Q.I’ve been diagnosed with a herniated disk, and I have been working with a physical therapist for about two and a half months. The doctor now recommends lumbar epidural injections. Can you tell me the short-term and long-term pros and cons of this treatment?
A.I recommend lumbar (lower back) epidural injections to patients with back or leg pain who have signs of nerve compression. The compression can be caused by a herniated disc pressing on a nerve root or by spinal stenosis, which is a narrowing of the area around the nerves. The primary objective of the epidural is to relieve the irritation around the nerves, thereby giving pain relief.
A. The doctor begins by numbing the skin over the spine in the lower part of the back. The doctor then inserts a small needle into the epidural space, which surrounds the spinal cord. Then a local anesthetic and some cortisone is injected into this space. In most cases, the epidural is performed without much difficulty and without significant pain.
The short-term benefit is a lessening of the inflammation around the nerve roots, which reduces the pain. Patients typically experience pain relief within two to three days after the epidural, but it is difficult to predict the duration or degree of pain relief for each individual. In my practice, I recommend that if a patient enjoys considerable relief after the first epidural, he or she should hold off on additional injections. If the patient has only have moderate relief, then I recommend a second and occasionally a third epidural injection. For a patient who gets virtually no relief, I usually recommend other treatment options.
Most epidurals are performed by anesthesiologists in a hospital or outpatient facility. Other physicians, including orthopedists, neurologists, neurosurgeons and physiatrists (rehabilitation specialists), also give these injections. I don’t think it matters which specialist performs an epidural, but the physician should be experienced and perform many epidurals. Some physicians feel most comfortable doing the procedure under X-ray guidance.
The epidural is a fairly low-risk procedure that can give relief and possibly enable the patient the avoid a surgical procedure. In the proper hands, an epidural is safe. However, I do discuss the possible complications with my patients. One complication is the possibility of a headache after the procedure. This is quite unusual, occurring in less than 1 percent of patients. In general, the headaches resolve within a few days. Although the risk of bleeding with an epidural is low, it remains a concern. If, for some reason, a patient has an underlying bleeding problem that has so far gone undetected, that person would be at risk for developing bleeding from the epidural. This could result in paralysis.
I inform my patients that the epidural, in general, does not burn any bridges, meaning that if it fails to give significant relief, they are still possible candidates for surgery. On the other hand, a patient who has surgery but still has persistent pain is very difficult to treat.