The Three Different Types Of Epidural Steroid Injections
Epidural steroid injections represent an excellent treatment option for pain management patients suffering from spinal nerve irritation, which is also termed radiculitis.
The injections work great for leg pain coming from spinal stenosis and its variations including foraminal, central, and lateral stenosis. The pain from herniated discs is controlled well with epidural steroids. Do the epidurals help with the pain in the back itself? They can and often help very much, but mostly the ESI’s are best for leg pain problems.
The true desire of pain doctors with steroid injections is to get patients “over the hump.” The steroid injections allow patients frequently the opportunity to do phoenix physical therapy better and hopefully socialize, work, and do things like play with their kids. The problem is not fixed by the steroids, but temporary pain relief may be sufficient.
Until we get a better substance, it’s usually steroids that are injected. What’s their mechanism of action?
They work by neural membrane stabilization along with blocking phospholipase A2 activity, and inhibiting neural peptide synthesis.
Local numbing medicine like Marcaine has been shown in and of itself to produce a dampening effect (and pain relief) of the dorsal horn and c-fiber activity. This can produce great pain relief by itself notwithstanding the steroid injection.
C-arm guidance (called fluoroscopy) is currently the standard of care with epidural steroids. Numerous research studies have shown up to a 35% misplacement of the needle without it.
Here are numerous injection types for epidurals and some info on each:
- 1. Caudal epidural injections – indications include when it’s difficult to get to the other types of injection such as intra-laminar or transforaminal approaches. Usually injected in post-surgery patients when transforaminal technique is impossible. There are also indications for caudal injections in patients with pelvic pain. These injections are least difficult to perform. The doctor needs a larger volume of medication to hit the targets, usually 10 milliliters are needed to reach L5-S1. The misplacement rate without fluoroscopy for caudal epidural steroid injections is 40%.
- Interlaminar Steroid Injections – This injection type allows for administration of steroid to higher lumbar areas. One of the downsides to the interlaminar injection is a significant incidence (5%) of dural tears which may lead to post dural puncture headaches. Advantages include being technically easy. It does necessitate scottsdale pain doctors being familiar with the “loss of resistance” technique. It also allows for delivery of medication to areas higher in the spine than the caudal route. Research shows 30% misplacement without fluoroscopy, and this is a disservice to the patient.
- Transforaminal ESI – The indication for TESI is for radicular pain, with the rationale being delivering the drug in maximum concentration and closer to the site of pathology. There are multiple studies demonstrating the efficacy. Disadvantages include very rare events of bad things happening. These injections are technically the most demanding, and there is a slight risk of direct nerve trauma. A study by Weiner in 1997 showed that these injections may be surgery sparing. There was a 46% rate of achieving complete pain relief. Multiple studies have shown that 2/3 of patients have been able to avoid surgery with these interventions. A 2010 study by Bogduk et al was a prospective randomized blinded study looking at transforaminal epidurals with steroid plus anesthetic, versus anesthetic alone versus saline in the epidural space. The study also looked at intramuscular injections without epidural injection. Well over 50% of patients received over 50% pain relief for the epidural injection with steroid and lidocaine. Twenty five percent of the patients ended up pain free completely. The other groups achieved between 7% and 21% pain relief, so much less.
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