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| Arizona Pain Specialists 9787 N. 91st Street, Suite 101 Scottsdale, AZ. 85258 Phone: 480-563-6400 |
Arizona Pain Specialists 2007. All rights reserved
Conditions commonly treated with ESIs:
• Degenerative Disc Disease (Botwin 2007)
• Spinal Stenosis
• Herniated Discs (Lin 2006)
• Spondylysis
• Sciatica
• Radiculitis
• Radiculopathy
A study done at the Florida Spine Institute in 2007 confirmed that Epidural Steroid Injections help reduce bilateral
radicular pain and improve standing and walking in patients with Degenerative Lumber Spinal Stenosis (Botwin 2007).
Procedure
The procedure involves injecting a medication into the epidural space, where irritated nerve roots are located. This
injection includes both a long-lasting steroid and a local anesthetic (lidocaine, bupivacaine). The steroid reduces the
inflammation and irritation and the anesthetic works to interrupt the pain-spasm cycle and nociceptor (pain signal)
transmission (Boswell 2007). The combination medicine then spreads to other levels and portions of the spine, reducing
inflammation and irritation. The entire procedure usually takes less than fifteen minutes.
The most important and greatest success achieved with the use of epidural steroid injections (ESI) is the rapid relief of
symptoms that allows patients to experience enough relief to become active again. With this help patients regain the
ability to resume their normal daily activities.
There are several types of Epidural Steroid Injection and the specific type you receive depends on the cause of your pain
syndrome. The trained pain specialist will decide which procedure is more beneficial to you after reviewing your history,
performing a physical exam, and determining the cause of your pain. The main difference in the types of ESIs is the
position where the needle is inserted as well as the amount of nerve roots treated.
Types of ESIs
• Intralaminar Injection: after your skin is anesthetized the needle enters the midline of your back between your spinous
processes (most prominent bones in the midline of your spine). The needle enters between the lamina of two vertebrae
directly posterior to the vertebrae. The combination of steroid and anesthetic is delivered into the epidural space in the
midline and spreads to the nerve roots on both sides of the spine. The evidence for interlaminar epidural steroid
injections is strong for short-term relief and limited for long-term relief in managing radiculopathy.
• Transforaminal Injection: after your skin is anesthetized the needle enters through the side of the vertebra above the
opening for the exiting nerve root. This approach treats one side at a time and is thought to be more specific. Pain
specialists who are treating patients who have undergone previous spine surgery and have foreign bodies (surgical pins,
surgical rods, screws) as well as previous scarring prefer this method because they are able to avoid these structures.
There is powerful evidence suggesting that transforminal ESIs are effective for short-term and moderate for long-term
improvement in managing lumbar back pain (Manchikanti 2007).
• Caudal Injection: after your skin is anesthetized a needle enters the epidural space by your tailbone. This technique
allows for a catheter to be placed (Racz catheter) and larger volumes of steroid and anesthetic to be delivered. The
additional medication can be used to affect more nerve roots distributing to the inflamed area at the same time. Often
caudal ESIs are combined with another procedure called Lysis of Adhesions or the Racz procedure, which is used to treat
epidural scaring. The evidence for caudal ESIs is similar to that of the transformational ESIs.
Benefits
Epidural Steroid Injections are considered routine and relatively painless. Approximately 72% of patients experienced
immediate pain relief in a 2007 research trial to evaluate the usefulness of a cervical interlaminar epidural steroid injection
in patients with neck pain and cervical radiculopathy (Kwon 2007). If pain relief is only moderately achieved with the first
injection then another injection can be given in 2 weeks and may provide additional relief.
The use of multiple injections was studied by the Department of Anesthesiology and Intensive Care at the University of
Pavia, Italy and they concluded that therapy with multiple ESIs provide better control of chronic neck pain compared to
that with a single injection (Pasqualucci 2007). Therefore likely your treating pain physician will recommend multiple ESIs.
Often these procedures are done in sets of three.
The most important and greatest success achieved with the use of ESIs is the rapid relief of symptoms that allows patients
to experience enough relief to become active again. With treatment patients are often able to resume their normal daily
activities.
Another common complication of chronic pain is Central Sensitization. This is a development involving both the peripheral
nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS,
which sends signals through the spinal cord to the brain. Central sensitization occurs when there is an increase in the
excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually normal inputs from the PNS
begin to produce abnormal responses. Low-threshold sensory fibers activated by very light touch of the skin activate
neurons in the spinal cord that normally only respond to painful stimuli. As a result, an input that would normally produce
a harmless sensation now produces significant pain.
Risks
ESIs are considered an appropriate non-surgical treatment for many patients who suffer from back and neck pain.
