Epidural Steroid Injection

Overview

Patient preparation

  • Patient history to confirm diagnosis, past treatment, medications, surgical evaluation
  • Consent obtained including risks (headache, infection, bleeding, nerve injury)
  • PIV placed, monitors in place, sedation if necessary

Room preparation

  • Spinal tray, syringes, needles, epidural kit, chlorhexidine prep
  • Meds: 2% lidocaine, sterile saline, non-preservative bupivacaine or lidocaine, dexamethasone
  • Resuscitation equipment and medications available

Injection technique

  • Sitting position with assistant and support preferred (lateral acceptable), identify space
  • Sterile prep and skin infiltration; loss-of-resistance technique to space
  • Injection of Dexamethasone 10mg + Lido OR Bupiv 2mL + Sterile saline 1-4mL; saline flush

Post-injection care

  • PACU monitoring for 15 minutes if no sedation
  • No movement restrictions

Notes

  • Review contraindications including anticoagulant medications
  • REDIRECT needle if paresthesia
  • STOP procedure and call for help if CSF flow, consider repeating injection at a different level

Summary of Procedure

Patient history

  • Low back pain, electric pain radiating to one or both lower extremities
  • Imaging (usually MRI) showing source of pain

Indications

  • Goal is to decrease inflammation and swelling at the nerve root
  • Prescribed for disc herniation, spinal stenosis, post-laminectomy syndrome, spondylothesis

Contraindications

  • Coagulopathy

-- LMWH (Enox) within 12 hours -- Rivaroxaban within 3 days -- Clopidogrel within 7 days -- INR > 1.4 -- Thrombocytopenia < 100 (not needed if no history or risk factors for low platelets)

  • Infection (Overlying skin, systemic)
  • Elevated ICP

Complications: Include in the consent for the procedure!

  • Bleeding
  • Infection
  • Post-dural puncture headache (quoted as 0.5%)
  • Injury to blood vessel or nerve
  • Vasovagal reaction (have an assistant and vasopressor/vagolytic ready)
  • No relief of pain

Outcomes

  • Steroid works in 24-48 hours so relief may be delayed (local anesthetic injection helps)
  • Pain relief outcomes vary depending on the study, many patients will get relief for 3-6 months
  • Some patients will require repeat injections, limit to 3-4 per year