Lumbar Epidural Steroid Injections for Low Back Pain and
Epidural steroid injections
(ESIs) are a common treatment option for many forms of low back pain and
leg pain. They have been used for low back problems since 1952 and are still an integral part of the non-
surgical management ofThe goal of the injection is pain relief; at times the
injection alone is sufficient to provide relief, but commonly an epidural steroid injection is used in
combination with a comprehensive rehabilitation program to provide additional benefit.
Most practitioners will agree that, while the effects of the injection tend to be temporary - providing relief from pain for one week up to one year - an epidural can be very beneficial for a patient during an acute episode of back and/orportantly, an injection can provide sufficient pain relief to allow a patient to progress with a rehabilitative stretching and exercise program. If the initial injection is effective for a patient, he or she may have up to three in a one-year period.
In addition to the low back (the lumbar region), epidural steroid injections are used to ease pain experienced in the neck (cervical) region and in the mid spine (thoracic) region. This article focuses on epidural injections in the low back area used to treat low back pain an(also referred to as leg pain or sciatica).
Efficacy of Injections
Although many studies document the short-term benefits of epidural steroid injections, the data on long-term effectiveness are less convincing. Indeed, the effectiveness of lumbar epidural steroid injections continues to be a topic of debate. This is accentuated by the lack of properly performed studies.
For example, many studies do not include use of fluoroscopy or x-ray to verify proper placement of the medication despite the fact that fluoroscopic guidance is routinely used today. Additionally, many studies do not classify patients according to diagnosis and tend to ‘lump’ different types sources of pain together. These methodological flaws tend to make interpretation and application of study results difficult to impossible.
More studies are needed to properly define the role of epidural steroid injections in low back pain and in sciatica. Despite this, most studies report that more than 50% of patients find measurable pain relief with epidural steroid injections. They also underscore the need for patients to enlist the services of professionals with extensive experience administering injections, and who always use fluoroscopy to ensure accurate placement.
Potential Benefits of Injections
Epidural steroid injections deliver medication directly (or very near) the source of pain generation. In contrast, oral steroids and painkillers have a dispersed, less-focused impact and may have unacceptable side effects. Additionally, since the vast majority of pain stems from chemical inflammation, an epidural steroid injection can help control local inflammation while also "flushing out" inflammatory proteins and chemicals from the local area that may contribute to and exacerbate pain. This article provides an overview of epidural steroid injections.
How Epidural Steroid Injections Work
An epidural steroid injection delivers steroids directly into the epidural space in the spine. Sometimes additional fluid (local anesthetic and/or a normal saline solution) is used to help ‘flush out’ inflammatory mediators from around the area that may be a source of pain.
The epidural space encircles the dural sac and is filled with fat and small blood vessels. The dural sac surrounds the spinal cord, nerve roots, and cerebrospinal fluid (the fluid that the nerve roots are bathed in).
Typically, a solution containing cortisone (steroid) with local anesthetic (lidocaine or bupivacaine), and/or saline is used.
A steroid, or cortisone, is usually injected as an anti-inflammatory agent. Inflammation is a common
component of many low back conditions and reducing inflammation helps reduce pain. Triamcinolone acetonide, Dexamethasone, and Methylprednisolone acetate are commonly used steroids.
Lidocaine (also referred to as Xylocaine) is a fast-acting local anesthetic used for temporary pain
relief. Bupivacaine, a longer lasting medication, may also be used. Although primarily used for pain relief, these local anesthetics also act as ‘flushing’ agents to dilute the chemical or immunologic agents that promote inflammation.
Saline is used to dilute the local anesthetic or as a ‘flushing’ agent to dilute the chemical or
Epidural Steroid Injections Control Inflammation
Epidural injections are often used to treat radicular pain, also calledwhich is pain that radiates from the site of a pinched nerve in the low back to the area of the body aligned with that nerve, such as the back of the leg or into the foot. Inflammatory chemicals (e.g. substance P, PLA2, arachidonic acid, TNF-α, IL-1, and prostaglandin E2) and immunologic mediators can generate pain and are associated with common back problems such as lumbar disc herniation or facet joint arthritis. These conditions, as well as many others, provoke inflammation that in turn can cause significant nerve root irritation and swelling.
Steroids inhibit the inflammatory response caused by chemical and mechanical sources of pain. Steroids also work by reducing the activity of the immune system to react to inflammation associated with nerve or tissue damage. A typical immune response is the body generating white blood cells and chemicals to protect it against infection and foreign substances such as bacteria and viruses. Inhibiting the immune response with an epidural steroid injection can reduce the pain associated with inflammation.
Indications for Lumbar Epidural Injections
Several common conditions that cause severe acute or chronic low back pain and/or leg paifrom nerve irritation can be treated by steroid injections. These conditions include:
A lumbar disc herniation, where the nucleus of the disc pushes through the outer ring (the annulus)
and into the spinal canal where it pressures the spinal cord and nerves. Reafor more information on diagnosis and treatments.
Degenerative disc disease, where the collapse of the disc space may impinge on nerves in the
Lumbar spinal stenosis, a narrowing of the spinal canal that literally chokes off nerves and the
spinal cord, causing significant pain. See
Compression fractures in a vertebra. Rea Cysts which are in the facet joint or the nerve root and can expand to squeeze spine structures.
Annular tear, a painful condition where a tear is present in the outer layer of the disc. See
For these and many other conditions that can cause low back pain and/or leg pain (sciatica), an epidural steroid injection may be an effective non-surgical treatment option.
Who Should Avoid Epidural Steroid Injections
Several conditions could preclude a patient from having an injection:
Pregnancy (if fluoroscopy, a type of x-ray, is used)
Bleeding problems - patient taking blood thinners (Coumadin, etc), or patients with a bleeding
Epidural steroid injections should also not be performed on patients whose pain could be related to a If suspected, an MRI scan should be done prior to the injection to rule out a tumor.
Injections may be done, but with caution, for patients with other potentially problematic conditions such as:
Uncontrolled medical problems such as renal disease, congestive heart failure and diabetes
because they may be complicated by the fluid retention that a small percentage of patients experience for a few days after the injections.
Use of high dose aspirin or other anti-platelet drugs (e.g. Ticlid, Plavix), all of which can cause bleeding from the procedure. These medications should be stopped prior to having an injection.
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