Questions and concerns about conditions and treatments

An epidural steroid injection (ESI) is a minimally invasive procedure to relieve neck, arm, back and leg pain caused by inflamed spinal nerves resulting from spinal stenosis or disc herniation. The goal is to reduce pain so that you may resume normal activities and a physical therapy program.
Injections are a nonsurgical treatment option for acute/chronic neck or back pain. An injection is considered to treat spinal pain after other nonsurgical measures, such as medications and/or physical therapy, have been tried before surgery is considered. Injections can provide pain relief and determine the source of a patient’s pain. Injections can also be used to determine anatomic spinal structure, which could potentially be the source of pain, including a herniated disc or a compressed nerve.
Many practitioners 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 beneficial during an acute episode of back and/or leg pain.
Diagnostic injections typically deliver an anesthetic medication near the suspected source of pain, such as a facet joint or a spinal nerve. If temporary pain relief is achieved until the effect of the local anesthetic wears off, it can be inferred that the specific region is the source of the pain.
Patients may feel some pressure during the injection. However, the procedure is not painful for many. Pain relief resulting from these injections may occur within a few hours or up to two weeks, allowing patients to resume routine activities. These treatment injections are commonly used in combination with physical therapy to strengthen the surrounding muscles and restore mobility.
The procedure usually takes approximately 10 minutes, followed by 20 minutes of recovery time at the clinic. On the day of the epidural steroid injection, the patient should not drive. Rest is needed and strenuous activities must be avoided.

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:

Epidural Steroid Injection

  • Infection. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
  • See Osteomyelitis, a Spinal Infection
  • 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.

In addition to risks from the injection, there are also potential side effects from the steroid medication. These side effects tend to be rare and much less prevalent than 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
  • transient decrease in immunity because of the suppressive effect of the steroid
  • stomach ulcers
  • severe arthritis of the hips (avascular necrosis)
  • cataracts
A facet joint injection is a relatively simple procedure usually performed in an office-based procedure suite or in an ambulatory surgical center.
  • Commonly, the procedure is performed without any sedation. However, an IV line can be started if relaxation medicine is needed.
  • The patient lies on a procedure table, and the skin over the area to be tested is well cleansed.
  • The physician treats a small area of skin with a numbing medicine (anesthetic), which may sting for a few seconds.
  • The physician uses X-ray guidance (fluoroscopy) to direct a very small needle into the facet joint.
  • A small amount of contrast dye is then injected to confirm that the needle is in the joint and that medication is contained inside the joint.
  • Following this confirmation, a small mixture of anesthetic (such as lidocaine) and anti-inflammatory medication (steroid/cortisone) is then slowly injected into the joint.

The injection itself only takes a few minutes, but the entire procedure usually takes between 15 and 30 minutes. When the local anesthetic used to numb the skin wears off, you will probably experience some discomfort where the needles were placed. Although pain relief with facet joint injection generally occurs within 3-5 days, some patients experience improvement before or after this time period.

Immediately following the injection:

  • The patient typically remains resting in the recovery area for 20 to 30 minutes and then is asked to perform some movements or activities that would usually provoke pain.
  • Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether the joints targeted are the main source of their pain. If the joint or joints being targeted are not causing their pain, a patient will not obtain immediate relief from injection.
  • On occasion, patients may feel numb or have a slightly weak or odd feeling in their neck or back for a few hours after the injection.
  • The patient will discuss with the doctor any immediate pain relief.

On the day of the injection, patients are typically advised to:

  • avoid doing any strenuous activities.
  • limit pain medicine within the first four to six hours after the injection so that the diagnostic information obtained is accurate.
  • avoid driving unless specifically approved by the treating physician. o If sedation was used, the patient should not drive for 24 hours after the procedure.
  • Allergic reaction
  • Bleeding
  • Infection
  • Discomfort at the point of the injection or worsening of pain symptoms Nerve or spinal cord damage or paralysis

Rhizotomy is a surgical procedure to sever nerve roots in the spinal cord. The procedure effectively relieves chronic back pain and muscle spasms. For spinal joint pain, a facet rhizotomy may provide lasting low back pain relief by disabling the sensory nerve at the facet joint.

Recovery & Results

Many patients report not feeling the full effects of the rhizotomy procedure until two to four weeks after the procedure. The pain relief induced by this procedure may last anywhere from six months to two years. As your nerve(s) heal from this procedure, the pain will continue to improve. Unfortunately, the nerve will eventually grow back, which may lead to a return of previous pain levels.

Many patients report not feeling the full effects of the rhizotomy procedure until two to four weeks after the procedure. The pain relief induced by this procedure may last anywhere from six months to two years. As your nerve(s) heal from this procedure, the pain will continue to improve. Unfortunately, the nerve will eventually grow back and that may lead to a return of previous pain levels.
You will be placed on the procedure table. The injection site is sterilized with either iodine or chlorhexadine. The site to be injected is numbed with a local anesthetic and a needle is directed to the target area. X-ray guidance is used to ensure proper placement and positioning of the needle. Once the needle is properly positioned, a test is performed to ensure that the needle tip is close to the appropriate nerve and that it is close enough to ensure a successful ablation. Radiofrequency waves are then transmitted to the tip of the needle, which causes it to reach a temperature of 80 degrees Celsius. The needle tip is heated to this level for sixty seconds in order to complete the ablation process. This process is repeated for each targeted nerve.

The injection can be painful. Therefore, we provide the option of receiving IV sedation. IV sedation, combined with local anesthetic, to make the injection nearly pain-free. This allows you to remain very still during the procedure, which can also make the injection easier, faster and more successful. If you decide to have IV sedation, you must have a driver to get you home safely afterwards. In addition, you cannot have anything to eat or drink within six hours of your appointment (clear liquids are allowed until two hours before the procedure). If you take medications for diabetes, these medications may need to be adjusted the morning of the procedure. Your primary care physician can help you with this adjustment.

• Arm or leg muscle weakness or numbness may occur due to the local anesthetic, effecting the nerves that control your arms or legs (This is a temporary effect and it is not paralysis.). If you have any leg weakness or numbness, walk only with assistance in order to prevent falls and injury. Your arm or leg strength will return slowly and completely.
• Dizziness may occur due to a decrease in your blood pressure. If this occurs, remain in a seated or lying position. Gradually sit up and then stand after at least 10 minutes of sitting.
• Mild headaches may occur. Drink fluids and take pain medications if needed. If the headaches persist or become severe, call the office.
• Moderate to severe discomfort at the injection site can occur. This can last for a couple weeks or longer, due to inflammation of ablated nerve(s). If this occurs, take anti-inflammatories or pain medications and apply ice to the area the day of the procedure. If it persists, apply moist heat in the day(s) following. The nerve(s) will heal slowly and the inflammation will resolve, leading to resolution of this pain caused by the procedure.

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