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lumbar transforaminal epidural steroid injection

A treatment option for sciatica, lower back pain and a herniated disc

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Transforaminal Epidural Steroid Injections: Indications

A transforaminal epidural steroid injection is helpful in a number of circumstances for back pain and lower back pain. First, if a disc has herniated in the lumbar region (resulting in lower back pain), an epidural injection could be helpful in decreasing inflammation and allowing the disc to heal. This treatment can also be used in degenerative disc disease where the height of the disc is affected and nerves are compressed. Those who have lumbar spinal stenosis also can achieve pain relief from an injection, and compression fractures of the lumbar vertebrae respond well to this treatment.
Finally, if you have a synovial cyst near a nerve root or an annular tear in a disc, the epidural steroid injection can help you. In general, this procedure is more likely to help those who have back pain that radiates down one or both legs, also called sciatica. Those who should not have this procedure are pregnant women when the procedure involves fluoroscopy, those on a blood thinner, and those with uncontrolled chronic disease, such as diabetes or chronic obstructive pulmonary disease.

Procedure for Epidural Steroid Injection

Outpatient Setting
  • This procedure is done on an outpatient basis, and sedation is rarely needed because it is generally not painful.
  • Patients lie on their stomach on an x-ray table with a pillow placed the abdomen for support
  • The skin over the disc involvement is prepped and numbed with a medication much like that used in dentistry.
  • The needle is placed alongside the nerve root where it exits the spinal column, because this is where the ganglionic pain center of the nerve is located.
  • A long needle is inserted into the numbed skin then using a live x-ray called fluoroscopy, the needle is guided to the epidural space.
  • The ganglionic pain center is vital in transmitting and processing painful stimuli to the spinal cord, and using the steroid and pain medication in this small area disrupts that signal.
  • Both steroids and an analgesic must be accurately placed in the foramen to the success of the procedure and X-Ray guided fluoroscopy is essential.
  • Often the foraminal opening is narrowed due to arthritic changes in the back, bone spurs, or protrusion of a herniated disc.
  • If the disc has herniated, the gel inside the disc is acidic, it can cause irritation to the nerve.
  • Contrast dye is injected doctor to ensure that the needle tip is in the right place.
  • Once placement is confirmed, approximately 2 ml of fluid is slowly injected into the space.
  • Although the injection is not fast, some pressure may be felt in the back due to the pressure of the medication against the nerve.
  • After the needle is removed, a bandage is placed on the insertion site.
  • After the procedure, the patient is brought to a recovery area for observation.
  • The patient will be monitored for half an hour after the procedure to ensure no reactions to the medications or the placement of the needle occur.

Recovery After Epidural Steroid Injection

Immediate Post Procedure Care
  • Patients are requested not to drive a car for the remainder of the day since reflexes can be dulled from the local anesthetic.
  • Patients are instructed not to swim or soak in a tub for the remainder of the day.
  • Return to normal activities the following day, though there can be some tenderness at the insertion site.
  • Using an ice pack on it for 15 to 20 minutes is usually enough to relieve the pain.
  • Some worsening back pain may occur for 2 to 3 days following the injection due to irritation of the medication near the nerve or from the steroid itself.
  • Pain relief should begin within a few days.
  • Epidural steroid injections are largely effective, but their effects can wear off after a period of time.
  • A repeat of the procedure may be up to 3 to 6 times per year, if symptoms persist.
  • In almost all cases, the procedures go well and without complication. Epidural steroid injections are considered to be a safe procedure.
  • Serious complications of the procedure are extremely rare and include bleeding, infection, and nerve damage.
  • Patients who develop severe back pain, new numbness or weakness in the legs, or difficulty with urinating after a spinal procedure are requested to call the office and go to an emergency room for immediate evaluation.
  • In less than 0.5 percent of cases, the needle may puncture the dura, and this may result in a spinal headache, which is uncomfortable, but treatable.
  • Transforaminal Epidural steroid injections can reduce sciatica pain by almost 90 percent, according to the Anesthesia and Analgesia, a noted reference on the subject.
  • In a study published in the journal PM & R: the Study of Injury, Function, and Rehabilitation found that the transforaminal approach was superior to placebo procedures in decreasing radicular, or nerve related pain.
  • It is most effective for sciatica pain, though less effective for simple lower back pain. Patients report feeling less pain, greater mobility, and increased quality of life. With relatively few side effects, epidural steroid injections are a viable treatment option.

References

Spine-Health; Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica; Richard A. Staehler, MD; July 2007.
http://www.spine-health.com/treatment/injections/lumbar-epidural-steroid-injections-low-back-pain-and-sciatica

 

Anesthesia and Analgesia;W.Ackerman, et. al.; May 2007; 1217-1222
PM & R: the Study of Injury, Function, and Rehabilitation; Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review; ST Roberts, et. al.; July 2009
http://www.ncbi.nlm.nih.gov/pubmed/19627959