Epidural steroid injection (ESI)

Overview

An Epidural Steroid Injection (ESI) treats pain brought on by irritation and inflammation of the spinal nerve roots by injecting an anti-inflammatory drug, such as a steroid or corticosteroid, into the area known as the epidural space surrounding your spinal nerves. Doctors employ ESI injections as a chronic pain management treatment. It can help ease pain in the arms, legs, back, and neck that is brought on by inflamed spinal nerves as a result of specific ailments or injuries. An ESI may provide pain relief for a few days or even months.

An epidural steroid injection is also known as back steroid injection, ESI injection, back pain injection, or spinal injection for back pain.

Epidural anesthesia or analgesia used for childbirth or specific surgical procedures is not the same as epidural steroid injections. With these kinds of epidurals, a local anesthetic injection is made into the epidural space, numbing specific body parts.

Types of ESI injections

Epidural steroid injections can be categorized based on their positioning along the spine. (cervical, thoracic, or lumbar) and how the needle enters the epidural space (interlaminar, transforaminal, or caudal).

Depending on the area of your spine your doctor injects the drug into, there are three different kinds of ESIs:

• Cervical (neck) ESI: In a cervical epidural steroid injection (ESI), the needle is inserted slightly to the side of the spine in the neck (cervical region). If you have pain in your neck that spreads down your arms from a herniated disk, bone spur or stenosis, your doctor may offer a cervical ESI.
• Thoracic (upper and middle back) ESI: In a thoracic epidural steroid injection, the needle is inserted slightly to the side of the spine in the upper or middle back (thoracic region). Your doctor can suggest a thoracic ESI if you experience discomfort in your upper or middle back that is related to a thoracic disk herniation or thoracic spinal stenosis.
• Lumbar (low back) ESI: In a lumbar epidural steroid injection, the needle is inserted slightly to the side of the spine in the low back (lumbar region).Your doctor might suggest a lumbar ESI if you experience lower back and leg pain due to a lumbar herniated disk, lumbar degenerative disk disease, or lumbar spinal stenosis.

You can access the epidural space surrounding your spinal nerves in a few different ways. The route the needle follows to access the epidural space are described by the following types of epidural steroid injections:

• Interlaminar (between the lamina) ESI: In order to reach the epidural space during an interlaminar ESI, the needle must pass through two laminae in your spine. The lamina is a flat bone plate that forms a component of each vertebra in the spine. Your spine’s laminae serve as the spinal canal’s outer wall and safeguard your spinal cord.
• Transforaminal (across the foramen) ESI: The foramina, or the openings which nerve roots leave your spine, are where the needle travels during a transforaminal ESI.
• Caudal (via the sacrum) ESI: In order to access the lowest spinal nerves during a caudal ESI, the needle passes through the sacral hiatus, which is located just above your tailbone and toward the bottom of your sacrum. The triangle-shaped bone in your lower back between your hip bones is called sacrum.

Healthcare professionals administering epidural steroid injections need to have extensive specialized training because the procedure is highly technique-sensitive. Among the medical professionals who could conduct ESIs are:

• Surgeons
• Radiologists
• Anesthesiologists
• Neurologists
• Physiatrists (physical medicine and rehabilitation providers)

Reasons for undergoing the procedure

Epidural steroid injections are used by medical professionals to treat persistent pain resulting from inflammation of the spinal nerve roots. Numerous conditions may irritate the spinal nerve roots. The most frequent manifestation of this type of nerve irritation is experiencing pain in the lower back (lumbar region), which may extend down into your buttocks or legs. Additionally, it often manifests as pain in the neck (cervical area) that can radiate into your arms.

The following conditions may result in discomfort that can be relieved by epidural steroid injections:

• A bulging or herniated disk that compresses nerves and hurts.
• Osteophytes or vertebral bone spurs.
• Spinal stenosis, which is the narrowing of one or more spinal spaces.
• Spine degeneration or spondylolysis.
• Scoliosis that produces nerve root irritation.
• Other damage to spinal nerves, vertebrae and surrounding tissues.
• “Failed back surgery syndrome” is a comprehensive term employed to describe the condition of individuals who have undergone surgery on their back or spine but have not achieved a successful outcome, continuing to endure pain.

Epidural steroid injections are just one of the various therapies used by doctors to address specific types of pain. If physical therapy, medication, or other nonsurgical therapies have not resulted in improved pain management, your practitioner might only suggest an ESI.

