Lumbar epidural steroid injections and facet blocks

syringe with small ampule bottle surrounding it bathed in a purple light

LUMBAR INJECTION THERAPY   

Dr. Osborn makes every effort to treat spinal conditions non-surgically prior to exposing an individual to the risks of an open procedure. Included in his treatment arsenal are modalities such as structured physical therapy, strength training, supplements (high-dose omega-3 fatty acids and curcumin for example) and injection therapies. The latter assume many forms and are geared towards the treatment of different symptomatology. 

In order or invasiveness, they are listed here:

  • Trigger point injections are administered into the soft tissues surrounding the spine.  
  • Facet blocks target the joints that flank the spine (often involved in the degenerative process and a source of low back pain).
  • Epidural injections are performed for radicular pain (sciatica) or neurogenic claudication (pain in the buttocks and legs precipitated by standing/walking). Epidural injections are administered into the spinal canal itself (via two different techniques: interlaminar or transforaminal approach).

PROCEDURE INDICATIONS

  • Trigger point injection: performed for myofascial (musculoligamentous) pain. Ever have a “crick in your neck?” Consider this treatment option.
  • Facet block: utilized to treat low back pain with a facetogenic component. What? Low back pain is multifactorial. The intervertebral disc, the muscular structures and the joints (facets) are all potential pain generators. Facets, or joints that flank the spine, are likened to knee joints. We all know of someone who has had a “cortisone injection in the knee,” right? A facet block is the spine surgeon’s equivalent.

    Facet blocks are performed under x-ray (fluoroscopic) guidance.  This allows for accurate needle trajectory/placement.

  • Epidural injection: This procedure is performed for radicular pain or neurogenic claudication as noted above. Long and short of it?  Pain related to nerve root compression (manifested as pain in a leg or legs) is treated with injections into the spinal canal (where the nerves live are housed). While it seems risky to place a needle into the canal, keep in mind that there is no spinal cord in the lower lumbar region (only nerve roots bathed in spinal fluid). Injury risk therefore is extremely low. The injection bathes the nerves and surrounding structures with steroid (and often times a short-acting anesthetic).

xray of L4 and L5 lumbar

WHAT YOU WANT TO KNOW

“Are you injecting me with the same steroids that bodybuilders use?”

“Steroids” are a group of chemically similar molecules that serve a variety of bodily functions. Testosterone is a steroid hormone yes, with powerful muscle-building (anabolic) properties. That is not what is being administered however. A glucocorticoid (steroid hormone with powerful anti-inflammatory effects) is being administered. Remember, the vast majority of disease processes affecting the spine have inflammatory underpinnings. Glucocorticoids squelch inflammation with a resultant reduction in pain.

“What is the success rate of an injection?”

Good question. The data vary. Having performed over 10,000 injections, I have observed pain reduction (of unpredictable magnitude and for an ill-defined period of time) in approximately 2/3.  The remaining 1/3 do not respond (even to multiple injections). This response rate is in alignment with national figures.

“Will I need more injections? How many can I have without experiencing side effects from the steroids?”

One may require multiple injections, yes. This will be determined by your pain response. Dr. Osborn never commits a patient to a “series of three.”  If a single injection does the trick, one does not undergo additional (and unnecessary) procedures. Steroid side effects are infrequent but may occur with repeat injections. They include weight gain, irritability, increased appetitite, palpitations, blood pressure elevations, insulin resistance, gastrointestinal distress and insomnia, to name a few. To minimize the occurrence of side effects, Dr. Osborn limits the frequency of injections although does not necessarily abide by the often-recommended protocol of “3 injections in a 6-month period.” There is NO data to support such recommendations.  In fact, neurosurgeons routinely utilize much higher dosages (and frequencies) of steroids to treat brain tumor-associated edema (swelling).

“Do I have to be put to sleep for the injections? Do they hurt”

Absolutely not. All injection procedures take less than 15 minutes. The skin is anesthetized with a numbing agent. You will neither be asleep nor sedated for the procedure. This allows for an expeditious discharge from clinic.

Pain? The local anesthesia tends to burn as it is injected. Thereafter, one typically experiences a “pressure” sensation and potentially radiating pain into the leg (in the case of an epidural steroid injection). Both are transient and well-tolerated.

“Someone told me that epidural injections make surgery more difficult in the event that it is required. Is this true?”

It is not.  Epidural injections may leave a residue within the spinal canal. This does not in any way hinder the surgical procedure, NOR DOES IT JUSTIFY DECLINING THE INJECTION.  YOU MAY BE ABLE TO STAVE OFF SURGERY BY VIRTUE OF IT.

REMEMBER, SURGERY IS A LAST RESORT, ALWAYS.

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