Image Guided Lumbar Epidural Corticosteroid Injection

Prof Mark Khangure
Dr Jason Wenderoth

What are the generally accepted indications for an image guided lumbar epidural corticosteroid injection?

  • Short term (i.e. up to 3 months) relief of radicular back pain.
  • Causes may include spinal stenosis, foraminal stenosis, disc protrusion, annular fissure in the disc and traumatic disc tear.
  • The procedure has been used as an interim measure to delay surgery, and post-spinal surgery to reduce oedema and inflammation in selected cases.

What are the prerequisites for having an image guided lumbar epidural corticosteroid injection done?

  • Clinical history and examination indicative of lumbar radicular pain.
  • Good quality recent imaging, either MRI or CT.
  • Consultation with a specialist highly desirable.
  • Exclusion of infection, malignancy or acute fracture as the cause for pain.

What are the absolute contraindications for an image guided lumbar epidural corticosteroid injection?

  • Epidural infection or meningitis.
  • Coagulation defects. Patients taking anticoagulants and/or antiplatelet agents need to have these discontinued for a period of time before the procedure
  • Features of cord compression or pain associated with significant weakness as a result of root compression.

What are the relative contraindications for an image guided lumbar epidural corticosteroid injection?

  • Severe hypertension.
  • Diabetes – steroid may raise blood sugar.
  • Known allergy to contrast anaesthetic agents and particular steroid preparation.
  • Chronic low back pain without radiculopathy.

What are the adverse effects of an image guided lumbar epidural corticosteroid injection?

Immediate:

  • transient increase in back or leg pain;
  • bleeding leading to thecal sac compression, this is rare in patients with normal clotting mechanism;
  • headache;
  • complete spinal block – usually indicated intrathecal injection.

Observation is usually all that is required, but in the case of bleeding the patient may need to be admitted for close clinical observation.

Delayed:

  • hot flushes and redness (lasting up to a week);
  • meningitis/epidural abscess;
  • posture-related headache from CSF leak (as a result of inadvertent thecal sac puncture) may require blood path if no relief with bed rest;
  • urinary retention – occasional catheterisation necessary;
  • allergic reaction.

Adverse events are very rare in experienced hands, particularly with CT guidance and attention to detail.

Is there any specific post procedural care required following an image guided lumbar epidural corticosteroid injection?

  • The patient is observed in the radiology department, in bed until normal power and sensation have returned.
  • Avoidance of strenuous activity for a couple of days.
  • Driving should be avoided on the day of the procedure (it is advisable to have someone drive the patient to and from the practice).
  • Patients are advised to continue any regular pain relief medications they are taking, particularly for the first 24 hours post-procedure, because the injection may in fact exacerbate symptoms during this period. After that, they are advised to wean off any medications they are on, tapering to zero on day 4–5 post-injection to assess the effect of the injection. If they are not on any medication at the time of the procedure, they are advised them to take 1g paracetamol every 6 hours for 24 hours post-procedure, then as needed according to the directions on the packaging thereafter.
  • Diabetic patients need to have blood sugar levels monitored.
  • In general, anticoagulant drugs may be started the day following the procedure, but it is advised to check this with the radiologist on the day of the procedure.

Are there alternative imaging tests, interventions or surgical procedures to an image guided lumbar epidural corticosteroid injection?

Non-invasive therapies (such as physiotherapy and pain medication, TENS, acupuncture) and surgery are alternatives to epidural steroid injections.

Further information about epidural corticosteroid injections:

Epidural steroid injection should be part of a ‘spinal rehabilitation programme’. They provide temporary relief, but best results are obtained when combined with other measures.

Useful websites about lumbar corticosteroid injections:

American Journal of Neuroradiology:
www.ajnr.org/cgi/content/full/25/10/1821

Last saved on 12 October 2016.

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