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Indications for an ESI
Epidural injections are used to treat radicular pain caused by nerve irritation. This type of pain is usually caused by herniated discs or spinal stenosis. A herniated disc occurs when pressure or degeneration produces a tear in the disc’s outer ring (the annulus), and the nucleus ruptures out of its normal space. If it rips near the spinal canal, the bulging disc can push out of its space and into the spinal canal, placing inappropriate pressure on the spinal cord and nerve roots. Spinal stenosis is a narrowing of the spinal canal that can cause pressure on the spinal cord and spinal nerves.
Epidural injections are also helpful when the main problem is arthritis of the facet joints in multiple areas of the spine. The medication coats the outside of the problem joints and absorbs into the joints. This type of injection reduces the inflammation in the joint. The injection is sometimes aimed at the small nerves that supply the joints.
It may be necessary to have several epidural injections in a series over a period of a few weeks. This is because the relief from the epidural injection usually decreases with time. It is not uncommon to have three lumbar epidural injections, each about ten days apart.
Contraindications for an ESI
Your doctor may suggest that an epidural injection not be considered if you have abnormalities of the epidural space. Either it has been altered from a congenital (present at birth) abnormality, or from a previous surgery that has left scarring.
Injecting steroids, such as cortisone, anywhere in the body allows for absorption of the medication into the bloodstream and can lower the body’s ability to fight infections. Cortisone should not be used if there is any type of serious infection in the body.
Absorption of the medication may also cause a systemic (whole body) corticosteroid effect such as fluid retention or interference with glucose control. An epidural might not be appropriate for patients with diabetes or congestive heart failure.
There are risks associated with epidural injections. This is not intended to be a complete list, but these are some of the most common.
A dural puncture, or “wet tap,” is perhaps the most common complication from an ESI. This complication only occurs in 0.1 to 5 percent of all injections. The result of a dural puncture is usually a spinal headache and nausea. A spinal headache occurs when the puncture in the spinal sac fails to seal itself off. This allows the spinal fluid to continue to leak out and lowers the spinal fluid pressure in the brain. When sitting or standing, the headache and nausea are much worse because the spinal fluid pressure is lower at the top (near your head) than at the bottom of the spine. The headache usually goes away when you lie down with your feet higher than your head.
To treat a spinal headache, a “blood patch” is usually recommended. If the doctor realizes immediately during the procedure that there is a wet tap, he may perform a blood patch before he removes the epidural needle. A blood patch is a simple procedure. About three ounces of blood are drawn from an arm vein and immediately injected into the epidural space with the epidural needle. The blood clots around the spinal sac and stops the leak by forming a “patch.”
There is a slight chance that the medication may be injected into one of the tiny blood vessels that runs through the epidural space instead of the epidural space itself. This can cause seizures, cardiac arrest, and even death if too much of the medication goes directly into the blood steam. The chance of this happening is very small. Your doctor can discuss it with you in further detail.
Epidural injections are done under sterile conditions very similar to surgery. Still, anytime a needle is inserted into the body there is a small chance of infection. Since the needle must be placed near the spine during an epidural, an infection is much more serious if it occurs. The chance that an infection will occur is extremely small.
An epidural injection can result in a hematoma. A hematoma is simply a collection of blood caused by an injury to a blood vessel. An epidural hematoma can be serious if it is big enough to put sufficient pressure on the spinal nerves so that they quit working. This can cause problems with the bowels and bladder.
The epidural injection actually paralyzes the nerves to the bowel and bladder for a short period. You may not have control over your bladder for one to two hours following the procedure.
There is always a small risk of damage to the spinal nerves. The spinal cord is a bundle of millions of nerves connecting the brain with the rest of the body. If the epidural needle directly injures the spinal nerves, it may result in injury to the nerves.
Mild pain medications can reduce inflammation and pain when taken properly. Pain medications cannot stop the effects of aging and wear and tear on the spine. But they can help control pain. If you are pregnant, you should not take any medication unless you have discussed it with your obstetrician.
Medications prescribed for back pain include
Aspirin compounds are over-the-counter medications that can help relieve minor pain and back ache. The main potential side effect with aspirin is the development of stomach problems- particularly ulcers with or without bleeding.
Non-steroidal anti-inflammatory drugs (NSAIDs) include over-the-counter pain relievers such as ibuprofen and naproxen. These medications were once only available by prescription. NSAIDs are very effective in relieving the pain associated with muscle strain and inflammation. Be aware that NSAIDs can decrease renal function if you are an older patient. Excessive use can lead to kidney problems.
A new class of NSAIDs is gaining wide acceptance in its ability to reduce inflammation. Commonly called COX-2 inhibitors, these newer NSAIDS work by selectively blocking the formation of pain-causing inflammatory chemicals. COX-2 inhibitors appear to be easier on the stomach, mainly because they don’t interrupt stomach enzymes like traditional NSAIDs. Celecoxib (Celebrex(r)) and refecoxib (Vioxx(r)) are two commonly prescribed COX-2 inhibitors.
