Epidural Steroid Injections

1
00:00:00.795 –> 00:00:01.665
Hello, Dr.

2
00:00:01.805 –> 00:00:03.265
Jed here. Today we’re talking about

3
00:00:03.345 –> 00:00:04.665
epidural steroid injections.

4
00:00:05.165 –> 00:00:07.265
So what is an epidural steroid injection

5
00:00:07.565 –> 00:00:09.825
and when would you get an epidural steroid injection?

6
00:00:10.565 –> 00:00:14.385
To begin with? An epidural steroid injection is a potential

7
00:00:14.865 –> 00:00:15.985
powerful tool in the toolbox

8
00:00:16.085 –> 00:00:19.145
to help reduce very specific types of back pain.

9
00:00:19.445 –> 00:00:22.185
The types of back pain, most responsive

10
00:00:22.185 –> 00:00:25.825
to an epidural steroid injection would be from neural

11
00:00:25.825 –> 00:00:27.905
impingement, and that is like, say for example,

12
00:00:28.115 –> 00:00:29.825
nerve root impingement here.

13
00:00:29.935 –> 00:00:33.145
Sometimes you could have nerve impingement, uh,

14
00:00:33.145 –> 00:00:35.985
from the central canal, could be from discs,

15
00:00:36.235 –> 00:00:38.145
could be from overgrown facet joints,

16
00:00:38.155 –> 00:00:40.225
could be from thickened structures,

17
00:00:40.225 –> 00:00:41.865
thickened ligaments underneath.

18
00:00:41.865 –> 00:00:45.465
Oftentimes these factors end up pinching on a nerve

19
00:00:45.565 –> 00:00:48.625
and causing pain across the back,

20
00:00:48.625 –> 00:00:51.505
oftentimes radiating into the lower extremities.

21
00:00:51.535 –> 00:00:53.545
Sometimes this is called sciatica.

22
00:00:54.105 –> 00:00:56.465
Sciatic like pain is pain

23
00:00:56.935 –> 00:00:59.945
that radiates down into the lower extremities,

24
00:00:59.945 –> 00:01:03.145
sometimes associated with numbness, tingling, burning,

25
00:01:03.705 –> 00:01:06.665
occasionally electrical shock-like symptoms, even weakness.

26
00:01:07.605 –> 00:01:10.225
If you are having any of these symptoms, it is important

27
00:01:10.225 –> 00:01:12.025
to be worked up by a physician as these

28
00:01:13.265 –> 00:01:16.265
symptoms can signify various serious underlying issues

29
00:01:16.325 –> 00:01:17.385
and should be worked up.

30
00:01:18.495 –> 00:01:22.665
Part of your workup will likely include an MRI to image

31
00:01:22.685 –> 00:01:24.745
and understand the soft tissue.

32
00:01:24.745 –> 00:01:27.945
Impingement on the nerves may include a CT myelogram.

33
00:01:27.945 –> 00:01:29.385
If you’re unable to get an MRI.

34
00:01:29.495 –> 00:01:32.825
However, it is important to understand the problem

35
00:01:33.325 –> 00:01:36.865
to help target appropriate therapy, appropriate treatment.

36
00:01:37.125 –> 00:01:40.345
So that brings me to an epidural steroid injection.

37
00:01:40.735 –> 00:01:42.785
When would you do that? Well, say for example,

38
00:01:42.965 –> 00:01:46.865
the workup does reveal that you have nerve root impingement,

39
00:01:47.125 –> 00:01:49.985
neural impingement, regardless precisely what it’s from.

40
00:01:50.485 –> 00:01:53.025
But uh, you do have the pain across the back.

41
00:01:53.095 –> 00:01:55.585
It’s significant pain is going down that leg,

42
00:01:55.995 –> 00:01:59.305
maybe the numbness, tingling, uh, maybe even weakness.

43
00:02:00.605 –> 00:02:05.225
So an epidural is the delivery of medication precisely

44
00:02:05.485 –> 00:02:08.065
around irritated nerve roots,

45
00:02:08.335 –> 00:02:11.105
perhaps sometimes centrally into this spinal canal.

46
00:02:11.685 –> 00:02:14.985
The commonalities of an epidural steroid injection are the

47
00:02:15.005 –> 00:02:16.585
use of x-ray guidance

48
00:02:16.845 –> 00:02:20.905
to precisely guide the needle into the precise position.

