Epidural Steroid Injections

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.

There are three different ways to perform an ESI and your physician will choose the route that offers the best chance of relieving your pain based on several factors. 

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 local anesthetic is used to numb your skin and subcutaneous tissue. The doctor will then insert a thin needle directly into the epidural space. X-ray guidance is used throughout to ensure the safe and proper position of the needle.

 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.

Yes. Every commercial insurance payor and most government advantage programs require preauthorization prior to proceeding with the injection. We try our very best to get the preauthorization approvals in a timely manner but there are factors that are beyond our control. 

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.  

There may be a temporarily sensation of pressure or numbness at the site of the injection. There may also be numbness in your legs from the injection of local anesthetic that usually resolves in few hours. Sometimes we request patients to bring their cane or walker to help them get to their cars safely. 

The effect from the steroid injection can take 48-96 hours to demonstrate its maximum benefit.

 Some patients feel improvement right away.

These are the most difficult questions to answer as outcomes vary from patient to patient. Some patients get excellent relief that can last months to years, and some unfortunately get no relief whatsoever. 

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. 

You will be scheduled for a follow-up visit in 1-2 weeks after your injection. At this visit, you and your doctor will discuss the outcome of your previous injection and plan for the next steps based on response. 

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!