Lumbar Epidural Injections
Epidural injections are the state of the art treatment for pain from disc prolapses. Patients are very commonly referred by orthopedic surgeons with a diagnosis of a disc prolapse to be treated with an epidural injection. Epidural injections can theoretically relieve the oedema around the nerve root, which results from the disc prolapse.
As I have stressed in previous sections, it is extremely important to undergo a very methodical clinical assessment prior to having an epidural injection. There are several other causes of pain radiating down the leg which can be treated with other methods such as prolotherapy, PRP and dry needling, all with negligible complications.
Assuming the clinical assessment does confirm that the pain arises from pressure from a disc on a nerve root, those patients who are expected to respond well to epidurals are younger (less than 50 years of age) and with relatively acute pain lasting less than 3 months.
When pain lingers on for more than this time, the chances of the cause being due to oedema are reduced, and the possibility increasesthat the pain results from more structural changes pressing on the nerve root, such as bony osteophytes, large disc extrusions etc. Having said that, epidural steroids can potentially prevent many unnecessary operations. Although epidurals do carry minimal risks of bleeding, infection and nerve damage, these hardly compare in magnitude to the potential complications of operations, so it is usually preferable to opt for an epidural before considering operative intervention.
If epidurals do not relieve the pain at all, this does not mean that one must undergo operative repair. First reconsider the diagnosis and ask yourself if a very methodical assessment has been done. If the decision to have an operation is not based on a very thorough clinical assessment, one may end up undergoing an unnecessary operation which is unlikely to bring about relief and leading to failed back surgery syndrome. Not infrequently, I encounter patients who suffer from disastrous complications from operations that were not warranted in the first place.
If there is acute loss of continence, surgery is warranted as soon as possible.
Cervical Epidural Injections
Epidural injections in the neck are much more risky than those done on the lumbar spine. The proximity of the epidural space to the spinal cord is very very close, and therefore injections in this region are potentially much more dangerous. Therefore there are relatively few pain centers that perform these procedures. These injections are performed in Hadassah, however it is the policy of the pain unit to wait until absolutely every other treatment alternative has been explored before opting for a cervical epidural injection.
I am developing a technique in which the nerve roots in the neck can be injected under ultrasound. Because there are several feeding arteries in the neck, injection of steroids is extremely dangerous, and injection of local anesthetic can theoretically cause convulsions. With this technique, only sterile water with a very low concentration of dextrose is injected, and patients have found immense relief within minutes and lasting for several months (much more than one gets with epidural steroid injections).