Epidural Steroid Injections

Epidurals are done to reduce pain and inflammation. The most common situation is when a nerve is being impinged, which can cause it to become inflamed. This inflammation causes pain in the spine and the nerve distribution in the arm or leg, so the goal of the epidural is to reduce inflammation and thus reduce pain.

Unfortunately, there is no guarantee that pain will be reduced with epidurals. However, about 70% of patients (with acute pinched nerves) receive at least 50% relief from epidurals. 

Generally, a patient may have up to three to four epidurals in a year, no earlier than two weeks apart (but it is advisable to have as few epidurals as possible). Epidurals may be repeated when necessary if pain recurs. Too many epidurals can have significant side effects.

Generally, epidurals are well-tolerated; however, sometimes side effects are experienced, which include but are not limited to insomnia, low-grade fever, steroid flare (increase in pain), facial flushing, mood changes, fluid retention, elevated blood pressure, and elevated blood sugars. These side effects are temporary. Prolonged use of high-dose steroids can cause an increased risk of infection, osteoporosis, and weight gain. People with diabetes should keep a close eye on their blood sugars after epidurals.

Everyone will feel a “pinch and burn” when the local numbing medicine is injected. Beyond that, feeling pressure as the needle travels to the target is normal. As the medicine is injected, it can sometimes increase the pain into the arm or leg when it flows around an inflamed nerve root. This increase in pain is temporary. Usually, patients only feel mild discomfort during these procedures. IV “conscious” sedation with Versed (Midazolam) can be used to help you relax during the procedure. This may or may not help with the pain during the procedure.

Risks include but are not limited to bleeding, infection, nerve damage, paralysis, and reaction to the medications used. Catastrophic outcomes to epidurals are exceptionally rare and have not happened at all in our clinic.

Sometimes, there is both pain and numbness in an arm or leg due to a pinched nerve. The epidural may make the pain better, thereby unmasking the numbness.

Alternatives to epidurals are determined on a case-by-case basis. Sometimes, if a nerve is impinged and epidurals and other conservative treatment options do not relieve the pain, a decompressive surgery (to relieve pressure on a nerve) may be an option.

Epidurals are highly specialized procedures that require an X-ray (fluoroscopy) machine, a physician trained to do these procedures, an X-ray technician, and a nurse. In many cases, they require insurance authorization as well. Before an epidural, you cannot eat anything for six hours or drink anything for two hours. Because of these reasons, epidurals are done on certain days when procedures are scheduled together for optimum efficiency. A clinic visit is generally done prior to this to review imaging, discuss the epidural in-depth, review risks and benefits, and give the patient a chance to ask any questions. This helps the procedure run smoothly.

Because of the position you will be in during the epidural (face down), there is a small risk of aspiration. This occurs when the stomach contents go up the esophagus and back down the windpipe. The risk of this is greater if IV sedation with Versed (Midazolam) is used.

Because an epidural involves using a spinal needle, there is an inherent risk of bleeding. If there is significant bleeding in the epidural space, this can cause paralysis. This risk increases when a patient is on a blood thinner. Therefore, we ask patients to hold their blood thinners for a certain number of days (depending on which blood thinner it is) prior to the epidural. It is the patient’s responsibility to obtain permission from the prescribing doctor (usually a cardiologist) to temporarily stop the blood thinner. We ask that this permission be written and faxed to our office, where it becomes part of your chart.

It can take up to 5-7 days for you to notice pain relief after the epidural is administered; however, many patients report pain relief much sooner.

Unfortunately, this cannot be predicted. Some patients get no relief from epidurals, whereas others get months or even years of relief from epidurals. Factors that influence this include but are not limited to the type and extent of pathology, length of diagnosis, past response to steroids, age, and health status.

Epidurals use lidocaine, which can temporarily cause the leg or arm to feel numb, making it dangerous to drive after the epidural. We recommend asking a friend or family member to drive you and not a taxi or Uber/Lyft, as a driver will not be able to help you get into your home if needed. If you arrive without a driver, you may be asked to reschedule.

You will be in our office for about one to one and a half hours. This includes checking in, reviewing risks, signing a consent form, performing the epidural, and recovering. The actual epidural takes less than 15 minutes in most cases.

If you are still having pain or functional limitation that is significant, an epidural can be repeated and may further reduce inflammation and pain. Remember that epidurals are not done to prevent pain, only to treat it, so you should not do another injection if your pain is resolved.

It is important to take it easy on the day of the epidural. Light activities such as walking, light housework, and even working (if it is not too strenuous) are OK. Also, it is OK to travel the day of the epidural, including plane travel (however, avoid driving for at least two hours after the epidural unless you received IV sedation, in which case avoid driving until the next day). Avoid soaking or submerging the injection area for 48 hours – this includes baths, hot tubs, and pools. Regular showers are OK. The band-aid placed at the injection site may be removed the same day as the epidural.

Call our office immediately if you experience a severe headache, severe pain in the arm or leg, redness or drainage at the injection site, fevers, chills, or weakness that is worse from when you leave the clinic. These symptoms are very rare. If you feel you require immediate medical care, call 911.

The most common reasons for canceling your epidural are if you forgot to stop your blood thinner or if you have an infection (such as a urinary tract infection), regardless of whether or not you are on antibiotics. An epidural can be performed when you have completely recovered from your infection and have had no symptoms (including fever) for 24 hours and your course of antibiotics is finished.

Epidurals involve a thorough check-in procedure, which includes verifying the exact procedure and reviewing the risks and benefits of the injection. Also, if IV sedation is desired (which is optional), the nurse will need to place an IV prior to the procedure. Therefore, to help ensure our procedures run as smoothly as possible, we ask patients to arrive 30 minutes prior to their scheduled epidural. If you arrive late, you may be asked to reschedule. Please let us know at least 24 hours in advance if you need to reschedule or cancel your procedure. A “no-show” may result in a $100 fee.