Chronic lower back pain is an extremely common condition and is the leading cause of disability around the world. There are a variety of conditions that lead to lower back pain with or without sciatica, including prolapsed intervertebral disc herniation. Various conservative treatment options exist including physiotherapy, manual therapy, manipulation, and numerous anti-inflammatory and pain medications. There are also a variety of surgical procedures available, however, surgery carries a number of disadvantages including persistent back pain, postoperative adhesions, infection, and mechanical instability. Epidural steroid injections have been used for over 50 years to manage lower back pain with or without sciatica symptoms, making them a valuable non-surgical treatment option.
Indications for Epidural Steroid Injection
Epidural steroid injections help to treat pain due to inflammation and irritation of spinal nerve roots. The most common cause of nerve root irritation is intervertebral disc pathology including disc herniation and degenerative disc disease. Another common condition that causes nerve root irritation is spinal stenosis, which is a narrowing of the spinal canal. Spinal stenosis is often caused by arthritis of the facet joints or by intervertebral disc pathology.
There are a variety of other conditions that may also be treated with an epidural steroid injection if the condition is causing nerve root irritation or inflammation, including:
- Vertebral bone spurs.
- Non-specific radiculitis.
- Ligamentum flavum thickening.
- Post-laminectomy syndrome.
- Nerve root cyst.
- Post-herpetic or intercostal neuralgia.
- Compression fracture.
Contraindications for Epidural Steroid Injection
Certain patients should not receive epidural steroid injection including those with the following conditions:
- Local or systemic infection at injection site.
- Bleeding disorders.
- Allergic reaction to anesthetic, contrast, and/or corticosteroid.
- Local malignancy.
Epidural steroid injection should be used with caution in individuals with the following conditions:
- Congestive heart failure.
- Uncontrolled diabetes.
- Pregnancy (due to radiation involved with fluoroscopy)
What the Procedure Involves
Epidural steroid injections are administered using fluoroscopy to help improve accuracy of needle placement. Using radiographic guidance also helps to minimize the risk of injuries to surrounding nerves and blood vessels.
The steps of an epidural steroid injection are as follows:
- The patient is informed of the risks and benefits of the procedure and provides written informed consent.
- The patient is positioned prone (face down) and is then draped appropriately.
- Intermittent fluoroscopy and a radiopaque marker identify the area of nerve compression.
- The skin and subcutaneous tissue of the affected area are cleaned and anesthetized.
- A spinal needle is inserted after the area is completely anesthetized and is advanced using intermittent fluoroscopy until the target area is reached.
- Dye is then injected using live fluoroscopy to confirm proper placement.
- Once placement is confirmed, a steroid and anesthetic solution is administered and the needle is then removed.
After the procedure, the patient can return home and can usually resume normal activities the following day. Typically, the steroids begin to work within 1 to 3 days of the injection, but in some cases, it may take up to a week to feel the full effect. Some individuals have decreased pain and improved function for several months after the injection. If the procedure is effective, it can be repeated once the effects wear off. However, if the patient does not experience symptom relief, it may be a sign that the pain is not coming from the spinal nerves and further diagnostic testing may be indicated.
Risks of Epidural Steroid Injection
As with any procedure, epidural steroid injection does have some risks involved, including:
- Injection site pain.
- Allergy to the steroid and/or anesthetic.
- Nerve injury.
- Accidental dural puncture with associated spinal headache.
- Epidural hematoma and/or abscess.
- Transient lower back or lower extremity pain.
- Adrenal suppression.
- Hot flashes, weight gain, fluid retention, increased blood sugar level, mood swings (side effects of steroids).
- Paralysis (rare).
The use of epidural steroid injection has been around for more than half a century and is an important therapeutic option for patients suffering with chronic lower back pain with or without radicular leg pain. When performed by a trained physician, epidural steroid injections are considered relatively safe and effective. Research has found that epidural steroid injection provides short to medium-term pain management in patients that suffer from chronic and/or severe lower back and leg pain. That being said, it’s important to keep in mind that everyone responds to treatment differently and often the response to epidural steroid injection is not immediate, and not everyone experiences pain relief. For those that do have pain relief, it is often temporary and other forms of treatment are needed to provide sustained pain relief.