Epidural steroid injection-Interlaminar
Overview
Epidural steroid injection (ESI) is a minimally invasive pain management procedure. There are three names due to different injection sites: cervical epidural steroid injection (CESI), thoracic epidural steroid injection (TESI), and lumbar epidural steroid injection (LESI). Lumbar epidural steroid injection is the most common procedure. It involves inserting a needle into the spine between two vertibrae and injecting a local anesthetic and a steroid into epidural space. Steroid can reduce inflammation and swelling, and then reduce the pain. The local anesthetic agent can quit the nerve down and reduce the pain. The pain relief from epidural steroid injections can be short-term or long -term. It may last from a few days or few weeks to months or years. The patient may have three epidurals in a year in general.
Epidural Injection Site
The line points epidural injection site in the middle of back and between two vertebrae. Needle is inserted here
The epidural space is the area between the dura mater (a membrane) and the vertebral wall, containing fat and small blood vessels. The space is located just outside the dural sac which surrounds the nerve roots.
This figure shows epidural space and related structures.
There is another type of epidural steroid injection, transforaminal epidural steroid injection. We will focus on interlaminar epidural steroid injection in this page. Transforaminal epidural steroid injection is discussed in detail in another webpage. Please click here for more information about transforaminal epidural steroid injection.
The figure shows transforaminal epidural injection, a needle in the foramen; and interlaminar epidural injection, a needle in epidural space.
The figure shows the needle position in lumbar epidural injection, a needle between two vertebrae.
The figure shows the needle position in transforaminal epidural injection, a needle in foramen
Indications
The epidural steroid injection is indicated in the pain of neck, arm, mid-back, low back. However, it is most commonly indicated for the arm pain, leg pain and chest wall pain caused by condition of the neck, mid-back or low back respectively. The following conditions are indicated for interlaminar epidural steroid injection.
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Sciatica, radicular pain or radiculopathy
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Spinal stenosis
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Spondylosis
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Disc herniation
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Degenerative disc disease
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Postlaminectomy syndrome
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Failed back surgery syndrome
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S/P fusion
Approach of Interlaminar Epidural Steroid Injection
Interlaminar epidural steroid injection is done by inserting a special needle, epidural needle into epidural space directly in the midline of back and between two vertebrae. It used to be done blindly. Currently standard practice is to be done under the guidance of Fluoroscope (C-Arm X-Ray).
In general, two types of medications are injected, anesthetic and steroid (cortison):
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Anesthetic agents can be lidocaine or bupivocaine. The injection of anesthetic can quiet down the nerves and give patients instant pain relief. The pain relief may not last long because the effectiveness of anesthetic agent is short. However, It can service as diagnostic tool: the pain source is in epidural space if the patient has good pain relief at least for hours after the injection.
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Steroid is strongest anti-inflammatory agent so far in the market. It reduces inflammation and swelling, and then reduce the pain. It is made in a form of very tiny particles. It will stick on the tissue around and slowly release to the epidural space. Therefore, steroid can be in the epidural space for about 2-4 weeks and reduce inflammatin gradually. It takes about 1-3 days to see the effect of pain relief.
The pain relief from epidural steroid injections can be short-term or long -term. It may last from a few days or few weeks to months or years. The short-term pain relief can be just effect of anesthetic agent. And the patient pathologic condition may not respond to steroid.
It is "shot-gun" procedure because when it is injected into epidural space, the medications can diffuse inside upper and down, and the right and the left. It is suitable for the pain from multi-level spines. The patient may have three epidurals in a year in general.
Lumbar Epidural Steroid injection
A epidural needle is inserted into epidural space directly in the middle of low back and between two lumbar vertebrae. It is indicated in the low back pain and the leg pain due to low back pathological changes, such as disc herniation, spinal stenosis, arthritis, post-surgical changes and son on.
Thoracic Epidural Steroid injection
A epidural needle is inserted into epidural space directly in the middle of mid-back and between two thoracic vertebrae. It is indicated in the mid-back pain and the chest wall pain due to mid-back pathological changes, such as disc herniation, spinal stenosis, arthritis, post-surgical changes and son on.
Cervical Epidural Steroid injection
A epidural needle is inserted into epidural space directly in the middle of neck and between two cervical vertebrae. It is indicated in the neck pain, and the shoulder and arm pain, and headaches due to neck pathological changes, such as disc herniation, spinal stenosis, arthritis, post-surgical changes and son on.
Preparation before Procedure
The treating physician will review the patient medical record and discuss with the patient If the patient have following conditions:
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Diabetes Mellitus: Steroid may increase level of blood sugar. It can be dangerous if the patient has uncontrolled diabetes.
