Epidural/ Spine & Joint Injection
There are many types of therapeutic injections for back and joint pain—epidural
injection, medial branch neurotomy, facet joint injection, and sacro-iliac joint
injection, among others. In most instances, a long-acting cortisone medication
is placed in area of the “pain generator”. This may reduce the pain
for weeks or even months, when it is successful. These injections never cure
a spine problem, but they can relieve pain to some degree and reduce inflammation
while nature heals, or while physical therapy helps a person control the pain.
Epidural steroid injections are the most common injection therapy
for back pain, and are generally effective at relieving chronic
back and/or leg pain due to inflammation in the spinal canal. They
are most effective for patients with an acute disc herniation or
for spinal stenosis.
Spinal injections have been used to treat back pain since the early
1900s, and epidural steroid injections were first used in 1952 to
treat back pain with sciatica (pain in the sciatic nerve caused by
herniation of the lumbar disc). Today, epidural steroid injections
are an important part of VIA physicians’ management of back
While its effects tend to be temporary, with relief lasting one
week to one year, an epidural can be very beneficial for patients
during a severe back pain episode. With pain managed by an epidural,
a patient can progress with rehabilitation and the injury or irritation
which caused the pain can heal.
An epidural will significantly reduce pain for about 75% of patients.
It works by delivering steroidal anti-inflammatory medications directly
to the injured or irritated area to help reduce the inflammation
that may be causing the pain. Some researchers believe that the injection
can help remove or "flush out" inflammatory proteins from
the painful area.
Epidural Steroid Injections are not effective for disc pain, facet
joint pain, or other sources of back pain. For facet joint pain,
your physician may recommend:
Medial Branch Neurotomy – A procedure in which the nerve to
the facet joint is heated.
Facet Joint Injections – These injections can be helpful when
the facet joint is the pain generator.
Back pain cause by a bulging disk
What Is An Epidural?
An epidural is an injection that delivers steroids directly into
the epidural space. Sometimes a flushing solution (either lidocaine
or normal saline) is also used to help "flush out" inflammatory
proteins from around the area that may be the source of pain.
The epidural space is the space between the dura mater (a membrane)
and the vertebral wall and is filled with fat and small blood vessels.
It is located just outside the dural sac. The dural sac surrounds
the nerve roots and cerebrospinal fluid (the fluid that the nerve
roots are bathed in).
There are often inflammatory factors and other substances that generate
pain (e.g. substance P) that are associated with lumbar disc herniation,
and this inflammation can cause significant nerve root irritation
Steroids (corticosteroids) have been shown to reduce inflammation
by inhibiting the production of substances that cause inflammation,
the epidural injection can be highly effective because it delivers
the medication directly to the site of inflammation.
When Is An Epidural Typically Recommended?
In general, epidural injections are used to help provide pain relief
to enable patients to progress with their rehabilitation. Individuals
who have less pain and feel more comfortable are generally able
to work on the active therapies – such as stretching, strengthening/pain
relief exercises and low impact aerobic conditioning – that
are critical in rehabilitating the lower back.
Several common conditions – including lumbar disc herniation,
degenerative disc disease, and lumbar spinal stenosis – can
cause severe acute or chronic low back and/or leg pain. For these
and other conditions that can cause chronic pain, an epidural steroid
injection may be an effective non-surgical treatment option.
How Is The Injection Performed?
An epidural steroid injection usually takes between 15 and 30 minutes.
The patient lies flat on an x-ray table on their abdomen. Prior
to the injection, the skin is numbed with lidocaine, which is similar
to the novocaine that the dentist uses (a "local" anesthetic).
Many types of physicians perform epidural injections, including
anesthesiologists, interventional radiologists, neurologists, physiatrists
and surgeons. Using fluoroscopy (live x-ray) for guidance, the physician
directs a needle toward the epidural space. Fluoroscopy is considered
important in guiding the needle into the epidural space, as controlled
studies have found that medication is misplaced in 13% to 34% of
epidural injections that are done without fluoroscopy.
Once the needle is in the exact position, the steroid solution is
injected. Following the injection, the patient is usually monitored
for 15 to 20 minutes before being discharged to go home.
Sedation is available for patient anxiety and comfort. However,
sedatives are rarely necessary, as the procedure is usually not uncomfortable.
If a sedative is used, the patient will need to be monitored for
a longer period following the injection.
Patients are usually asked to rest on the day of the epidural steroid
injection. Normal activities (those that were done the week prior
to the injection) may typically be resumed the following day.
What Are The Benefits?
The benefits of the epidural steroid injections include a reduction
in pain, primarily in leg pain. Patients seem to have a better
response when the injections are coupled with an organized therapeutic
While the effects of an epidural injection tend to be temporary—providing
relief from pain for one week up to one year—an epidural can
be very beneficial for patients during an episode of severe back
pain. Importantly, it can provide sufficient pain relief to allow
the patient to progress with their rehabilitation program.
An epidural is generally successful in relieving pain for approximately
50% of patients. If a patient does not experience any pain relief
from the first injection, further injections will probably not be
beneficial. However, if there is some improvement in pain, one to
two additional injections may be recommended.
What Are Potential Risks And Side Effects?
As with all invasive medical procedures, there are potential risks
associated with lumbar (lower back) epidural steroid injections.
Generally, however, there are few risks associated with epidural
injections and they tend to be rare. Risks may include:
- Infection. Minor infections occur in 1% to 2% of all injections.
Severe infections are rare, occurring in 0.1% to 0.01% of injections.
- 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 secondarily from infection or
- 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 gets better within
a few days. Although rare, a blood patch may be necessary to alleviate
Paralysis is not a risk since there is no spinal cord in the region
of the epidural steroid injection.
In addition to risks from the injection, there are also potential
risks and side effects from the steroid medication. These side effects
from an epidural steroid injection tend to be rare. Side effects
from steroids are more common when taken daily for several months.
Risks and side effects may include:
- A transient decrease in immunity
- High blood sugar
- Stomach ulcers
- Severe arthritis of the hips (avascular necrosis)
- Transient flushing
- Increased appetite.
Lumbar epidural steroid injections should not be performed on patients
who have a local or systemic bacterial infection, are pregnant (if
fluoroscopy is used) or have bleeding problems. Epidurals should
also not be performed on patients whose pain is from a tumor or infection,
and if suspected, an MRI scan should be done prior to the injection
to rule out these conditions.
Injections may be done, but with extreme caution, for patients with
allergies to the injected solution, uncontrolled medical problems
(such as congestive heart failure and diabetes), and those who are
taking aspirin or other antiplatelet drugs (e.g. Ticlid, Plavix).
How Frequently Can Epidural Steroid Injections Be Performed?
There is no definitive research to dictate the frequency of epidural
steroid injections for low back pain and/or leg pain. In general,
it is considered reasonable to perform up to three injections per
Typically, epidural injections are done in two-week intervals. However,
there is no general consensus in the medical community as to whether
or not a series of three injections need always be performed. If
one or two injections lessen the patient’s low back and/or
leg pain, some physicians prefer to save the third injection for
any potential recurrences of back pain later in the twelve-month period.