Skip to main content

Epidural Injections for the Treatment of Spine-Related Pain Syndromes

  • Chapter
  • First Online:
Image-Guided Spine Interventions

Abstract

The use of epidural injections has become a common procedure for the treatment of spinal diseases causing pain. In some settings, such as that of acute lumbar radiculitis, the uses of these techniques have substantial benefits. In other clinical scenarios, such as chronic axial spinal pain, the utility of these procedures is debatable. Epidural steroids are an option in the broad algorithm of pain treatment, but they are a more conservative option than many more permanent techniques.13 This chapter will review the proper use of epidural injections with a focus on patient selection, technical aspects of the procedure, risk and complication management, and outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 139.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 179.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Deer TR, Raso LJ. Spinal cord stimulation for refractory angina pectoris and peripheral vascular disease. Pain Physician 2006;9:347-352.

    PubMed  Google Scholar 

  2. Deer TR, Caraway DL, Kim CK, Dempsey CD, Stewart CD, McNeil KF. Clinical experience with intrathecal bupivacaine in combination with opioid for the treatment of chronic pain related to failed back surgery syndrome and metastatic cancer pain of the spine. Spine J 2002;2:274-278.

    Article  PubMed  Google Scholar 

  3. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L, American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007;10:107-111.

    Google Scholar 

  4. Sicard MA. Les injections médicamenteuses extradurales par voie sacro-coccygienne. C R Soc Dev Biol 1901;53:396-398.

    Google Scholar 

  5. Cathelin F. Une nouvelle voie d'injection rachidienne. Methodes des injections epidurales par Ie precede du canal sacre. Applications a l'homme. C R Soc Dev Biol 1901;53:452-453.

    Google Scholar 

  6. Robecchi A, Capra R. Hydrocortisone (compound F); first clinical experiments in the field of rheumatology. Minerva Med 1952;43:1259-1263.

    CAS  PubMed  Google Scholar 

  7. Landau WM, Nelson DA, Armon C, Argoff CE, Samuels J, Backonja MM. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007;69:614, author reply 614-615.

    Article  PubMed  Google Scholar 

  8. Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine 1991;16:572-575.

    Article  CAS  PubMed  Google Scholar 

  9. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R, Parent F, Lévesque J, Bergeron V, Montminy P, Blanchette C. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997;336:1634-1640.

    Article  CAS  PubMed  Google Scholar 

  10. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291-300.

    Article  CAS  PubMed  Google Scholar 

  11. Andersson GB. Epidemiology of low back pain. Acta Orthop Scand Suppl 1998;281:28-31.

    CAS  PubMed  Google Scholar 

  12. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin 2007;25:353-371.

    Article  PubMed  Google Scholar 

  13. Croft PR, Lewis M, Papageorgiou AC, Thomas E, Jayson MI, Macfarlane GJ, Silman AJ. Risk factors for neck pain: a longitudinal study in the general population. Pain 2001;93:317-325.

    Article  CAS  PubMed  Google Scholar 

  14. Cote P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998;23:1689-1698.

    Article  CAS  PubMed  Google Scholar 

  15. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006;88(Suppl. 2):21-24.

    Article  PubMed  Google Scholar 

  16. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006;296:2441-2450.

    Article  CAS  PubMed  Google Scholar 

  17. Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. Am J Neuroradiol 1991;12:1003-1007.

    CAS  PubMed  Google Scholar 

  18. Tryba M. Epidural regional anesthesia and low molecular heparin. Pro Anasthesiol Intensivmed Notfallmed Schmerzther 1993;28:179-181.

    Article  CAS  Google Scholar 

  19. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28:172-197.

    PubMed  Google Scholar 

  20. Cronberg S, Wallmark E, Soderberg I. Effect on platelet aggregation of oral administration of 10 non-steroidal analgesics to humans. Scand J Haematol 1984;33:155-159.

    Article  CAS  PubMed  Google Scholar 

  21. Rodgers RP, Levin J. A critical reappraisal of the bleeding time. Semin Thromb Hemost 1990;16:1-20.

    Article  CAS  PubMed  Google Scholar 

  22. Benzon HT, Wong HY, Siddiqui T, Ondra S. Caution in performing epidural injections in patients on several antiplatelet drugs. Anesthesiology 1999;91:1558-1559.

    Article  CAS  PubMed  Google Scholar 

  23. White AH. Injection techniques for the diagnosis and treatment of low back pain. Orthop Clin North Am 1983;14:553-567.

    CAS  PubMed  Google Scholar 

  24. White AH, Derby R, Wynne G. Epidural injections for the diagnosis and treatment of low-back pain. Spine 1980;5:78-86.

    Article  CAS  PubMed  Google Scholar 

  25. Abram SE. Intrathecal steroid injection for posttherapeutic neuralgia: what are the risks? Reg Anesth Pain Med 1999;24:283-285.

    Article  CAS  PubMed  Google Scholar 

  26. Mateo E, Lopez-Alarcon MD, Moliner S, Calabuig E, Vivo M, De Andres J, Grau F. Epidural and subarachnoidal pneumocephalus after epidural technique. Eur J Anaesthesiol 1999;16:413-417.

