The spine is generally comprised of 24 bones: 7 in the cervical region, 12 in the thoracic region, and 5 in the lumbar region. These bones are called vertebrae. Soft discs found between these vertebrae cushion them, hold them together, and control motion.
If a disc tears, the nucleus (jelly) inside the disc may leak out. This jelly can put pressure on the nerve roots or the dural sac causing inflammation which results in pain and discomfort.
As we age, due to arthritis, bone spurs called osteophytes can develop and press against the nerve roots, causing pain and discomfort.
In some circumstances, fluid containing cysts or nerve sheath tumors can also press against the nerves causing pain and discomfort.
They are most performed for patients with spine related pain which radiates or travels into either the arms or legs. Injections are performed under x-ray guidance for safety and accuracy.
The three methods of ESI are described below:
Interlaminar ESI: The interlaminar approach can be performed at all levels of the spine from the low back to the neck. This approach may not be possible if you have had spine surgery in the region or have metallic hardware. An advantage of this approach is that medication maybe delivered closer to the area of pain.
Transforaminal ESI: The transforaminal approach involves placement of the needle into the area where your spinal nerve exits the spine. It can be done throughout the spine but is done most frequently in the mid and lower back only due to safety reasons. The approach can be used in areas of prior surgery and may deliver medication directly to the inflamed nerve root.
Caudal ESI: The caudal approach involves an injection at the base of the spine near the tailbone. An advantage of this approach is that it can be performed even if you have had major spine surgery and the pain is usually in lower buttocks and legs only.
Patient is placed prone on a fluoroscopy table. The site of the injection is identified using x ray machine.
The skin and site of injection area are cleaned with antiseptic solution.
A contrast dye is usually injected to ensure correct placement of the needle in the epidural space or around the nerve root. When the needle is confirmed to be in the correct position, the doctor will inject the steroid medication mixture.
The correct positioning on the table, identification of the injection site and skin preparation with antiseptic solution takes 10 minutes or so. The actual injection depending on the anatomy is usually completed in 5 minutes or less.
The injection can take slightly longer if your anatomy is challenging due to age, previous surgery, presence of hardware, or if the physician recommends an approach at two different levels of your spine.
Most insurance companies have their own internal teams that reviews these requests on case-by-case basis.
There is a prerequisite checklist that some insurance companies follow, and these can include but not limited to duration of symptoms, modalities trialed, medications trialed, imaging results (MRIs or X rays). We must document this information in an accurate and thorough manner in your office visit note, hence, the first visit with Dr. Bhatia is a consultation visit to start the insurance authorization and approval process.
Once we obtain insurance authorization, we will schedule you for an injection based on availability. We request most patients to bring an escort to drive them safely. In most cases, patient feel slight discomfort at the injection site which usually resolves with ice and over the counter medications such as acetaminophen or ibuprofen.
The effect from the steroid injection can take 48-96 hours to demonstrate its maximum benefit.
Some patients feel improvement right away.
There are various factors at play which results in variable outcomes. These include but not limited to age, duration of ongoing symptoms, severity of underlying condition, anatomical variations and challenges, previous history of spinal surgery, their physiologic response to steroid based medications.
Most patients require a series of injections few weeks apart based on their response to initial injection to maximize benefit and longevity.
Please do not hesitate to ask any other questions that you may have. We want you to feel comfortable and at ease knowing that you will always get an honest response!