Mark J. Downey, MD & Alex Cotter, MD
10 Old Montgomery Hwy #200. Homewood, AL 35209
Appointments & Referrals: (205) 271-6511
If you are scheduled for an ESI, then you are most likely experiencing neck, mid or lower back pain with possible referral into the shoulders, arms, hips or legs. The most likely cause for these symptoms is inflammation in your spine that can cause localized pain in the back as well as nerve referred pain into the extremities.
If the typical treatments of rest, medications and physical therapy have been unsuccessful in removing your symptoms, then there is a very good chance that a steroid could dramatically improve your pain. In order to avoid all the side effects of high dose oral steroids, a small amount of steroid can be placed precisely into the location of the irritation and inflammation within the epidural space. The epidural space is a thin space that covers the entire spine and provides a buffer of protection between the spinal nerves and the bony vertebral column.
By eliminating the inflammation at the site of injury, there is a high likelihood of long-lasting relief that can prevent or post-pone the need for surgery. Epidural steroid injections are commonly used to treat a variety of spinal conditions including degenerative disc disease, disc bulges, herniations, or spinal stenosis caused by arthritis and spurring.
In cases where the nerve is only inflamed and not actually compressed or “pinched”, a single epidural could give relief up to several years. However, the average length of benefit gained after a single injection is somewhere between 3 and 6 months. Although patients often report relief up to one year, this occurs in less than 1/3 of patients. When the relief is partial or temporary, only giving just a few weeks of relief, the epidural can be repeated as soon as 2 weeks after the first injection for a “booster” effect. If the first 2 epidurals have failed to provide any significant relief, it is rare that a 3rd epidural would show much difference. At this time, another type of injection or surgical options may need to be discussed.
Most epidural steroid injections are given with some local 1% lidocaine which usually provides some initial pain relief for a few hours on the day of the procedure. In most cases, it takes about 2 to 3 days for the steroid to begin healing the inflamed area inside the spine. Prior to the onset of relief, a small percent of patients can have an increase in their pain for up to 3 days. This is usually related to either pressure of the medicine within the inflamed epidural space or compensatory muscle spasm in the back. It may be necessary to continue your current pain medication and muscle relaxant for the first few days following the procedure. However, the point of the procedure is to heal the affected area and therefore eliminate the need for pain medications all together.
Note: We do not routinely provide pain prescriptions on the day of the procedure, and prefer to keep all prescriptions handled through our main Alabama Orthopaedic Center office. Call our office number (205) 271-6511 for all prescription medications.
There is no definitive research to mandate the frequency of how often you should have these injections. In general, it is considered reasonable to perform up to three epidurals within a six-month period of time. In certain cases, a fourth epidural can be performed in the following 6 months.
Although it is safe to give occasional steroid injections, there can be cumulative negative systemic effects on the bones (osteoporosis) and adrenal glands from too much steroid annually. Be sure to inform Dr. Downey or his staff of any other steroids given by another physician.
As with all invasive medical procedures, there are potential risks associated with epidural steroid injections. Generally, however, there are only a few rare risks with epidurals. Infection is uncommon because this procedure is performed under sterile technique just as would be seen in surgery. Excessive bleeding within the epidural space forming a hematoma is also an extremely rare risk. This is why you have been asked to discontinue all anti-inflammatories and blood-thinners prior to the procedure.
A spinal tap or dural puncture causing a spinal leak of spinal fluid is also a rare possibility. This risk is increased in patients with severe stenosis or post-surgery scar. Using X-ray guidance has drastically decreased the risk to less than 1/1000 patients. In most cases, 2-3 days of lying flat with aggressive hydration, caffeine, and pain medicine is effective for the leak to close on its own. If the patient develops a positional headache (aggravated by upright position and relieved by lying flat) that persists for more than 48 hours, a simple outpatient epidural blood patch procedure is then scheduled. Following the blood patch, the headache quickly resolves in most cases.
There is an extremely rare (less than one in one million) risk of nerve damage or paralysis when placing a needle in the spine. The majority of cases reported occurred when the epidural injection was not performed under fluoroscopy (X-ray guidance). You can rest assured that Dr. Downey does all of his procedures under fluoroscopy for added safety. Great precautions are taken to prevent these risks from occurring.