The epidural steroid injection is the most commonly performed pain management injection. It has been used for years, with little alteration, to effectively treat spinal pain in patients suffering from injuries. Like all medical procedures, there are specific indications for epidural injections. If performed for the appropriate indications, these procedures likely will be beneficial to the patients that receive them.
Radiculopathy (nerve pain)
According to the alphabet soup of medical spine societies, (NASS, SIS, AAPMR, ASIPP), the basic indication for an epidural injection is nerve pain. This is seen as radiating pain in the distribution of a cervical, thoracic or lumbar nerve. In cases of cervical injury, this usually means pain radiating down the arm to the hand. In cases of lumbar injury, this means pain radiating down the leg to involve the calf, shin or foot.
Failure of conservative care
The medical societies are consistent in that one should first undergo at least 4 weeks of conservative care before considering epidural injections. Conservative care is not defined or stipulated. However, reasonable conservative care may include activity limitation, over the counter or prescribed medications, home exercise/stretching, chiropractic care or physical therapy. It may also include non-traditional methods such as acupuncture, cupping and herbal remedies. While optimizing conservative care under physician supervision will lead to more rapid improvement, the outcome of conservative care will depend more on time than anything else.
Functional impairment
When there is functional impairment a patient should be considered for an epidural injection no matter how long the duration of conservative care. This means that patients should be considered for an epidural injection when they cannot care for themselves, cannot work, cannot perform their usual leisure activities or cannot exercise. In other words, an epidural injection should be considered when there is some level of significant disability, whether the patient has completed a prescribed term of conservative care or not.
Neck or back pain
Although insurance adjusters and defense experts often argue to the contrary, epidural injections are effective at treating axial neck or back pain. Axial pain means non-radiating neck or back pain. This is pain that is unlikely to be of nerve involvement. In the case of high-level athletes and pregnant women, medical treatment guidelines allow epidural injections for back or neck pain. Although not present in medical guidelines statements, there is ample evidence to believe that epidural injections may also benefit the average patient with neck or back pain due to disc injury, even with an absence of nerve symptoms. The medical and scientific literature possesses multiple studies of moderate evidence. While the level of evidence has not been high enough to be incorporated into a guidelines statement, it is compelling enough that it is standard practice for interventional physicians to use epidural injections to treat back and neck pain thought to be caused by a disc.
Conclusion
Epidural injections provide patients with an effective means to treat long-lasting and significant pain before turning to surgical means. Patients do not have to wait months to get these injections. According to professional practice guidelines, they can receive them as early as 4 weeks if they are not improving or sooner if there is functional impairment. The injections are indicated for the treatment of nerve pain as well as back and neck pain due to disc injury.
Charles Bovary, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
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