Dr. W. L. Lippert, M.D.
Pain clinics across the country see patients with a variety of complaints. All have a common element, pain.
Pain has a fundamental constituent that is its primary foundation, its essence; that essence is inflammation. Inflammation (Latin: inflamatio for to set on fire), is a process that initially is a protective mechanism in the body to help repair injured tissues and restore health. If this process is left unchecked, rather than healing we are instead, “set on fire” and tissue destruction occurs. In the spinal canal, this inflammation is directed at the nerves and results in their swelling, increased sensitivity, and often dysfunction. Research tells us that without inflammation there can be no pain and that most, if not all, human medical frailties are linked to this.
Effectively treating pain then, requires effectively treating inflammation. Of the many options available to reduce pain (inflammation), one of the most common is the epidural steroid injection. Epidural steroid injections introduce potent steroids, powerful anti-inflammatory medications, into the epidural space. The steroids, by stopping the inflammatory process, limit possible future damage and reduce pain in the area they are introduced.
Epidural refers to the space inside the spinal canal that surrounds your spinal cord and spinal fluid. Since the nerves from the spinal cord have to reach all areas of the body, they all pass through the epidural space. This makes the epidural space, whether it is in the cervical, thoracic, or lumbar region, invaluable as an access area to the nerves.
With injury or aging, several structures in the spine can deteriorate causing problems for these nerves that pass through it. Discs can deteriorate, usually by herniating (breaking), or bulging. The spinal canal or its openings can narrow (called stenosis) from deterioration of several structures in the spine. This narrowing and disc change can pose two substantial problems: they can mechanically assault the nerves, or disc contents from a herniation can come in contact with the nerves. Either situation can result in an inflammatory change in the nerve environment.
With inflammation, pain will follow. Treatment will initially involve conservative methods such as anti-inflammatory medications, physical therapy/manipulative therapy, and bed rest. If conservative methods fail, and the pathology of the spinal canal too great, more aggressive methods may be required to control inflammation. Often, the method of choice is epidural steroid injection.
Injection of steroids into the epidural space should be performed by a pain specialist who is board certified in Pain Management and preferably devotes full time to the practice of pain medicine to ensure the highest quality care. Injection should be image guided with x-ray and contrast should be used to verify delivery of medication to the desired location.
Complications from epidural injections include those from the injection itself: local soreness, headache, rarely infection or bleeding and an exceedingly rare chance of nerve injury. What are more common are steroid side effects including fluid retention, facial flushing, mood swings and elevated blood sugars.
While permanent pain relief is unusual with epidural steroid injections, long term relief (several months) is common particularly when treatment includes physical therapy. Radicular pain (leg pain/sciatica) is very responsive to injection, axial (midline) pain less so. Injections can be repeated if the patient shows substantially decreased pain, increased function or improved ability to participate in physical therapy. On a chronic basis, steroids can be reinjected several times each year as a palliative treatment. This decision should be based on quality of life and function versus the risk of the injections and possible alternative therapies.
Few pain treatments have afforded more relief to patients with advanced spine disease than epidural steroid injections. Hopefully, the healthcare reform agenda will continue to allow patients access to these treatments.