Lumbar Epidural Injection

What is it?

Epidural steroid injections are one of the most common non-surgical treatment options for acute/chronic back/neck with arm/leg pain. Epidural steroid injections (ESIs) have been commonly used in the treatment of low back and leg pain since 1952 and is still an essential part of non-surgical treatment of sciatica and other low back pain problems.  A lumbar epidural steroid injection (LESI) delivers steroid medication in the area of spinal nerve roots that reside in the lumbar (lower back) region, in order to provide relief from painful symptoms. 

Lower back pain can be caused by a bulging/herniated disc, arthritic bone spurs, lumbar spinal stenosis, degenerative disc disease, synovial cyst or annular tear within the disc. Any condition or injury that causes nerve root irritation and inflammation can lead to lower back pain and referred pain from irrupted lumbar nerve roots. A common example of referred pain from general compression or irritation of the lumbar nerve roots is a condition known as sciatica.

The sciatic nerve is the longest and largest spinal nerve in the human body. This nerve originates from the lower spine, extending all the way down the back of the leg to the toes, delivering nerve signals to the muscles and skin along the way. Therefore, if this nerve becomes injured or irritated in the lower spine, pain symptoms can travel from the lower back, through the pelvis, and down the leg. Often times the pain felt in the leg from sciatica is worse than pain felt in the back.

Managing Lumbar Spinal Pain with Epidural Steroid Injections

Pain that emanates from compressed or irritated nerves of the lower back can be managed with lumbar epidural steroid injections. This type of injection delivers a steroid medication (‘cortisone’) mixed with a local anesthetic into the epidural space. The epidural space is the fat filled ‘sleeve’ that surrounds and provides cushioning for the spinal cord and nerve roots.  
As opposed to oral steroids and painkillers, steroid injections can deliver very potent anti-inflammatory medication directly to the source of pain. This method provides a more targeted and powerful impact on symptoms with less overall side effects. Additionally, an ESI can help with “flushing out” inflammatory proteins and chemicals from the area that may be contributing to or exacerbating pain.  
Although lumbar epidural steroid injections do not eliminate the underlying condition, they do provide enough pain relief to allow the patient to move forward with their rehabilitation program. Breaking the cycle of inflammation and pain allows the body to compensate and improve function. For this reason, the benefits of the injection often outlast the effects of the steroid medication itself.

Different Approaches for Delivering Steroid into the Epidural Space

Multiple methods are used to reach the lumbar epidural space. The three most commonly used methods for the application of epidural steroids include:

• Interlaminar
• Transforaminal
• Caudal

The interlaminar approach is currently the most common method used for epidural injections. All three approaches involve the placement of a thin needle utilizing x-ray guidance (fluoroscopy). Prior to the steroid injection, a contrast dye is used to confirm that the medication will flow into the desired region.  
An interlaminar ESI, which is often simply referred to as an ‘epidural injection’, places the needle into the back of the epidural space, delivering the steroid medication over a wider area.  It is sometimes described as a “shotgun” approach as the medication is delivered in a wider area.

The caudal approach uses a small boney opening just above the tailbone, known as the sacral hiatus. This method allows for needle placement at the very bottom of the epidural space. A transforaminal ESI, which is often referred to as a ‘nerve block’, places the needle alongside the nerve as it exits the spine, administering medication into the ‘nerve sleeve’. The medicine then travels up the sleeve and into the epidural space from the side. This approach allows for a more concentrated delivery of the steroid into one affected area (e.g., one segment or one side). This type of injection can be modified for more specified coverage of a single nerve, providing enhanced diagnostic benefit, along with improved function and pain relief.

An epidural injection is placed by the injured disc to relieve inflammation and pain of the affected nerve. By volume, what is injected consists mostly of sterile saline (salt water), a nerve numbing agent (local anesthetic) and a very small amount of potent anti-inflammatory (steroid). An epidural injection can help heal the injured nerve. An epidural does not heal a torn (herniated) disc. That will either heal on its own or may require surgery if it does not.  

An epidural injection can be performed in your cervical, thoracic, or lumbar spine to provide pain relief and relieve nerve swelling and inflammation. Epidural injections are a minimally invasive procedure that can deliver pain relief and allow patients to improve their function and become active again.

During Procedure

Injections are performed sterilely in our fluoroscopy suite using live image guidance. You will be comfortably positioned with your face down. If you would like sedation, please ask your physician. The skin over the site to be injected with be sterilely cleaned. Local anesthesia will be used to numb the skin. The epidural needle will be placed under live fluoroscopic guidance. Once the needle is in place a steroid medication will then be administered, and needles removed. Bandages will be placed, and you will be taken to the recovery room until you are ready for discharge home.

What Happens after an injection?

You will be monitored for a short period of time.  Take it easy for the rest of the day.  You may feel immediate relief and numbness in your back and leg for a period of time after the injection.  This may indicate the medication is in the right area.  Your pain will return after this short period of pain relief.  However, it is also very common that your pain may actually worsen because of irritation from the needle or from the steroid medication itself.  

When will I get pain relief?

An epidural steroid injection can potentially reduce the chemical irritants in the epidural space and reduces inflammation of the nerve root, and it will take time to heal. Typically, patients experience pain relief in three to seven days, although in some cases it can be up to 14 days. The amount of relief is dependent upon the amount of inflammation, severity of the nerve compression and duration of the chronic pain.  Unfortunately, the longer patients have had their pain the more difficult it is to treat. Pain relief can be complete with one treatment, or it may require a subsequent injection. The duration of relief usually depends on the health of the disc, the severity of the injury and amount of arthritis. If after a series of injection is not helpful, then your physician may recommend a referral to a surgeon for surgical options.

• Other Treatments

• Conservative Therapy
• Joint Injection
• Lumbar Epidural Injection
• Lumbar Radiofrequency Ablation (RFA)
• Medial Branch Block
• MLS Laser Therapy
• Peripheral Nerve Stimulation
• Regenerative Therapy
• Sacroiliac Injection (SI)
• Spinal Cord Stimulation For Diabetic Foot Pain
• Sympathetic Nerve Block
• Trigger Point Injection