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Spinal Injections For Back Pain

In this article you will find out about the most effective spinal injections for back pain in 2022. We will explain the pros and cons of each injection.

Lower back pain is a common complaint in individuals with various health conditions worldwide. While some cases of lower back pain may go away and the individual may not require any treatment, many cases move on to become chronic and lead to the individuals consulting a healthcare professional like orthopaedic physicians or orthopaedic surgeons. One treatment modality commonly recommended for back pain is injections, which may be done in conjunction with physical therapy and steroid medications.

What are the Causes of Back Pain?

To understand how spinal injections for back pain work it is first important to understand what the most common causes of back pain are. There may be many causes of back pain, including mechanical causes, inflammatory causes, degenerative causes, oncologic causes, and even infectious causes. (1)

Mechanical Causes of Back Pain

Mechanical causes of back pain include any injuries that may have resulted from trauma or accident. These injuries commonly affect the spine, intervertebral discs, and soft tissues. A common type of back pain caused by mechanical injury to the back includes disc herniation. Pregnancy may also be a cause of mechanical back pain.

Degenerative Causes of Back Pain

Degenerative causes of back pain may include degeneration of the facet joint, commonly seen in conditions like Osteoarthritis. This may also be experienced by individuals diagnosed with spinal stenosis, sacroiliac joint osteoarthritis, and degenerative joint disease. In addition, individuals who are at an increased risk for fracture due to osteoporosis may also experience back pain.

Inflammatory Causes of Back Pain

Inflammatory causes of back pain may include conditions like spondylarthrosis like ankylosing spondylitis. These inflammatory disorders are usually seronegative.

Infectious Causes of Back Pain

An infection may also cause back pain in the body. Most commonly, the infections that may present with back pain include infections of the spine, disc infections, abscesses in the epidural space, or muscles and soft tissue abscesses.

What are the Indications for spinal injections for back pain?

Spinal injections for back pain, like epidural steroid injections may be recommended for individuals experiencing inflammation or irritation in their spinal nerve roots. The type of nerve and the location of the irritation may lead to the appearance of different characteristics of pain. For example, Radicular pain is often reported along the dermatomes of the spinal nerve. The conditions responsible for disturbing the spinal nerve roots may present with symptoms like lower back or lumbar pain that radiates down to the buttock.

This is also referred to as Sciatica. These individuals may also report cervical pain, where the pain radiates to their arms. Hence, the two conditions caused by spinal nerve root pinching, where a back pain injection may be indicated, include herniated discs and lumbar spinal stenosis. (2)

Disc herniation occurs when the central region of the disc, also known as the nucleus pulpous, pushes out and causes increased pressure on the surrounding spinal nerves. This also leads to pinching of these nerves. This pinching leads to back pain and muscle weakness. Some individuals may also report numbness.

Lumbar Spinal Stenosis is another common indication for an epidural steroid injection, which is directed to the irritated nerve root. This is associated with the narrowing of the spinal nerve root canals, which is also known as stenosis. This may be caused by arthritis or other pathologies affecting the intervertebral disc.

How is Back Pain Diagnosed?

In the majority of the cases, back pain is diagnosed by conducting a detailed history and physical examination of the patient. However, if the orthopaedic or other healthcare physician suspects an underlying cause that requires immediate attention, they may conduct other tests. These additional tests may include evaluation of pain signals, and anteroposterior and lateral X-rays, which may help the doctor identify any bony pathology.

They may also suggest an MRI if they need a thorough evaluation of sifting tissues. (3)  For example, if an individual is suspected of having a herniated disc, the radiologist may conduct an MRI, while a CT scan may be conducted to rule out radiculopathies like separation or apophyseal ring. (4)

What are the Treatment Options for Back Pain?

The first step that is considered to hold crucial importance in the management of back pain is the identification of any red flags which may put the individual at health risk. These red flags should be immediately recognized and treated as a priority (5). Moreover, these may differ in importance between individuals of different ages and with different medical conditions. Once the cause of the back pain is evaluated, the orthopaedic experts can then start planning the treatment for the patient.

