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Lumbar Epidural Injection

Lumbar Epidural

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Why should I have a Lumbar Epidural Spinal Injection?

The purpose of the injection is to carry medication to the inner part of the spine where the more serious types of strain and injury can affect the disc and spinal joints, causing pressure or irritation of the nerves, or pain arising from the joints.  In most cases, the medication that is going to be used is a very potent anti-inflammatory steroid.  Many doctors and patients refer to this medication as “cortisone”, although hydrocortisone is rarely used anymore.  There are better types of medication similar to hydrocortisone. In our practice, we usually use triamcinolone or Depo-Medrone which are the same family of medications as cortisone.  The goal of the injection is to deliver this potent anti-inflammatory steroid as close as possible to the anatomical structure that we believe is causing your pain, thus providing the greatest chance of pain relief.

A Lumbar epidural injection usually takes between 15 and 30 minutes. An IV needle will be placed in your arm in case any medication is needed during the procedure. The patient lies on a side. Prior to the injection, the skin is numbed with lidocaine, which is similar to the novocaine that the dentist uses (a “local” anesthetic). Sedation is available for patient anxiety and comfort. However, sedatives are rarely necessary, as the epidural steroid injection procedure is usually not uncomfortable
Using a special technique called “Loss of resistance” the physician directs a needle into the lumbar spine through a thick ligament called the ligamentum flavum into the spinal canal (epidural space). Once the needle is in the exact position, the epidural steroid solution is injected. Following the injection, the patient is usually monitored for about 2 to 3 hours before being discharged home.
Patients are usually asked to rest on the day of the epidural steroid injection. Normal activities (those that were done the week prior to the epidural injection) may typically be resumed the following day.

Pain relief from an epidural steroid injection

While the effects of an epidural steroid injection tend to be temporary—providing relief from pain for one week up to one year—an epidural injection can be very beneficial for patients during an episode of severe back pain. Importantly, it can provide sufficient pain relief to allow the patient to progress with their rehabilitation program.

Epidural steroid injection success rates

An epidural steroid injection is generally successful in relieving pain for approximately 70% of patients. If a patient does not experience any back pain or leg pain relief from the first epidural injection, further injections will probably not be beneficial. However, if there is some improvement in back pain or leg pain, one to two additional epidural steroid injections may be recommended.

What are the benefits of an epidural steroid injection?

Patients will find that the benefits of an epidural steroid injection include a reduction in pain, primarily in leg pain. Patients seem to have a better response when the epidural steroid injections are coupled with an organised therapeutic exercise program and therefore we routinely refer patients for physiotherapy following an injection.

Risks of an epidural steroid injection

As with all invasive medical procedures, there are potential risks associated with lumbar (lower back) epidural steroid injections. Generally, however, there are few risks associated with epidural steroid injections and they tend to be rare. Risks may include:
Infection. Minor infections occur in 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or secondarily from infection or bleeding.
Dural puncture (“wet tap”). A dural puncture occurs in 0.5% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually gets better within a few days. Although rare, a blood patch may be necessary to alleviate the headache.
Paralysis is not a risk since there is no spinal cord in the region of the epidural steroid injection.

Side effects of an epidural steroid injection

In addition to risks from the injection, there are also potential risks and side effects from the steroid medication. These side effects from an epidural steroid injection tend to be rare. Side effects from steroids are more common when taken daily for several months. Risks and side effects may include:
A transient decrease in immunity
High blood sugar
Stomach ulcers
Severe arthritis of the hips (avascular necrosis)
Transient flushing
Increased appetite.

Are there any long-term complications or side effects from using cortisone?

Much misinformation exist with regards to cortisone-type medications.  It is very true that when an anti-inflammatory steroid, such as prednisone, has to be taken daily, it can cause significant side effects.  Many patients with conditions such as rheumatoid arthritis, lupus, or patients who have had organ transplants, have to take oral steroids on a daily basis.  When this medication is used daily, common adverse side effects include loss of bone density, weight gain, glaucoma, stomach ulceration, and other undesirable problems.  IT MUST BE EMPHASISED THAT THERE IS NO SATISFACTORY EVIDENCE OF ANY LONG TERM COMPLICATION FROM THE USE OF ANTI-INFLAMMATORY STEROIDS INJECTED IN THE EPIDURAL SPACE OR WITHIN A JOINT.

How many times a year can I have a spinal injection?

Most medical professionals who treat patients by injections of anti-inflammatory steroids feel that it is very safe to inject the same joint or epidural space up to three times per year.

How long does it take for the numbing medicine to wear off?

Due to the numbing medicines, some patients experience numbness in the arms or legs after the procedure.  The numbing medicine wears off in one to eight hours, causing the numbness or weakness to go away.

How long will It take before I see relief from the injection?

Increased pain is often experienced the evening after the injection and the following day.  Although unusual, this pain may last up to seven days.  The benefits from the cortisone-type medication injected generally take 24 to 72 hours to occur.  Occasionally, it can take ten days for beneficial affects to occur.  The medication usually reaches its peak effect by three weeks.

How long will the benefits of the injection last?

Many patients ask how long the injection will last or if the injection “wears off”.  Simply put, the medication is a potent anti-inflammatory and will cause a reduction in inflammation and pain in the area where it is injected.  If the injection relieves 75% to 100% of your pain one to two weeks after the injection, most likely the results will be long lasting.  This assumes that the problem that caused the inflammation in the first place is removed.  Sometimes the injection will not work at all.  This usually means one of two things.

What if the injection does not work?

1. The medicine was not put in the proper place where the pain is coming from.  This means that your doctor should reassess your history and physical examination to re-diagnose the problem.  Although disappointing, an injection that does not provide pain relief often helps to correctly diagnose your problem.
2. Another possibility is that the medicine was put in the proper place, but that the problem causing your pain, such as a large slipped disc or severe spinal stenosis, is too great to be overcome by a simple injection.  When this is the case, the patient will generally experience some very minor pain relief for several days and then the pain will be as bad as it was previously.  When this occurs, it is generally not worthwhile performing any further injections.

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