Epidural injections for back pain

An epidural steroid injection (ESI) is the delivery of powerful anti-inflammatory medicine directly into the space outside of the sac of fluid around your spinal cord. This area is called the epidural space.

It is not the same as an epidural anesthesia given prior to childbirth.

Description

You will be asked to change into a gown, then lie face down on an x-ray table with a pillow under your stomach. If this position causes pain, you will be asked to either sit up or lie on your side while in a curled position.

The health care provider cleans the area of your back where the needle will be inserted, and may use medicine to numb the area. You may be given medicine to help you relax.

Most of the time, your doctor will use an x-ray machine that produces real-time pictures to help guide the needle to the correct spot in your lower back. The doctor injects a mixture of steroid and numbing medicines into the area. This medicine decreases swelling and pressure on the larger nerves around your spine and helps relieve pain.

You may feel some pressure during the injection, but most of the time the procedure is not painful.

You will be watched for 15 – 20 minutes after the injection before going home.

Why the Procedure is Performed

Your doctor may recommend an epidural spinal injection if you have pain that spreads from the lower spine to the hips or down the leg (radicular low back pain). Such pain is caused by pressure on a nerve as it leaves the spine, most often due to a bulging disc.

The injections are rarely used unless your pain has not improved with medicines, physical therapy, or other nonsurgical treatments.

Risks

Epidural injections are generally safe. Possible complications may include:

  • Dizziness, headache, or feeling sick to your stomach. Most of the time they are mild.
  • Nerve root damage with increase pain down your leg
  • Infection in or around your spine (meningitis or abscess)
  • Allergic reaction to the medicine used
  • Bleeding around the spinal column (hematoma)

Talk to your doctor about your risk of complications.

Having these injections too often may weaken the bones of your spine or nearby muscles. Receiving higher doses of the steroids in the injections may also cause these problems. As a result, most doctors limit patients to two or three injections per year.

Outlook (Prognosis)

Epidural steroid injections provide short-term pain relief for at least half of the people who receive them. Symptoms may remain better for weeks to months, but rarely up to a year.

The procedure does not cure the cause of your back pain. You will need to continue back exercises and other treatments.

Before the Procedure

Your doctor will most likely have ordered an MRI scan of the back before this procedure. This helps your doctor determine the area to be treated.

Before your procedure, tell your doctor or nurse:

  • If you are pregnant or might be pregnant
  • What medicines you are taking, including herbs, supplements, and other drugs you bought without a prescription

You may be told to stop taking medicines that make it hard for your blood to clot for several days before the test. This may include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), naproxen (Aleve, Naprosyn), and heparin.

Always check with your doctor before stopping any medications.

Recovery

You may feel some discomfort in the area where the needle. This should only last a few hours.

Your doctor may ask you to rest for the remainder of the day.

Your pain may become worse for 2 – 3 days after the injection before it begins to improve. The steroids usually takes 2 – 3 days to work.

If you receive medicines to make you sleepy, you must arrange for someone to drive you home.

Radiofrequency Ablation for Back or Neck pain

Radiofrequency ablation is the delivery of heat through the use of radiofrequency waves to the same sensory nerves that innervate your facet joints either in your neck or low back.

Description

You will be asked to change into a gown, then lie face down on an x-ray table with a pillow under your stomach.

The health care provider cleans the area of your back where the needle will be inserted, and may use medicine to numb the area. You may be given medicine to help you relax.

Your doctor will use an x-ray machine that produces real-time pictures to guide the needle to the correct spot in your lower back. Testing is then performed to ensure the needle is in the correct position.

The doctor injects a mixture of steroid and numbing medicines into the area to prevent pain during the treatment process.  The treatment takes slightly over a minute per site after each needle is placed.

You will be watched for 15 – 20 minutes after the injection before going home.

Why the Procedure is Performed

Your doctor may recommend a radiofrequency nerve ablation if you have pain in your neck or low back that is typically worse with prolonged sitting, standing, walking up stairs or extension of your neck or back.. Such pain is caused by inflammation within your facet joints due to trauma or degeneration within the joint.

The injections are rarely used unless your pain has not improved with medicines, physical therapy, or other nonsurgical treatments.  A diagnostic procedure will be performed to diagnose your facet joint as the source of your pain prior to the radiofrequency procedure.

Risks

Radiofrequency treatments are generally safe. Possible complications may include:

  • Dizziness, headache, or feeling sick to your stomach. Most of the time they are mild.
  • Nerve root damage with increase pain down your leg
  • Infection in or around your spine (meningitis or abscess)
  • Allergic reaction to the medicine used
  • Bleeding around the spinal column (hematoma)

Talk to your doctor about your risk of complications.

Outlook (Prognosis)

Radiofrequency treatments provide medium-term pain relief for at least half of the people who receive them. Symptoms may remain better for 6-12 months, but rarely much over a year.

The procedure does not cure the cause of your back pain. You will need to continue back exercises and other treatments.

Before the Procedure

Your doctor will most likely have ordered an MRI scan of the back before this procedure. This helps your doctor determine the area to be treated.

Before your procedure, tell your doctor or nurse:

  • If you are pregnant or might be pregnant
  • What medicines you are taking, including herbs, supplements, and other drugs you bought without a prescription

You may be told to stop taking medicines that make it hard for your blood to clot for several days before the test. This may include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), naproxen (Aleve, Naprosyn), and heparin.

Always check with your doctor before stopping any medications.

Recovery

You may feel some discomfort in the area the needles were placed. This should only last a few hours.  You may feel like you have a sunburn in the skin over the area treated for up to 3 weeks.

Your doctor may ask you to rest for the remainder of the day.

Your pain may become worse for 2 – 3 days after the injection before it begins to improve. The steroids usually takes 2 – 3 days to work.

If you receive medicines to make you sleepy, you must arrange for someone to drive you home.

Kyphoplasty

Kyphoplasty is an outpatient procedure used to treat painful compression fractures in the spine. In a compression fracture, all or part of a spine bone collapses.

The procedure is also called balloon kyphoplasty.

Description

Kyphoplasty is done in a hospital or outpatient clinic.

  • You may have local anesthesia (awake and unable to feel pain). You will likely also receive medicine to help you relax and feel sleepy.
  • You may receive general anesthesia. You will be asleep and unable to feel pain.

You lay face down on a table. The health care provider cleans the area of your back and applies medicine to numb the area.

The doctor places a  large needle through the skin and into the spine bone. Real-time x-ray images are used to guide the doctor to the correct area in your lower back.

A balloon is placed through the needle, into the bone, and then inflated. This restores the height of the vertebrae. Cement is then injected into the space to make sure it does not collapse again.

Why the Procedure is Performed

A common cause of compression fractures of the spine is thinning of your bones, or osteoporosis. Your doctor may recommend this procedure if you have severe and disabling pain for 2 months or more that does not get better with bed rest, pain medicines, and physical therapy.

Your doctor may also recommend this procedure if you have a painful compression fractures of the spine due to

  • Cancer, including multiple myeloma
  • Injury that caused broken bones in the spine

 

Risks

Kyphoplasty is generally safe. Complications may include:

  • Bleeding
  • Infection
  • Allergic reactions to medicines
  • Breathing or heart problems if you have general anesthesia
  • Leakage of the bone cement into surrounding area (this can cause pain if it affects the spine or nerves)

Outlook (Prognosis)

You will probably go home on the same day of surgery. You should not drive, unless your doctor says it is OK.

After the procedure:

  • You should be able to walk. However, it’s best to stay in bed for the first 24 hours, expect to use the bathroom.
  • After 24 hours, slowly return to your regular activities.
  • Avoid heavy lifting and strenuous activities for at least 6 weeks.
  • Apply ice to the wound area if you have pain where the needle was inserted.

Before the Procedure

Before surgery, always tell your doctor or nurse:

  • If you could be pregnant
  • What drugs you are taking, even those you buy without a prescription
  • If you have been drinking a lot of alcohol

During the days before the surgery:

  • You may be asked to stop taking aspirin, ibuprofen, coumadin (warfarin), and other drugs that make it hard for your blood to clot.
  • Ask your doctor which drugs you should still take on the day of the surgery.
  • If you smoke, tried to stop

On the day of the surgery:

  • You will usually be told not to drink or eat a anything for several hours before the test.
  • Take your drugs your doctor told you to take with a small sip of water.
  • Your doctor or nurse will tell you when to arrive.

Recovery

Patients who have kyphoplasty usually have less pain and a better quality of life after the surgery. They usually need fewer pain medicines, and can move better than before.

 

Spinal Cord Stimulation

Spinal cord stimulation is a treatment for back pain that uses a mild electric current to block nerve impulses in the spine.

Description

A trial electrode will be put in first to see if it helps your pain.

