Injections

Frequently asked questions

Lower Back Pain

Lower Back Pain
Over 80% of the population will suffer from lower back pain during their lives. Most cases of lower back pain can be linked to a general cause—such as muscle strain, injury, or overuse—or can be attributed to a specific condition of the spine, most commonly:

• Herniated Disc
• Degenerative Disc Disease
• Spondylolisthesis
• Spinal Stenosis
• Osteoarthritis

Common Sources of Lower Left Back Pain
Lower left back pain is typically caused by either of the following sources:

1. Damage to the soft tissues supporting the spine and/or certain spinal structures, such as muscles, ligaments, and jointsSee Lumbar Spine Anatomy and Pain

2. A problem or disease involving an internal organ in the mid back, abdominal or pelvic region, such as the kidneys, reproductive organs, and intestines

Most cases of lower back pain stem from minor injuries, such as a strained lower back muscle or ligament. While a muscle strain is minor and will heal within a few days or weeks, the pain may be severe and incapacitating.

A Guide to Lower Right Back Pain

1. Injury to the muscles, ligaments, and/or tendons surrounding and supporting the spine (collectively called soft tissues)
2. Problems with the spinal structures, such as the facet joints or intervertebral discs
3. Issues or diseases affecting the internal organs in the mid-back, abdominal, or pelvic regions

Seeing a doctor is recommended if lower right back pain continues or worsens after a few days, or if there is sudden onset of severe pain, or if it occurs with other concerning symptoms.

See When Back Pain May Be a Medical Emergency

Most cases of low back pain stem from minor injuries to the muscles and/or ligaments in the lower back, and the body is usually well-equipped to heal itself after these types of injuries. While the initial pain of a muscle strain may be significant, the pain tends to subside on its own over a few days or weeks.

Abdominal Aortic Aneurysm

The aorta is the body’s main artery that stretches from the heart and down through the abdomen. When it weakens or balloons in size, the condition is known as an aortic aneurysm. This condition can cause significant abdominal pain and back pain and may lead to the artery’s leak or rupture, at which point it becomes a life-

An aortic enlargement occurs when the arterial walls are weakened, and is considered an aneurysm when the artery grows to at least 1 or 1.5 times its original size, or 3 cm in diameter for the abdominal aorta.

In the elderly population, abdominal aortic aneurysms are not uncommon and are rarely symptomatic. Abdominal aneurysms are most common after age 65, and are more prevalent among men and those who smoke cigarettes.

Function of the Abdominal Aorta

The aorta is the main artery that transports blood away from the heart to deliver it throughout the body, moving blood directly down through the chest and abdomen. All along the aorta are smaller arteries branching off to the various organs and systems of the body.

The abdominal aorta is the portion of the artery that sits deep in the abdomen below the kidneys and near the front of the spine. Because the aorta is near the lower spine, sudden intense pain that is felt in the lower back is a common symptom.

Aortic aneurysms are most common in the abdominal aorta, with some estimates suggesting as many as 80% of aortic aneurysms occur in the abdomen.

Rupture of an Abdominal Aortic Aneurysm

The weakened aorta may develop a leak, called a rupture, or blood may pool up between layers in the arterial walls and quickly lead to rupture, called a dissection. Internal bleeding caused by a ruptured aorta is the primary complication from an abdominal aortic aneurysm.

The loss of blood from aortic rupture is considered a catastrophic and potentially fatal medical emergency; the mortality rate for this condition increases significantly when the artery leaks. There are few ways of forecasting when an abdominal aortic aneurysm will rupture, making the condition important to detect, monitor, and manage when possible.

An aneurysm’s risk for rupture is typically dependent on the following factors:

• Size of aneurysm. Abdominal aortic aneurysms that are smaller than 5 cm in diameter tend to be considered a low risk for rupture, while aneurysms larger than 5 cm in diameter are typically considered a high risk. An aneurysm’s size tends to be the best predictor for its chance of rupturing.
• Rate of growth. Aneurysms that expand by more than half a centimeter over 6 months of regular monitoring are considered fast-growing and high risk. 1Aneurysm growth tends to be faster in people who smoke or have high blood pressure.