49
00:02:21.205 –> 00:02:22.225
So say for example,

50
00:02:22.525 –> 00:02:25.385
the physician oftentimes uses what’s called a C arm.

51
00:02:25.535 –> 00:02:28.425
It’s this big machine, you can’t really see my arm here,

52
00:02:28.605 –> 00:02:30.545
but it is shaped like a C.

53
00:02:30.885 –> 00:02:34.225
It is called fluoroscopy, and that is live action X-ray.

54
00:02:34.565 –> 00:02:37.105
The physician may use the x-ray

55
00:02:37.105 –> 00:02:38.185
and take many pictures

56
00:02:38.245 –> 00:02:40.465
to guide the needle down towards either,

57
00:02:40.655 –> 00:02:42.745
that would be called an interlaminar approach.

58
00:02:43.045 –> 00:02:44.825
If you go from the side, that would be called a

59
00:02:45.485 –> 00:02:46.785
transforaminal approach.

60
00:02:46.975 –> 00:02:49.585
There’s another approach called a coddle approach,

61
00:02:49.965 –> 00:02:53.185
and that is right down here at the very lowest level

62
00:02:53.325 –> 00:02:54.465
of the spine.

63
00:02:55.685 –> 00:02:57.705
So let’s take those one by one

64
00:02:57.725 –> 00:03:02.325
to give you some more detail on the various causes of pain,

65
00:03:02.625 –> 00:03:03.685
neural impingement

66
00:03:03.825 –> 00:03:06.885
and the various approaches of an epidural steroid injection.

67
00:03:08.185 –> 00:03:10.765
So let’s go back to causes for just a moment.

68
00:03:11.355 –> 00:03:14.645
Once again, a common cause may be a bulge disc.

69
00:03:15.035 –> 00:03:17.725
Here, for example, we have a, this is the sacrum.

70
00:03:17.725 –> 00:03:19.525
There’s L five, L four, L three.

71
00:03:20.075 –> 00:03:23.205
This is a representation of an L three four

72
00:03:25.065 –> 00:03:28.995
disc protrusion pinching onto a nerve root.

73
00:03:29.105 –> 00:03:30.795
That would be the L three nerve root.

74
00:03:31.105 –> 00:03:33.075
That right there could give you pain, numbness,

75
00:03:33.235 –> 00:03:36.395
tingling down your thigh to the knee.

76
00:03:36.855 –> 00:03:38.875
Say for example, if you had nerve root impingement

77
00:03:38.875 –> 00:03:42.155
of L four, it would go down further into the ankle L five,

78
00:03:42.305 –> 00:03:44.075
perhaps all the way into the foot.

79
00:03:45.575 –> 00:03:47.195
So that would be one potential.

80
00:03:47.195 –> 00:03:49.155
Cause would be a disc bulging backwards.

81
00:03:49.465 –> 00:03:53.515
Another potential cause could be from arthritic, uh,

82
00:03:53.535 –> 00:03:57.515
and degenerative change overgrowths from these facet joints.

83
00:03:57.965 –> 00:03:59.395
Facet joints right here.

84
00:04:00.255 –> 00:04:04.195
So as the facet joints become arthritic, they may encroach

85
00:04:04.215 –> 00:04:05.435
and pinch that way.

86
00:04:05.575 –> 00:04:07.755
If you have a little bit of a disc pushing back,

87
00:04:07.755 –> 00:04:10.875
that way they can act together to pinch your nerves.

88
00:04:11.265 –> 00:04:14.355
Also, sometimes thickening of other structures

89
00:04:14.355 –> 00:04:18.555
and ligaments down deeper here may also act to pinch on

90
00:04:18.935 –> 00:04:22.275
and uh, cause pain either pinch centrally,

91
00:04:22.465 –> 00:04:25.875
that would be at the uh, spinal canal.

92
00:04:25.975 –> 00:04:27.955
The spinal cord right there pinching centrally

93
00:04:28.215 –> 00:04:32.515
or pinching at the nerves once they come down the leg.

94
00:04:33.615 –> 00:04:36.035
So those would be the factors that could contribute

95
00:04:36.335 –> 00:04:37.675
to sciatica.

