EPIDURAL STEROID INJECTIONS (ESI)

FREQUENTLY ASKED QUESTIONS

What is a Pinched Nerve?

What is an Epidural Steroid Injection (ESI)?

Are Epidural Steroid Injections Painful?

Can I be put to “Sleep” for an ESI?

Can I have any Sedation for an ESI?

Are there any Risks with IV Sedation?

Will an ESI make all my Pain go Away?

How Long until the ESI Starts to Work?

How Long will Pain Relief Last after an ESI?

How many ESIs will I need?

What if the ESI does not Help my Pain?

What are the Risks of an ESI?

What are the Side Effects of Steroids?

Do I Need to Stop Any Medications for the ESI?

What Happens on the Day of the ESI?

What Happens After the ESI?

What is a Pinched Nerve?

  • Common term used to describe a nerve being compressed by some structure.

  • Nerve compression may affect the nerve’s ability to send electrical impulses.

    • If a large rock compresses a hose, it may affect the flow of water through that hose.

    • If a structure compresses a nerve, it may affect the flow of impulses through that nerve.

  • Possible Symptoms of a Pinched Nerve 

    • Pain

    • Numbness

    • Weakness

 

What is an Epidural Steroid Injection (ESI)?

  • Epidural Space: Location in the spine where nerves often get pinched

  • An ESI often places an anti-inflammatory medication at the site of the pinched nerve.

  • Goal: Reduce nerve inflammation in order to reduce pain and other symptoms.

 

Are Epidural Steroid Injections Painful?

  • Most individuals tolerate ESIs well with little discomfort.

  • If any discomfort is felt, it is usually short-lived and tolerable.

  • If you feel any significant discomfort during the procedure, tell your doctor.

 

Can I be put to “Sleep” for an ESI?

  • Stone Med DOES NOT recommend general anesthesia during any spinal procedure.

  • Risk of complications increases if an individual is “put to sleep”.

 

Can I have any Sedation for an ESI?

  • Individuals may choose to have “light” IV sedation for their injection.

  • Light sedation is not designed to put you completely to sleep.

  • Goal of Sedation: Reduce pain/anxiety enough to make the procedure more comfortable

  • Decision to have sedation is up to the individual having the procedure, not the doctor.

 

Are there any Risks with IV Sedation?

  • IV sedation increases the risk of nausea and vomiting during the procedure.

  • Vomiting while sedated may cause you to aspirate (inhale) some vomit into your lungs.

    • Could cause a serious pneumonia, requiring antibiotics and possible hospitalization.

  • Risk of aspiration is significantly reduced if you do not eat or drink prior to the procedure.

    • Do not eat for 6 hours prior to the procedure.​

    • Do not drink for 4 hours prior to the procedure.

 

Will an ESI make all my Pain go Away?

  • Goal: Reduction of pain enough to allow the individual to regain quality of life and function.

  • While it is possible to obtain complete pain relief after an ESI, this is not always possible.

 

How Long until the ESI Starts to Work?

  • Most individuals start to feel pain relief within 1-3 days after the steroid injection.

  • In some cases, it may take up to 7-10 days after the injection to feel any benefit.

  • Maximum improvement usually occurs around 7-14 days after the injection.

 

How Long will Pain Relief Last after an ESI?

  • Everyone responds differently to steroid injections.

  • An ESI works by reducing inflammation caused by the pinched nerve.

    • Pain often improves as nerve inflammation decreases.

    • Pain relief often lasts as long as inflammation does not return.

  • ESIs are basically “Band-Aids” designed to treat symptoms of inflammation.

    • Injections do not heal/remove the actual cause of the inflammation.

    • If the injection reduces pain for a long period of time, this can be a great Band-Aid.

  • Unfortunately, pain always has potential to return in the future if inflammation returns.

    • If inflammation returns quickly after the injection, pain may also return quickly.

    • If inflammation never returns, pain may resolve forever.

  • A “Good Response” for an ESI is considered at least 3-4 months of significant pain relief.

    • If symptoms return, another ESI may be needed to reduce inflammation again.

  • Medications, exercise and/or therapy can often enhance/prolong the benefit of the ESI.

 

How many ESIs will I need?

