Epidural steroid injection:
Before an Epidural Steroid Injection
An Epidural Steroid Injection usually takes between 15 and 30 minutes. The patient lies flat on an x-ray table on their abdomen. Prior to the epidural injection, the skin is numbed with lidocaine, which is similar to the Novocain that the dentist uses (a “local” anesthetic).
What to Expect During an Epidural Steroid Injection
An epidural steroid injection is generally administerd using the following process:
Using fluoroscopy (live x-ray) for guidance, the physician injects steroids into the epidural space — that area that lies between the inner surface of the bony vertebral column and the outer, sleeve-like covering (the dura) of the spinal cord. Sometimes a flushing solution (either lidocaine or normal saline) is also used to help “flush out” inflammatory proteins from the region that is believed to be the source of pain.The Epidural Steroid Injection procedure is usually not uncomfortable; however, sedation is available for patient anxiety and comfort. The procedure takes about 30 minutes, plus approximately forty-five minutes recovery time.Following the injection, the patient is usually monitored for 15 to 20 minutes before being discharged to go 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.
What happens before treatment?
The doctor who will perform the injection reviews your medical history and previous imaging studies to plan the best approach for the injections. Be prepared to ask any questions you may have at this appointment.
Patients who take take blood thinner medication (Coumadin, Heparin, Plavix, Ticlid, Fragmin, Orgaran, Lovenox, Innohep, high-dose aspirin) may need to stop taking it 3 to 5 days before the ESI. Discuss any medications with your doctors, including the one who prescribed them and the doctor who will perform the injection. If you take Coumadin, a blood draw may be done at least 2 hours prior to the procedure to test your blood clotting (PT-INR test).
If you think you may be pregnant or are trying to get pregnant, please tell the doctor. Fluoroscopy x-rays used during the procedure may be harmful to the fetus.
What happens during treatment?
The goal is to inject the medication as close to the pain site as possible, using either a translaminar, caudal, or transforaminal injection. The right type of injection depends on your condition and which procedure will likely produce the best results and the least discomfort or side effects. Studies have shown that use of fluoroscopy (X-ray) to guide the needle into the epidural space is more effective than when the ESI is performed without fluoroscopy. The procedure usually takes 15-30 minutes and is followed by a recovery period.
Step 1: prepare the patient
Patients can remain awake for the entire process. Sedatives can be given to help lessen anxiety. Lying face down on the table, the patient receives a local anesthetic, which will numb the skin before the injection is given. If IV sedation is used, blood pressure, heart rate and breathing are monitored during the procedure.
Step 2: insert the needle
With the aid of a fluoroscope (a special X-ray), the doctor directs a hollow needle through the skin and between the bony vertebrae into the epidural space. Fluoroscopy allows the doctor to watch the needle in real-time on the fluoroscope monitor, thus ensuring that the steroid medication is delivered as close to the inflamed nerve root as possible. Some discomfort occurs but patients typically feel more pressure than pain.
There are three ways to deliver epidural steroid injections: translaminar, transforaminal, or caudal approaches. The best method depends on the location and source of pain.
Translaminar ESI. The needle is placed between the lamina of two vertebrae directly from the middle of the back. Also called interlaminar, this method accesses the large epidural space overlying the spinal cord.
Transforaminal ESI. The needle is placed to the side of the vertebra in the neural foramen, just above the opening for the nerve root and outside the epidural space. Use of a contrast dye helps to confirm where the medication will flow when injected. This method treats one side at a time.
Step 3: inject the medication
When the needle is in place, the local anesthetic and steroid medication are delivered to the epidural space. The needle is then removed.
What happens after treatment?
Most patients can walk around immediately after the procedure. After being monitored for a short time, you usually can leave the office or suite. Someone must drive you home.
Typically patients resume full activity the next day. Soreness around the injection site may be relieved by using ice and taking a mild analgesic (Tylenol).
The doctor’s office may want to follow up 7 to 10 days after the procedure to ask about your symptoms and the level of pain relief obtained. You may want to record your levels of pain during the next couple of weeks in a diary. For patients whose pain is greatly improved, further procedures or surgery may be unnecessary. For patients whose pain is not relieved, the next steps in their care are discussed with their physicians.