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Epidural Steroid Injections

Understanding Anatomy
Click on picture for understanding anatomy

Overview
This procedure is named after the space in your spine where steroids will be placed. The epidural space is actually a space that surrounds the tissue layer holding the spinal fluid around the spinal cord. This is a theoretical space filled with blood vessels and fat. The size of the space depends on anatomical differences that may be normal or abnormal. If you have had surgery, have a thickened ligamentum flavum, or bulging or extruded disc material, then these can contribute to a narrowed spinal canal. Another name for a narrow spinal canal, from any or a combination of these instances, is called spinal stenosis. Symptomatically, these problems may produce pain, numbness, a tingling sensation, or a burning that may be felt all the way into the toes. The procedure is designed to reduce inflammation (swelling and irritation) affecting one or more spinal nerves and the corresponding distribution in the back, buttock, and leg. It may affect one side and leg, or both sides and legs. If only one side is affected, then a Selective Epidural Steroid Injection will be done. If you have had back surgery, then a Caudal Epidural Steroid Injection may be done.

Getting Ready
You will need to prepare by following the orders given to you on the day your procedure was scheduled. Call the office if you have any questions.

Wear comfortable clothes, preferably without belts, zippers or metal closures.

In the preoperative area, you will be asked several questions and your vital signs will be measured. An intravenous line may be placed in the preoperative area. If you are allergic to tape, let someone know.

Someone is required to drive you home afterward.

Possible Injection Sites
Click on picture for possible injection sites

The Procedure
You will be laying face down on a special bed that will allow the use of fluoroscopy (special X-Ray machine). Monitoring devices will be attached to your chest, side, finger, and arm. Your back will be cleaned with a special cleaning solution. Be sure to tell anyone if you are allergic to Betadine/Iodine cleaning solutions. A sterile drape is placed over your back. A local anesthetic, numbing medicine, will be injected into the skin in the area where the epidural/caudal will be done(neck, upper back, low back, or caudal area). You may have the option of receiving medicine to help you relax during the procedure, but it isn’t always necessary. The physician will determine how much to administer. Using the X-Ray guidance and a special viewing television, the needle will be inserted into the epidural space. Special dye is used to verify that the needle is in the desired location. Once the physician is satisfied, the steroid, either plain or mixed with a local anesthetic, will be injected and the needle will be removed and the procedure is over.

Complications
During the needle placement in a selective epidural, you may feel and “electric shock” sensation, like when you hit your “funny bone”(elbow). This is normal and lasts only a second and goes away. It is more startling and not painful. The opening through which the nerve passes as it comes out of the spinal canal may be severely narrowed and the fluoroscopy machine doesn’t show the nerves.

During any of the epidural injections, you may experience an increase in pain until the physician is finished injecting. This transitory pain is from the pressure placed on the tissue layer around the spinal cord and nerves, during injecting, but goes away as the medicine flows and distributes within the epidural space.

There is always the risk of bleeding from the skin or from the blood vessels within the spinal canal (rare). Bleeding in the skin can be controlled by direct pressure, but bleeding in the spinal canal cannot. If allowed to continue, this bleeding may further press on the spinal cord and cause a worsening of your symptoms, incontinence of bladder or bowel, or a temporary paralysis. This type of bleeding may need surgical intervention. It is for this reason, you are required to stop any blood thinners, non-steroidal anti-inflammatories, or anti-platelet medications five days before the procedure. Blood tests will be done prior to the procedure to ensure that you will clot, as intended. Any abnormal results may cause your procedure to be rescheduled. You will be notified in the event this happens.

Infection (rare) is another possible complication. In order to minimize this risk, you must come, having recently bathed at home. Your skin is prepared with a solution, which is designed to kill most bacteria, sterile gloves, gown and instruments are used, a sterile drape is placed over the prepared area, and sterile technique is used. If you have a fever greater than 100.4ºF, you need to call and let us know.

Spinal headache (rare) may occur if the tissue layer, holding the spinal fluid in place, is punctured and a significant amount of spinal fluid is lost or continues to be lost. A certain amount of spinal fluid can be lost without any problems ever occurring and just because a puncture is made, does not mean you will develop a headache. A spinal headache is not one that develops after twenty-four hours, but if you are diagnosed with one, usually goes away within twenty-four hours, without anything needing to be done. Tissue is very resilient and usually closes the puncture site, preventing any further leaking of spinal fluid. If you are diagnosed with a spinal headache and it persists, you may need to undergo a blood patch to fix the headache. This patch is 95% effective, immediately relieving your headache, nausea and/or vomiting.

What to Expect
The local anesthetics may decrease your pain somewhat, or take it all away, leaving a numb feeling. The numbness should last about an hour. Everybody gets varying degrees of relief of symptoms—some hours, some days. There may also be some soreness at the injection site. These injections are designed to break the pain cycle. But, everybody gets varying degrees of relief. Some people may need more than one injection. No more than three epidural steroid injections can be done in a six-month period. Not everyone will get complete pain relief.

It is actually the steroid-effects that work, acting as an anti-inflammatory to stop nerve irritation. These effects won’t be seen for two to three days, so you may be in no better pain relief than before the injection. You may even have an increase in the pain, for about one day. The steroids can cause other varied effects, which include a transient increase in blood sugar (you will need to monitor your blood sugar closely and adjust diet and insulin accordingly), nervousness, difficulty sleeping, and a flushed feeling, like hot flashes. These can last for about a week.

You don’t need to stay in bed on the day of your procedure. You should walk around about every half hour. Lack of movement can slow down healing.

Don’t do heavy lifting or strenuous activities. Your body needs time to heal. Likewise, if you feel significantly better, you should gradually increase your activity level, as discussed with your physicians and physical therapists. Physical therapy will be instituted as soon as possible.

What If This Doesn’t Work?
Remember, any improvement in the numbness, pain, tingling or burning sensations, no matter how slight (10%), in one or all of these symptoms, is considered an improvement. This is not considered a failure. Even a slight change is a step in the right direction. It is recommended that you design a pain diary. With this diary you will make notations of dates, times, places, treatments, and characteristics of your condition—pain, numbness, tingling, burning, throbbing, heaviness. Use these words to describe what it is that you are feeling before and after any intervention, whether medication, physical therapy, other therapies, or injections. This will guide both you and your physicians in your progress.

Next Step
In about one week after your injection, you will come back to the office for an appointment to see the physician or physician assistant. At this visit you should let them know how you are doing. This is a good time to explain to them things you wrote in your pain diary. We want to know these changes, good or bad, in daily activities—things you could or couldn’t do, but now cannot or can do. At this visit, you may be scheduled for another injection. Other sources of pain can also be investigated, as well. You may call the office at any time, and someone will try to assist you with any questions you may have.

 

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