PATIENT EDUCATION

Epidural Steroid Injection

What is an Epidural Steroid Injection?

An Epidural Steroid Injection (ESI) is a simple, safe, and effective non-surgical treatment that involves the injection of a steroid medication similar to cortisone into the Epidural Space of the spine. The epidural space is the portion of the spine where inflamed nerves are located. The intent of this procedure is to reduce inflammation and therefore relieve pain. Performed by an interventional pain management, ESI is a minimally invasive technique used to relieve a variety of painful conditions, including chronic pain anywhere in the spine.

How is this injection done?

Although there are different techniques used for Epidural Steroid Injection, the most common technique employed by interventional pain management specialists now is with X-Ray guidance (fluoroscopy), usually with the patient lying on his or her stomach. Dr. Garg uses fluoroscopy for all of his ESI procedures. The injection is performed under local anesthesia. The procedure usually takes no more than 5-10 minutes, followed by a brief 5-10 minute recovery before discharge home.

What types of conditions will respond to Epidural Steroid Injection?

For over forty years, ESI has been used to effectively treat chronic neck and back pain as well as a variety of other conditions. The most common diagnoses treated with ESI include herniated or bulging discs, spinal stenosis, and recurrent pain following spine surgery. Other conditions that may also respond to ESI include spondylolisthesis (slippage of the vertebral column) and post-herpetic neuralgia (pain after shingles).

Does the injection hurt?

The injection of local anesthetic (numbing medicine) at the beginning of the procedure may sting some, but ESI is an otherwise routine procedure that is extremely well tolerated by patients ranging in age from the mid-teens to well over ninety years old. If you are anxious or concerned about pain during the procedure, please discuss with Dr. Garg the possibility for your receiving intravenous sedation.

What should I do to prepare for my injection?

On the day of your injection, you should not have anything to eat or drink for at least eight (8) hours before your scheduled procedure. If you are scheduled to receive sedation during the procedure, you must have someone available to drive you home. If you usually take medication for high blood pressure or any kind of heart condition, it is very important that you take this medication at the usual time with a sip of water before your procedure.

If you are taking any type of medication that can thin the blood and cause excessive bleeding, you should discuss with your doctors whether to discontinue this medication prior to the procedure. These anticoagulant meds are usually prescribed to protect a patient against stroke, heart attack, or other vascular occlusion event. Therefore the decision to discontinue one of these medications is not made by the pain management physician but rather by the primary care or specialty physician (cardiologist) who prescribes and manages that medication. Examples of medications that could promote surgical bleeding include Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox.

What should I expect after the injection?

You may notice some reduction in your pain for the first 1-2 hours after the injection if local anesthetic is injected with the steroid. When this anesthetic wears off, your pain will return as it was before the procedure. Although pain relief with ESI generally occurs within 3 – 5 days, some patients experience improvement before or after this time period. Diabetic patients should be on the alert for a rise in blood sugar during the first few days after injection and must monitor blood sugar accordingly.

What should I do after my injection?

Following discharge home, you should plan on simple rest and relaxation. If you have pain at the injection site, application of an ice pack to this area should be helpful. If you receive intravenous sedation, you should not drive a car for at least eight hours. Patients are generally advised to go home and not return to work after this type of injection. Most people do return to work the next day.

How many injections will I need during my treatment?

A typical injection series consists of three injection sessions with an interval of two weeks between each session. However, the number of injections that you may require will depend on your response to each individual injection. If you have no pain following one injection, you will probably not need any additional treatment. Alternately, if you have absolutely no pain relief after two injections, Dr. Garg may recommend a different treatment for your pain. Please note that the alternatives to Epidural Steroid Injection may, in some cases, involve vastly different treatments such as Facet Joint Injection, Sacroiliac Joint Injection, Percutaneous Disc Decompression or even surgery. If you are not sure whether you should have your next procedure or if you feel that a different type of injection or treatment should be considered, please contact Dr. Garg’s staff well in advance of your next appointment to discuss your situation.

Could there be side effects or complications?

Minor side effects from the injected medications are not uncommon and can include nausea, itching, rash, facial flushing and sweating among other things. Some patients notice a mild increase or worsening of their pain for the first day or two after injection. Fortunately Epidural Steroid Injection has an extremely good safety profile, and serious complications are quite rare. Just like any other medical procedure, there are potential complications associated with ESI. Dr. Garg will discuss these issues with you, and you will be asked to carefully read and sign a consent form before any procedure is performed.

What are the chances that this treatment will help my pain?

