Dr. Jerry Sobel frequently uses many different types of fluoroscopically (x-ray) guided injections to help reduce pain. These procedures are either directed towards the spinal nerves – epidural or selective nerve root block or joints in the low back and neck – facet joints. Both types of injections involve the placement of a concentrated dose of an anti-inflammatory (cortisone/steroids) and an anesthetic (lidocaine) to the area(s) of inflammation in the spine. Nerve irritation (radiculopathy/pinched nerve) can result from a herniated disc or bone spurs (spinal stenosis). Joint pain is usually related to arthritis in the spine.
- Cervical Selective Nerve Root Block
- Lumbar Selective Nerve Root Block
- Lumbar Epidural
- Cervical and Lumbar Facet Injections
- Cervical and Lumbar Medial Branch Blocks
- Sacroiliac Joint Injections
- Hip Joint Injections
Epidural steroid injections/Selective Nerve Root Blocks
Epidural steroid injections (ESIs) are a common treatment option for many forms of low back pain and leg pain. They have been used for sciatica since the early 1950′s and are still an integral part of the non-surgical management of leg pain (radiculopathy) that may or may not be accompanied by low back pain. The goal of the injection is primarily to relieve buttock and leg pain, but back pain might also be reduced or eliminated. The injection itself may be sufficient to provide relief, but commonly an ESI is used in conjunction with a comprehensive rehabilitation program to provide additional benefit with respect to discomfort and function.
The effects of the injection may be temporary or permanent. An epidural can be very beneficial for a patient during an acute episode of back and/or leg pain and in some specific chronic pain situations. In a comprehensive pain management program an ESI can provide enough pain reduction to allow a person to progress with an exercise program. After the intial injection, the patient is seen back in the office in 10-14 days to determine its effectiveness. Additional injections may be necessary if pain improvement is not adequate. Three to four total injections may be performed at a frequency of roughly one every two weeks. After several months, these injections may be repeated if necessary. With that said, there is, however, no consensus in the medical community as to the maximum number of injections per year as it has never been studied.
Epidural steroid injections can also be performed in the neck or cervical region to relieve neck and arm pain or in the mid back or thoracic spine.There are two ways to direct medication to the epidural space, an interlaminar approach or one that is transforaminal, or into the nerve root hole. The latter is also known as a selective nerve root block (SNRB) because medication is placed very close to a selected spinal nerve root that may be inflammed and painful. As compared to a SNRB, larger volumes are used in the interlaminar approach in order to cover many nerve root levels in the spine. SNRBs use smaller volumes of more concentrated medication placed on the nerve root sleeve. SNRBs are used for both diagnostic and therapeutic purposes. During the procedure one or at most two spinal nerve roots are treated. If the patient gets relief of their pain then the painful area can be more accurately localized than can be done when a larger amount of medication is dispersed over several spinal levels all at once.
Selective nerve root blocks or transforaminal epidurals can be performed in both the lower back (lumbar) and neck (cervical).
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.
What is an epidural and why is it helpful?
An epidural injection places anti-inflammatory medicine (corticosteroids – cortisone) 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 with healing 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.
What should you expect during the procedure
Prior to the procedure the patient should review the pre-injection instructions. Certain medications may increase the risks of complications. Please inform you doctor if you are taking any of the following:
- Aspirin- stop 5 days before the injection. A baby aspirin can be continued
- NSAIDs- Ibuprofen (Advil), Naprosyn (Aleve), Voltaren, Meloxicam, Indocin, etc
- Celebrex can be continued
- Coumadin (Warfarin)
- Plavix (Clopidogrel)
- Ticlid (Ticlopidine)
- Lovenox (Enoxoparin)
Continue with your routine medications before the procedure. If you have an infection please notify your physician. It is best to wait for it to resolve before getting your injection. There is no eating or drinking for four hours before the procedure. Small amounts of clear liquids are allowed up to two hours before and can be used to take your pills if necessary.
Patients are generally asked to be at the surgical center one hour prior to the procedure and can expect to be at the 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 unless otherwise directed by their doctor.