  • Your skin will be numbed with a local anesthetic.
  • Wires (leads) will be placed under your skin and stretched into the space on top of your spinal cord.
  • These wires will be connected to a small current generator outside of your body that you carry like a cell phone.
  • The procedure takes about 1 hour. You will be able to go home after the leads are placed.

If the treatment reduces your pain by 50% or more, you will be offered a permanent generator. The generator will be implanted a few weeks later.

  • You will be asleep and pain-free with general anesthesia.
  • The generator will be inserted under the skin of your abdomen or buttocks through a small surgical cut.
  • The procedure takes about 1 to 2 hours.

The generator runs on batteries. Some batteries are rechargable. Others last 2 to 5 years. You will need another surgery to have the battery replaced when it gets too old.

Why the Procedure is Performed

Your doctor may recommend this procedure if you have:

  • Back pain that continues or gets worse, even after surgery to correct it
  • Complex Regional Pain Syndrome(CRPS)
  • Long-term (chronic) back pain, with or without arm or leg pain
  • Nerve pain or numbness in the arms or legs
  • Swelling (inflammation) of the lining of the brain and spinal cord

SCS is used after you have tried other treatments such as medication and exercise and they have not worked.

Risks

Risks from any surgery are:

  • Allergic reactions to medications
  • Bleeding
  • Breathing problems
  • Infection

Risks from this surgery are:

  • Cerebrospinal fluid (CSF) leakage
  • Damage to the nerves that come out of the spine, causing paralysis, weakness, or pain that does not go away
  • Infection of the battery or electrode site (if this occurs, the hardware usually needs to be removed)
  • Movement of or damage to the generator or leads that requires more surgery
  • Pain after surgery
  • Problems with how the stimulator works, such as sending too strong of a signal, stopping and starting, or sending a weak signal

The SCS device may interfere with other devices, such as pacemakers and defibrillators. After the SCS is implanted, you may not be able to get an MRI anymore (discuss this with your health care provider).

Outlook (Prognosis)

After the permanent generator is placed, the surgical cut will be closed and covered with a dressing. You will be taken to the recovery room to wake up from the anesthesia.

Most people can go home the same day, but your doctor may want you to stay overnight in the hospital. You will be taught how to care for your surgical site.

You should avoid heavy lifting, bending, and twisting while you are healing. Light exercise such as walking can be helpful during recovery.

Before the Procedure

Always tell your doctor or nurse what drugs you are taking, even drugs or herbs you bought without a prescription.

During the days before the surgery:

  • Prepare your home for when you come back from the hospital.
  • If you are a smoker, you need to stop smoking. Your recovery will be slower and possibly not as good if you keep smoking. Ask your doctor for help quitting.
  • Two weeks before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and other drugs like these.
  • If you have diabetes, heart disease, or other medical problems, your surgeon will ask you to see your regular doctor.
  • Talk with your doctor if you have been drinking a lot of alcohol.
  • Ask your doctor which drugs you should still take on the day of the surgery.
  • Always let your doctor know about any illnesses you may have.
  • Your doctor or nurse will tell you when to arrive at the hospital.

On the day of the surgery:

  • You will usually be asked not to drink or eat anything for 6 to 12 hours before the procedure.
  • Take the drugs your doctor told you to take with a small sip of water.
  • Bring your cane, walker, or wheelchair if you have one already. Also bring shoes with flat, nonskid soles.

Recovery

Patients who have this procedure may have less back pain and need to take fewer pain medications. However, the treatment does not completely cure back pain or treat the source of the pain.

 

Sacroiliac injection for back (sacroiliac joint) pain

A sacroiliac joint injection is the delivery of powerful anti-inflammatory medicine directly into the sacroiliac joint.

Description

You will be asked to change into a gown, then lie face down on an x-ray table with a pillow under your stomach.

The physician cleans the area of your back where the needle will be inserted, and may use medicine to numb the area. You may be given medicine to help you relax.

Your doctor will use an x-ray machine that produces real-time pictures to help guide the needle to the correct spot in your lower back. The doctor injects a mixture of steroid and numbing medicines into the area. This medicine decreases swelling and pressure in the joint.

You may feel some pressure during the injection, but most of the time the procedure is not painful.

You will be watched for 15 – 20 minutes after the injection before going home.

Why the Procedure is Performed

Your doctor will recommend a SIJ injection if you have symptoms consistent with inflammation in the sacroiliac joint. Such pain is caused by overuse injuries, arthritis and altered mechanics from compensation from other pain.

The injections are rarely used unless your pain has not improved with medicines, physical therapy, or other nonsurgical treatments.

Risks

Sacroiliac injections are generally safe. Possible complications may include:

  • Dizziness, headache, or feeling sick to your stomach. Most of the time they are mild.
  • Nerve root damage with increase pain down your leg
  • Infection
  • Allergic reaction to the medicine used
  • Bleeding

Talk to your doctor about your risk of complications.

Having these injections too often may weaken the bones of your spine or nearby muscles. Receiving higher doses of the steroids in the injections may also cause these problems. As a result, most doctors limit patients to two or three injections per year.

Outlook (Prognosis)

Sacroiliac injections provide short-term pain relief for at least half of the people who receive them. Symptoms may remain better for weeks to months, but rarely up to a year.

The procedure does not cure the cause of your back pain. You will need to continue back exercises and other treatments.

Before the Procedure

Before your procedure, tell your doctor or nurse:

  • If you are pregnant or might be pregnant
  • What medicines you are taking, including herbs, supplements, and other drugs you bought without a prescription

You may be told to stop taking medicines that make it hard for your blood to clot for several days before the test. This may include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), naproxen (Aleve, Naprosyn), and heparin.

Always check with your doctor before stopping any medications.

Recovery

You may feel some discomfort in the area where the needle. This should only last a few hours.

Your doctor may ask you to rest for the remainder of the day.

Your pain may become worse for 2 – 3 days after the injection before it begins to improve. The steroids usually takes 2 – 3 days to work.

If you receive medicines to make you sleepy, you must arrange for someone to drive you home.

 

 

MONTY’S INTERVIEW LINK (bad link on website pdf – please provide correct one)
  1. Nonsteroidal Anti-inflammatory Drugs and Acetaminophen: There are many different types of nonsteroidal anti-inflammatory medications (NSAIDs), some of them (such as ibuprofen) may be obtained over-the-counter. NSAIDs can be very effective for acute muscular and bone pain as well as some types of chronic pain syndromes. When taken for an extended period of time or in large quantities, they may have negative effects on the kidneys, clotting of blood, and gastrointestinal system. Bleeding ulcers is a risk of these medications. Long-term use of cyclooxygenase II (COX II) inhibitors may be associated with an increase in cardiovascular (heart) risks. Acetaminophen is easily obtained over-the-counter, however, care should be taken not to take more than 4000 mg in 24 hours; otherwise, several liver failure may occur. There are some opioid medications that combine acetaminophen within the medication. You should be aware that many over-the-counter
    medications have acetaminophen as one of their ingredients and when taken in combination with prescribed medication, this may result in an overdose of acetaminophen.
  2. Antidepresssants: Some of the older categories of antidepressants may be very helpful in controlling pain; specifically the tricyclic antidepressants. The pain relieving properties of these medications are such that they can relieve pain in doses that are lower than the doses needed to treat depression. These medications are not meant to be taken on an “as needed” basis but must be taken every day whether or not you have pain. Your physician may attempt to lessen some of the side effects, particularly sedation, by having you take these medications at night. There are some other side effects like dry mouth that can be treated with drinking water or fluids. These medications may not be given to patients with certain types of glaucoma. In addition, these medications should never be taken in larger doses than are prescribed.
  3. Anticonvulsants (Anti-seizure) Medications: These medications can be very helpful for some kinds of nerve type pain (such as burning, shooting pain). These medications also are not meant to be taken on an “as needed” basis. They should be taken every day whether or not you feel pain. Some of them may have the side effect of drowsiness which often improves with time. Some have the side effect of weight gain. If you have kidney stones or glaucoma, be sure to tell your doctor as there are some anticonvulsants that are not recommended to be given under those conditions. The newer anticonvulsants do not need liver monitoring but required caution if given to patients with kidney disease.
  4. Muscle Relaxants: These medications are most often used in the acute setting of muscle spasm. The most common side effect seen with these medications is drowsiness.
  5. Opioids: When used appropriately, opioids may be very effective in controlling certain types of chronic pain. They tend to be less effective or require higher doses in nerve type pain. For pain is present all day and night, a long acting opioid is usually recommended. One of the most frequent side effects is constipation, which if mild may be treated by drinking lots of liquids, but may need to be treated with medications. Drowsiness is another side effect which often gets better over time as you get used to the medication. Excessive drowsiness should be discussed with your physician. Nausea is another side effect which may be difficult to treat and may require changing to another opioid.
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