Nonnarcotic Prescription Pain Medications
Nonnarcotic analgesics (pain relievers) are ideal in the treatment of mild to moderate chronic pain. Tylenol(tm) and aspirin are the most widely used over-the-counter analgesics. Medications that are analgesics and require a prescription from the doctor include NSAIDs, such as carprofen, fenoprofen, ketoprofen, and sulindac. To reduce side effects do not lie down for 15 to 30 minutes after taking the medication, avoid direct sunlight, and wear protective clothing and sun block. Avoid using these medications if you have recurrent ulcers or liver problems.
Narcotic Pain Medications
If you experience severe pain, your doctor might prescribe a narcotic pain medication such as codeine or morphine. Narcotics relieve pain by acting as a numbing anesthetic to the central nervous system. The strength and length of pain relief differs for each drug.
Narcotics can have side effects such as nausea, vomiting, constipation, and sedation (drowsiness). These side effects are predictable and can often be prevented. Common preventive measures include not taking sleeping aids or anti-depressants along with narcotics, avoiding alcohol, increasing fluid intake, eating a high fiber diet, and using a fiber laxative or stool softener to treat constipation. Remember that narcotics can be addictive if used excessively or improperly.
If you are having muscle spasms, muscle relaxants may help relieve pain. They have only been shown to be marginally effective. Muscle relaxants also have a significant risk of drowsiness and depression. Long-term use is not suggested; only three to four days is typically recommended.
Back pain is a common symptom of depression and could be an indicator of its presence. Similarly back pain can lead to emotional distress and depression. It seems that the same chemical reactions in the nerve cells that trigger depression also control the pain pathways in the brain. Anti-depressants can relieve emotional stress associated with back pain. Some anti-depressant medications seem to reduce pain-probably because they affect this chemical reaction in the nerve cells.
Some types of anti-depressants make good sleeping medications. If you are having trouble sleeping due to your back pain, your doctor may prescribe an anti-depressant to help you get back to a normal sleep routine. Anti-depressants can have side effects such as drowsiness, loss of appetite, constipation, dry mouth, and fatigue.
Your recovery from spine pain or injury can be improved by learning new ways to strengthen your spine and prevent future problems. A physical therapist can teach you ways to help reduce your pain now and form new habits to keep your spine healthy. Learn about spinal rehabilitation including
Your physical therapist (PT) will gather information about your spine condition. You may be asked questions about when it started, where you hurt, and how your symptoms affect your day-to-day activities. This helps your PT to begin zeroing in on the source of your problem and to know what will be needed to help relieve it.
After reviewing your answers, your therapist will do an exam that may include some or all of the following checks. Posture – Imbalances in the position of your spine can put pressure on sore joints, nerves, and muscles. Improving your posture can oftentimes make a big difference in easing pain. Range of motion (ROM) – Measurements are taken of how far you can move in different directions. Your ROM is recorded to compare how much improvement you are making with treatment. Nerve Tests – Your PT may do checks of reflexes, sensation, and strength. The results can help determine which area of the spine is causing problems and the types of treatment that will be best for you. Manual Exam – Your PT will carefully move your spine in different positions to make sure that the joints are moving smoothly at each level. Muscle and soft tissue flexibility is also tested. Ergonomics – Ergonomics involves where and how you do your work or hobby activities. By understanding your ergonomics, your PT can begin to learn if the way you do your activities is making your condition worse. Sometimes even simple corrections of your hobby or workstation can make a big difference in easing spine problems. Palpation – Palpation involves feeling the soft tissues around your spine. This is used to check the skin for changes in temperature or texture, which could tell if you have inflammation or nerve irritation. Palpation also checks whether there are tender points or spasms in the muscles near the spine.
Your therapist will evaluate your answers and your exam results to determine the best way to help you. Your therapist will then write a plan of care, which lists the treatments to be used and the goals that you and your therapist decide on to do your daily activities safely and with the least amount of discomfort. The plan also includes a prognosis, which is your therapist’s idea of how well the treatments will work and how long you’ll need therapy in order to get the most benefit.
The main goal of therapy is to make sure you have ways to take care of future spine pain or problems. You’ll be shown ways to help control pain or symptoms if they don’t go completely away and if they return in the future. Because you’ve experienced spine pain, there is a possibility you may have soreness in the future. You may be encouraged to continue with some of the exercises to help keep your spine healthy over time.
Controlling Pain and Symptoms
Your therapist may choose from one or more of the following treatment interventions to help you control your pain and symptoms.
Resting the painful joints and muscles helps calm soreness, giving your spine time to heal. If you are having pain with an activity or movement, it should be a signal that there is still irritation going on. You should try to avoid all movements and activities that increase the pain. In the early stages of your problem, the doctor or therapist may have you wear a brace to limit movement.
Specific rest encourages safe movement of the joints and muscles on either side of a painful area, while protecting the sore spot during the initial healing phase. If a brace was prescribed, you may be instructed to take it off a few times each day so you can do some gentle and controlled exercises.
Your PT will work with you to find ways to position your spine for the greatest comfort while sleeping or resting. You may receive advice on positions that reduce stress on your spine while you are at work.