Abdominal aortic aneurysms generally do not produce severe abdominal and/or lower back pain or other symptoms until the artery has ruptured. In some cases, if an abdominal aortic aneurysm has significantly expanded it may cause symptoms similar to a rupture.

Abdominal Aortic Aneurysm Causes
Health conditions associated with a heightened risk for abdominal aortic aneurysm include the following:

• Atherosclerosis. This condition occurs when plaque buildup in the bloodstream causes the body’s blood vessels to harden and narrow. Atherosclerosis may develop during young adulthood, but only becomes problematic later in life.
• High cholesterol. Cholesterol may build up in the blood vessels, which can narrow the bloodstream and harden the arterial walls.
• High blood pressure. A sustained increased force of blood moving through the aorta can weaken the artery walls. High blood pressure is a common condition that is most prevalent in those who smoke cigarettes, people who are overweight, and older adults. An estimated 65% of people over age 60 have high blood pressure.
• Inflamed arteries. Inflammation can constrict blood flow and cause the arterial walls to weaken, increasing the risk for aneurysm. Arteries may become inflamed by trauma to the abdomen, disease (such as vasculitis), genetic predisposition, and conditions such as atherosclerosis and high cholesterol.
• Connective tissue disorders. Hereditary conditions that weaken the body’s connective tissues can lead to degeneration of the aortic walls and raise a person’s risk for aneurysm. Two of the most common connective tissue disorders are Ehlers-Danlos syndrome, a group of conditions that affect collagen production, and Marfan Syndrome, which increases production of the protein fibrillin.

Other health and lifestyle factors put additional strain on the cardiovascular system and increase the risk of weakened or damaged blood vessels, raising the chance an abdominal aortic aneurysm will develop. Such risk factors include:

• Smoking and tobacco oral use is one of the biggest contributors to diminished cardiovascular health. People with a history of smoking are 3 to 5 times more likely to develop an abdominal aortic aneurysm. 2
• Advanced age. Aneurysm is most common in older adults who are more predisposed to cardiovascular problems and are more likely to have higher levels of plaque buildup in the arteries.See Low Back Pain in Older Adults
• Genetics and family history. Between 12% and 19% of immediate relatives of a patient with an abdominal aortic aneurysm will also develop the condition.
• Physical activity level. Not receiving adequate exercise puts a person at a higher risk for heart and cardiovascular disease. Regular aerobic exercise increases the heart rate and blood flow through the body, keeping tissues and blood vessels strong.
• Gender. Two-thirds of those affected by abdominal aortic aneurysms are men, and men are more likely to experience heart and cardiovascular problems in general.

While the above factors contribute to an increased likelihood of developing an abdominal aortic aneurysm, people who have not known risk factors may also develop the condition.

Treatment strategies for abdominal aortic aneurysm are not dependent on the cause of aneurysm, but rather on its size and risk for complications. Treatments may range from regular monitoring and lifestyle changes to urgent or emergency surgery.

Answers to Common Spondylosis Questions

In order to better focus the best type of treatment, patients who have been told they have spondylosis should ask their treating physician several questions for clarification about which part of the spine is degenerating. For example:

• If it is degeneration in the facet joints, then it is likely to be osteoarthritis.
• If it is degeneration of the spinal discs, it is likely to be degenerative disc disease.

Patients should also ask whether or not any related conditions, such as spinal stenosis, require attention. If a person can get these questions answered, he or she is likely to have a better idea of what is causing the pain and thus is more likely to find effective treatments.

Finally, patients who have evidence of spondylosis on an MRI or a CT scan should not assume that their pain is being caused by the degeneration. Spinal degeneration is a natural part of aging, and the patient’s pain may or may not be caused by it.

Axial Back Pain: Most Common Low Back Pain
Axial low back pain can vary widely. It can be a sharp or dull pain, it can be felt constantly or intermittently, and the pain can range from mild to severe.

