Alternatives to Spinal Surgery Part 2: Epidurals

Saturday, May 25, 2002 | 0

Spinal injections are not new and have been documented to treat low back pain since 1901. In 1952 epidural steroid injections were first used to treat low back pain with sciatica. Today they have become an integral part of non-surgical management of low back pain sufferers.

An epidural injection is typically used to alleviate chronic low back and/or leg pain. While the effects tend to be temporary - providing relief from pain for one week to one year - an epidural can be very beneficial for patients during an episode of severe back pain. Most importantly, it can provide sufficient pain relief to allow the patient to progress with their rehabilitation program.

An epidural is effective in significantly reducing pain for approximately 50% of patients. It works by delivering steroids directly to the painful area to help decrease the inflammation that may be causing the pain. It is thought that there is also a flushing effect from the injection that helps remove or "flush out" inflammatory proteins from around the structures that may cause pain.

The epidural space is an area around the spinal fluid sac. The space typically contains only blood vessels and fat. It does allow for placement of an anti-inflammatory steroid very close to the spinal nerves and tissues that may be inflamed or irritated and potentially causing pain.

Steroids work by relieving inflammation and irritation in the area they are placed. Thus, if there is no inflammation or irritation, steroids will not reduce pain or symptoms. Likewise, if the injection is not placed at the correct site of the inflammation or irritation, there will be no benefit.

A candidate for an epidural injection will be interviewed as to their pain history and location. What makes the pain better or worse will be sought. The area a patient feels the pain beginning in and then going to is important. MRI or CAT scans - if available- will be review with the patient.

Allergies and current medications are reviewed as they can affect the safety of an injection. Anyone taking blood thinners such as Heparin or Coumadin should NOT have epidural injections until it is established that taking them off those medications are both safe and that their blood is no longer thinned. (e.g. PT and PTT values are within normal levels). Allergies to the medications used in epidural injections - such as local anesthetics or steroids can also prohibit an injection or require modification of the procedure.

The injection is done under X-Ray guidance with the patient either seated or in the prone (face down) positioning on the side that is most painful for them.

The patient's skin is then cleansed with an antiseptic solution. Local anesthetic is then injected into the skin overlying the spinal level that is to be injected. Following this, the special epidural needle is placed (usually using x-ray to guide the needle) and the epidural space is injected with an anti-inflammatory steroid. Sometimes there is a "reproduction" of pain with this injection that lasts less than 10 seconds. This is a positive event for it further confirms correct injection near the site of pain. The needle is removed and the patient is monitored for about 20 minutes following the procedure.

The injection is done on an "outpatient" basis and the whole procedure lasts less than 15 minutes but the patient will need a driver following any injection.

There is no definitive research to dictate the frequency of epidural steroid injections for low back pain and/or leg pain. In general, it is considered reasonable to perform up to three injections per year.

Typically, epidural injections are done in two-week intervals. However, there is no general consensus in the medical community as to whether or not a series of three injections need always be performed. If one or two injections lessen the patient's low back and/or leg pain, some physicians prefer to save the third injection for any potential recurrences of back pain later in the twelve-month period.

This article was authored by Dr. Michael Minehart. Michael Minehart, MD, is the Department of Anesthesiology Chair at Santa Teresita Hospital and Founder of the Advanced Pain Institute located in Duarte, CA, which specializes in the treatment of the chronic pain sufferer. His CV can be viewed here. He can be reached at 626-932-3499.