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Lumbar epidural steroid injections

In this procedure normal saline and a steroid solution are mixed and injected into the lumbar epidural space.  The epidural space is a space surrounding the spinal cord membranes within the bony spinal canal.  Of course the lumbar epidural space is this section of epidural space which is located in the back area of the spine.  This is from the mid back to the tailbone.  This injection is not a spinal block that is the procedure where local anesthetic is placed within the spinal membranes containing the fluid, cerebral spinal fluid that surrounds the spinal cord.  The spinal injection is an anesthetic technique that is done in the lumbar spine or the back section of the spine do produce anesthesia in the abdomen and lower extremities for surgical procedures as done in an operating room.  A physician who is trained in spinal injections and procedures generally performs injection into the epidural space.  This is generally an anesthesiologist who has interventional pain medicine training as well.  The solution injected as mentioned above, is a special steroid that is microencapsulated.  That is the compound steroid is surrounded by a compound, which makes the molecules of the steroid lasts longer in the epidural space for longer effect.  In other words the body will have a more difficult time removing or clearing this material from the epidural space.  In contrast when a steroid injection is made into a muscle such as the hip or buttock, the molecules of the steroid are not microencapsulated and thus are cleared by the body faster to be distributed all over the body for a generalized effect.  In this spinal injection the goal of the injection is effect only in the area injected such as the cervical epidural space.  The steroid injected into the body generally is a very potent anti-inflammatory drug. The body makes its own steroids naturally as these compounds are hormones and necessary for life.  One of the well-known naturally occurring steroids of the body is cortisone.  The injected steroids are more potent and active than the body's cortisone.  Therefore the injected steroid in the cervical epidural space will produce more potent anti-inflammatory response once injected in this space.  Occasionally a very small amount of local anesthetic such as lidocaine is also injected with the mixture.  This is to reduce abnormality of the function of the nerves in the spinal canal.  Once the mixture of the steroid and local anesthetic in saline is injected in the epidural space, the solution disperses itself in this space to surround the spinal nerve roots, capsules of the spinal joints (known as the facet joints), spinal ligaments and coverings of the bones of the spine (vertebral elements) and the spinal cord coverings known as dural membranes.  As mentioned reduction of the inflammatory changes of these structures reduces pain, reflex spasm of the muscles of the neck, reduce inflammation of the joints and of course the spinal nerves. This injection may be performed in the office setting or done in the ambulatory outpatient setting.  This specialist performing this procedure may use x-ray control to do this procedure.  This procedure can easily be done without x-ray control as well.  X-ray control is known as fluoroscopic guidance or fluoroscopy. This procedure may be done in the sitting, supine or with the patient on his or her side. The patient may or may not be given sedative medication before procedure.  This is generally determined by the physician who performs the procedure after assessing the patient and the patient's ability to tolerate the procedure with or without medication. The skin and the tissues below the skin are localized with a local anesthetic injection prior to placement of the needle into the epidural space.  The interventional pain specialist after evaluation may recommend this procedure which then can be performed.  These injections are done in a series.  Usually 1 injection is done every 2 weeks for a total of 3 to 4 injections.  It is possible that the interventional pain specialist may not recommend a second injection after the first injection be done because of inadequate response.  If this is the case, other procedures or treatments will be recommended which will be more beneficial for the particular condition.  Sometimes a second injection is done despite less than adequate response after the first injection.  This is done because the first injection will produce a certain amount of anti-inflammatory response and a second injection will allow the solution to spread more in the epidural space at produce further anti-inflammatory response.  In any event your interventional pain anesthesiologist/specialist who is trained in the determination of responses after these procedures can make that determination.

It is important to note that an epidural injection is not a targeted injection.  This means that when a needle is placed into the epidural space, the fluid injected will take the path of least resistance. Therefore in the areas of inflammatory change that is sometimes accompanied by viscoelastic adhesions because of inflammatory changes, may not allow the solution to seep into the correct area.  The solution injected may go to another place in the epidural space that may not be as inflamed and thus inadequate response may be obtained after the injection.  In this situation your interventional pain anesthesiologist will determine other targeted injections that will ensure placement of this material into the correct place so that it may do the most good.

There are complications and side effects associated with this injection that are infection and bleeding which is common to any procedure where the body is invaded with a sharp instrument.  In this case a needle is used.  If the dual membrane that is the sac that the spinal cord is within with its cerebral spinal fluid is punctured then there is a risk of postural headache.  In this situation when the patient gets in the sitting or standing position, a headache will develop which can be mild to severe.  This is not a serious complication however it can be incapacitating to an individual.  This will eventually stop with at any treatment at all.  However in severe cases where the patient is incapacitated and in severe pain, a blood patch can be done which generally will immediately resolve the headache.  Finally there are risks of spinal nerve and spinal cord injury, which are very very rare.  These complications generally do not occur in hands of experienced practitioners.  It is important for the performing physician to be well experienced in the procedure as development of these complications is not as important as there appropriate treatment as soon as they occur.

Dr. Daneshfar is an interventional pain management specialist and performs many of these procedures routinely and daily at the Acute and Chronic Pain and Spine Center (ACPSC) and the local hospitals.    

Copyright © 2002 Acute & Chronic Pain and Spine Center
Last modified: 10/12/06