The most common type of axial back pain is “mechanical” and is characterized as:

• Low back pain that gets worse with certain activities (e.g. certain sports)
• Low back pain that gets worse with certain positions (e.g. sitting for long periods)
• Low back pain that is relieved by rest

Axial pain represents the most common type of low back pain, and it is usually non-specific – meaning that the anatomical structure responsible for the pain need not be identified because symptoms are usually self-limited and resolve with time.

Area of Pain Distribution

Axial pain is confined to the low back area. Unlike other low back problems, this type of pain does not travel into the buttock, legs and feet, or other areas of the body.

Diagnosis of Axial Back Pain

The exact diagnosis as to which structure is causing the low back pain rarely has significance to treatment. Only in chronic and severe cases is further evaluation and diagnosis helpful.

With axial pain, the presence of an anatomical lesion that can be seen on an MRI scan, such as a herniated disc, may have nothing to do with the low back pain episode. This common finding is part of what makes diagnosis difficult. A variety of structures in the low back can cause axial or mechanical lower back pain, such as a degenerated disc, facet joint problems, and damage to soft tissues – muscles, ligaments, and tendons – and it is often difficult to identify which anatomical structure(s) is the underlying cause of the patient’s pain.

Back Care for Lower Back Pain
For everyday causes of lower back pain, standard at-home pain management is a reasonable approach. In fact, most cases of lower back pain are caused by a muscle strain and will get better relatively quickly and do not require treatment from a medical professional.

If pain has lasted longer than one to two weeks, or begins to interfere with one’s mobility and daily activities, or if there are troubling symptoms, seeking care from a medical professional is recommended.

Back Care: First Line Treatments

In most cases, back pain is caused by a simple muscle strain and can be managed by the individual through common self-care practices.

• A short period of rest, limited to one or two days, in which strenuous activity is minimized and excess pressure is kept off the spine. Sitting in a reclined position, with the legs supported and elevated (such as in recliner, or in bed supported by cushions) is typically a comfortable position that minimizes stress on the lower back.
• Over-the-counter pain medication, including NSAIDs(such as ibuprofen, naproxen, or aspirin) or acetaminophen. Popular brand names include Tylenol, Advil, and Aleve.
• Application of ice or a cold pack to the lower back to decrease local inflammation, which often accompanies back pain as a response to injury. Ice is typically recommended within the first 48 hours of the onset of pain. It is important to avoid direct application of ice to the skin (to avoid ice burn).
• Application of heat to ease muscle tension, relieve muscle spasms, and increase oxygenated blood flow to the area to facilitate healing. Most of the time, heatworks best when used after the first 48 hours of back pain.
• Small adjustments to posture or daily activities that take pressure off the spine. For example, move carefully and/or with assistance from a sitting to a standing position, and take frequent short walks, as tolerated, to maintain a healthy blood flow and reduce stiffness.

After a short rest period, it is recommended that patients stay active, as too much rest can add to stiffness and discomfort.

Stretches that mobilize the spine’s joints and gently stretch back muscles can help the patient return to normal daily function. The sooner a patient can return to everyday activity, the sooner low back pain is likely to alleviate.

Physical Activity and Low Back Care

Regular physical activity is necessary even during an episode of back pain, as exercise helps maintain muscle strength and joint function. Regular exercise also encourages the healing process by increasing oxygen and nutrient rich blood flow to the spine.

People with back pain may find that low-impact aerobic exercise, which raises the heart rate without jolting the spine, allows for adequate exercise despite pain. Examples of simple, low-impact aerobic exercises include:

• Exercise walking or walking briskly enough to elevate the heart rate for between 30 and 40 minutes. Walking can serve as a good starting point for someone looking to improve their physical health, and it is versatile enough to be done anywhere the patient is comfortable—on the track or treadmill at a local gym, around the neighborhood, or at a shopping mall. For many with lower back pain, it is a good idea to start with shorter walks and gradually, over a period of weeks, build up to walking for 30 minutes or more at a time.
• If walking is too painful or makes pain worse, water therapy may be a good alternative. The buoyancy of the water helps to support the patient’s weight in a more controlled manner, allowing for adequate exercise without putting as much pressure on the spine.