96
00:04:37.865 –> 00:04:41.235
That is pinched nerves causing severe pain.

97
00:04:41.695 –> 00:04:42.755
Uh, moderate

98
00:04:42.935 –> 00:04:45.715
to severe pain across the back down into the leg.

99
00:04:46.095 –> 00:04:50.115
So we had bulging disc, we had degenerative changes

100
00:04:50.335 –> 00:04:53.035
and thickening from arthritic changes in these joints

101
00:04:53.175 –> 00:04:54.835
or thickening of the tissues.

102
00:04:55.415 –> 00:04:58.275
So if you have those symptoms, what would you do about them?

103
00:04:58.335 –> 00:04:59.915
That’s when you would consider an

104
00:04:59.915 –> 00:05:01.315
epidural steroid injection.

105
00:05:02.485 –> 00:05:03.995
There are a few different approaches

106
00:05:04.015 –> 00:05:05.595
for an epidural steroid injection.

107
00:05:06.285 –> 00:05:09.955
Those would be an interlaminar, a transforaminal,

108
00:05:10.055 –> 00:05:11.275
or a coddle approach.

109
00:05:11.815 –> 00:05:15.395
You would choose each of these based on specifics

110
00:05:15.395 –> 00:05:16.955
of your particular case.

111
00:05:17.375 –> 00:05:19.595
Say for example, an interlaminar approach.

112
00:05:19.705 –> 00:05:21.955
This would be an L five S one approach.

113
00:05:22.335 –> 00:05:25.355
You may select this one when you have multiple levels

114
00:05:25.415 –> 00:05:27.795
of nerve root impingement, uh,

115
00:05:27.995 –> 00:05:30.795
particularly if you maybe have back pain

116
00:05:30.825 –> 00:05:32.075
greater than leg pain.

117
00:05:32.495 –> 00:05:34.075
Here’s an example of me getting set

118
00:05:34.075 –> 00:05:35.555
Up to perform an intra laminar

119
00:05:35.555 –> 00:05:36.835
Epidural steroid injection.

120
00:05:37.415 –> 00:05:39.995
You can see here the C-arm that I’ll be taking,

121
00:05:40.135 –> 00:05:42.835
the X-ray pictures that are the fluroscopic pictures.

122
00:05:43.135 –> 00:05:44.635
You can see over here in the screen.

123
00:05:44.905 –> 00:05:47.395
I’ll be following along the progress throughout

124
00:05:47.395 –> 00:05:48.395
The procedure. In

125
00:05:48.395 –> 00:05:51.355
this picture, you can see the initial placement

126
00:05:51.415 –> 00:05:52.435
of the needle.

127
00:05:52.535 –> 00:05:55.435
It is the black dot right here on the X-ray

128
00:05:55.435 –> 00:05:56.675
picture. This could be called

129
00:05:56.875 –> 00:05:57.965
A safety view

130
00:05:58.145 –> 00:05:59.925
and it demonstrates the initial placement

131
00:05:59.925 –> 00:06:01.245
of the needle over bone.

132
00:06:01.435 –> 00:06:03.645
Next, the needle will be directed towards the top

133
00:06:03.645 –> 00:06:06.165
of this picture into the interlaminar space.

134
00:06:07.075 –> 00:06:10.295
In this still shot, the C-arm has been adjusted somewhat

135
00:06:10.435 –> 00:06:12.855
and I’m about to put in contrast agent here,

136
00:06:13.325 –> 00:06:15.735
verifying the appropriate placement of the needle

137
00:06:15.875 –> 00:06:17.975
before injecting the final medication.

138
00:06:18.715 –> 00:06:21.215
The other very commonly used approach is called a

139
00:06:21.395 –> 00:06:23.535
transforaminal approach right there

140
00:06:23.665 –> 00:06:27.255
where the nerve root is coming out of the spine,

141
00:06:27.365 –> 00:06:29.415
that is called the neuroforamen.

142
00:06:29.415 –> 00:06:31.895
Imagine a little hole there, the nerve coming out

143
00:06:31.895 –> 00:06:33.015
of the neuroforamen.

144
00:06:33.195 –> 00:06:36.895
If you direct a needle down from the side

145
00:06:37.885 –> 00:06:39.175
into the neuroforamin,

146
00:06:39.175 –> 00:06:41.415
that is called a transforaminal approach.

