Transforaminal Epidural steroid injection
Overview

A transforaminal epidural injection is minimally invasive pain management procedure. It involves inserting one or two needles into neural foramen, the opening at the side of the spine where a nerve root exits, and injecting a local anesthetic with a steroid into the epidural space in the spine. Steroid medication can reduce inflammation and swelling, and then reduce pain. The procedure can be done in the neck, midback, and low back for neck pain, mid-back pain, and low back pain respectively. However, it is most commonly performed for arm pain due to neck conditions, and leg pain due to low back conditions. The pain relief from epidural steroid injections can be short-term or long -term. It may last from a few days or few weeks to months or years. The patients may have three epidurals in a year in general.

Transforaminal epidural steroid injection is a targeted injection as a local anesthetic and a steroid is injected directly to problematic area(s). This injection is suitable for the patients who have problem with only one or two levels of vertebrae.

A needle in neural foramen, the opening at the side of the spine where a nerve root exits

A needle in neural foramen and contrast dye flows up into the epidural space and down to the nerve.

There are other types of epidural steroid injections, interlaminar epidural steroid injection. Interlaminar epidural injection is inserted a needle into epidural space directly in the middle of back between two vertebrae.  It is called cervical, thoracic or lumbar epidural steroid injection if it is done in the neck, mid back or lumbar region respectively. It is "shot-gun" procedure because it is injected into epidural space and allow medications to diffuse inside upper and down, and the right and left. It is suitable for the pain from multi-level spines. For more detail information about interlaminar epidural steroid injection, please click here to see our web page for interlaminar epidural steroid injection.

The figure shows transforaminal epidural injection, a needle in the foramen, and interlaminar epidural injection, a needle in epidural space.

The epidural space is the area between the dura mater (a membrane) and the vertebral wall, containing fat and small blood vessels. The space is located just outside the dural sac

This figure shows epidural space and related structures.

Indications

The epidural steroid injection is indicated in the pain of neck, mid-back and low back. However, it is most commonly used for the arm pain, caused by the neck condition; leg pain, caused by the low back conditions; and chest pain, caused by mid-back condition. The following conditions are indicated for transforaminal epidural steroid injection. 

  • Sciatica, radicular pain or Radiculopathy

  • Spinal stenosis

  • Spondylosis

  • Disc herniation

  • Degenerative disc disease

  • Postlaminectomy syndrome

  • Failed back surgery syndrome

  • Status post fusion

Preparation for Procedure

The treating physician will review the patient medical record and discuss with the patient If the patient have following conditions:

  • Diabetes Mellitus: Steroid may increase level of blood sugar. It can be dangerous if the patient has uncontrolled diabetes.

  • High Blood Pressure: It can be problematic if the patient has uncontrolled high blood pressure.

  • Renal Disease: The contrast dye may aggravate the renal condition.

  • Allergy: It can be dangerous if the patient is allergic to contrast dye or any medications being used for the injection.

  • Pregnancy: X-Ray should not be used for women who are pregnant.

The patient should discuss medications with treating doctors, including prescription medications and over-the-county medications.

 

Blood thinner may thin the blood and increase risk of bleeding. It includes the medications as follow:

Anticoagulants: 

  • Coumadin has to be stopped 5 days before the injection and laboratory test for INR should be checked in the morning of the injection.  INR should be around 1 for this type of procedure.

  • Lovenox has to be stopped 24 hours before the injection.

  • Pradaxa, Eliquis and Xarelto should also be stopped. 

 

Anti-inflammatory medications (NSAID):

  • Ibuprofen, Motrin, Advil, Aleve, Naproxen, Aspirin, Plavix and some other medications should be stopped for 7 days before the injection.

Medications should be reviewed with the treating physician before the injection. Some other medications may thin the blood except the medications as mentioned above.

The patient should not eat or drink anything after midnight the night before your procedure if you are going to have IV sedation. The patient may also need to consult with his or her physician to find out what other medications he or she can take or can’t take in the next morning.

The patient does not have to stop eating or drink if he or she does not need sedation. 

The physician may prescribe Valium for the patient if the patient is anxious and if the patient don't need sedation.

 

The patient  needs a driver to drive him or her home after the procedure.  The patient may need driver to drive him or her to the facility and home if the patient takes Valium.

Procedure

The procedure can be performed in a doctor's office or in the hospital. The procedure may last 15-30 minutes.

The doctor may review the patient's case again with the patient and answer his or her questions before the procedure. The patient should always mention his or her allergy to the treating physician. The patient is going to sign consent form first. 

The spine model shows a needle in the foramen. 

X-Ray images show injection site pointed with clamp on the left and a needle in the foramen with contrast dye on the right

The patient is then brought into procedure room and placed in the prone position (face down) in a surgical table.The treatment area is disinfected with Beta-dine three times. A C-Arm X-Ray is brought into field to locate injection sites.  Local anesthetic agent is used to numb the injection sites with a very fine needle. The patient may feel some discomfort with transient burning sensation. Spinal needles are then inserted under the guidance of real-time fluoroscope. The needles are placed to the side of vertebra, the opening for the nerve root.  The patient may feel the pain travelling down the leg when the needles are inserting. This is good sign and tells the treating physician that the needles may be in the right position. Once the physician feels the needles are in the right location, contrast dye is injected into the area to confirm the needle position. The contrast dye may travel along the nerve root and flow into epidural space. Then the medications, local anesthetic agent and steroids are injected. The needles are withdrawn and puncture areas are dressed with a Band-Aid. 

The patient will be observed for about 20 minutes after the procedure.

Post Procedure Care.

  • The patient may restart blood thinner and anti-inflammatory medications after the procedure.

  • The patient should check blood sugar and blood pressure closely if the patient has diabetes or high blood pressure. 

  • The patient may remove Band-Aid or other dressing in 6 hours and may take shower thereafter.

  • The pain can be worse in a few hours after the injection and it can last 1 to 3 days, then the pain starts to subside. Initial pain relief is due to local anesthetic and the pain relief later on is due to steroid effect.

  • If the area is uncomfortable in the first two to three days after the injection, a cold pack can be use to reduce the pain.

  • The patient should not drive the day of the injection unless approved by the treating physician.

  • If sedation was used, the patient should not drive for 24 hours after the procedure.

  • The patient is advised not to do anything strenuous.

  • If the patient has sign of infection, such as fever, chills, or redness or drainage at the treatment site or have temperature of 101 degrees or greater, call the treating physician’s office or go to emergency room if the treating physician is not available.

  • Follow up with treating physician in 1 to 2 weeks to plan for next treatment.

 

Risks and Complications

The potential risks are very low and complications are rare.

Related to needle:

  • Bleeding.

  • Infection

  • Nerve or spinal cord damage

Those are very rare complications.

Related to Medications

  • Allergy:  Allergic to contrast, steroid, local anesthetic agent.  As general rule, patients should always mention their allergy to treating physician before any procedures.

Side effect due to steroid:

  • Transient hot flashes

  • Fluid retention

  • Weight gain

  • Increased appetite

  • Elevated blood pressure

  • Mood swings, irritability, anxiety, insomnia

  • High blood sugar - The patients with uncontrolled diabetes should inform their primary care physicians about the injection.

  • Steroid psychosis, very rare.

Fortunately, the side effects from steroid only last 1-3 days in general.

 

Case Study

Coming soon.

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