Other low-impact aerobics include the use of stationary bicycles or elliptical machines.

Finding effective exercise that does not exacerbate pain may be a process of trial and error, and is typically up to the preference of the patient.

Injections

Cervical, Thoracic and Lumbar Facet Joint Injections

Facet joints are small joints at each segment of the spine that provide stability and help guide motion. The facet joints can become painful due to arthritis of the spine, a back injury, or mechanical stress to the back.

A cervical, thoracic or lumbar facet joint injection involves injecting a small amount of local anesthetic (numbing agent) and/or steroid medication, which can anesthetize the facet joints and block the pain. The pain relief from a facet joint injection is intended to help a patient better tolerate a physical therapy routine to rehabilitate his or her injury or back condition.

See Facet Joint Injections and Medial Branch Blocks

Facet joint injections usually have two goals: to help diagnose the cause and location of pain and also to provide pain relief:

• Diagnostic goals: By placing numbing medicine into the facet joint, the amount of immediate pain relief experienced by the patient will help determine if the facet joint is a source of pain. If complete pain relief is achieved while the facet joint is numb, it means that joint is likely a source of pain.
• Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release steroid (cortisone) into the facet joint to reduce inflammation, which can sometimes provide longer-term pain relief.

The injection procedure may also be called a facet block, as its purpose is to block the pain.

Facet Joint Anatomy

The facet joints are paired joints in the back and neck, one pair at each vertebral level (one joint on each side of the vertebrae). These joints have opposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule that is filled with synovial fluid, which reduces the friction between bones that rub together.

Costotransverse and Costovertebral Joint Injections
Rib dysfunction syndromes may cause one or a combination of the following symptoms: upper back pain, arm pain, pain between the ribs, and/or generalized upper back area discomfort. Patients with upper back pain and the above symptoms may be candidates for a costotransverse or costovertebral joint injection to both help diagnose the condition and provide pain relief. It is important to note that these injections should not be considered a cure for upper back pain: rather, the goal is to help patients get enough pain relief in order to be able to progress with their rehabilitation program.

Costotransverse and costovertebral joint injections both involve carefully injecting medication into the small joints where the ribs join with the spine in the upper back. These injections are types of pain blocks and may also be referred to as a costovertebral block or a costotransverse block.
Costotransverse and costovertebral joint injections are used to both confirm a diagnosis that these joints are the source of the patient’s upper back pain as well as to provide pain relief.

• Diagnostic goals: by placing numbing medicine into the joint, the amount of immediate pain relief that the patient experiences will help confirm or deny the joint as a source of the upper back pain. If complete pain relief is achieved while the joints are numb it means that these joints are likely the source of patient’s upper back pain and other symptoms, and if not, then there is likely another pain generator. If partial pain relief is obtained, then the joints may be part of the problem.
• Pain relief function: along with the numbing medication, time release cortisone is also injected into these joints. The cortisone helps reduce any inflammation, which usually surrounds the painful joints in the upper back. Reducing inflammation in the upper back area can often provide long term pain relief.

These injections are typically done by a pain management specialist, such as an anesthesiologist, physiatrist, radiologist, or other medical specialist with advanced training (which may include board certification in pain medicine and pain management).

Anatomy of the Upper Back and Costovertebral and Costotransverse Joints

At each level of the thoracic spine (the upper back), the ribs are attached to the corresponding vertebrae (the bony building blocks of the spine) on the right side and left side with small joints. The rib joints from the second to the tenth vertebrae in the upper back comprise costotransverse and costovertebral joints that are located in the back of the vertebrae. These joints provide stability to the upper back and chest wall. The joints are supported by ligaments, which add strength to the junction of bones and limit the motion of the joints in the upper back.