Most studies show that this treatment helps relieve pain for approximately half (50%) of the patients treated. The degree and duration of pain relief are variable and depend on many different factors, including the underlying diagnosis or condition being treated, duration of symptoms before treatment, whether previous back (neck) surgery has been performed and other factors.

Can these injections be repeated if my pain returns?

YES! This ESI can definitely be repeated if it was helpful for your pain in the past. Although there is some flexibility in the timing of repeat injection, Dr. Garg will probably want you to wait for at least four to six months after your last injection. This issue can be discussed during a follow-up office visit.

ESI Patient Information Pre-surgical

Patient Information

Epidural Steroid Injection (ESI) Your referring physician has requested that you have an epidural steroid injection. The following is a description of the procedure and a description of the potential complications, so that you can give informed consent to have the procedure. An epidural steroid injection (or ESI) is an invasive procedure with some uncommon risks, so you will need to give informed consent. Local anesthesia (numbing medicine) will be injected underneath your skin. A needle will be placed with fluoroscopic (x-ray) guidance into the spine along the fibrous fluid-containing sac that contains the lumbar nerve roots. A small of contrast (x-ray dye) will be injected to confirm correct needle placement. Then an injection of steroids will be made into the same location. You will then be monitored for potential complications in the hospital for a short time after the procedure (usually about 30 minutes) until you are discharged. You will be able to eat and drink as well as use the bathroom while in the hospital after the procedure. Most complications of epidural steroid injections are rare and the procedure is very safe. You need to know the potential complications, which include:

BLEEDING

As with all needle procedures, bleeding can occur. As long as you have no bleeding tendency and are not on any blood-thinners such as Coumadin, bleeding complications are extremely rare. However, patients have rarely had to undergo emergency surgery to relieve pressure on the nerve roots and spinal cord because of bleeding after needle procedures like epidural steroid injections.

INFECTION

Any needle passing through the skin can introduce infection, which in an epidural injection would be meningitis. This is an extremely rare complication and sterile technique will be used.

SPINAL HEADACHE

This is a rare complication that may occur if a small hole is made in the fibrous sac and does not close up after the needle puncture. These small holes are only made in less than 1% of epidural injections and usually heal on their own. The spinal fluid inside can leak out, and when severe, the brain loses the cushioning effect of the fluid, which causes a severe headache when you sit or stand. These types of headaches occur typically about 2-3 days after the procedure and are positional – they come on when you sit or stand and go away when you lie down. If you do develop a spinal headache, it is OK to treat yourself. As long as you do not feel ill and have no fever and the headache goes away when you lay down, you may treat yourself with 24 hours of bed rest with bathroom privileges while drinking plenty of fluids. This almost always works. If it does not, contact the radiologist who performed the procedure or your referring physician. A procedure (called an epidural blood patch) can be performed in the hospital that has a very high success rate in treating spinal headaches.

STEROID SIDE EFFECTS

Epidural steroids may rarely produce unwanted side effects. Some of these potential side effects include increased blood sugar or hyperglycemia (especially in diabetic patients), fluid retention, elevated blood pressure, and transient redness or facial flushing. (Side effects from steroids may be common if they are taken daily over a length of time, rather than as an isolated epidural injection.)

ALLERGIC REACTION

The use of any medication, including x-ray contrast, has the possibility of producing an allergic reaction. Please inform your physician of all of your known medical allergies before the procedure. If you have any questions, please feel free to ask the physician performing the procedure prior to signing the consent form.

Diagnostic Nerve Blocks

What is a Nerve Block?

A Nerve Block is a procedure performed by a pain management physician to anesthetize or numb a particular nerve in the body to treat certain forms of chronic pain. A Nerve Block involves the injection of a local anesthetic like Lidocaine or Bupivicaine onto a target nerve or group of nerves. An example of a therapeutic nerve block used to treat chronic pain is the Stellate Ganglion Block, performed in the front of the neck to treat Complex Regional Pain Syndrome (CRPS or RSD). The local anesthetic works by interrupting conduction of electrical impulses along the target nerve for a limited period of time. The duration of the numbing effect varies with the local anesthetic used. Lidocaine usually lasts for one hour, and Bupivicaine lasts for 3-4 hours. When the local anesthetic effect wears off, nerve conduction and function to the numbed area resumes normally.

What is a Diagnostic Nerve Block?

