FAQ ABOUT PAIN

Q. Should I apply ice or heat to an injury?
A. Ice should be used in the acute stage of an injury (within the first 24-48 hours), or whenever there is swelling. Ice helps to reduce inflammation by decreasing blood flow to the area in which cold is applied. Heat increases blood flow and may promote pain relief after swelling subsides. Heat may also be used to warm up muscles prior to exercise or physical therapy.

Q. What is physical therapy?
A. Physical therapy is the treatment of musculoskeletal and neurological injuries to promote a return to function and independent living. Physical therapy incorporates both exercise and functional training. Exercise restores motion and strength while functional training facilitates a return to daily activities, work, or sport.

Q. What is a cortisone/corticosteroid injection?
A. Cortisone is a steroid that is produced naturally in the body. Synthetically-produced cortisone can also be injected into soft tissues and joints to help decrease inflammation. While cortisone is not a pain reliever, pain may diminish as a result of reduced inflammation. In orthopedics, cortisone injections are commonly used as a treatment for chronic conditions such as bursitis, tendinitis, and arthritis.

Q. What is an epidural?
A. An epidural is a potent steroid injection that helps decrease the inflammation of compressed spinal nerves to relieve pain in the back, neck, arms or legs. Cortisone is injected directly into the spinal canal for pain relief from conditions such as herniated disks, spinal stenosis, or radiculopathy. Some patients may need only one injection, but it usually takes two or three injections, given two weeks apart, to provide significant pain relief.

Q. What are NSAIDs and how do they work?
A. Non-steroidal anti-inflammatory drugs (NSAIDs) are non-prescription, over-the-counter pain relievers such as aspirin, ibuprofen, and naproxen sodium. They are popular treatments for muscular aches and pains, as well as arthritis.

NSAIDs not only relieve pain, but also help to decrease inflammation, prevent blood clots, and reduce fevers. They work by blocking the actions of the cyclooxygenase (COX) enzyme. There are two forms of the COX enzyme. COX-2 is produced when joints are injured or inflamed, which NSAIDS counteract. COX-1 protects the stomach lining from acids and digestive juices and helps the kidneys function properly. This is why side effects of NSAIDs may include nausea, upset stomach, ulcers, or improper kidney function.

FAQ EPIDURAL SHOT

The following Frequently Asked Questions and answers are for epidural steroid injections. It is one of the most commonly performed procedures at ELIH.

The following material is given as general information only, and is not to be considered as medical advice or consultation.

Q. WHAT IS AN EPIDURAL STEROID INJECTION?
A. An epidural steroid injection is the administration of long lasting steroid (Triamcinolone, Depo-Medrol or Celestone) into the epidural space, which is the area surrounding the spinal cord and nerve roots. All of the nerve roots in the spine are covered with a protective sheath called the dura. When a prescribed amount of saline or long-acting local anesthetic agent (Bupivacaine) combined with a steroid medication (Triamcinolone, Depo-Medrol or Celestone) is injected adjacent to the affected nerve root, significant pain relief is often obtained. This is performed by a Board Certified Anesthesiologist, with subspecialty training in Interventional Pain Management and Pain Medicine. Anesthesiologists are trained early in their careers in the use of epidural placement techniques, which they then use on a daily basis to administer regional anesthesia in the operating room, and in the obstetric units to provide analgesia for childbirth. Their extensive experience with this technique makes them specially suited for this procedure.

Q. WHAT IS THE PURPOSE OF THE EPIDURAL STEROID INJECTION?
A. Asteroid injection reduces the inflammation and swelling of nerves in the epidural space. This will reduce pain, tingling, numbness and other symptoms caused by nerve inflammation or swelling. It also serves a diagnostic purpose in which the physician can obtain significantly useful information, depending on the patient’s response. Epidural injections are often recommended as an alternative, or at least an attempt to ward off the need for surgery. You may also have a condition in which surgery would never be of benefit, and the epidural injections may provide an alternative form of treatment.

Q. HOW DOES AN EPIDURAL STEROID INJECTION WORK?
A. There are two ways that epidural steroid injections work. Pain involves the inflammation of one or more nerves in the spine. The injection of steroids directly into the part of the spinal column called the epidural space aids in reducing this inflammation. Secondly, steroids act like a local anesthetic decreasing the pain long enough to allow the body to begin the process of repairing itself. The primary goal of an epidural steroid injection is to reduce pain. Relief could last weeks, months, or even years. On the other hand, some patients experience little or no relief.

Q. HOW LONG DOES THE INJECTION TAKE?
A. The actual injection takes a few minutes.

Q. WHAT IS ACTUALLY INJECTED?
A. The injection consists of a mixture of saline or a long-acting local anesthetic (Bupivacaine) and a steroid medication (Triamcinolone, Depo-Medrol or Celestone).

Q. WILL THE INJECTION HURT?
A. The procedure involves inserting a needle through the skin and deeper tissue (like getting blood drawn). There is minor discomfort involved. However, we numb the skin and deeper tissue with a local anesthetic (Lidocaine) using a very thin needle prior to inserting the epidural needle. In fact, the worse part is usually the injection of the numbing medicine, which will feel similar to a bee sting. Most of the time you will feel a strong pressure and not much pain.

Q. WILL I BE “PUT OUT” FOR THIS PROCEDURE?
A. No. This procedure is done under local anesthesia. Doing this procedure with the patient under general anesthesia or heavy sedation is contraindicated since it can lead to serious complications.

Q. HOW IS THE INJECTION PERFORMED?
A. It is done with the patient sitting up using fluoroscopic (x-ray) guidance. The area is cleaned with antiseptic solution, local anesthesic (numbing medication) is injected, then the epidural steroid injection is performed. In most cases, this process takes 3 to 5 minutes. After the procedure, you are placed on your back or side until ready to stand.

Q. WHAT SHOULD I EXPECT AFTER THE INJECTION?
A. Immediately after the injection, you may notice that your pain may be decreased or completely resolved. This is due to the local anesthetic. This will last only for 4 to 6 hours. Your pain will return and you may actually have more pain than usual for a few days. This is from the mechanical process of the needle insertion as well as initial irritation of the steroid. You should start noticing pain relief several days after the injection. Although the steroid will begin to work immediately after the injection, it will take 5 to 6 days for the swelling to diminish. Please remember that this is what takes place for the average patient, meaning that there are some that get immediate relief, while others may require 1 to 2 weeks to experience the full benefits.

Q. WHAT SHOULD I DO AFTER THE PROCEDURE?
A. We advise patients to take it easy for 24 hours, then you may resume regular activities and return to work. Please remember to remove the bandage one day after the procedure.

Q. HOW LONG DOES THE EFFECT OF THE MEDICATION LAST?
A. The immediate effect is usually from the local anesthetic injected. This wears off in 4 to 6 hours. The steroid starts working immediately after being injected, but most patients will not feel a difference until 5 to 6 days after the injection. This effect can last for several days to months or significantly longer.

Q. HOW MANY INJECTIONS DO I NEED TO HAVE?
A. After the first injection you will return in three weeks for a second epidural injection. Depending on your symptoms, additional injections may be indicated. It is recommended that no more than three injections be done in a six-month period, or six in a one-year period. It is also not recommended to continue with injections for more than a year, if no long-term relief is achieved.

Q. CAN I HAVE MORE THAN THREE INJECTIONS?
A. In a six-month period, we generally do not perform more than three injections. This is because the medication injected may last up to six months. If three injections have not helped much, it is very unlikely that you will get any further benefit from additional epidural injections. Other techniques should be performed if the first series of injections afford little relief.

Q. WHAT RESULTS CAN BE EXPECTED?
A. Generally most arthritic conditions of the neck or back with or without nerve-root symptoms (arm or leg pain), will obtain varying degrees of relief. Overall, approximately 50-75% of patients receive moderate to excellent pain relief. The relief is often permanent, especially in self-healing conditions such as mild “bulging” or "herniated" discs. For more severe conditions, relief depends on the amount of time that the patient has been in pain. In cases of severe nerve root compression syndromes (pressure on a nerve), the therapeutic pain relief will often be very brief. Significant pressure on a nerve may only improve by surgically removing part of the herniated disc. For other conditions, especially arthritic induced pain, 2 to 3 months of relief can be seen. A trial of two may be given, but usually no more than three are recommended over a six-month period.

Q. WILL THE EPIDURAL STEROID INJECTION HELP ME?
A. It is very difficult to predict if the injection will indeed help you. Patients who have “radicular symptoms” (arm or leg pain) respond better to the injections than patients who have only neck or back pain. Though certain types of neck or back pain from a bony abnormality will derive considerable benefit from the injections. Similarly, patients with a recent onset of pain may respond much better than the ones with long-standing pain.

Q. WHAT ARE THE RISKS, SIDE EFFECTS AND POSSIBLE COMPLICATIONS?
A. This procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The most common side effect is back or neck pain and spasms, which are temporary. Other risks include dural puncture with possible spinal headaches. Bleeding is more common in patients with genetic predispositions like Hemophilia, or patients taking blood thinners such as Coumadin, Warfarin, Plavix, NSAID's, anti-inflammatory medications, Lovenox or Aspirin. Bleeding into the spine may cause compression of the spinal cord with resultant paralysis. This would require emergency decompresive surgery and there would be no guarantee of recovery. Rarely, an infection may occur leading to meningitis.

Risks and side effects related to the medications include: weight gain, elevated blood sugar in diabetics, water retention, suppression of the body’s own natural production of cortisone as well as temporary suppression of the immune system. Minor temporary side effects are seen in 1-2% of patients: puffy red cheeks (facial flushing) or ankle swelling from fluid retention. Because the injection occurs next to an inflamed nerve root, sensations of increased pain, numbness in one or both legs, and difficulty voiding can occur temporarily. Rarely, side effects can occur including: steroid myopathy (weakness of the thigh muscles), temporary steroid psychosis, possible worsening of osteoporosis if present, and congestive heart failure.

Other side effects of the steroid medications include: low-grade fevers, hiccups, insomnia, headaches, increased heart rate and abdominal cramping or bloating. These side effects occur in only about 5% of patients and commonly disappear within 1-3 days after the injection.

Q. WHO SHOULD NOT HAVE THIS INJECTION?
A. Patients allergic to any of the medications to be injected, on blood thinning medication (Coumadin, Warfarin, Plavix, NSAID's, anti-inflammatory medications, Lovenox or Aspirin), with bleeding disorders (Hemophilia, Thrombocytopenia or any other Coagulopathies), or have an active infection should not have the injection.

Q. HOW SHOULD I PREPARE FOR THE PROCEDURE?
A. Stop any blood thinners (Coumadin or Warfarin) 4 days prior to your procedure. Always consult your primary care physician before stopping these medications. All antiplatelet medications (Plavix, NSAID's, anti-inflammatory medications, Lovenox or Aspirin) will need to be stopped 7 days prior to the procedure.

If you have a cold or an active infection, please call The Pain Center and reschedule the procedure for a later time. Remember that steroids may temporarily depress your immune system possibly worsening the infection.

PREDICTIVE FACTORS
Patients with classic disc related syndromes (arm or leg pain) with symptoms of less than 3 months duration have an excellent chance of symptomatic relief by epidural steroid injections. Epidurals have a lesser effect on patients with symptoms persisting for periods longer than 3 months or in patients treated previously by surgical methods.

CONCLUSION
Conclusions made after reviewing the studies are: two thirds of patients with acute disc related disease will benefit from epidural steroids. Only one third will benefit after 6 months. Three weeks after an epidural steroid injection the patient should be reevaluated. If there is significant improvement in function and subjective pain relief, a second epidural steroid injection is administered. If there is no change in the patient's condition after the first injection, an alternative intervention is sought. Because epidural steroid injections are often the last recourse before surgery, the benefit of up to three injections in a six month period should be considered for patients with pain related to neck or back problems.