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Epidural Steroid Injections: A Treatment for Chronic Neck and Back Pain Due to Disc Bulge, Protrusion, and Stenosis
After conservative treatment fails..
What happens after you have been treated with physical therapy, medications, activity modification, chiropractic treatment and acupuncture? Some would think that the only reasonable treatment for their spinal condition would be surgery. However, a less invasive, and commonly effective treatment would include epidural steroid injections. These injections can be performed on an outpatient basis in a surgery center without the need for general anesthesia in most cases.
What conditions are treatable with epidural injections?
Most people who have chronic lower back and neck pain as a result of degenerative disc disease of the spine also have significant pain, numbness, and tingling into the arms and legs. The pathology involved in this condition is somewhat complex. When a disc breaks down (or becomes degenerated) as a result of trauma or as a result of the normal aging process, the structures in the spine around the disc are affected. In the spine (reference the picture provided), there are foraminal spaces through which our nerves travel on the way to the legs and arms. In these spaces, there are nerves that travel to a very specific part of your arm or leg, depending on the level. Levels in the cervical spine include C1-2, C2-3, C3-4, C4-5, C5-6, C6-7 and C6-T1. In the lumbar spine, L1-1, L2-3, L3-4, L4-5, and L5-S1. When a disc degenerates at one of these levels, for example, L5-S1, the nerves that exit that level in the foraminal space can be impinged, irritated or compressed. A person who has disc problems at L5-S1 that affects the nerve roots exiting the foramina, would develop pain, numbness and tingling sensations in an L5-S1 pattern in the legs. Typical symptoms would include pain radiating from the lower back down the posterior aspect of the leg all the way to the foot and big toe. Muscle weakness can be found in the foot and ankle, specifically, when this level is affected. If there are changes at other levels, other patterns of pain can be found. (Reference the picture provided regarding dermatomes)
A person with disc disease and, what we would call, "radiculopathy" or "radicular" pain, would be a candidate for epidural injections. This is an option that can be considered to treat the pain in the arms and legs without the need for surgery.
At the time of the injections, a doctor may use either local anesthesia to numb the area or general anesthesia, depending on the location of the pathology and some other factors. The whole procedure can take about 20 to 30 minutes only and you would be observed for a few hours after the injection and then discharged to home.
An injection of steroids and lidocaine (or similar anesthetic agent) is applied to the specific level where pathology exists in the foraminal space or epidural area. The injection is performed using fluoroscopy, an imaging procedure that can be taken live during the injection to ensure proper placement.
Once the injection is applied to the correct area, the expectation is that the anesthetic agent will provide immediate relief of symptoms for the first day to several days, depending on what specific agent is used and the duration of agent. The steroids that are applied are expected to decrease imflammation in the area, relieve pressure on the nerve roots, and provide longer term relief of symptoms. A successful injection will provide 50% or greater relief of symptoms in the arms or legs, for a duration of at least 2-3 months. During that time period, some people have little to no symptoms and can be more active and take less pain medications.
The intent of these injections is not usually to resolve the condition and they are typically only able to provide short term benefit of 3-6 months duration, at which time they can be repeated. Some patients, however, when treated with a series of 2-3 injections can have complete resolution of symptoms and not have return of symptoms at all. This is somewhat of an unusual or less common result, but it does occur. This would prevent the need for surgery. If there is not long term benefit, it is reasonable for these injections to be repeated up to 3-4 times per year without the risk of serious complications. Of course there is a small risk of scar tissue formation in the area with repeated injections, which would need to be treated surgically.
If the injections do not provide any benefit or fail to provide benefit after a series of injections over time, the need for surgery is considered. Definitive treatment for this condition is always surgery, but epidural injections provide a reasonable alternative in an attempt to avoid or prolong the need for surgery. If your doctor is considering surgery and has not tried epidural injections, do your due diligence and ask for a consultation with a pain management doctor to discuss this option.
Conservative options to use at home for back pain
A TENS unit is an electrical stimulation device that can be applied locally to the lower back. This unit delivers electrical impulses directly into the tissues and muscles in the lower back region. I recommend TENS units for my patients after they have completed a formal physical therapy program. Generally I recommend that my patients use the TENS unit in conjunction with an active stretching program for the muscles of the lower back. I have found that TENS units are usually effective to provide short term relief of pain so that patients can then exercise effectively. A TENS unit can also be used after epidural injections to help facilitate the ability to exercise more aggressively.
Moist heating pad for home use
Similar to a TENS unit, a heating pad or ice pack can also provide local relief of pain and allow for better tolerance for exercises. For most of my patients, I recommend a combination of ice/heat for about 15-20 minutes each day followed by a TENS unit treatment for 30 minutes, and then an active exercise program. These pre-exercise modalities are important because they bring down the level of pain to a more tolerable level and decrease the resistance to movement. In my experience, this allows my patients the most optimal outcome from their daily program of exercise. Even in patients who just had epidurals, I recommend continuation of the home regimen of heat/ice, TENS, and exercise.