In the pre-operative area a nurse will interview you and place and IV in your arm. This allows you to receive a relaxing and/or pain medication during the procedure if necessary. You will be lying on your stomach and your back will then be cleaned prior to beginning the injection. The skin and underlying tissues will then be numbed with an anesthetic (lidocaine). This can sting for several seconds. Using fluoroscopy (x-ray) a small needle will be placed in the epidural space. Prior to injection of cortisone, a contrast agent (dye) is used to determine the proper placement of the needle. After correct localization of the needle is performed, a mixture of an anti-inflammatory (cortisone/steroid) and a anesthetic (lidocaine) is then injected. Sometimes, patients feel an increase in leg pain in the exact area that they have been feeling pain. If pain is increased the pace of the injection of the medication is slowed to make it more tolerable.
Post-injection you will be taken to the recovery area and observed for 30-60 minutes. You will be given post-injection instructions to read and follow. Once it is determined that your vitals signs are stable, you are discharged home with your driver. You will be asked to follow up in the office in 10-14 days.
After the procedure, it can take up to two weeks to achieve relief from the symptoms. However, most people feel a benefit from the injection in 3-5 days.
Risks and Side Effects
There are several risks associated with epidural injections, and although they are all very uncommon it is worth discussing each with the physician who will be performing the procedure.
As with all invasive medical procedures, there are potential risks associated with lumbar epidural steroid injections. In addition to temporary numbness of the bowels and bladder, the most common potential risks and complications include:
- Infection – Severe infections are rare, occurring in 0.1% to 0.01% of injections.
- Dural puncture (“wet tap”) – A dural puncture occurs in 0.5% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually improves within a few days. Although infrequent, a blood patch may be necessary to alleviate the headache. A blood patch is a simple, quick procedure that involves obtaining a small amount of blood from an arm vein and immediately injecting it into the epidural space to allow it to clot around the spinal sac and stop the leak
- Bleeding – Bleeding is a rare complication and is more common for patients with underlying bleeding disorder
- Nerve damage – While extremely uncommon, nerve damage can occur from direct trauma from the needle, or from infection or bleeding.
- There have been reports in the medical literature of very rare complications from epidural steroid injections in the neck. Cases of spinal cord injuries, strokes and deaths have been reported. These complications have been associated with certain medications injected and incorrect place of the medication. The choice of cortisone (steroid), the use of fluoroscopy (x-ray) and other precautions are taken to greatly minimize the risk.
All corticosteroids have potential side effects. These tend to range from uncommon to rare but can occur and you need to be aware of them. They are usually much less prevalent than the side effects from taking oral steroids.
- Facial flushing
- Fluid retention
- Elevated blood pressure
- Fever the night of injection
- Elevated blood sugar for 2-3 days- diabetics need to monitor their blood sugars closely
- A transient decrease in immunity because of the suppressive effect of the steroid
- Heartburn/stomach ulcers
- Severe arthritis of the hips (avascular necrosis)
- Post-injection flare – an increase in pain that can occur several hours after the injection and can last for several days
Epidural steroid injections are frequently used for the following conditions:Herniated Disc
- Spinal Stenosis
- Back and Neck Pain
Facet Joint Injections
A zygapophysial or facet joint is a joint between one vertebrae and another. There are two facet joints in each spinal motion segment. The function of each pair of facet joints is to guide and limit movement of the spinal motion segment. A small capsule surrounds each facet joint providing a nourishing lubricant for the joint. Also, each joint has a rich supply of tiny nerve fibers that provide a painful stimulus when the joint is injured or irritated. Just like any other joint in the body, facet joints are subject to degeneration, inflammation, fracture, injury, and arthritis.
Facet joint injections are used to diagnose and treat painful and inflamed joints in the spine.
The pre-injection and post-injection procedures are the same as noted under the heading what should you expect during the procedure in the epidural section above. It is important to read and follow the pre-injection instructions prior to the procedure. You may read the post-injections instructions or wait for them to be given to you after the procedure. Using modern X-ray technology, multiple x-ray snapshots are taken during the procedure to ensure that the spinal needle and injected agents are placed into the correct location. After the procedure, it can take up to two weeks to achieve relief from the symptoms. However, most people feel a benefit from the injection in 3-5 days.
- Image-guided spine procedures provide physiological information not available from diagnostic imaging studies
- Fluoroscopy provides the advantage of real-time observation during contrast injection to assess for vascular opacification.
- Early intervention for spine pain sufferers helps to decrease dependence on oral pain medication, improve physical performance and facilitate a rapid return to normal activities of daily living and vocational pursuits
- Image-guided spine procedures are minimally invasive and can be performed on an outpatient basis