Although ESIs are considered safe and are one of the most commonly performed procedures in the world, there are risks
associated with the procedure. The major risks associated with this procedure involve bleeding, infection, post-dural
puncture headache, and nerve damage.
The other risks of the ESIs may be directly related to the medications injected. Some of the potential side effects of
corticosteroids include elevated blood sugars, weight gain, arthritis, stomach ulcers, and transient decrease in immune
system function. All patients before receiving an ESI should be assessed by their physician about risk assessment for the
procedure.
Patients with an allergy to any anesthetic, are on blood thinning medications, have an active infection, or are pregnant
should consult with your pain physician before receiving the procedure.
Outcomes
The amount and duration of pain relief vary from person to person, and is dependent on many other factors including
underlying pathology and activity level. Some can have relief that lasts for years while others have short-term relief. It is
important to discuss with your physician your response to epidural steroids in order to plan future treatment options.
The Department of Rehabilitation Medicine at the University of Washington conducted a study that compared the risks
and efficacy between surgical alternatives versus lumbar ESIs. In their conclusion, “when weighing the surgical
alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable non-surgical
option in select patients.” (Young 2007)
Studies
Epidural Local Anesthetic Plus Corticosteroid for the Treatment of Cervical
Brachial Radicular Pain: Single Injection Versus Continuous Infusion. Pasqualucci
A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F,
Paladini A, Mojoli F. PMID: 17710003 [PubMed - as supplied by publisher]
Fluoroscopically guided caudal epidural steroid injections in degenerative lumbar
spine stenosis. Botwin K, Brown LA, Fishman M, Rao S. PMID: 17660853
[PubMed - in process]
The use of lumbar epidural/transforaminal steroids for managing spinal disease.
Young IA, Hyman GS, Packia-Raj LN, Cole AJ. PMID: 17426294 [PubMed -
indexed for MEDLINE]
The use of lumbar epidural/transforaminal steroids for managing spinal disease.
J Am Acad Orthop Surg. 2007 Apr;15(4):228-38 Young IA, Hyman GS, Packia-Raj
LN, Cole AJ
Cervical epidural steroid injections for symptomatic disc herniations. J Spinal
Disord Tech. 2006 May;19(3):183-6. Lin EL, Lieu V, Halevi L, Shamie AN, Wang
JC
Cervical interlaminar epidural steroid injection for neck pain and cervical
radiculopathy: effect and prognostic factors. Skeletal Radiol. 2007 May;36(5):
431-6. Epub 2007 Mar 6
Kwon JW, Lee JW, Kim SH, Choi JY, Yeom JS, Kim HJ, Kwack KS, Moon SG, Jun
WS, Kang HS
Epidural steroids in the management of chronic spinal pain: a systematic review.
Pain Physician. 2007 Jan;10(1):185-212. Abdi S, Datta S, Trescot AM, Schultz
DM, Adlaka R, Atluri SL, Smith HS, Manchikanti L.
Epidural Steroid Injections
by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D
Epidural steroid injections (ESIs) are a frequently used treatment
for chronic pain syndromes. A common characteristic among the
syndromes treated with ESIs is a pain described as “radicular pain
“. The word radicular means root and typically refers to an
irritated nerve root “Radiculitis” or weakness associated with an
affected nerve root “Radiculopathy.”
by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D
Epidural steroid injections (ESIs) are a frequently used treatment
for chronic pain syndromes. A common characteristic among the
syndromes treated with ESIs is a pain described as “radicular pain
“. The word radicular means root and typically refers to an
irritated nerve root “Radiculitis” or weakness associated with an
affected nerve root “Radiculopathy.”
Radicular pain is pain that radiates
from the spine down an irritated
spinal nerve root. Irritation of a
spinal nerve in the low back, called
lumbar radiculopathy, causes pain
that typically travels down a leg.
Cervical radiculopathy describes
pain that travels down an arm.
Epidural injections are also used to
treat nerve compression in the
neck (cervical spine), and well as
the low back (lumbar spine).
from the spine down an irritated
spinal nerve root. Irritation of a
spinal nerve in the low back, called
lumbar radiculopathy, causes pain
that typically travels down a leg.
Cervical radiculopathy describes
pain that travels down an arm.
Epidural injections are also used to
treat nerve compression in the
neck (cervical spine), and well as
the low back (lumbar spine).
