By: Tarun Jolly, MD, Elizabeth Srejic
Louisiana Pain Specialists is proud to offer epidural steroid injections (ESIs), a highly effective treatment for chronic pain syndromes that pertain to compressed nerves.
Surrounded by interlocking vertebrae, the epidural space is located directly outside of the spinal cord and the nerves within the spinal canal. The epidural space houses lymphatic vessels, nerve roots, loose fatty tissue, arteries, and a branching network of permeable blood vessels called the epidural venous plexus.
During the procedure, the doctor injects a combination of medications – a long-lasting steroid, saline, and a local anesthetic – into the epidural space. Upon injection, the medication migrates throughout the vertebral column and related tissues, targeting irritated nerve roots and lowering inflammation throughout the spine. The injection can be administered in the neck, upper back, and low back to treat pain associated with these regions.
In general, epidural steroid injections are a beneficial, low-risk, rapid-results treatment option for patients with radiating pain, degenerative disc disease, and chronic low back pain (Butterman, 2004). Used alone or in concert with other therapies, epidural steroid injections interrupt the pain-spasm cycle rapidly and effectively, and relief of symptoms occurs quickly, allowing patients to resume their customary daily activities.
Radicular Pain
Epidural steroid injections are most commonly used to treat conditions involving compression of spinal nerve roots. The pain resulting from compressed spinal nerves is termed radicular pain or radiculitis and refers to pain that radiates along the length of a nerve due to inflammation or other irritation of the nerve root. When radicular pain occurs in the in the neck, the pain may travel down an arm. When it occurs in the low back, the patient typically experiences pain that radiates down a leg. Sciatica is radiculopathic nerve pain caused by compression of the large sciatic nerve that travels down the back of the leg. A 2009 study noted improvements in 72.1% of patients administered ESIs for low back pain and sciatica (Sayegh, 2009).
Epidural steroid injections may provide relief to patients whose radiculitis has developed into radiculopathy, a more severe nerve root condition. When radiculitis goes untreated, complications such as muscle atrophy, reflex changes, and sensory loss may occur over time. In addition, a patient may begin to favor their unaffected side, causing overdevelopment of unaffected muscles. The threat of developing radiculopathy underscores the importance of seeking help for your radiating nerve pain.
An abundance of recent research supports the efficacy of epidural steroid injections in managing radicular pain. For example, a 2010 study published in the journal Pain Medicine found subjects who received fluoroscopically guided, contrast-enhanced lumbar epidural steroid injections for radicular pain reported improved scores on a numeric pain-rating scale for at least 3 months (Furman, 2010). Further, a randomized, double-blind, controlled trial published the same year found cervical interlaminar ESIs were effective in 77% of patients with chronic function-limiting neck and upper extremity pain secondary to cervical disc herniation and radiculitis (Manchikanti, 2010). And another recent study conducted at a specialty referral pain center found 86% of enrolled patients with lumbar disc herniation or radiculitis benefitted from epidural injections in the low back, based on a self-reported pain rating scale, disability index, employment status, and opioid intake (Manchikanti, 2010).
Indications for ESIs
Generally, epidural steroid injections are used to treat radicular pain in health conditions that involve compression of spinal nerve roots. Their purpose is to soothe irritation and inflammation in these nerves.
One such condition treated by epidural steroid injections is degenerative disc disease, or gradual, age-related deterioration of the intervertebral discs that lend the spine its flexibility and provide shock absorption. As the body ages, the intervertebral discs can become thinner and more spongy. The reduction in intervertebral space that occurs with shrinking discs can crowd spinal nerve roots, causing pain. ESIs can help patients with degenerative disc disease by calming inflammation and soothing irritated nerve roots.
As discs degenerate, their supportive collagen exterior grows less stable. Tears in this collagen covering may cause discs to herniate, or bulge out of place, which can lead to painful nerve root compression. Although disc herniation is associated with degenerative changes caused by aging, it can occur in younger people by trauma or heavy lifting. Epidural steroid injections have been used successfully in most age groups to treat disc herniation of various etiologies, or causes.
Spinal stenosis is another condition that may improve with epidural steroid injections. In spinal stenosis, abnormal narrowing of the spinal canal puts painful pressure on the spinal cord and related nerve roots. ESIs have been found to calm nerve irritation originating from harmful compression in these areas. For example, a 2010 randomized equivalence trial conducted by an American Pain Management Center found up to 65% of spinal stenosis patients with chronic function-limiting low back and lower extremity pain who received caudal (tailbone area) epidural injections reported significant pain relief (Manchikanti, 2008). And a study conducted at the Florida Spine Institute in 2007 confirmed that ESIs help reduce bilateral radicular pain and improve standing and walking in patients with degenerative lumbar spinal stenosis (Botwin, 2007).
Types of ESIs
Your pain doctor will review your history, administer a physical exam, diagnose the cause of your pain, and develop an appropriate treatment plan accordingly. There are several types of ESIs formulated to treat specific pain syndromes. These include:
- Intralaminar ESIs: The doctor anesthetizes the area to be treated and introduces a needle into the middle of the back between the spinous processes (the most prominent bones in the midline of the spine). The needle enters the lamina between two vertebrae and injects steroid and anesthetic, and the medication spreads to the nerve roots on both sides of the spine.
- Transforaminal ESIs: Compelling evidence suggests transforaminal ESIs are effective for short-term and moderate for long-term improvement in managing lumbar back pain (Manchikanti, 2007). They are preferable for patients who have surgical implants (e.g., pins, rods, screws) and scarring from previous spine surgery since the entry point of the injection bypasses these areas. The doctor anesthetizes the area to be treated and introduces the needle through the side of the vertebra above the opening for the exiting nerve root. Transforaminal injections treat one side at a time and are believed to be more targeted treatments.
- Caudal ESIs: After your skin is anesthetized, the doctor inserts a needle into the epidural space by your tailbone and administers sizeable volumes of steroid and anesthetics. Like transforaminal ESIs, caudal ESIs are thought to be effective for short-term pain management and moderate for long-term improvement in pain levels.
- Lysis of Adhesions or the Racz procedures: Often caudal epidural steroid injections are combined with a special catheter that is placed through the needle. This technique is used to treat epidural scaring and radiating nerve pain.
Outcomes
The amount and duration of pain relief vary between individuals treated with ESIs and depend on many factors including underlying cause of pain and activity level. Some patients experience only short-term relief, while others report relief that lasts for years. It is important to discuss your response to your epidural steroid injections treatment with your physician in order to plan future treatment options.
Louisiana Pain Specialists cares about your quality of life and understands the burden of living with pain. Our caring practitioners will listen to your concerns and work with you to develop a pain management program that will help you regain health and happiness.
Sources
Buttermann, G. (2004). The effect of spinal steroid injections for degenerative disc disease. Spine Journal, 4(5), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15363419
Cicala, R. (1989). Long-term results of cervical epidural steroid injections. Clin J Pain, 5(2), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2520395
Furman, M, et al. (2010). Efficacy of fluoroscopically guided, contrast-enhanced lumbosacral interlaminar epidural steroid injections: a pilot study. Pain Med, 11(9), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20667021
Manchikanti, L. (2008). Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: part 4–spinal stenosis. Pain Physician, 11(6), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19057629
Manchikanti, L. (2010). The effectiveness of fluoroscopic cervical interlaminar epidural injections in managing chronic cervical disc herniation and radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician, 13(4), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20495586
Manchikanti, L. (2010). Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind, controlled trial. Pain Physician, 13(4), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20648203
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