  • Number of ESIs needed depends on the response to the injections.

  • Many pain clinics perform a series of three ESIs on every patient no matter what.

  • At Stone Med, we have a different approach with injections.

    • If the first ESI works, there is no need to have a second or third injection.

    • If the first ESI helps, but some pain remains, a second ESI may provide “additive” benefit.

    • In some cases, three ESIs may be needed to achieve the desired reduction of pain.

  • Even if the ESI helps reduce pain significantly, pain may return again in the future.

    • If this occurs, it may be necessary to repeat the ESI again.

  • Steroid medications and injections are not without risk.

    • Recommendation: Limit number of ESIs to no more than 3-4x per body region per year.

    • As with any medical treatment, the minimal number of ESIs needed to have the desired effect is recommended.

 

What if the ESI does not Help my Pain?

  • Possible reasons why an ESI may not have helped reduce pain:

    • Some require more than one ESI to get adequate pain relief.

    • Sometimes pain is not due to inflammation.

      • ESIs work better when pain is due to inflammation.

    • There may be another cause of pain in the spine.

      • An ESI only treats pain related to the spinal nerves.

    • Individuals with severe spinal conditions may not respond well to injections.

      • Sometimes, more aggressive treatments like surgery, are better treatment options.

  • If the ESI does not help your pain, your provider will discuss other treatment options.

 

What are the Risks of an ESI?

  • All injections have possible risks, side effects, and complications.

    • When performed correctly, all the following risks are rare.

PAIN

  • ESIs usually do not cause significant discomfort during or after the procedure.

  • Any increased discomfort usually lasts less than 24 hours.

BRUISING

  • Superficial bruises resolve without any specific treatment.

  • More common in older individuals and those taking blood thinning medications.

INFECTION

  • Minimal risk, as we thoroughly clean the skin prior to every injection.

  • All needles are brand new (never reused) and opened just prior to the injection.

BLEEDING

  • Excessive bleeding is rare, even if the needle hits a deeper blood vessel near the spine.

    • Any bleeding usually stops on its own without complications.

  • Risk of Bleeding increases if:

    • You have a genetic bleeding disorder.

    • You are taking medications that thin your blood.

NERVE DAMAGE, PARALYSIS

  • Very Rare Complications

  • Direct Nerve Trauma from the Needle is very unlikely.

    • Risk is higher if the patient is “put to sleep” for the injection.

  • Damage to the anterior spinal artery could result in a spinal cord injury.

    • This artery supplies blood to the front of the spinal cord.

    • Contrast is injected to ensure the needle is not in a major artery.

SEIZURES, DEATH

  • Exceptionally Rare Complications

  • Even if all precautions are taken, these severe complications are never reduced to zero.

 

What are the Side Effects of Steroids?

  • Steroid medications have many potential side effects.

  • Steroid Injections usually cause less side effects than Steroid Pills.

  • Common Steroid Side Effects: Usually Mild and Temporary

    • Flushing of the Skin

    • Indigestion/Upset Stomach

    • Increased Appetite

    • Increased Blood Glucose Levels (See Section Below for Diabetic Patients)

    • Difficulty Sleeping/Insomnia

    • Increased Anxiety/Restlessness

    • Racing/Pounding Heart (Tachycardia, Palpitations)

    • Headaches

  • Rare, Severe Steroid Complications

    • Thinning of the Skin and Soft Tissue at the Injection Site

    • Weakening/Rupture of Tendons

    • Hypopigmentation (Whitening/Lightening) of the Skin around the Injection Site

    • Damage of Cartilage

    • Thinning of Bone (Osteoporosis)

    • Death of Bone (Osteonecrosis)

  • Diabetes Patients

    • Steroid medications will temporarily increase blood glucose levels.

    • If you use insulin, you may need to adjust your insulin dosing temporarily.

    • Be sure to discuss this with your primary care doctor or endocrinologist.

  • To reduce risk of steroid medications, it is best to limit the dose of steroids.

    • For injections, we recommend limiting ESIs to no more than 3-4 injections per year.

      • Less injections mean less risk of potential complications.

    • Although it seems like common sense, steroid injections should only be used if they provide significant benefits for pain.

      • Do not continue to get steroid injections if they do not help you.