Patient Testimonial - Cervical Epidural Steroid Injection
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Book I - Pain Syndromes
Chapter 1 Low Back Pain
Chapter 2 Neck Pain
Chapter 3 Cancer Pain
Chapter 4 Headaches
Chapter 5 Spinal Stenosis
Chapter 6 Sciatica
Chapter 7 Arthritis
Chapter 8 Fibromyalgia
Chapter 9 Motor Vehicle Injuries
Chapter 10 Complex Regional Pain
Syndrome
Chapter 11 Vertebral Body
Fractures
Chapter 12 Hip and Leg Pain
Chapter 13 Diabetic Peripheral
Neuropathy
Book II - Interventional Procedures
Chapter 14 Epidural Steroid
Injection
Chapter 15 Facet Injections/Medial
Branch Blocks
Chapter 16 Radiofrequency Ablation
Chapter 17 Spinal Cord Stimulator
Implants
Chapter 18 IntraDiscal
Electrothermal Therapy (IDET)
Chapter 19
Vertebroplasty/Kyphoplasty
Chapter 20 Discography
Chapter 21 Percutaneous
Discectomy
Chapter 22 Occipital Nerve Block
Chapter 23 Sympathetic Block
Chapter 24 Stellate Ganglion Block
Chapter 25 Intrathecal Pump
Implants
Chapter 26 Caudal Steroid Injection
Chapter 27 Adhesiolysis
Chapter 28 Cervical Steroid
Injection
Chapter 29 Sacroiliac Joint
Injections
Chapter 30 Celiac Plexus Block
Chapter 31 Head and Neck
Procedures
Chapter 32 Joint Injections
Chapter 33 Continuous Catheter
Nerve Blocks
Chapter 34 Peripheral Nerve
Stimulation/Field Stimulation
Chapter 35 Disc Denervation
Book III Other Treatments
Chapter 36 Medication Management
Chapter 37 Acupuncture
Chapter 38 Prolotherapy
Chapter 39 Botox
Chapter 40 Massage
Chapter 41 Alternative and
Complementary Medicines
Chapter 42 Exercise and Nutrition
Counseling
Chapter 43 Prayer
Chapter 44 Cognitive Behavioral
Therapy
Chapter 45 Group Therapy
Chapter 46 Biofeedback
Chapter 47 Chiropractic
Manipulations
Chapter 48 Vitamin Supplements
Chapter 49 Customized
Pharmaceutical Formulations
Chapter 50 Hormone Therapy
Frequently Asked Questions
Chapter 1 Low Back Pain
Chapter 2 Neck Pain
Chapter 3 Cancer Pain
Chapter 4 Headaches
Chapter 5 Spinal Stenosis
Chapter 6 Sciatica
Chapter 7 Arthritis
Chapter 8 Fibromyalgia
Chapter 9 Motor Vehicle Injuries
Chapter 10 Complex Regional Pain
Syndrome
Chapter 11 Vertebral Body
Fractures
Chapter 12 Hip and Leg Pain
Chapter 13 Diabetic Peripheral
Neuropathy
Book II - Interventional Procedures
Chapter 14 Epidural Steroid
Injection
Chapter 15 Facet Injections/Medial
Branch Blocks
Chapter 16 Radiofrequency Ablation
Chapter 17 Spinal Cord Stimulator
Implants
Chapter 18 IntraDiscal
Electrothermal Therapy (IDET)
Chapter 19
Vertebroplasty/Kyphoplasty
Chapter 20 Discography
Chapter 21 Percutaneous
Discectomy
Chapter 22 Occipital Nerve Block
Chapter 23 Sympathetic Block
Chapter 24 Stellate Ganglion Block
Chapter 25 Intrathecal Pump
Implants
Chapter 26 Caudal Steroid Injection
Chapter 27 Adhesiolysis
Chapter 28 Cervical Steroid
Injection
Chapter 29 Sacroiliac Joint
Injections
Chapter 30 Celiac Plexus Block
Chapter 31 Head and Neck
Procedures
Chapter 32 Joint Injections
Chapter 33 Continuous Catheter
Nerve Blocks
Chapter 34 Peripheral Nerve
Stimulation/Field Stimulation
Chapter 35 Disc Denervation
Book III Other Treatments
Chapter 36 Medication Management
Chapter 37 Acupuncture
Chapter 38 Prolotherapy
Chapter 39 Botox
Chapter 40 Massage
Chapter 41 Alternative and
Complementary Medicines
Chapter 42 Exercise and Nutrition
Counseling
Chapter 43 Prayer
Chapter 44 Cognitive Behavioral
Therapy
Chapter 45 Group Therapy
Chapter 46 Biofeedback
Chapter 47 Chiropractic
Manipulations
Chapter 48 Vitamin Supplements
Chapter 49 Customized
Pharmaceutical Formulations
Chapter 50 Hormone Therapy
Frequently Asked Questions
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