Ice makes blood vessels vasoconstrict (get smaller), decreasing the blood flow. This helps control inflammation, muscle spasm, and pain.
Heat makes blood vessels vasodilate (get larger), increasing the blood flow. This action helps flush away chemicals that cause pain. It also helps bring in healing nutrients and oxygen.
Ultrasound can reach tissues that are over two inches below the surface of your skin. The ultrasound machine directs high-frequency sound waves toward the sore area. As the waves pass through the body’s tissues, they vibrate molecules. The vibration causes friction and warmth. The remaining sound waves are converted to heat in the deeper tissues of the body. This heating effect helps flush the sore area and brings in a new supply of blood that is rich in nutrients and oxygen.
Electrical stimulation is a gentle treatment used to stimulate nerves. The current passes through pads applied on the skin. Some people say it feels like a massage on their skin. Electrical stimulation can ease pain by sending impulses that are felt instead of pain. Once the pain eases, muscles that are in spasm begin to relax, letting you move and exercise with less discomfort.
Soft Tissue Mobilization/Massage
Therapists are trained in many different forms of massage and mobilization. Massage has been shown to calm pain and spasm by helping muscles relax, by bringing in a fresh supply of oxygen and nutrient-rich blood, and by flushing the area of chemical irritants that come from inflammation. Soft tissue treatments can help tight muscles relax, getting them back to a normal length. This will help you begin to move with less pain and greater ease.
Graded pressures and movements for joint mobilization may be performed by skilled therapists. Gentle graded pressures help lubricate joint surfaces, easing stiffness and helping you begin moving with less pain. As your pain eases, more vigorous grades of mobilization may be used to lengthen tissues around the joint in order to restore better movement in your spine.
Sore joints and muscles often feel better when traction (pull) is used. Therapists apply traction manually or with a traction machine. There are also traction devices that can be issued to you for use at home. The amount of pull that is used will depend on your condition. A gentle on/off pressure may be better early on to help control arthritis pain. More vigorous traction can help take away pain if a spinal joint is mildly sore or tight.
Specialized treatments and exercises can help maximize your physical abilities, including flexibility, stabilization, coordination, and fitness conditioning.
Exercises that increase flexibility help to reduce pain and make it easier to keep your spine in a healthy position. Flexibility exercises are helpful for establishing safe movement. Tight muscles cause imbalances in spinal movements. This can make injury of these structures more likely. Gentle stretching increases flexibility, eases pain, and reduces the chance of re-injury.
The “core” muscles you’ll be working on are closer to the center of the body and act as stabilizers. These key muscles are trained to help you position your spine safely and to hold your spine steady as you perform routine activities. These muscles form a stable platform letting you move your limbs with precision. If the stabilizers aren’t doing their job, your spine may be overstressed with daily activities.
Strong muscles need to be coordinated. As the strength of the spinal muscles increases, it becomes important to train these muscles to work together. Learning any physical activity takes practice. Muscles must be trained so that the physical activity is under control. Spine muscles that are trained to control safe movement help reduce the chance of re-injury.
Improving overall fitness levels aids in recovery of spine problems. Fitness conditioning involves safe forms of aerobic exercise. The term aerobic means “with oxygen.” When using oxygen as they work, muscles are better able to move continuously, rather than in spurts. Exercise has other benefits as well. Vigorous exercise can cause chemicals, called endorphins, to be released into the blood. These chemical hormones act as natural pain relievers in reducing your pain. Examples of aerobic exercise include
If you decide you want some extra conditioning, always check with your doctor or therapist before beginning a program on your own. It is important that you choose an aerobic activity you enjoy. This will help you stick with it-guaranteeing you the long-term benefits that come with a well-rounded fitness program.
Therapists use functional training when you need help doing specific activities with greater ease and safety. Examples include posture, body mechanics, and ergonomics.
Using healthy posture keeps the spine in safe alignment, reducing strain on the joints and soft tissues around your spine. The time and effort you take to use good posture are vital to spine care, including prevention of future spine problems. As you gain strength and control with your stabilization exercises, proper posture and body alignment will be easier to remember and apply with all your activities.
Think of body mechanics as putting safe posture into action. It’s one thing to sit or stand with good posture, it’s another to keep safe posture as you actually move with activity. You want to keep your body in its safest alignment as you go about your daily tasks, such as
Safe body movement is especially important during lifting. To avoid extra spine strain when lifting, use these safety tips.
Ergonomics looks at the way people do work. It’s possible that even minor changes in the way you do your work or hobby activities could keep your pain and symptoms in check, while protecting your spine from further injury. Ergonomics doesn’t usually involve expensive changes. Even minor adjustments in the way you do your activities can make a huge difference in easing your pain and preventing further problems.
Once your pain is controlled, your range of motion has improved, and your strength is returning, you will be progressed to a final home program. Your therapist will review some of the ideas listed above to help take care of any soreness at home. You’ll be given some ways to keep working on your range of motion and strength. Before you are done with therapy, more measurements may be taken to see how well you’re doing now compared to when you first started in therapy.
Epidural Steroid Injection (ESI)
Back and Neck Braces
NON - OPERATIVE TREATMENT
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