In our post last week we discussed the use of epidural injections for spinal stenosis pain, this week we will take a look at the effectiveness, limitations, side effects and risks involved in the use of steroid injections as a spinal stenosis treatment.
Epidurals can be very effective for relieving the chronic pain associated with spinal stenosis. Epidural steroid injections are usually used for leg pain rather than back pain, or neck pain residing higher up in the spine. The effects last for 2-3 weeks in the majority of people, but it is as yet unknown how well injections for spinal stenosis and other spine conditions work over extended time periods. One of the benefits outside pain relief is it may help some patient delay spinal stenosis surgery or even remove its necessity.
Limitations, Side Effects and Risks of Epidural Steroid Injections
Unfortunately there are potential side-effects to epidural steroid injections. These include the possibility of complications with the procedure itself, namely a risk of infection at the injection site. Other side effects are usually fairly minor in nature, but as the longer-term effects of epidurals have not been studied it is inadvisable to have more than three injections in a 12 month period with most doctors recommending no more than one in a 2 month period. Three or four injections at one site are the normal limit advised for most patients.
Side effects can include tenderness in the area for a few days at the site of injection, nausea and vomiting, dizziness, and headaches. There is also a very small chance of spinal fluid leakage, although the use of the fluoroscope normally minimizes this risk. Epidurals are usually avoided in the cervical spinal stenosis as the structures here are harder to navigate safely. Oral steroids may be an option instead of a steroidal injection.
As the steroids are being injected into a specific space there is only a small amount of corticosteroid which reaches systemic circulation. Side effects in the case of these circulating steroids include water retention, weight gain, and the potential for blood sugar control being compromised (particularly in diabetics).
Rare, but dangerous side effects also include nerve root injury, bleeding, infection, and meningitis. Those with immune system problems are usually ill-advised to have epidural steroid injections, and those with mental health disorders also have a higher risk of complication with this procedure. If the patient has an infection at the time of the procedure then they should postpone their treatment until the infection has cleared. Those with a congenital form of spinal stenosis are also advised against epidural injections as the corticosteroids may exacerbate their condition, with increased pain and numbness.
Spinal Stenosis Pain Management
When the pain and symptoms of spinal stenosis are persistent, epidural steroid injections are just one option in the treatment and management of spinal stenosis. If patients feel it may benefit them they should discuss this option with their health care professional to see if it is appropriate for their circumstances. Epidurals should not be used in isolation, instead they should be incorporated into a management program and facilitate rehabilitation (alongside exercises for spinal stenosis) rather than acting as a short-term substitute for it. If an epidural is not effective the physician may suggest another injection later at a different site. A review of the benefits of epidural steroid injections by Botwin (2002) found that the transforaminal injection site provided significant short and long-term improvements in patients as opposed to other injection sites. If long-term benefits are felt then the likely mechanism is that the cycle of inflammation has been broken by the steroids, allowing the body time to repair and recover.
North American Spine Society, (2007), Diagnosis and treatment of degenerative lumbar spinal stenosis: Evidence-based clinical guidelines for multidisciplinary spine care. Available online: http://www.spine.org/Documents/NASSCG_Stenosis.pdf.
Isaac, Z., et al, (2005), Lumbar spinal stenosis, In Koopman, W.J., ed. Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 2, pp.2087–2092, Philadelphia, Lippincott, Williams, and Wilkins.
Botwin, K.P., Gruber, R.D., Bouchlas, C.G., Torres-Ramos, F.M., Sanelli, J.T., Freeman, E.D., Slate, W.K., Rao, S., (2002), Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study, Am J Phys Med Rehabil, Vol.81, no.12, pp.898-905.
Written by Leigh Matthews