c- Injection and Radiofrequency Methods Applied to the Epidural Area

Patient Information Form Frequently asked questions about epidural injections include:

1. What is an epidural injection, what is its purpose, and how does it work?
2. What preparations are required before the injection?
3. How is the injection administered, and how long does it take?
4. Is the injection painful?
5. What should I expect from the injection?
6. How many injections are required?
7. When can I return to work after the injection?
8. What benefits can I expect?
9. What are the risks and side effects?
10. Who should not have this injection?

 

Epidural Injection

 

 

1. What is an epidural injection?

An epidural injection is a medical procedure where drugs such as steroids, local anesthetics, or hyaluronidase are administered directly into the epidural space—a fat-filled area between the bone and the protective sac of the spinal nerves. This treatment is typically used to alleviate pain caused by pressure on spinal nerves, often due to conditions such as herniated discs, also known as slipped or ruptured discs, which can cause intense pain.

The human spine is composed of a series of bones called vertebrae, stacked on top of one another, forming the spinal column. Between these vertebrae are intervertebral discs, which act as cushions. When these discs herniate or rupture, they can put pressure on the nearby spinal nerves, leading to pain. This pain can be localized or can radiate to other areas, depending on the location of the herniation.

By injecting medication into the epidural space, the goal is to reduce swelling, inflammation, and pain in the affected area. The injected fluid can also help to break up scar tissue, allowing for improved movement. Local anesthetics provide immediate pain relief by numbing the area, hyaluronic acid can help reduce tissue inflammation, and steroids reduce swelling and inflammation.

The procedures are usually guided by imaging techniques such as fluoroscopy to ensure the medication is delivered to the correct location.

The combined effects of these mechanisms not only reduce pain but also help to treat the damage caused by the disc herniation by removing inflammation around the nerves.

Steroid Administration in the Epidural Space

It is important to correct a common misconception about the use of steroids or cortisone in medicine. The general belief among the public is that cortisone has extremely significant side effects. To some extent, this is true. However, like antibiotics, cortisone comes in many different forms and properties. It is not a single type of medication. Therefore, when used correctly, it does not cause any significant side effects.

Administering steroids around the nerves in the spinal cord has been practiced for over 50 years. After the nerves leave the spinal cord, they reach a cylinder-like sheath called the epidural space. If inflammation - a swelling - has occurred within this sheath due to a disc herniation or another cause, administering steroids directly to the diseased area, rather than systemically (that is, orally or through a vein), is much more effective.

    

 

Steroids can be administered directly to the affected area in cases of disc herniation, spinal canal stenosis, and arthritis in the facet joints.

They are especially preferred for disc-originated back, leg, neck, and arm pain that have not improved with conservative methods such as medication treatment, exercise, and physical therapy.

In the majority of patients who undergo this procedure, pain is completely eliminated. Significant improvements are also observed in symptoms associated with pain, such as numbness, tingling, and muscle weakness. In the small number of patients where improvement is not achieved, the procedure can be repeated. The general consensus is that the procedure can be performed up to three times within a few months.

        1. Epidural injections are administered in the following conditions:

For acute pain:

• Post-surgical pain,
• Post-trauma pain,
• Hip fractures,
• Pain after herpes,
• Pain due to vascular occlusions,
• Ureteric colic, kidney stones.

For chronic pain:

• Back and leg pain,
• Neck and arm pain,
• Spinal canal narrowing,
• Pain after spinal disc surgery,
• Pain due to occlusion of leg vessels,
• Phantom limb pain in amputees.

2. Preparations before the injection:

• Ask your doctor to explain the method in detail before the epidural injection. Your doctor will require written consent from you as required by law.
• Inform your doctor about all other illnesses you have, medications you use, and factors and medications that cause allergies. Herbal medications like vitamin E, glucosamine, garlic, and ginseng can also cause bleeding.
• It is advisable to consult your doctor about stopping all blood-thinning medications except aspirin.
• Bring all your previous test results, such as MR, CT scans, and laboratory findings, when you go for the procedure.
• Wear comfortable clothing and leave your watch, rings, and other jewelry at home.
• Food and water intake should be stopped at least 4 hours before the procedure. However, medications for other systemic diseases can be taken with a small amount of water.
• Sedation, which is a form of anesthesia, will be applied during the procedure, so you are not allowed to return home alone. You should come with an attendant. Also, the local anesthetic applied can cause temporary weakness and numbness in the legs, so you should not drive.

