically two reasons for having a facet joint injection:

  1. Diagnosis (to determine the source of pain).
  2. Therapy (to treat an abnormality that has been detected).

Most back pain will improve within a few weeks with conservative medical care including options like relative rest, nonsteroidal anti-inflammatory medications, physical therapy, and exercises. If you suffer from back pain for more than six weeks despite appropriate medical care, a problem (such as inflammation, irritation, swelling, or arthritis) in the facet joints may contribute to low back pain and may be visualized on diagnostic imaging. However, normal appearing joints on diagnostic imaging do not completely rule out facet joints as source of pain.

How Are Facet Injections Performed?

Facet injections may be intraarticular (into the joint) or medial branch blocks (where the medication is injected onto the nerve). These procedures are performed while awake using local anesthetic (numbing) or some medications may be given to help one feel more relaxed or comfortable for the procedure. The injection is performed with the use of x-ray guidance called fluoroscopy.

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