Costotransverse and Costovertebral Injection Procedure

Costovertebral and costotransverse joint injections, as with many spinal injections, should only be performed using fluoroscopy (live X-ray). Fluoroscopy allows for guidance in properly placing the needle into the target, and helps avoid injury to adjacent structures.

The injection procedure includes the following steps:

• An IV line may be placed so that relaxation medicine can be given, as needed.
• The patient lies on an X-ray table and the skin over the mid-back is well cleaned with an antiseptic solution.
• The physician numbs a small area of skin with local anesthetic, which may sting for a few seconds.
• The physician uses X-ray guidance (fluoroscopy) to direct a very small needle into the joint. Several drops of contrast dye are then injected to confirm that the medicine only goes into the joint.
• Following this confirmation, a mixture of small amount of numbing medicine (anesthetic) and anti-inflammatory (steroid) will then be slowly injected into the joint in the upper back.

The procedure usually takes approximately 15-30 minutes, followed by about 30-45 minutes of recovery time at the clinic.

Costovertebral and Costotransverse Joint Injection Results and Follow-Up

Twenty to thirty minutes after the procedure, the patient will be asked to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the area injected is the main source of the patient’s upper back pain. On occasion, patients may feel numb or a slightly weak/odd feeling for a few hours after the injection. This may last several hours, but the patient should be able to function safely, if proper precautions are taken.

On the day of the injection, patients are advised to avoid doing any strenuous activities, unless instructed by their physician. The patient should not drive the day of the injection unless approved by the treating physician. If sedation was used, the patient should not drive for 24 hours after the procedure. Patients may notice a slight increase in pain lasting for several days as the numbing medicine wears off and before the cortisone starts to take effect. If the area is uncomfortable in the first two to three days after the injection, applying ice or a cold pack to the general area of the injection site will typically provide pain relief.

On the day after the procedure, patients may return to their regular pre-injection level of activity. When the pain is improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to gradually increase activities over one to two weeks to avoid recurrence of pain.

Patients may continue to take their regular pain medicine after the procedure, with the exception of limiting pain medicine within the first four to six hours after the injection so that the diagnostic information obtained is accurate. Patients may also be referred for physical therapy or manual therapy, and this may be an appropriate time for the patient to have manipulation, while the numbing medicine from the injection is effective and/or over the next several weeks while the cortisone is working.

The patient may begin to notice longer lasting pain relief starting two to five days after the injection. If no improvement occurs within ten days after the injection, then the patient is unlikely to gain any pain relief from the injection and further diagnostic tests may be needed to accurately diagnose the patient’s upper back pain and other symptoms.

Ideally, patients will record the levels of pain relief in a ‘pain diary’ for the week following the injection. A pain diary is helpful to clearly inform the treating physician of the injection results and in planning future tests and/or treatment, as needed.

Potential Risks and Complications

As with all invasive medical procedures, there are potential risks associated with costovertebral and costotransverse joint injections. However, in general the risk is low, and complications are rare. Potential risks include:

• Allergic reaction. Usually an allergy to X-ray contrast or steroid; rarely to local anesthetic.
• Infection. Minor infections occur in less than 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
• Bleeding. A rare complication, bleeding is more common for patients with underlying bleeding disorders.
• Nerve or spinal cord damage or paralysis. While very rare, damage can occur from direct trauma from the needle, or secondarily from infection, bleeding resulting in compression, or injection into an artery causing blockage.
• Punctured lung (pneumothorax). This complication is uncommon, but at times requires that a small catheter be placed in the chest wall to re-inflate the lung.

