Accurate Education – Epidural injections

Epidural injections

An epidural injection is a technique using a needle to inject a local anesthetic, with or without corticosteroids,  into the epidural space around the spinal cord and spinal nerves. It is often done under x-ray guidance and may be performed in a physicians’s office or in a surgical setting.

 

Epidural injections are used in managing spinal pain secondary to discogenic pain, disc herniation, spinal stenosis, postsurgery syndrome and other conditions. In general, epidural injections are directed at the treatment of symptoms and not solely based on MRI findings. A 2011 study showed that MRI findings do not necessarily predict success of ESIs.

See Also:

Low Back Pain (LBP) – Overview

LBP – Disc Pain

LBP – Facet Pain

LBP – Failed Back Surgery Syndrome

LBP – Myofascial Pain

LBP – Sacroiliac (SI) Joint Pain

LBP – Sciatica

LBP – Spinal Stenosis

 

Treatment Procedures:

Epidural Injections

Facet Joint Injections and Nerve Procedures

Heat & Cold Therapy

Inversion Therapy

Massage Therapy

Physical Therapy

Trigger Point Therapy

 

There are three separate approaches or techniques for epidural steroid injections, each with its unique advantages and disadvantages.

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Epidural injections

 

Effectiveness of Epidural Injections

Epidural injections are one of the most commonly performed non-surgical treatments for low back pain (LBP). However, their extent of effectiveness in managing low back pain and lower extremity pain has been controversial. “Successful” relief of pain may be defined differently based on the individual and their expectations. It is commonly reported that epidural steroid injections are “effective” in reducing pain about 50% of the time, but the duration and extent of pain reduction may range considerably from one individual to the next. Arguably, one can hope for benefit to persist for up to 3 months, possibly longer.

 

Several studies and systematic reviews have been conducted recently to assess the benefits of epidural injections and it appears there is now high quality evidence to support the likelihood of benefit for multiple LBP conditions, including lumbar discogenic pain and lumbar radicular pain associated with disc herniation. Overall, these procedures are well tolerated.

 

Relative Contraindications to Epidural Steroid Injections:

1. Poorly controlled diabetes—steroids increase glucose levels
2. Poorly controlled glaucoma
3. Severe spinal stenosis
4. For diagnosis or treatment of facet pain
5. Local infection at site of injection
6. Diffuse infection
7. Dehydration
8. Pregnancy
9. Epidural lipomatosis: steroids may increase the lipomatosis
10. Use of Anticoagulants (blood thinners): increased risk of hematomas and bleeding
11. Osteopenia and osteoporosis
12. Risk for avascular necrosis
13. Risk for adverse effects with suppression of the hypothalamic–pituitary–adrenocortical axis scheduled for major surgery
14. Those with poor wound healing and immunosuppression.

 

 

Three Routes of Administration of Epidural Injections

These procedures should be performed using fluoroscopic guidance. There are three routes of administration of epidural injections including transforaminal, interlaminar, and caudal approaches:

 

Interlaminar Epidural Injections

 

Several systematic reviews that compared the efficacy of these three approaches provided conflicting results, although a 2015 review article supported the efficacy of epidural injections of local anesthetic with or without steroids administered with all three approaches: caudally, interlaminar, and with a lumbar transforaminal approach.

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Epidural injections: Anesthetics Alone or with Steroids

Epidural injections may be given with anesthetics alone or with steroids (cortisone-like drugs including methylprednisolone, hydrocortisone, triamcinolone, betamethasone, and dexamethasone). There is currently a lack of evidence to support that local anesthetic with steroids is superior to local anesthetic alone in the use of ESIs for treating chronic low back with the exception of treating lumbar disc herniation associated with lower extremity radicular pain where the inclusion of steroids provided added benefit.

Mechanisms of Action

The findings of a 2015 systematic review, showing the equal effectiveness of local anesthetics alone and local anesthetics with steroid administered into the epidural space, facet joints, or over facet joint nerves, contrasts a long-held belief in the medical community emphasizing the effectiveness of steroids in treating spinal pain based on the theory of spinal pain having an inflammatory component. At least in the short-term, most of the benefit of epidural injections may derive from the solution itself, rather than the steroid. It may be explained by various mechanisms of steroids and local anesthetics, including the suppression of ectopic discharges from inflamed nerves, enhancing blood flow to ischemic nerve roots, the lysing of post-operative and inflammatory adhesions, a washout of proinflammatory cytokines, and reversal of peripheral and central sensitization. It has been theorized that the steroids may hasten the healing of annulus tears.

 

Safety of Epidural Injections

 

Patients at higher risk for complications from the use of steroids.

Since it appears that using epidural injections with local anesthetic alone may be a viable option, this choice may reduce the risk of complications from steroids. Patients at higher risk for complications from the use of steroids may benefit from ESIs with anesthetic alone. Higher risk patients include not only postsurgery patients, but also patients with diabetes at risk of hyperglycemia, plus those at a high risk of osteopenia and osteoporosis, those at risk for avascular necrosis, those with a risk for adverse effects with suppression of the hypothalamic–pituitary–adrenocortical axis scheduled for major surgery and those with poor wound healing and immunosuppression.

 

Complications of Epidural Injections

Even though the complications of fluoroscopically directed epidural injections are fewer than blind epidural injections, and have better effectiveness, multiple complications have been reported in scattered case reports, with only minor complications in randomized or non-randomized studies and systematic reviews. Most complications from epidural injections and nerve blocks are minor and consist of soreness and tenderness, itching, nausea and vomiting, rash and sweating. There may be a transient increase in pain for a few days in the area of the procedure. Serious complications fortunately are rare – but, unfortunately, they may be catastrophic.

Any surgery or procedure involving a penetration of the skin can result in local infection which may in turn lead to an abscess which can be quite destructive to local tissues including the discs, vertebrae and spinal cord. The consequence of such destructive infections is often significant chronic pain.

Additionally, epidural procedures including injections and spinal taps involve a penetration of the dura, the outer protective lining of the spinal canal, which can result in inflammation of the linings of the spinal cord, called arachnoiditis. The onset of symptoms related to arachnoidits may not develop until months, possibly years, after the procedure. Arachnoiditis, while relatively rare, can be a debilitating condition associated with severe pain and marked compromise to quality of life. It is not understood what the specific risk factors for developing arachnoiditis are, nor what the actual frequency of this complication is.

 

Other potentially serious complications of epidural injections include: the failure of targeted delivery of injectate; increased levels of pain and soreness; facial flushing and vasovagal reactions; intravascular penetration of the needle with bruising, local or profuse bleeding, local or epidural hematoma, spinal cord hematoma; dural or subdural puncture with subarachnoid or subdural blockade; postlumbar puncture headache, meningismus, pneumocephalus, infectious complications including epidural abscess, discitis, and meningitis; neurological trauma with thromboembolic phenomenon, cauda equina syndrome; and adrenocortical suppression, nerve root trauma, spinal cord injection, spinal cord trauma, stroke, paralysis or death.

 

Many of these complications are predominantly found in cervical and thoracic transforaminal epidura
l injections that are now performed with decreasing frequency.

 

Mixed Safety Studies of Cervical and Lumbar ESIs

Published results of 4,265 injections on 1,857 patients over 7 years with 161 cervical interlaminar injections, 123 lumbar interlaminar injections, 17 caudal injections and 3,964 lumbar transforaminal injections (no thoracic epidural injections) identified a lack of major complications and reported 103 minor complications, for an overall complication per injection rate of 2.4%. In a review of complications of transforaminal lumbar epidural steroid injections, a study published the results of a total of 562 patients performed 1,305 times, with an overall incidence of vascular penetration encountered in 7.4%, an overall rate of minor complications of 11.5%, and no major complications.

 

In 2014, the Food and Drug Administration (FDA) issued a warning about the risk of serious, though rare, but potentially fatal, complications such as meningitis and rare, but catastrophic consequences, such as paralysis and death. The warning also cautioned against a possible lack of effectiveness of epidurally administered steroid injections. However, this advice was issued based on cervical transforaminal epidural particulate steroid injections that resulted in catastrophic complications related to an improperly manufactured batch of injectable steroid solutions. Only 3% of total epidural injections involve cervical and thoracic transforaminal epidural injections.

 

Safety Studies of Lumbar ESIs

In a review of the complications of lumbar interlaminar and transforaminal epidural injections, it was reported that complications from lumbar epidural injections are extremely rare. In a review of complications of transforaminal lumbar epidural steroid injections, Karaman et al published the results of a total of 562 patients performed 1,305 times, with an overall incidence of vascular penetration encountered in 7.4%, an overall rate of minor complications of 11.5%, and no major complications. McGrath et al, in an evaluation of 3,964 lumbar transforaminal epidural injections, reported only minor complications in a small proportion of patients including flushing, chest pain, headache, weakness, itching, leg cramps, fever, etc.

References

LBP: Disc Pain Tx – Epidural Injections

1. Epidural injection with or without steroid in managing chronic low back and lower extremity pain – a meta-analysis – 2015
2. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials – 2015
3. A Prospective Evaluation of Complications of 10,000 Fluoroscopically Directed Epidural Injections
4. 2016 NIA clinical guidelines

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Emphasis on Education

 

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