147
00:06:41.835 –> 00:06:44.895
You may select that when you have one discreet level

148
00:06:45.035 –> 00:06:47.095
of nerve root impingement, such as right here,

149
00:06:47.195 –> 00:06:49.255
an L three L four, you might select

150
00:06:50.175 –> 00:06:53.895
a transforaminal epidural steroid injection at L three slash

151
00:06:53.965 –> 00:06:56.015
four on the right, you would deliver

152
00:06:56.015 –> 00:06:57.415
that steroid medicine right there.

153
00:06:58.675 –> 00:07:01.175
The third approach that is done much less commonly

154
00:07:01.245 –> 00:07:04.975
nonetheless, at sometimes it is a useful intervention

155
00:07:04.995 –> 00:07:07.615
to use, is called the coddle approach.

156
00:07:07.925 –> 00:07:11.335
That is down here at the lowest levels of the spine.

157
00:07:11.565 –> 00:07:12.615
This is the sacrum.

158
00:07:12.955 –> 00:07:16.415
So if you have nerve root impingement at the sacral levels,

159
00:07:16.445 –> 00:07:19.415
perhaps you could select a transforaminal

160
00:07:19.415 –> 00:07:21.295
and deliver medicine here,

161
00:07:21.955 –> 00:07:24.575
or you may consider delivering medicine

162
00:07:24.575 –> 00:07:25.975
through the sacral hiatus

163
00:07:26.195 –> 00:07:28.215
and uh, sending a needle just up

164
00:07:28.215 –> 00:07:30.135
that little hole there a little ways

165
00:07:30.155 –> 00:07:32.375
to deliver the medic medication up there.

166
00:07:32.805 –> 00:07:34.535
That is a good approach to use.

167
00:07:35.525 –> 00:07:38.495
Also, if you have extensive degenerative changes,

168
00:07:38.525 –> 00:07:40.015
perhaps had a prior surgery,

169
00:07:40.395 –> 00:07:43.055
and there are many factors up here that would make the other

170
00:07:43.775 –> 00:07:47.735
epidural steroid injection approaches difficult regardless

171
00:07:47.795 –> 00:07:48.815
of the approach used.

172
00:07:48.875 –> 00:07:50.255
The end result is the delivery

173
00:07:50.435 –> 00:07:53.375
of a steroid medication near the area

174
00:07:53.555 –> 00:07:55.095
of nerve root irritation.

175
00:07:55.655 –> 00:07:57.775
Steroid is a potent anti-inflammatory.

176
00:07:57.885 –> 00:07:59.455
That is, it is going

177
00:07:59.455 –> 00:08:02.695
to very strongly inhibit the inflammatory pathway

178
00:08:03.355 –> 00:08:07.255
and it is going to decrease inflammation irritation.

179
00:08:07.355 –> 00:08:10.455
It is going to directly decrease pressure in the area.

180
00:08:10.885 –> 00:08:15.095
That in turn, may result in substantially decreased pain,

181
00:08:15.365 –> 00:08:16.415
both across the back,

182
00:08:16.415 –> 00:08:18.575
substantially decreased pain down the legs.

183
00:08:19.295 –> 00:08:20.975
A question I’m frequently asked is,

184
00:08:21.155 –> 00:08:22.535
doc, how long will this last?

185
00:08:22.925 –> 00:08:25.135
Well, I have to say results may vary.

186
00:08:25.835 –> 00:08:27.895
It varies based on many, many factors.

187
00:08:28.895 –> 00:08:31.415
Specifically, it is the more

188
00:08:32.325 –> 00:08:34.055
extensive degenerative changes,

189
00:08:34.355 –> 00:08:37.495
the more true structural impingement that you have,

190
00:08:38.035 –> 00:08:40.695
the less long the results may last.

191
00:08:41.065 –> 00:08:42.935
Let’s talk on the other end of the spectrum.

192
00:08:43.025 –> 00:08:46.935
Let’s say for example, that you’ve never had a bulge disc

193
00:08:46.935 –> 00:08:49.575
before, perhaps somewhat younger forties, fifties,

194
00:08:49.755 –> 00:08:51.775
and you just have one single area

195
00:08:51.995 –> 00:08:54.335
of just maybe a minor disc bulge.

