Lumbar Transforaminal Epidural Steroid Injection

Janet D. Pearl, MD, MSc

Suffering From Pain?

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Suffering From Pain?

We Can Help

Suffering From Pain?

We Can Help

Suffering From Pain?

We Can Help

Lumbar Transforaminal Epidural Steroid Injection

Indications

A transforaminal epidural steroid injection is helpful in a number of circumstances for back pain and lower back pain. First, if a disc has herniated in the lumbar region (resulting in lower back pain), an epidural injection could be helpful in decreasing inflammation and allowing the disc to heal. This treatment can also be used in degenerative disc disease where the height of the disc is affected and nerves are compressed. Those who have lumbar spinal stenosis also can achieve pain relief from an injection, and compression fractures of the lumbar vertebrae respond well to this treatment.

Finally, if you have a synovial cyst near a nerve root or an annular tear in a disc, the epidural steroid injection can help you. In general, this procedure is more likely to help those who have back pain that radiates down one or both legs, also called sciatica. Those who should not have this procedure are pregnant women when the procedure involves fluoroscopy, those on a blood thinner, and those with uncontrolled chronic disease, such as diabetes or chronic obstructive pulmonary disease.

Procedure

This procedure is done on an outpatient basis, and sedation is rarely needed because it is generally not painful. You will be asked to lie on your stomach on an x-ray table with a pillow placed under your abdomen.The skin over the disc involvement is prepped and numbed with a medication much like that used in dentistry. A long needle is then inserted into the numbed skin. Using a live action x-ray called fluoroscopy, the needle is guided to the epidural space.

The needle is placed alongside the nerve root where it exits the spinal column, because this is where the ganglionic pain center of the nerve is located. This nexus is vital in transmitting and processing painful stimuli to the spinal cord, and using the steroid and pain medication in this small area disrupts that signal. For this reason, precise placement with fluoroscopy is necessary. Often the opening is narrowed due to arthritic changes in the back, bone spurs, or protrusion of a herniated disc. In addition, if the disc has herniated, the gel inside the disc is acidic, and it can cause irritation to the nerve. This is why both steroids and an analgesic must be accurately placed in the foramen and fluoroscopy is essential to the success of the procedure.

The doctor will then inject contrast dye to ensure that the needle tip is in the right place. Once placement is confirmed, approximately 2 ml of fluid is slowly injected into the space. Although the injection is not fast, you may feel some pressure in your back due to the pressure of the medication against the nerve. The needle is then removed, a bandage is placed on the insertion site, and you will be brought to a recovery area for observation.

transforaminal injection
Transforaminal injection

Recovery

You will be monitored for half an hour after the procedure to ensure that you do not have a reaction to the medications or the placement of the needle. You are requested not to drive a car for the remainder of the day since reflexes can be dulled from the local anesthetic. You are also instructed not to swim or soak in a tub for the remainder of the day. You should be able to return to normal activities the following day, though you can expect some tenderness at the insertion site. Using an ice pack on it for 15 to 20 minutes is usually enough to relieve the pain. Your back may initially feel worse for 2 to 3 days following the injection due to irritation of the medication near the nerve or from the steroid itself. You should begin feeling pain relief within a few days.

Although epidural steroid injections are largely effective, their effects can wear off after a period of time. You may need to have this procedure performed again and up to 3 to 6 times per year, if symptoms persist. Serious complications of the procedureare extremelyrare and include bleeding, infection,and nerve damage. Patients who develop severe back pain,new numbness or weakness in the legs, or difficulty with urinating after a spinal procedure are requested to call the office and go to an emergency room for immediate evaluation. In less than 0.5 percent of cases, the needle may puncture the dura, and this may result in a spinal headache, which is uncomfortable, but treatable. In almost all cases, the procedures go well and without complication. Epidural steroid injections are considered to be a safe procedure.

Transforaminal Epidural steroid injections can reduce sciatica pain by almost 90 percent, according to the Anesthesia and Analgesia, a noted reference on the subject.In addition, a study published in the journal PM & R: the Study of Injury, Function, and Rehabilitation found that the transforaminal approach was superior to placebo procedures in decreasing radicular, or nerve related pain. It is most effective for sciatica pain, though less effective for simple lower back pain. Patients report feeling less pain, greater mobility, and increased quality of life. With relatively few side effects, epidural steroid injections are a viable treatment option.

References

Spine-Health; Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica; Richard A. Staehler, MD; July 2007
http://www.spine-health.com/treatment/injections/lumbar-epidural-steroid-injections-low-back-pain-and-sciatica

Anesthesia and Analgesia;W.Ackerman, et. al.; May 2007; 1217-1222

PM & R: the Study of Injury, Function, and Rehabilitation; Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review; ST Roberts, et. al.; July 2009
http://www.ncbi.nlm.nih.gov/pubmed/19627959

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