In addition to risks from the injection, some patients will experience side effects from the steroid medication, such as:

• Transient flushing with a feeling of warmth (‘hot flashes’) for several days
• Fluid retention, weight gain, or increased appetite
• Elevated blood pressure
• Mood swings, irritability, anxiety, insomnia
• High blood sugar – diabetic patients should inform their primary care physicians about the injection prior to their appointment
• Transient decrease in immunity
• Cataracts – a rare result of excessive and/or prolonged steroid usage
• Severe arthritis of the hips or shoulders (avascular necrosis) – a rare result of excessive and/or prolonged steroid usage

Costovertebral and costotransverse joint injections should not be performed on patients who are taking blood thinners (Coumadin), aspirin or other antiplatelet drugs (e.g. Ticlid, Plavix). Baby aspirin (81mg) may be an exception, depending upon the specific injection and the physician’s discretion. Costovertebral and costotransverse joint injections should not be performed on patients who have a local or systemic bacterial infection, are pregnant (if fluoroscopy is used), or have bleeding problems. Patients should also let their doctor know of any allergies they have to medications that may be used for the procedure.

Epidural Injection Procedure
An epidural steroid injection is a minimally invasive procedure that is performed at a doctor’s office, surgical center, or hospital. Patients usually return home the same day. The injection may be administered by spine and pain management specialists, such as physiatrists, anesthesiologists, radiologists, neurologists, and spine surgeons.

A complete list of current medications and medications taken in the recent past, such as blood thinners and antibiotics, must be discussed with the doctor. Some of these medications may need to be stopped a few days before the injection procedure to avoid complications. It will also be necessary to sign a consent form before the procedure after the possible benefits and risks have been discussed with the doctor.

Preparing to Receive an Epidural Steroid Injection

The injection procedure is usually scheduled for the morning. Instructions typically include no eating and drinking for about 6 hours before the procedure. A hospital gown is worn to allow better access to the injection site. Conscious sedation using relaxation medication may be given to ease the patient’s anxiety.

Procedure for Lumbar Epidural Steroid Injection: Steps and Precautions

The injection is usually given while the patient lies on their stomach (prone position) on a fluoroscopy (live x-ray) table. The procedure may take up to 30 minutes. The doctor may decide to use a transforaminal, interlaminar, or caudal route to administer the injection. An intravenous (IV) line is started if relaxation medicine is needed.

The common steps involved in the injection procedure are as follows 1 :

• The skin over the injection site is marked and cleaned with betadine.
• A fluoroscopic x-ray is used to locate the correct vertebral level for needle guidance; the live images can be seen on a computer screen.
• A local anesthetic is injected into the skin and underlying tissues to numb the area.
• An epidural spinal needle is inserted into the intended injection site and guided using fluoroscopy.
• A contrast dye is injected into the epidural space to check the spread of the injected contents.
• Once the spread is confirmed, the steroid medication is injected into the epidural space.

A tingling or mild burning sensation or the feeling of pressure may be experienced as the medication enters the epidural space. When the injection is completed, the irritation and discomfort usually disappear within a few minutes. The patient is usually monitored in a recovery room for 30 minutes to an hour where vital signs are continuously monitored.

Driving and strenuous physical activities and flying in an airplane are not recommended on the same day after the procedure.

Recovery and Post-Injection Care Following Epidural Injection

While the local anesthetic in an epidural steroid injection usually provides immediate pain relief, it may take up to 2 weeks for the steroids to take effect.

Regular activities may be resumed slowly on the day after the injection. Ice packs may be used at home if pain occurs at the injection site. Ice packs are usually used for 15 to 20 minutes at a time with a break of at least two hours in between to avoid skin injury. Hot baths, sauna, and swimming are usually not recommended for 2 to 3 days after the injection to avoid the risk of infection.

The epidural injection procedure is usually painless, but light soreness or discomfort may occur in some patients over the next day or two. With adequate precautionary measures and post-injection care of the treatment site, patients can typically resume all their daily activities within a week of the injection.

Epidural Steroid Injection Pain Relief Success Rates
The success rates of epidural steroid injections can vary depending on several factors. While some patients experience significant pain relief, others may not experience any pain relief from this procedure. The effects of the injection may be short-term, such as a week, or may continue for a year.