A Diagnostic Nerve Block involves numbing a specific nerve or group of nerves that may be involved in carrying a patient’s pain. The physician performing the nerve block is assumed to be an expert in anatomy so that he/she knows the location of various pain-carrying nerves. A local anesthetic is injected in very small amounts onto target nerves, and the patient is then assessed for any change in pain symptoms. If a particular pain-carrying nerve or group of nerves is/are numbed and a patient notes significant improvement in pain symptoms, the location of the pain generator is likely confirmed. If a patient notes no change or limited change in pain symptoms following a diagnostic nerve block, the treating physician may conclude that a patient’s pain is originating from a different area.

Why is a Diagnostic Nerve Block used in the treatment of chronic pain?

One of the most important aspects to the treatment of chronic pain is the identification of the underlying cause of pain or the PAIN GENERATOR. For many forms of chronic pain, especially neck and back pain, there can be significant overlap or similarity in the pain symptoms produced by multiple pain generators. For example, low back pain can originate from at least six different sources, including the intervertebral disc, facet joint, sacroiliac joint, vertebral body, interspinous ligaments, and the paraspinal muscles. The treatment for each of these problems can be quite different, so it is very important to identify the pain generator. A Diagnostic Nerve Block is used to confirm the location of the pain generator(s) and the nerve(s) carrying pain impulses from these painful structures. Once identified, the pain generator can be treated with a variety of interventional treatments including repeated nerve blocks, Radiofrequency Ablation/Lesioning, or Cryotherapy.

What is the Medial Branch Nerve?

The Medial Branch Nerves are small nerves that supply sensory innervation to the Facet Joint in the spine, from the base of the skull down to the sacrum. If a facet joint in the neck or back becomes painful due to injury, wear and tear, or arthritis then the medial branch nerves will carry that pain information from the pain source to the brain. For patients with chronic neck or back pain who have limited or short term pain relief with  medication and physical therapy or after cortisone injection directly into the facet joints, a diagnostic nerve block to the Medial Branch Nerves in the area of the pain will tell the physician if the patient has painful facet joints and if he/she is a candidate for Medial Branch Neurotomy – a Radiofrequency Ablation/Lesioning procedure that very specifically targets and destroys the sensory nerve supply to painful facet joints. Selective destruction of well selected Medial Branch Nerves can result in pain relief for several months or longer.

How is a Diagnostic Nerve Block performed?

The technique will depend on the target nerve. For superficial nerves that are located outside of the spine, the doctor may simply palpate or feel the area to locate the nerve. For other nerves, including those in or around the spine (eg. Medial Branch Nerve), fluoroscopy or live video X-ray will be employed to locate the target nerve. A patient is generally not sedated for a diagnostic nerve block procedure because he/she must be able to provide reliable information regarding any change in pain symptoms immediately after the procedure. Although a diagnostic nerve block sounds like it might be painful, this technique is very well tolerated by adult patients of all ages.

What should I do to prepare for my procedure?

You should not eat or drink anything at all for at least eight (8) hours before your scheduled procedure. You must have a responsible adult available to drive you home. If possible, you should shower and use an antibacterial soap like Lever 2000 before your procedure. If you usually take medication for high blood pressure or any kind of heart condition, it is very important that you take this medication at the usual time with a small sip of water before your procedure.

If you are taking any type of medication that can thin the blood and cause excessive bleeding, you should inform Dr. Garg and discuss with your other doctors (PCP, Cardiologist) whether to discontinue this medication prior to the procedure. Examples of medications that could promote surgical bleeding include Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox. Anticoagulant meds are usually prescribed to protect a patient against stroke, heart attack, or other vascular occlusion event. Therefore, the decision to discontinue one of these medications is not made by the pain management physician but by the primary care or specialty physician (cardiologist) who prescribes and manages that medication.

Could there be side effects or complications?

Modern medicine has improved safety with every aspect of patient care, but there is no guarantee of a perfect outcome with any test or procedure. Fortunately the side effects and complication profile for a Diagnostic Nerve Block is very low. There may be some temporary discomfort in the area of injection, but this will improve within a few days or sooner. The doctor will discuss this issue with you before the procedure.

What should I do after a Diagnostic Nerve Block procedure?

Immediately after this procedure, the office or recovery room staff will question you to determine if there has been a change in your pain symptoms. You will be asked to stand, walk, bend, twist, and perform other activities that will provoke your typical pain symptoms. You will also be asked to provide a numerical (0 to 10) pain score every few minutes until you are discharged home. The information that you provide regarding the presence or absence of pain as well as its location will be used to formulate a treatment plan. You will also be given a form so that you can continue to record your pain score at home every hour for the next four hours after arrival home. Following discharge home, apply ice to the injection sites for the next few hours. You should be able to return to work or your usual daily routine the next day.

