Epidural Steroid Injections for Relief of Spinal Stenosis
For patients with severe and persistent pain in the spine from conditions such as spinal stenosis, regardless of whether they also have neck pain or back pain, an epidural steroid injection can provide welcome relief for spine pain. These injections are a combination of a local anesthetic and a corticosteroid which work to relieve pain straight away and have a longer-lasting effect as an anti-inflammatory to relieve some of the pressure on the spinal column, muscles and nerves. Epidurals do not cure spinal stenosis, instead they can provide effective pain-relief and reduction in inflammation for a 2-3 week period in most cases.
Some of the common medications used as epidural steroid injections include betamethason, methylprednisolone, and triamcinolone (their respective brand names are Celestone Soluspan, Depo-Medrol, and Aristospan). These are strong anti-inflammatories which are injected into the space around the spinal cord and spinal nerve roots. The steroids work by reducing the oedema, improving micro-circulation and reducing ischaemia around the nerve roots. They also inhibit pro-inflammatory prostaglandin synthesis (an action shared by substances such as fish oil and flaxseed oil). Steroids also work through direct action in inhibiting C-fiber neuronal membrane excitation; which is a key source of experienced pain in spinal stenosis.
When to Use an Epidural Injection for Spinal Stenosis
Epidurals are not usually the first recourse of physicians when treating spinal stenosis; more conservative methods are normally employed in the first instance. If an epidural is recommended then the patient will likely undergo an MRI (magnetic resonance imaging) scan prior to treatment so as to ascertain the exact location of the troubled nerves. During the injection itself the physician may use a fluoroscope (x-ray machine) to help guide the needle to the correct place for optimum effect. The needle does not enter the membrane (dura) that contains the spinal cord and nerve roots, instead the injection is administered to the epidural space that surrounds this membrane.
Epidurals are mostly conducted at outpatient clinics, or at the patient’s doctor’s office. They can be performed by anesthesiologists, radiologists, neurologists, and surgeons, amongst other health professionals. Medical centers often have specific pain management clinicians who conduct epidurals and can advise on conditions such as spinalstenosis.org/blog/spinal-stenosis-arthritis/
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The epidural injection procedure is usually commenced with an intravenous sedative (though this is optional) to help the patient relax , and then positioning the patients so as to allow easier access to the injection site. This may involve the patient lying face down, or sitting upright in a chair. The site of injection is then swabbed with an antiseptic and an injection of a local anaesthetic is given. Using a fluoroscope to help guide them, the physician will then insert the needle into the epidural space and, to check the needle’s position, inject a contrast dye before injecting the steroid and the anesthetic themselves. The needle will then be removed and the area swabbed with antiseptic and bandaged.
After the epidural (which takes about 15-30 minutes) the patient is usually monitored for 30-60 minutes and then allowed to leave if everything is satisfactory. Patients should not drive after an epidural and should make alternative arrangements to get home. They should avoid strenuous activity that day also and follow other guidance as given by their physician to aid their recovery.
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.