Factors that Contribute to a Successful Epidural Steroid Injection: All You Need to Know

The efficacy of an epidural depends on many factors, including but not limited to:

• Underlying condition. This injection treatment is usually more effective in managing lower back pain with radiating leg pain or sciatica versus lower back pain alone. While the injection may also be used to treat non-radicular, localized back pain, the efficacy may be low.
• Route of administration. Research indicates that the transforaminal and interlaminar routes may obtain more effective results compared to the caudal route.
• Type of steroid. Poorly soluble or particulate steroids, such as methylprednisolone or triamcinolone, have a long duration of action. Water-soluble or non-particulate steroids, such as dexamethasone, are considered safer than particulate steroids but tend to have a short-term effect.

The injection may sometimes be used in combination with a comprehensive rehabilitation program to increase the likelihood of longer-term pain relief and return to everyday activities.

Other factors that may affect the outcome of this treatment include the physician’s skill and experience in administering the injection, the use of guided fluoroscopy, and the patient’s general health. The treatment may also be more effective in treating acute pain (versus chronic symptoms).

The success rates of epidural steroid injections for the treatment of a few common conditions are discussed below.

Epidural Steroid Injections: Success Rates for Treating Sciatica from Different Conditions

Sciatica, which is medically known as lumbar radiculopathy, is nerve pain that originates deep in the buttock and travels down to the thigh and/or leg. Sciatica is commonly caused when a herniated disc or narrowing of the bony opening for spinal nerves (foraminal spinal stenosis) compresses a nerve root in the lumbar spine. 1

Clinical trial results in the treatment of sciatica pain with epidural steroid injections have the following success rates:

• Lumbar herniated disc. An analysis of several large clinical trials indicated that 40% to 80% of patients experienced over 50% improvement in sciatica pain and functional outcome from 3 months up to 1 year when 1 to 4 injections were given in that year. Typically, a better outcome is seen in acute sciatica pain of recent onset with a lesser degree of spinal nerve compression.
• Foraminal spinal stenosis. In a study group of 60 participants, sciatica pain was relieved in 87% of patients with mild to moderate stenosis and 42% of patients with severe stenosis. The treatment included 1 injection and the effects lasted up to 3 months.

Other conditions such as spinal cysts or ligament thickening that cause spinal nerve compression and radicular nerve pain in the legs may also yield similar results when treated with these injections.

Effectiveness of Epidural Injections for Axial Back Pain

Localized lower back pain is typically caused due to inflammatory changes within the spinal soft tissues or lumbar discs.

In a study involving 120 participants with axial low back pain, treatment with 4 injections given over a span of 1 year showed more than 50% improvement in pain and functional outcome in 68% of patients. Other studies have reported pain relief for 2 years when 6 injections were spaced out and given during this period.

Analyzing Success Rates for Neurogenic Claudication

Neurogenic claudication, characterized by pain felt in both legs while walking variable distances, is usually treated with bilateral transforaminal epidural steroid injections (given on both sides of the spine).

A study involving 22 participants showed 30% of patients experiencing pain relief at 1 month, 53% at 3 months, and 44% at 6 months after receiving bilateral injections. Other studies have reported pain relief for 2 years when 6 injections were spaced out and given during this period.

Number of Epidural Steroid Injections Needed for Pain Relief

Research indicates that an additional injection may be given if the following criteria are met:

• More than 50% of pain reduction was experienced after the first injection
• The effect of the first injection decreased after a considerable relief period, for example, over 1 month

Common guidelines recommend that if more than 4 epidural steroid injections are needed in 1 year, the underlying condition must be managed by other treatment methods.

To improve the overall outcome of the procedure and reduce the risk of side effects, using a blunt needle, live fluoroscopy, and administering a small test dose initially may be helpful.

Benefits of Combining Physical Therapy with Epidural Steroid Injection

A guided physical therapy program may be combined with the epidural steroid injection treatment for an added benefit. Studies suggest that combining physical therapy with the injection treatment of herniated discs may improve the quality of pain relief and overall satisfaction in the patient. 16Injection treatment of lower back conditions such as spinal stenosis may benefit from improved quality of life and overall health when combined with physical therapy; with no direct effect on pain-relief values
request an appointment