frequent procedures
EPIDURAL STEROID
INJECTIONS
Epidural steroid injections are procedures
done in pain management in an attempt to introduce into the epidural
space anti-inflammatory medications that are highly potent and close
to the site of the inflammatory process and the source of the
patient’s pain generation. The epidural space is the space
immediately lying outside the thecal sac surrounding the CSF along
the axial spine. The epidural space in and of itself is a potential
space in the living human and next to it lays the ligamentum flavum.
This space may contain tiny venous blood vessels as well as epidural
fat and some minimal connective tissue. The epidural space when
expanded can continue from the sacral hiatus at the junction of the
coccyx and the sacrum and go all the way to the foramen magnum along
the axial spine or spinal canal.
The indications for this procedure are multiple, but I will provide
a few examples:
-
Lumbar disk
herniation.
-
Lumbar disk bulge.
-
Lumbar spinal
canal stenosis.
-
Reflex sympathetic
dystrophy.
-
Chronic lumbar
sprain.
-
Lumbar facet
arthropathy.
The actual procedure
itself can be done with or without fluoroscopic guidance. However,
to ensure accurate placement of the injectate, which usually
consists of local anesthetic solution and a Depo steroid,
fluoroscopic guidance can be an invaluable tool when used in
conjunction with contrast material (dye) injection into the epidural
space to confirm adequate needle placement before injecting the
therapeutic suspension. Epidural steroid injection is a frequently
used but highly effective and safe tool in the management of the
patient with Low Back pain and Neck pain.
Types and Location of Epidural Steroid Injections
Epidural steroid injections can be accomplished by the following
approaches depending on the location and target zone of the
pathology or disease:
-
CAUDAL APPROACH.
This can be used to access the epidural space via the sacral
hiatus for treatment of lumbar pathology related symptoms as
well as sacral pathology related symptoms.
-
INTERLAMINA
APPROACH. Epidural steroid injections
can be achieved via access into the epidural space posteriorly
and between the lamina and spinous processes of the vertebra
above and the vertebra below using a loss of resistance
technique. This is the most commonly used approach in pain
management but has its limitations.
-
ATRANSFORAMINAL
APPROACH. Epidural steroid injections
can be done via a transforaminal approach within the cervical
spine, thoracic spine, lumbar and sacral spine. In this
technique, the plan of care is to access the region suspected to
be contributing maximally to the patient’s axial pain or
radiculopathy and access that zone from the foramen through
which the nerve root exits and carefully place a limited amount
of dye to define this site and confirm adequate needle placement
followed by injection of the suspension described above in order
to achieve anti-inflammatory response. The injection itself
could be either diagnostic or therapeutic.
Prognosis
The prognosis of epidural steroid injection is often dependent on
the etiology or the indications for the treatment itself. In most
situations, as in lumbar herniation and disk bulge, serial epidural
steroid injections are done and achieve complete resolution of pain
generated by the inflamed site in the axial spine for which
treatment had been given. However, it is important to know that the
pathology that necessitated epidural steroid injections may coexist
with other pain generating sites in the region for which treatment
is being undertaken. For a particular situation, it is prudent to
identify and treat these additional pain generators in order to
accomplish complete pain resolution in these patients.
Complications
Complications in epidural steroid injections are infrequent.
However, the most common complication in routine clinical practice
is post dural puncture headache, which results from the needle
passing beyond the epidural space and producing a tiny temporary
hole in the thecal sac that holds the cerebro-spinal fluid (CSF) and
resulting in spinal headache. This post dural puncture headache in
and of itself is easily treated with pain medication, bed rest, and
oral fluids and tends to resolve in a few days. However, if it does
not resolve, it is easily treated by doing an epidural blood patch
to which the headache usually responds within one to two hours
following the injection with resolution. Epidural steroid injections
with fluoroscopic guidance should not be done in patients who are
pregnant or suspected to be pregnant. Patients who undergo this
procedure should continue to take their usual medications including
pain medications and routine medications that they were taking that
are not pain related. A contraindication to epidural steroid
injection is the patient who is currently on Coumadin or
anticoagulant medication like heparin. Patients on Coumadin are
required to discontinue the use of that anticoagulant three days
prior to their procedure being done. Each patient is required to
check with the physician prescribing that anticoagulant before
stopping the medication in order to undergo the procedure. The
patient may immediately resume the use of the usual anticoagulant
medication soon after the procedure is completed.
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