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Epidural Steroid Injections

Steroid Injection FAQ

Epidural steroid injections (ESI) are a common treatment option for many forms of low back pain and leg pain. They have been used for low back problems since 1952 and are still an integral part of the non-surgical management of sciatica and low back pain. The goal of the injection is pain relief; at times the injection alone is sufficient to provide relief, but commonly an epidural steroid injection is used in combination with a comprehensive rehabilitation program to provide additional benefit.

Most practitioners will agree that, while the effects of the injection tend to be temporary - providing relief from pain for one week up to one year - an epidural can be very beneficial for a patient during an acute episode of back and/or leg pain. Importantly, an injection can provide sufficient pain relief to allow a patient to progress with a rehabilitative stretching and exercise program. If the initial injection is effective for a patient, he or she may have up to three in a one-year period.

In addition to the low back (the lumbar region), epidural steroid injections are used to ease pain experienced in the neck (cervical) region and in the mid spine (thoracic) region. This article focuses on epidural injections in the low back area used to treat low back pain and radicular pain (also referred to as leg pain or sciatica).

There are several risks associated with epidural injections, and although they are all relatively rare it is worth discussing each with the specialist who will be conducting the procedure to determine the incidence of prevalence in their practice.

How Epidural Steroid Injections Work

An epidural steroid injection delivers steroids directly into the epidural space in the spine. Sometimes additional fluid (local anesthetic and/or a normal saline solution) is used to help ‘flush out’ inflammatory mediators from around the area that may be a source of pain.

The epidural space encircles the dural sac and is filled with fat and small blood vessels. The dural sac surrounds the spinal cord, nerve roots, and cerebrospinal fluid (the fluid that the nerve roots are bathed in).

Typically, a solution containing cortisone (steroid) with local anesthetic (lidocaine or bupivacaine), and/or saline is used.

A steroid, or cortisone, is usually injected as an anti-inflammatory agent. Inflammation is a common component of many low back conditions and reducing inflammation helps reduce pain.
Lidocaine (also referred to as Xylocaine) is a fast-acting local anesthetic used for temporary pain relief. Bupivacaine, a longer lasting medication, may also be used. Although primarily used for pain relief, these local anesthetics also act as ‘flushing’ agents to dilute the chemical or immunologic agents that promote inflammation.
Saline is used to dilute the local anesthetic or as a ‘flushing’ agent to dilute the chemical or immunologic agents that promote inflammation.

Epidural Steroid Injections Control Inflammation

Epidural injections are often used to treat radicular pain, also called sciatica, which is pain that radiates from the site of a pinched nerve in the low back to the area of the body aligned with that nerve, such as the back of the leg or into the foot. Inflammatory chemicals and immunologic mediators can generate pain and are associated with common back problems such as lumbar disc herniation or facet joint arthritis. These conditions, as well as many others, provoke inflammation that in turn can cause significant nerve root irritation and swelling.

Steroids inhibit the inflammatory response caused by chemical and mechanical sources of pain. Steroids also work by reducing the activity of the immune system to react to inflammation associated with nerve or tissue damage. A typical immune response is the body generating white blood cells and chemicals to protect it against infection and foreign substances such as bacteria and viruses. Inhibiting the immune response with an epidural steroid injection can reduce the pain associated with inflammation.

Epidural Steroid Injections Potential Risks

As with all invasive medical procedures, there are potential risks associated with 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 a patient 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 disorders.
Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or from infection or bleeding.

Epidural Steroid Injection Side Effects

In addition to risks from the injection, there are also potential side effects from the steroid medication itself. These tend to be rare and much less prevalent than the side effects from oral steroids. Nonetheless, reported side effects from epidural steroid injections include:

Localized increase in pain
Non-positional headaches resolving within 24 hours
Facial flushing
Anxiety
Sleeplessness
Fever the night of injection
High blood sugar
A transient decrease in immunity because of the suppressive effect of the steroid
Stomach ulcers
Severe arthritis of the hips (avascular necrosis)
Cataracts

When to Report Epidural Side Effects to a Doctor

While each physician has a different approach to patient follow-up depending on their practice and the patient’s clinical situation, some conditions that always warrant a call to a doctor following an epidural steroid injection include:

Experiencing a painful headache while sitting up or standing that feels better after lying down, which may indicate a dural puncture
Having a fever of 101 degrees or greater for more than 24 hours, which may be indicative of infection
Losing function or feeling in the legs or arms
Loss of bowel or bladder control (meaning either the inability to produce or hold urine or stools) after the local anesthetic and temporary numbness wear off
Severe pain not controlled by over-the-counter pain medication or other measures used in the past

All of these symptoms are atypical effects, and need to be assessed and addressed immediately by a professional.

In general, epidural steroid injections are a low risk, useful, non-surgical tool to combat lower back pain and sciatica (radicular pain) caused by inflammation. A conservative analysis of patient outcomes suggests that at least 50% of patients will experience pain relief, although the exact degree of relief enjoyed depends on a number of factors. Their relative safety and efficacy makes epidural steroid injections an integral part of the non-surgical treatment of low back and radicular pain.