196
00:08:54.525 –> 00:08:57.845
Well, perhaps an epidural steroid injection in that case

197
00:08:58.435 –> 00:09:00.965
will significantly impair the inflammation

198
00:09:01.225 –> 00:09:02.845
and it will give your body a chance

199
00:09:02.865 –> 00:09:04.525
to get ahead on its own healing process

200
00:09:05.105 –> 00:09:07.445
and you are good to go forever.

201
00:09:07.735 –> 00:09:09.405
These symptoms essentially go away.

202
00:09:09.665 –> 00:09:11.605
It is not that the medicine lasts forever.

203
00:09:11.825 –> 00:09:14.045
It is that it gave your body a chance

204
00:09:14.045 –> 00:09:15.805
to get ahead on the healing process.

205
00:09:16.945 –> 00:09:19.125
At the other end of the spectrum, if you have

206
00:09:19.685 –> 00:09:22.165
multiple levels of advanced degenerative changes,

207
00:09:22.555 –> 00:09:24.445
that is discs bulging back

208
00:09:24.865 –> 00:09:27.405
and if they are, have been bulged back over many months,

209
00:09:27.475 –> 00:09:29.885
sometimes the body has calcified the disc.

210
00:09:29.915 –> 00:09:33.325
That is what’s called a disc osteophyte complex.

211
00:09:34.145 –> 00:09:36.245
If you have a disc osteophyte complex

212
00:09:37.145 –> 00:09:41.485
and extensive arthritic changes at the facet joints and

213
00:09:41.485 –> 00:09:45.685
or thickening of the ligamentum flam, that is a ligament

214
00:09:45.685 –> 00:09:49.125
that extends on the underside of that is called the lamina.

215
00:09:50.305 –> 00:09:54.125
If you have extensive structural neural impingement,

216
00:09:54.345 –> 00:09:58.205
the results at the epidural will most likely be more short

217
00:09:58.275 –> 00:10:00.845
lasting and not necessarily as profound.

218
00:10:02.375 –> 00:10:04.795
So is an epidural steroid injection right for you?

219
00:10:04.975 –> 00:10:06.115
It depends on many factors

220
00:10:06.375 –> 00:10:08.315
and you need to discuss that along

221
00:10:08.315 –> 00:10:10.315
with your imaging with your physician.

222
00:10:10.615 –> 00:10:13.795
So to make the most of your beneficial response following an

223
00:10:13.795 –> 00:10:18.435
epidural steroid injection, it is critical to both restore

224
00:10:18.815 –> 00:10:21.355
and maintain appropriate mechanics

225
00:10:21.495 –> 00:10:24.075
and mobility throughout the spine and your body.

226
00:10:24.375 –> 00:10:25.475
Now, this is not accomplished

227
00:10:25.475 –> 00:10:28.115
by a single visit with physical therapy.

228
00:10:28.495 –> 00:10:31.195
It isn’t accomplished by even a full eight

229
00:10:31.195 –> 00:10:32.875
to 12 week session with physical therapy.

230
00:10:33.335 –> 00:10:36.675
It is only accomplished by an ongoing commitment to yourself

231
00:10:37.015 –> 00:10:41.275
to engage in ongoing consistent therapeutic

232
00:10:41.955 –> 00:10:44.875
activity, therapeutic exercises for yourself.

233
00:10:45.305 –> 00:10:48.155
That can be very short. However, they need to be frequent.

234
00:10:48.775 –> 00:10:52.595
So ideally, you should be giving yourself perhaps like a

235
00:10:52.595 –> 00:10:56.355
little session, five, 10 minutes, 15 minutes if you can,

236
00:10:56.775 –> 00:10:58.515
2, 3, 4 times a week,

237
00:10:58.695 –> 00:11:02.075
and that will help to maintain appropriate mechanics,

238
00:11:02.515 –> 00:11:06.075
maintain appropriate mobility for the oncoming weeks,

239
00:11:06.215 –> 00:11:08.235
months, years, and decades ahead.

240
00:11:08.465 –> 00:11:11.475
Well, thank you for tuning into dr jed.com here.

241
00:11:12.035 –> 00:11:14.235
Continue to take care of yourself and be well.