Lumbar & Cervical Radiofrequency Ablation/Lesioning

What is Radiofrequency?

Radiofrequency waves are electromagnetic waves which travel at the speed of light, or 186,000 miles per second (300,000 km/s). Radiofrequency Energy is a type of heat energy that is created by a special generator at very high or super high frequencies. With the use of this specialized generator, heat energy is created and delivered with precision to target nerves that carry pain impulses. The resulting “lesion”involves a spherical area of tissue destruction at the tip of the RF needle that can include pain-carrying nerves.

Why is this procedure done?

Radiofrequency ablation/lesioning is a procedure used to provide longer term pain relief than that provided by simple injections or nerve blocks. Many patients who are being considered for this procedure have already undergone simple injection techniques like Epidural Steroid Injection, Facet Joint Injection, Sympathetic Nerve Blocks, or other nerve blocks with pain relief that is less prolonged than desired. By selectively destroying nerves that carry pain impulses, the painful structure can be effectively denervated and the pain reduced or eliminated for anywhere from a few months to up to 12 months.

How is this procedure done?

Once a structure has been determined to be a pain generator, its nerve supply is targeted for interruption. A small insulated needle or RF cannula is positioned next to these nerves with fluoroscopic guidance (live video X-Ray). Your doctor knows where to place the RF cannula because he is an expert in anatomy. The shaft of this cannula except for the last 5 to 10 mm is covered with a protective insulation so that the electric current only passes into the surrounding tissues from the very tip of the cannula. When the cannula appears to be in good position, the doctor may perform a test and release a small amount of electric current through the needle tip at two different frequencies. This test helps to confirm that the cannula tip is in close proximity to the target nerve and that it is not near any other nerve. After a successful test confirms good cannula tip position, a local anesthetic is injected to numb the area. The RF generator is then used to heat the cannula tip for up to 90 seconds, and thus the target nerve is destroyed.

What types of conditions will respond to Radiofrequency Lesioning?

There are a multitude of chronic pain conditions that respond well to this treatment. Chronic spinal pain, including spinal arthritis (spondylosis), post-traumatic pain (whiplash), pain after spine surgery, and other spinal pain conditions are those most commonly treated with RFL. Other conditions that are known to respond well to RFL include some neuropathic pain conditions like Complex Regional Pain Syndrome (CRPS or RSD), peripheral nerve entrapment syndromes, and other assorted chronic pain conditions. A patient’s candidacy for RFL is usually determined by the performance of a Diagnostic Nerve Block. This procedure will help to confirm whether a patient’s pain improves just for the duration of the local anesthetic (or not). Patients who have little to no pain relief after a diagnostic nerve block are not candidates for a neurodestructive procedure like RF Lesioning.

Does the procedure hurt?

This procedure is no more painful than any other injection procedure that is performed in interventional pain management. Patients are often given mild intravenous sedation during the procedure, but sedation is not absolutely required. Deep sedation is not a safe alternative and is therefore not offered for my RF procedures. It is quite common for neck or back pain to increase for a few days or longer after the RFL procedure before it starts to improve.

What should I do to prepare for my procedure?

On the day of your injection, you should not have anything to eat or drink for at least eight (8) hours before your scheduled procedure. If you are scheduled to receive sedation during the procedure, you must have someone available to drive you home. If you usually take medication for high blood pressure or any kind of heart condition, it is very important that you take this medication at the usual time with a sip of water before your procedure.

If you are taking any type of medication that can thin the blood and cause excessive bleeding, you should discuss with your doctors whether to discontinue this medication prior to the procedure. These anticoagulant meds are usually prescribed to protect a patient against stroke, heart attack, or other vascular occlusion event. Therefore the decision to discontinue one of these medications is not made by the pain management physician but rather by the primary care or specialty physician (cardiologist) who prescribes and manages that medication. Examples of medications that could promote surgical bleeding include Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox.

What should I do after my procedure?

Following discharge home, you should plan on simple rest and relaxation. If you have pain at the needle puncture sites, application of an ice pack to this area should be helpful. If you receive intravenous sedation, you should not drive a car until the next day. Patients are generally advised to go home and not return to work after this type of procedure. Some patients do return to work the next day.

Could there be side effects or complications?

Dr. Garg will discuss these issues with you, and you will be asked to carefully read and sign a consent form before any procedure is performed.

Can this procedure be repeated if my pain returns?

It is possible for the treated nerve(s) to regenerate, which could lead to recurrent pain. However, RF Lesioning is repeatable for nerve regeneration if it worked the first time around.

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