    CAS  PubMed  Google Scholar 

  27. Hodge J. Facet, nerve root, and epidural block. Semin Ultrasound CT MR 2005;26:98-102.

    Article  PubMed  Google Scholar 

  28. Johnson BA, Schellhas KP, Pollei SR. Epidurography and therapeutic epidural injections: technical considerations and experience with 5334 cases. Am J Neuroradiol 1999;20:697-705.

    CAS  PubMed  Google Scholar 

  29. Safriel Y, Ali M, Hayt M, Ang R. Gadolinium use in spine procedures for patients with allergy to iodinated contrast - experience of 127 procedures. Am J Neuroradiol 2006;27:1194-1197.

    CAS  PubMed  Google Scholar 

  30. FDA: Public Health Advisory - Gadolinium-containing Contrast Agents for Magnetic Resonance Imaging (MRI): Omniscan, OptiMARK, Magnevist, ProHance, and MultiHance, 2007.

    Google Scholar 

  31. Leeda M, Stienstra R, Arbous MS, Dahan A, Th Veering B, Burm AG, Van Kleef JW. Lumbar epidural catheter insertion: the midline vs. the paramedian approach. Eur J Anaesthesiol 2005;22:839-842.

    Article  CAS  PubMed  Google Scholar 

  32. Botwin K, Brown LA, Fishman M, Rao S. Fluoroscopically guided caudal epidural steroid injections in degenerative lumbar spine stenosis. Pain Physician 2007;10:547-558.

    PubMed  Google Scholar 

  33. Ergin A, Yanarates O, Sizlan A, Orhan ME, Kurt E, Guzeldemir ME. Accuracy of caudal epidural injection: the importance of real-time imaging. Pain Pract 2005;5:251-254.

    Article  PubMed  Google Scholar 

  34. Cluff R, Mehio AK, Cohen SP, Chang Y, Sang CN, Stojanovic MP. The technical aspects of epidural steroid injections: a national survey. Anesth Analg 2002;95:403-408, table of contents.

    Article  PubMed  Google Scholar 

  35. Amar AP, Wang MY, Larsen DW, Teitelbaum GP. Microcatheterization of the cervical epidural space via lumbar puncture: technical note. Neurosurgery 2001;48:1183-1187.

    Article  CAS  PubMed  Google Scholar 

  36. Ackerman 3rd WE, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg 2007;104:1217-1222, tables of contents.

    Article  PubMed  Google Scholar 

  37. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine 2007;32:1249-1256.

    Article  PubMed  Google Scholar 

  38. Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology 2004;100:1595-1600.

    Article  PubMed  Google Scholar 

  39. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain 2003;103:211-215.

    Article  PubMed  Google Scholar 

  40. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain 2005;117:104-111.

    Article  PubMed  Google Scholar 

  41. Furman MB, Giovanniello MT, O'Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine 2003;28:21-25.

    Article  PubMed  Google Scholar 

  42. Dreyfuss P, Baker R, Bogduk N. Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med 2006;7:237-242.

    Article  PubMed  Google Scholar 

  43. Huntoon MA, Martin DP. Paralysis after transforaminal epidural injection and previous spinal surgery. Reg Anesth Pain Med 2004;29:494-495.

    PubMed  Google Scholar 

  44. Alleyne Jr CH, Cawley CM, Shengelaia GG, Barrow DL. Microsurgical anatomy of the artery of Adamkiewicz and its segmental artery. J Neurosurg 1998;89:791-795.

    Article  PubMed  Google Scholar 

  45. Rathmell JP, Benzon HT. Transforaminal injection of steroids: should we continue? Reg Anesth Pain Med 2004;29:397-399.

    PubMed  Google Scholar 

  46. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology 2007;106:331-338.

    Article  CAS  PubMed  Google Scholar 

  47. Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 1971;53:891-903.

    CAS  PubMed  Google Scholar 

  48. Gajraj NM. Selective nerve root blocks for low back pain and radiculopathy. Reg Anesth Pain Med 2004;29:243-256.

    PubMed  Google Scholar 

  49. Fenton DS, Leo F. Image-Guided Spine Intervention, 1st ed. Philadelphia: Saunders, 2003:298.

    Google Scholar 

  50. Datta S, Pai U. Selective nerve root block - is the position of the needle transforaminal or paraforaminal? Call for a need to reevaluate the terminology. Reg Anesth Pain Med 2004;29:616-617, author reply 617.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2010 Springer Science+Business Media, LLC

About this chapter

Cite this chapter

Ranson, M.T., Deer, T.R. (2010). Epidural Injections for the Treatment of Spine-Related Pain Syndromes. In: Mathis, J., Golovac, S. (eds) Image-Guided Spine Interventions. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-0352-5_8

Download citation

  • DOI: https://doi.org/10.1007/978-1-4419-0352-5_8

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4419-0351-8

  • Online ISBN: 978-1-4419-0352-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics