FAQ’s on Lumbar Epidural Injection
How long have Lumbar Epidural Injections been used for Pain Management?
The oldest procedure in pain management just happens to also be one of the best. Lumbar epidural injections started being performed 60 years ago and consistently provide excellent results for patients suffering from sciatica to this day with pain management doctors in Arizona.
At any point in time in the United States, 1% of the population is suffering sciatica symptoms from a pinched nerve. That amounts to a few million people who are potentially candidates to benefit from epidural injections.
The “epidural” space is located right around the spinal cord and the nerve roots that come off of it. The injections involve placing long lasting steroid medication around nerves that are pinched to provide relief and help patients avoid surgery.
Why Are Epidural Injections Performed
The pain from a pinched nerve in the low back with sciatica radiates down the leg and is often burning or searing. The patient may also have a pins and needles sensation and if it’s serious enough then muscle weakness may be present. Overall, sciatica presents a miserable situation with the problem emanating from the inflammation resulting from the nerve compression.
Sciatic pain may result from a herniated disc, spinal stenosis pinching on nerves, or maybe a chemical inflammation of a nerve root such as can be sparked up from a ruptured or bulging disc. Spinal stenosis involves overgrowth of both bone and soft tissue around the spine from arthritis. This may have the additional problem of pinching on multiple nerve roots at the same time.
An epidural injection’s purpose is to reduce the inflammation causing the sciatica and help with pain relief. The hope is that the pain relief will last for many months, at which point the procedure may be repeated if the pain returns.
What Are the Different Types of Epidural Injections?
There are 3 well-known types of lumbar epidural steroid injections:
- Interlaminar Epidural Injections
- Transforaminal Epidural Injections
- Caudal Epidural Injections
What are Interlaminar Epidural Injections?
The first variation, interlaminar epidurals, were invented 60 years ago. A needle is placed through the back and into the spinal canal going between 2 bony areas overlying the spine. “Inter” means between, and “laminar” refers to the bone on the back of the spine. A lot of physicians used to do these in an office setting without any sort of x-ray assistance (and some unfortunately still do).
A study approximately 20 years ago showed that without fluoroscopy, which is a real-time form of x-ray, doctors often missed their mark with the needle about 40% of the time (Renfrew et al, AJNR Am J Neuroradiol1991). This is unfortunate as it becomes a disservice to a patient who is in extreme pain from sciatica, and the steroid medication was not being placed in the right spot four out of ten times. So more and more, the standard of care is for a pain management doctor to use fluoroscopy to ensure the most accurate needle placement possible for the epidural injection.
Once the needle is in position, dye is then injected to make sure the pain doctor is satisfied with the accuracy. Once ensured, the numbing medicine and steroid are injected.
What are Transforaminal Epidural Injections?
The second type of epidural steroid injection is called a transforaminal epidural. These became popular as the use of fluoroscopy was increasing, and involves the pain management doctor placing the needle in the area where the nerve root is leaving from the spinal canal. It leaves through an area called the foramen and that is typically where it gets pinched by a herniated disc.
Therefore, the theory with a transforaminal injection is to place the anti-inflammatory steroid medication as close as possible to the point of nerve root compression. Prior to fluoroscopy, this injection was simply not possible with any sense of accuracy.
What are Caudal Epidural Injections?
The 3rd type of epidural injection in the low back is called a caudal injection. These involve the pain doctor placing the needle very low where the sacrum is in the buttock region.
The doctor places a needle through an area called the sacral hiatus, and is able to then inject numbing medicine and the steroid in a larger amount as it then migrates and reaches multiple levels of the spine.
This type of injection is common for spinal stenosis, as typically multiple nerve roots are being pinched and this allows for multiple areas to be reached with the anti-inflammatory steroid medication rather than necessitating multiple injections.
What are the Results of Epidural Injections?
Studies have shown that all of the varieties of epidural injections for the lumbar spine work well. Overall, the good to excellent results have been shown in 75% to 90% in various studies (Chen et al, 2011 medscape.com).
They can help patients avoid surgery, and a large study in the Journal of the American Medical Association has shown that the results from the injections are equivalent to surgical outcomes at the one year point.Therefore, if epidural injections can help the patient avoid surgery that would be best.
Patients may need a series of epidural injections for the best results. This may include up to three injections one to two weeks apart. Pain doctors debate how many injections are appropriate for patients along with how frequently they can be performed. It may be that the patient gets excellent pain relief after the 1st injection, or it may take a 2nd and a 3rd to achieve optimal pain relief.
Where are the injections performed and how long does the pain relief last from epidural injections?
These injections are performed in an outpatient setting. Patients may need IV sedation for the injection, but it is often not necessary. They may simply receive a numbing local medicine or maybe a Valium by mouth 30 minutes or so before the procedure.
Injection relief may last for anywhere from one day to six months. The numbing medicine included with the injection will start right away and last for about a day. Then the steroid hopefully “kicks in” after 1 to 3 days and will provide relief. It is important to remember that an epidural steroid injection is not going to fix the herniated disc. These injections are a proverbial “band-aid” with the hopes the body will disentegrate the piece of disc that has ended up where it is not supposed to be.
The results are extremely variable between patients but with a full series of injections patients should reasonably be able to expect at least 6 weeks of substantial pain relief. Once again, these results are not uniform.
What are the Risks of an Epidural Injection?
Complications from lumbar epidural injections are infrequent. There is a low risk of infection (well under 1%), and a low risk of bleeding along with a puncture of the spinal cord covering. Normally the puncture heals up uneventfully, but if not patients may develop a Post Dural Puncture Headache and need further treatment, such as an epidural blood patch. The risks of cortisone injections include slight weight gain, temporary elevation of blood sugar, decrease of the body’s own cortisone production, and temporary water retention.
Patients should stop taking any anti-inflammatory medications or blood thinners for a minimum of 5 to 10 days prior to the procedure. Your doctor will be able to tell you the specific time frame.
The Arizona Pain clinic locations serve Phoenix, Tempe, Mesa, Scottsdale, Chandler, Glendale, Gilbert, Sun Lakes, Queen Creek, Avondale, Apache Junction, Casa Grande, San Tan, Buckeye, Maricopa, Goodyear, Laveen, Litchfield, Ahwatukee, Tolleson, Surprise, Fountain Hills, Tonopah, El Mirage, Sun City, Florence, Wickenburg, Litchfield, Carefree, Peoria, Cave Creek, Prescott, Anthem, and Coolidge.