Basis, indications and risk

Treatments Basis, indications and risk Patient information Postural hygiene Exercise Maintaining level of Activity Bed rest Pharmacological therapy Neuroreflexotherapy (NRT) Spinal column surgery Surgery for Pain and Pain Clinics Vertebral manipulation Behavioral treatment Epidural injections Facet joint infections Trigger point and ligament infections Rhizotomy Corsets and lumbar belts Traction Physical therapy/physiotherapy Electromyografic Feedback TENS: Transcutaneous electrical Nerve Stimulation Shoe insoles and shoe lifts Acupunture Recommended treatments

Epidural injections

It consists of the injection of steroid anti-inflammatory agents derived from cortisone, and/or local anesthetics in the medullary canal, in the area surrounding the membranes that cover the medulla. This area is called the epidural space.

Objective

To reduce inflammation, especially of the nerve roots, and improve pain.

Theoretical base

Nerve root inflammation is sometimes produced by compression, this being the cause for the onset of radiated pain. Cortisone derivatives have a potent anti-inflammatory effect, although their risks and contraindications do not allow a continued administration. When generally administered, only a portion of the administered dose reaches the swollen areas. To increase their anti-inflammatory effect and to reduce risks, steroids are injected into the dural space so as to obtain a potent local effect and less adverse reactions. This significantly reduces nerve root inflammation and improves radiating pain.

Administration of local anesthetics into the dural space permits a major percentage of the administered dose to have a full effect, thus improving the intensity of radiated pain.

Evidence of efficacy

Some of the early recommendations based on scientific evidence indicated that epidural injections have no effect in acute patients. However, later ones that consider the results of more recent studies, state that epidural steroid injections, with or without local anesthetics, appear to produce better short-term relief of back pain with sciatica.

A study subsequent to those recommendations shows that in patients with sciatica who are being considered for surgery, epidural injections yield a temporary improvement, without avoiding eventual surgery.

Risks and contraindications

Some of the existing recommendations based on scientific evidence point out that epidural injections are invasive and pose rare but serious potential risks. Common adverse effects are headache, increased intensity of back pain and sciatica, and fever. Inadvertent puncture of the dural membrane occurs between 0.5% and 2.5% of the cases. Exceptionally, dural abscesses or meningitis have been reported following epidural injections.

Indications

The existing recommendations based on scientific evidence do not include epidural injections in standard managed care for back pain. Based on the available studies, it may be wise to consider their use on patients, for temporary relief of sciatica, when pain is intense and resistant to all other treatments and when there is no indication for surgery.