Risks

Although problems and certain adverse effects are rare, epidural steroid injections are generally safe. Risks and consequences associated with ESI injections include:

• Having a reaction to the drugs, such as hot flashes or a rash.
• Experiencing hypotension, which may cause dizziness.
• Bleeding in the event that an injection unintentionally damages a blood vessel, which could result in the formation of a hematoma or blood clot.
• Having nerve injury where the injection was made.
• Developing an infection following the epidural procedure, such as meningitis, osteomyelitis, discitis, or epidural abscess.
• Temporarily losing the capacity to regulate your bladder and intestines. To assist you urinate, you might require a catheter—a tiny tube—in your bladder.
• Having a really bad headache as a result of spinal fluid leaks. It is less than 1% of the population that has this adverse effect.
• Frequently administering ESI injections or using larger dosages of steroid medicine may cause your spine’s bones or surrounding muscles to deteriorate. As a result, the majority of healthcare providers only allow two or three ESIs annually.

Although very uncommon, problems from an epidural steroid injection may result in long-term effects such as:

• Chronic pain owing to spinal cord or nerve root injury from the epidural injection.
• Permanent neurologic disability owing to spinal cord or nerve root injury from the epidural injection.
• Permanent paralysis resulting from a hematoma between the dura mater and the spinal cord.

Before the procedure

It’s crucial to let your doctor know if you are pregnant or suspect you could be pregnant before your ESI injection. It’s also important to let your doctor know about any over-the-counter, herbal, and supplement medications you take.

You will receive detailed instructions from your doctor regarding how to get ready for your ESI injection. Make sure you adhere to their guidelines. Your doctor could possibly as you to:

• For a specific period of time prior to your ESI injection, refrain from eating or drinking (fasting).
• Modify the dosage of some of your medications, particularly the blood thinners.
• Prior to your ESI injection, have a back Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scan performed to help identify the affected area.
• If you plan to take a sedative for your ESI, make sure you have a driver with you to take you home.

During the procedure

Your epidural steroid injection will probably take place in an outpatient clinic or hospital.

Your doctor will inject the epidural somewhere along your spine, depending on what’s causing your pain. The general steps for administering an epidural steroid injection are as follows:

• You’ll lie on a cozy table on your stomach after changing into a medical gown.
• To reduce the chance of infection, your doctor will meticulously clean the region of your back where the epidural will be inserted.
• A tiny needle will be used by your doctor to inject local anesthetic near the epidural site. This is so that when the larger-than-normal epidural needle is inserted, you won’t experience as much pain. Also, they might give you a sedative or other medication to help you relax.
• After the area has become numb, your doctor might use an imaging device, like an X-ray or fluoroscopy, to help precisely insert the epidural needle. It’s critical that you remain still throughout this process.
• Your doctor may inject contrast material while the epidural needle is in the epidural space surrounding your spinal cord. Your doctor will be able to view the targeted area on the imaging machine’s screen more easily thanks to the contrast material. This makes it more likely that the drug will get to the inflamed nerves it is intended to treat.
• After that, your doctor will gradually inject the drug, which is typically an anti-inflammatory drug like a steroid or corticosteroid. Some doctors might inject a corticosteroid and local anesthetic combination.
• After administering the injection, your doctor will clean the area once more, apply a bandage, and apply pressure to the spot to stop the bleeding. You’ll spend a few minutes to an hour resting in a chair or bed. This is to enable your healthcare provider to ensure there are no adverse reactions to the medication before you are discharged.

When your doctor administers the local anesthetic to numb the area prior to your ESI injection, you probably feel a slight pinch.

During the ESI injection, you might not feel anything at all or you might feel anything like this:

• Pressure
• Tingling
• Temporary pain
• A burning sensation

Any soreness you experience during the injection normally goes away after it’s done.

Notify your doctor right away if you have severe, stabbing pain during or after your ESI injection.

After the procedure

You might experience some discomfort where your doctor put the needle following the injection. It’s typical and should pass quickly—a few hours at most.

It’s possible that your doctor will advise you to relax and limit your activities for the remainder of the day.

After your ESI, your pain can go worse for two to three days before becoming better. The effects of epidural steroid injections can be felt for several days or longer, with the pain reduction starting to take effect in two to seven days.

Outcome

There are varying degrees of success for ESIs because there are numerous causes of chronic pain that an ESI may be able to cure and because every person is different. That being said, about half of those who receive an ESI report feeling less discomfort.

The effectiveness of epidural steroid injections in relieving pain has been demonstrated, although the duration of the pain alleviation may differ. This particularly depends on what is causing the pain in the first place. It is rare for the pain alleviation to persist up to a year, but it may last weeks or months.

Over time, you might receive more than one ESI; however, most doctors only allow two or three ESIs annually. Generally speaking, ESIs don’t address the underlying source of your discomfort. Individuals using ESIs for chronic pain frequently require additional therapies to provide long-term pain relief.