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Lumbar Epidural Steroid Injection (E.S.I.)

Indications

  • Spinal stenosis
  • Lumbar disc herniation
  • Post-operative back pain

As an alternative to surgery, or as an adjunct to physical therapy, E.S.I. offers the potential for significant improvement in pain. Studies vary in the effectiveness of this technique, with reports varying between 50 - 90% of patients showing significant improvement.

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Sagittal MRI image demonstrating herniated disc (asterisk).

The Procedure

Treatment usually consists of a series of three injections, each two weeks apart. Some experts say that if one injection does not help, the likelihood of a second or third injection helping is low. We have not necessarily seen this to be the case, and it is often helpful to complete a series of three injections.

The two most common methods of injection include a peri-laminar approach at the affected level, or the sacral / caudal injection technique. The caudal approach is most commonly used in our practice, but both methods are available.

In the caudal approach, a needle is placed through an opening to the epidural space at the tailbone. Local anesthesia is used to minimize discomfort.

Some tenderness at the injection site can occur after the procedure. The procedure itself has a low risk of complication with spinal headache (dural puncture), infection, bleeding, or allergic reactions occurring quite uncommonly (less than 1%). Diabetics could see a rise in blood sugars temporarily.

Symptoms usually improve within 3-5 days, but many patients begin to feel better the next day. The duration of benefit from the procedure is variable. Studies show between 50 and 90% of patients have significant improvement or resolution of pain for more than three months, with many benefiting for over a year. Our experience is that about 75% of patients will experience noticeable improvement.

If pain recurs, a second series of injections can be performed six months after the first series. Some patients will not experience benefit.

Lumbar Facet Injection

Arthritis of the joints in the spine (facet joints) can cause significant local back pain. Injection of anesthetic and steroid can confirm the arthritis as the cause of pain as well as treat the underlying inflammation. Synovial cysts can also be injected in patients who are poor surgical candidates.

Selective Nerve Root Block

If a nerve root is pinched as it exits the spine (at the neural-foramen), pain can occur along the course of that nerve (radiculopathy), including buttock, hip, leg or foot pain. The cause of the pinched nerve could be disc herniation, bone spurs from arthritis, or irritation after surgery.

Selective injection of the nerve root sleeve can be achieved with the assistance of CT scanning or fluoroscopy. Steroid and anesthetic are typically injected.

S.I. (Sacroiliac) Joint Injection

The cause of low back or hip pain may actually be due to arthritis of the sacroiliac joint at the back of the pelvis.

X-rays, CT or bone scanning in addition to a physical evaluation should be performed prior to injection to suggest the S.I. joint is the cause of pain. CT guided injection of steroid and anesthetic can then be performed and often significantly improves symptoms.

Sympathetic Nerve Block

As a potential treatment for reflex sympathetic dystrophy (R.S.D.), sympathetic nerve block can be performed.

CT guidance is utilized in this procedure.

Nerve Plexus or Celiac Block

When chronic pain from tumors (for example, cancer of the pancreas) does not respond to conventional medical treatment, celiac as well as other nerve plexus block is an option.

CT guidance is typically utilized. CT allows precise and confirmed delivery of anesthetic or ablative agents.

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Celiac block: Needle tip (asterisk) position confirmed with CT scan allows delivery of agent into celiac plexus in patient with pancreatic tumor and biliary stent (arrowhead).

Vertebroplasty

For the treatment of painful spinal compressions, vertebroplasty offers an alternative to the disadvantages of narcotic therapy or failed narcotic therapy.

Joint Injection

Determining if pain in or around a joint is actually due to the joint itself can be difficult to distinguish from pain caused by the adjacent muscles and nerves.

Fluoroscopic guided injection of anesthetic can prove or disprove the joint as the cause of pain depending on whether symptoms improve with the injection. The hip and subtalar joint at the ankle and knee are common areas to perform these injections.

In cases of proven joint abnormality or arthritis, steroid can then be injected to improve symptoms for months to years.

Additional information:

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