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Lumbar Epidural Injection

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What is the epidural space?
The membrane that covers the spinal cord and nerve roots in the spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to the back and into the legs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contract in some way with the bony structure of the spine.

spinal nerve structures

What is an epidural and why is it helpful?
An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in the back or legs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing.

 

syringe, injection

 

What happens during the procedure?
An IV is started so that relaxation medication can be given. The patient is placed lying on their side on the x-ray table and positioned in such a way that the physician can best visualize the low back using x-ray guidance. The skin on the back is scrubbed using 2 types of sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance into the epidural space. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. A mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?
Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next week on a post injection evaluation sheet ("pain "diary"). This will be given to the patient when they are discharged home.

A follow-up appointment will be made for a repeat block if indicated. These injections are usually done in a series of three (3), about two (2) weeks apart. The back or legs may feel weak or numb for a few hours. This is to be expected, however it does not always happen.

General Pre/Post Instructions
Patients can eat a light meal within a few hours before the procedure. If a patient is an insulin dependent diabetic, they must not change their normal eating pattern prior to the procedure. Patients may take their routine medications. (i.e. high blood pressure and diabetic medications).

Patients should not take pain medications or anti-inflammatory medications the day of their procedure. Patients have to be hurting prior to this procedure. They may not take medications that may give pain relief or lessen their usual pain. These medicines can be restarted after the procedure if they are needed.

If a patient is on Coumadin (blood thinner) or Glucophage (a diabetic medicine) they must notify the office so the timing of these medications can be explained.

Patients are generally asked to be at the appropriate facility one hour prior to the procedure and can expect to be at that facility approximately 2-3 hours. A driver must accompany the patient and be responsible for getting them home. No driving is allowed the day of the procedure. Patients may return to their normal activities the day after the procedure, including returning to work.

Updated on: 03/26/10
Gerard Malanga, MD
Epidural Injections can be a very helpful adjunct in rehabilitation of patient's the spine pain that radiates into an arm or leg or in the thoracic spine around the chest or trunk. They work by placing cortisone (a potent anti-inflammatory medication) close to an inflamed nerve. This allows the patient to be fully able to regain full motion and increase the muscular support of the spine critical in the recovery and prevention of future episodes. They are generally not indicated in spine pain that does NOT radiate from an irritated spinal nerve. Most patients actually respond to just 1-2 injections; therefore, they should not be routinely performed in a "series of three". In my experience, 60 % of patients require only one injection and only 10-20 % will require 3 injections. Certainly, if there is little or no pain relief after trying 2 injections, it is unlikely that the third injection will be of benefit. In addition, most patients can be treated with a local anesthetic without the need for sedation which requires an IV and a longer recovery immediately after the procedure.
Leonardo Kapural, MD, PhD
Epidural glucocorticoid injections are commonly given to relieve pain and improve mobility without surgery, buying time for healing to occur or as an attempt to avoid surgery after other conservative approaches failed. Those injections have a good theoretical rationale, but they do not help every patient. Who then should receive an epidural glucocorticoid injection and how many? For leg pain greater than the back pain, guidelines from a respected source (Abram S. Anesthesiology 91:1937-1942, 1999) suggest that patients who had full pain relief from the first epidural injection should not receive another one but to be re-evaluated in 4 weeks and followed thereafter. Those patients who still have some residual pain after the first injection should receive a second and third injection and patients who did not get any benefit from the first injection should not receive another one. Patient selection is very important in deciding on the type of injections patients should receive. Transforaminal injections (different approach to the epidural space) may produce longer pain relief and may also predict whether a patient might benefit from surgery or not (for details, see review McLain et al, Spine Journal 2005). For patients with the diagnosis of lumbar canal stenosis, improvement after such injections may be longer lasting than it was initially thought (Kapural et al., 2005).
Steven Richeimer, MD
Epidural injections can be done at any level of the spine: cervical (neck), thoracic (mid-back), lumbar (low back), and sacral (tailbone area). The thoracic epidural may be a valuable tool in the treatment of mid-back and chest wall pains. These problems might be caused by disc problems, arthritis of the spine, or even shingles.
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