3. How is the injection applied, and how long does it take?

The procedure is carried out under imaging guidance:

• The epidural injection procedure takes 15-20 minutes and is performed under operating room conditions.
• The patient lies face down on the operating table. A vein is accessed for medication administration, and for neck regions, the patient may lie on their back.
• The patient is connected to a device to monitor heart rate, pulse, blood pressure, and respiration.
• Sedatives and pain relievers are administered intravenously.
• The skin is then cleaned with an antiseptic solution and covered with sterile drapes.
• Fluoroscopy, which is an imaging technique, is used to determine the area of intervention, and a local anesthetic is applied to the skin area corresponding to this region.
• Under imaging guidance, electrodes similar to needles are inserted to reach the area closest to the disc that is pressing on the nerve.
• Stimulation is given through the electrode to confirm that the needle is in the correct place.
• A dye is injected through the needle under imaging to further confirm the correct position of the needle. This confirms the needle position twice.
• Local anesthetic, hyaluronidase, and depot steroid solutions are then injected under imaging guidance.
• The patient is allowed to recover.
• The needle entry site is closed in a sterile manner.
• After the procedure, the patient is taken to their room for observation and is usually discharged after an average observation period of 2-3 hours.

Final Appearance of the Electrode

4. Is the injection painful?

The injection is not painful. Sedative drugs and analgesics are given to ensure the patient does not experience pain. During procedures such as endoscopy, a method called "sedation" is applied, where drugs are administered intravenously, putting the patient into a temporary sleep; however, the patient wakes up immediately after the procedure ends.

Neck area epidural procedure

5.  What should I expect after the injection?

 The pain decreases. The reduction in pain is due to the effect of the local anesthetic and lasts about 4-6 hours. Afterward, the pain may return and can be more intense than before the procedure for about 5-6 days. The pain is expected to gradually decrease and disappear within an average of 3 weeks. Generally, there is a 50-70% success rate.

6. How many injections are needed?

 If the patient does not benefit from the first procedure, it may be repeated. However, it is not recommended to repeat more than twice within 6 months. Especially in cases called disc herniation, the improvement is often permanent. In more serious cases, the chance of success is inversely proportional to the duration of the disease. In cases of severe nerve compression, recovery may be superficial. Surgery may be recommended when there is mechanical pressure on a nerve.

 

 

7. When can I return to work after the injection?

After the procedure, bed rest for about 3-4 days is recommended. Bed rest implies a limitation of activities. It is advised to rest in a comfortable position, except for eating, bathroom needs, and bathing. Patients can usually return to work a week after the injection.

8. What benefits can I expect?

For patients who have no permanent numbness, strength loss, or reflex loss in their arm or leg, and only suffer from pain, this method is extremely effective for 50-75% of them. Patients should be educated on how to move, behave, and lift weights afterward. If this education is provided correctly, the effect can be permanent.

9. What are the risks and side effects?

Epidural injections are safe methods that have been used for over 50 years. The method is adjusted under imaging with needle-like electrodes. These electrodes can measure the resistance of the application area electronically in ohms. Therefore, the method is not applied when unintended areas are reached. Side effects are very rare. Because it is administered to a limited area and systemic spread is minimal, side effects related to steroids are almost never seen. Some patients may experience temporary headaches, which can be controlled with bed rest and painkillers, after the procedure. This condition occurs in approximately one in a thousand patients. As seen, even the most common complication of an epidural injection is quite rare. Infection is a very rare serious side effect. To prevent this, the procedure must be carried out in completely sterile conditions. Since the entry point of the needle and the epidural space are determined under radiological imaging, serious side effects such as bleeding or nerve damage are almost never encountered.

10. In which patients is it not applied?

 Epidural injections, like all other interventional procedures, are not applied in patients who have an infection source in any part of their body, patients with bleeding disorders, patients on anticoagulants like warfarin, and in pregnant women.