 

Do I Need to Stop any Medications for the ESI?

Blood Thinning Medications

  • Blood thinners are often stopped about 3-7 days prior to spinal injections.

  • Tell your provider if you are taking any blood thinning medications.

    • Examples: Coumadin (Warfarin), Pradaxa, Eliquis, Xarelto, Plavix, Aspirin, etc.

  • These medications are usually prescribed for serious medical conditions.

    • We will contact your prescribing doctor to ensure it is safe to temporarily stop these medications for your procedure.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

  • NSAIDs are often stopped about 5-7 days prior to spinal injections.

    • These medications can increase your risk of bleeding.

  • Tell your provider if you are taking any NSAIDs.

    • Examples: Ibuprofen (Advil, Motrin), Naproxyn (Aleve, Naprosyn), Indocin (Indomethacin), Lodine (Etodolac), Relafen (Nabumetone), Meloxicam (Mobic), Diclofenac (Voltaren), etc.

  • Celebrex (Celecoxib) is an NSAID that does not significantly increase the risk of bleeding.

    • Celebrex does not have to be stopped prior to spinal injections.

Supplements

  • Many natural supplements can affect clotting pathways, increasing the risk of bleeding.

  • For safety, please stop taking supplements for at least 5 days prior to your injection.

    • Examples: Fish Oil, Vitamin E, Ginko Biloba, Ginseng, Garlic, St. John’s Wort

Other Medications

  • Do not stop taking any medications unless you are specifically told to stop.

  • If you have any questions about taking a certain medication, ask your provider.

 

What Happens on the Day of the ESI?

Where do I go?

  • All ESIs are performed in an outpatient ambulatory surgery center.

  • The address and phone number of the surgical center will be provided to you.

When Should I Arrive?

  • Please arrive at least 15 minutes prior to your appointment to get checked in.

How Long will the Procedure Take?

  • Expect your appointment to last around one hour from arrival to discharge.

Should I Take my Blood Pressure Medications on the Morning of the Procedure?

  • Yes; these medications do not thin your blood. Take them always.

Can I Eat or Drink prior to the Procedure?

  • If you are not having Sedation, you can eat and drink before the procedure.

  • If you want Sedation:

    • Do not eat for 6 hours prior to your injection.

    • Do not drink for 4 hours prior to your injection.

      • You may take your medications with small sips of water.

Can I Drive Myself to the Procedure?

  • If you are not having Sedation, you may drive yourself or use a Taxi/Uber/Lyft service.

  • If you are having Sedation, you MUST have an adult over 18 years old to drive you home.

    • You cannot use a Taxi/Uber/Lyft service unless you have an adult with you.

    • Your driver must remain at the surgery center throughout the entire procedure.

      • Your driver is not allowed to leave and come back later to pick you up.

      • Individuals have been left at the surgery center with no way home (sad but true).

 

What Happens After the ESI?

ACTIVITY

  • On the day of the injection, you may resume normal, everyday activities.

  • Try to avoid strenuous lifting/activities for about 2-3 days after the procedure.

MEDICATIONS

  • You may take pain medications immediately after your injection, if needed.

  • You may resume NSAIDs, Aspirin and other blood thinners the following morning.

PAIN

  • You may use ice over the injection site, 20 minutes on, 20 minutes off, repeating as needed.

EATING/DRINKING

  • You may eat and drink immediately after your injection is finished.

WATER/BATHS/SHOWER

  • You may shower the evening of your procedure, if desired.

  • Avoid submerging the injection site under water for 24 hours to reduce any risk of infection.

    • No Baths, No Swimming Pools, No Hot Tubs, etc.

CALL YOUR DOCTOR IF YOU DEVELOP ANY OF THE FOLLOWING:

  • Fever/Chills

  • Drainage/Other Signs of Infection

  • Excessive Swelling or Redness at the Injection Site

  • New/Worsening Severe Pain

  • New/Worsening Bowel/Bladder Dysfunction

  • New/Worsening Numbness/Weakness

  • New Headache that does not Resolve on its own

FOLLOW UP

  • Typically, you will be seen in the office about 2 weeks after the injection.

  • If you have not made a follow up, please call the Stone Med office to set up this appointment.