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High Blood Pressure: It can be problematic if the patient has uncontrolled high blood pressure.
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Renal Disease: Contrast dye may aggravate the renal condition.
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Allergy: It can be dangerous if the patient is allergic to contrast dye or any medications being used for the injection.
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Pregnancy: X-Ray should not be used for women who are pregnant.
The patient should discuss medications with treating doctors, including prescription medications and over-the-county medications.
Blood thinner, thin the blood and increase risk of bleeding. It includes the medications below:
Anticoagulants:
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Coumadin has to be stopped 5 days before the injection and check INR in the morning of the injection. INR has to be around 1.
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Lovenox has to be stopped 24 hours before the injection.
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Plavix, Pradaxa, Eliquis and Xarelto should also be stopped.
Anti-inflammatory medications (NSAID):
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Ibuprofen, Motrin, Advil, Aleve, Naproxen, aspirin and so other anti-inflammatory medications should be stopped for 7 days before the injection.
Other Medications: the physician will review the patient's medication list before the injection. Some other medications may thin the blood except the medications mentioned above.
The patient should not eat or drink anything after midnight the night before theprocedure if the patient is going to have IV sedation. The patient may also need to consult with his or her physician to find out what other medications he or she can take or can’t take before the injection.
The patient does not have to stop eating or drink if he or she does not need IV sedation.
The physician may prescribe Valium for the patient if the patient is anxious and if the patient does not need IV sedation.
The patient needs a driver to drive him or her home after the procedure. The patient may need driver to drive him or her to the facility and home if the patient takes Valium or has IV sedation.
Procedure of Epidural Steroid Injection
The procedure can be performed in a doctor's office or in the hospital. The procedure may last 15-30 minutes.
The doctor may review the patient's case again with you and answer your questions before the procedure. The patient should always mention his or her allergy to the treating physician.
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The patient is going to sign consent form first.
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The patient is placed in the prone position (face down) in a surgical table.
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The treatment area is disinfected with Beta-dine three times.
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A C-Arm X-Ray is brought into field to locate injection site.
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Local anesthetic agent is used to numb the injection sites with a very fine needle. The patient may feel some discomfort with transient burning sensation.
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A special epidural needle is then inserted under the guidance of real-time fluoroscope.
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The needle is inserted into epidural space directly in the middle of neck or back between two vertebrae.
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Once the needle is positioned in the right location, contrast dye is injected to confirm the needle position. The contrast dye may flow in epidural space up and down, and right and left with bubbling appearance. The patient may feel pressure and some discomfort while the medications is injecting.
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The medications, local anesthetic agent and steroids are injected into the epidural space
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The needle is withdrawn and puncture area is dressed with a Band-Aid.
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The patient will be observed for about 20 minutes after the procedure.
The figure shows a needle is in the middle of lumbar spine and between two vertibrae.
The figure shows a needle is in the lumbar epidural space. It is confirmed with contrast.
The figure shows a needle is in the lumbar epidural space. It is confirmed with contrast.
Post Procedure Care
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The patient may restart blood thinner after the procedure.
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The patient should check blood sugar and blood pressure closely if the patient has diabetis or high blood pressure.
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The patient may remove Band-Aid or other dressing in 6 hours and may take shower at the night.
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The pain may be worse in a few hours after the injection and it can last 1 to 3 days, then the pain starts to subside. Initial pain relief is due to local anesthetic and the pain relief later on is due to steroid effect.
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If the area is uncomfortable in the first two to three days after the injection, a cold pack can be used to reduce the pain.
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The patient should not drive the day of the injection unless approved by the treating physician.
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If sedation is used, the patient should not drive for first 24 hours after the procedure.
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The patient is advised not to do anything strenuous.
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If the patient has sign of infection, such as fever, chills, or redness or drainage at the treatment site or have temperature of 101 degrees or greater, call the treating physician’s office or go to emergency room if the treating physician is not available.
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Follow up with the treating physician in 1 to 2 weeks to plan for next treatment.
Risks and Complications
The potential risks are very low and complications are rare.
Related to needle:
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Bleeding.
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Infection
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Nerve or spinal cord damage
Those are very rare complications.
Related to Medications
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Allergic to contrast, steroid, local anesthetic agent.
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As general rule, patients should always mention their allergy to treating physician before any procedures.
Side effect due to steroid:
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Transient hot flashes
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Fluid retention
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Weight gain
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Increased appetite
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Elevated blood pressure
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Mood swings, irritability, anxiety, insomnia
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High blood sugar - diabetic patients should inform their primary care physicians about the injection prior to their appointment
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Steroid psychosis
Fortunately, the side effects from steroid only last 1-3 days and they do not happen in general.