Lumbar Epidural Steroid Injection (ESI)

Introduction

Epidural therapy is effective in the treatment of many painful conditions that originate from the spine.  These conditions include disc herniation and injury, acute herpes zoster, post-herpetic neuralgia, sciatica pain, radicular nerve pain, cancer pain, and post-surgical pain. Epidural steroid injections are used as a minimally invasive, non-surgical therapy to supplement other conservative medical therapies, such as physical therapy or rehabilitation programs.

There are several specific techniques or approaches to epidural steroid injections. The specific type of epidural steroid injection chosen by your doctor or provider will depend on the underlying condition and symptoms you are having. These are not limited to, but may include:

• Interlaminar epidural steroid injections
• Transforaminal epidural steroid injections
• Caudal epidural steroid injections

There are also different types of steroid medications that may be administered.  These may include, but are not limited to:

• Dexamethasone (Decadron)
• Methylprednisolone (Depomedrol)
• Triamcinolone (Kenalog)
• Betamethasone (Celestone)

Goal of the procedure

Inflammation is the most common source of pain and irritation that involves the spine and nerves.  Nerve inflammation from various sources causes an increase in firing of the pain signal and has been shown to contribute to the perpetuation of many types of persistent pain states. Injection of steroid (cortisone or corticosteroid) into the epidural space around the nerves of the spine is a safe and effective treatment directed at reducing inflammatory pain and irritation.

The procedure

Epidural steroid injections are performed by your doctor in a sterile procedure suite utilizing X-ray guidance. This procedure is often done without sedation, as the skin over the area of interest is anesthetized with local anesthetic. In certain types of epidural injections, where the needle is placed in close proximity to a specific nerve, it is possible to have a very brief electric type pain “shoot” into an extremity. This is a common occurence and is typically mentioned during the procedure to reassure you that it is not abnormal or harmful.

Following the procedure, which often takes less than 10 minutes, you will be cared for by a nurse in the recovery area until you are ready to be discharged home.

After the procedure

Follow the specific instructions given to you by the nurses at the time of discharge from the recovery area:

• Do not drive or operate heavy machinery for 24 hours after your procedure, if you received sedation
• Resume “normal” daily activities as tolerated after your procedure. You may shower.
• Do NOT soak in a bathtub or lake for 24 hours after your procedure
• It may take 7-10 days for the procedure to be effective
• You will receive a phone call from a clinic nurse, the following day to check in and see how you are recovering.

If your procedure includes sedation

• You should have no solid foods for 8 hours before the procedure.
• You may have clear liquids up to 2 hours before your procedure. Examples of these clear liquids are:  water, broth, clear juices with NO pulp, tea, coffee WITHOUT cream. Carbonated beverages are NOT allowed.
• No gum chewing for 2 hours before your procedure.
• No candy, throat lozenges, or mints.
• A nurse will call you before your procedure to review your medications and make recommendations as to what medicines you should take before your procedure.

Failure to comply with these instructions may result in cancellation and rescheduling of your procedure.

Potential risks of the procedure

Epidural steroid procedures are considered safe, non-surgical, minimally invasive treatments for patients suffering from certain types of pain. As with all medical procedures, there are associated risks and possible side effects that may vary between each patient. These rare but potential risks are:

• Pain at the injection site
• Infection in the form of an epidural abscess or at the skin. In very rare instances minor infections can occur
• Stroke
• Dural puncture or cerebral spinal fluid leak.  This typically presents as a headache that is worse with upright position and completely alleviated when lying flat
• Increased pain or worsening symptoms.
• Bleeding in the form of an epidural hematoma or at the site. You may suffer bleeding from undergoing procedures, especially while on blood thinning medications. Please notify us if you are taking any of the following blood
• thinning medications:
  Plavix (Clopidogrel), Aspirin, XareltoWarfarin (Coumadin), 
• (Rivaroxaban), Heparin, Lovenox  (Enoxaparin), Brilinta (Ticagrelor), or any others not listed.
• Nerve or spinal cord damage. In extremely rare instances, a patient may suffer nerve or spinal cord damage from direct trauma from a needle. This could potentially result in permanent nerve damage or paralysis.
• Allergic reactions to medications. The commonly used medications in this procedure include: Lidocaine, Bupivacaine, Ropivacaine, and IV contrast dye.
• Other risks are not limited to, but include:  epidural fibrosis, aseptic meningitis, GI side effects, renal failure, seroma, and paralysis.
• Inability to complete the injection due to technical or anatomic difficulty.

When should I expect results?

Epidural steroid injections reduce pain by decreasing inflammation of damaged or irritated structures.  The steroid (cortisone or corticosteroid) medication works on a cellular level, by decreasing inflammatory mediators.  This process is slow and often takes 7-10 days to produce results.  The immediate relief felt by the injection may be attributed more to the local anesthetic used by the doctor during the procedure.

Often times if one specific type of epidural steroid injection does not provide the relief that is expected, a different approach may be recommended by your doctor or provider. Typically, you will follow-up with the doctor 1 month after the procedure to evaluate results and come up with a plan if benefit was not obtained.

Insurance requirements

Insurance companies have a series of requirements that must be met, prior to their approval of epidural steroid injections. These may vary between insurance companies, however; they commonly include:

• Physical Therapy – often a minimum of 4 weeksin duration
• Appropriate imaging, which may include X-raysor MRI.
• Documentation of failure to improve with otherconservative medical therapies