The treatment modalities for back pain may be divided into two types based on invasiveness. These include conservative management and surgical management. The conservative management may include anti-inflammatory medications like NSAIDs, over-the-counter pain medication, muscle relaxants, and topical local anaesthetics for low back pain. (6)

Since most of the cases of low back pain arise from mechanical causes, they may be significantly improved by taking short-term rest, icing the inflamed area, and applying heat were recommended by the doctor or physiotherapist.

Individuals being treated with conservative and invasive approaches may be recommended physical therapy and undergo muscle strengthening exercises under the supervision of an expert. If lower back pain has turned into chronic pain and does not seem to be improving with interventional physiotherapy and pain management, and lasts more than six months, then the doctor may recommend another x-ray to detect signs of any acute injury. The individual may also be recommended corticosteroid injections, ablative therapy, spinal cord stimulation, and Kyphoplasty. (7)

What type of spinal injections for back pain are available?

Facet Joint Or Nerve Block Injections

The facet joint injections, which may also be referred to as the nerve block injections, are usually injected in the area around the nerve. The injection consists of a local anaesthetic or numbing agent like lidocaine. After the injection, most individuals report a feeling of numbness and an adequate level of pain relief. This may last for several hours.

Lumbar Epidural Steroid Injections

The lumbar epidural steroid injections, as the names suggest, are redirected around the spinal cord at the lumbar region. These injections contain corticosteroids, which may be given in conjunction with anaesthetic agents. Their effects last for a short time, and they are reported to offer a moderate intensity of pain relief. However, this makes them ineffective for long-term pain relief and may be administered repeatedly.

What does a spinal injection for back pain procedure involve?

The injection administration procedure includes the orthopaedic physician and their staff, including the nurse, physician’s assistant, anaesthesiologist, and fluoroscopic c arm operator. Before starting the procedure, the patient may be asked to fill out a form; their vitals may be taken, including their blood pressure and blood sugar. The patients may also be asked about their vaccination status and checked and asked about any allergies to ensure they don’t have an allergic reaction during the procedure. This is followed by the injection site being assessed, after which it may be marked. The patient is usually lying on a fluoroscopy table in a prone position. The marked injection sites are then carefully cleaned and may be covered with a sterile drape. No sedation is generally required.

The epidural steroid injections can be of various types, depending n their unique site of application on the body, the path followed by needles, and the technique used. The site for steroid injection commonly includes the lumbar region, thoracic region, and cervical region. This path of the needle may be interlaminar, transforaminal, or caudal. While the interlaminar injections are administered between the lamina, the transformational is administered across the foramen. The caudal injection is administered through the sacrum. (8)

Medial Approach

The Medial approach for steroidal injections starts by placing the individual in a prone position. The interlaminar space in the vertebrae is first recognized through anteroposterior x-ray guidance. The tissues and skin are then numbered through a local anaesthetic injection, usually comprises lidocaine or bupivacaine. This is followed by the insertion of the epidural spinal needle into the injection site marked earlier. The needles are inserted into the skin slowly, from the superficial o the deeper layers. Once this is done, an x-ray with a lateral view is conducted, which helps the doctor confirm the position of the needle. Once inserted into the epidural space, the doctor injects a few MLS of normal saline. The syringe is again filled, but this time it is filled with a contrast medium. Injection f this contrast medium into the epidural space is done to reconfirm that the needle is placed in the epidural space. Once this is confirmed, the doctor may then inject steroids like methylprednisolone, dexamethasone, triamcinolone, and betamethasone. A local anesthetic solution may also accompany this. After removing the needle from the epidural space, the doctor may maintain pressure at the injection site to prevent bleeding.

Lateral Approach

The lateral approach is also known as the Transforaminal Epidural Steroid Injection technique. This procedure starts by first recognizing the injection site, which in this case is the lateral foramina space. This space I found between two vertebrae may be identified using an oblique view on a fluoroscopic x-ray. Once this is confirmed, the doctor may start injecting a local anesthetic into the skin and underlying tissues. This mainly consists of bupivacaine or lidocaine. The epidural needle insertion follows this in the below superior vertebrae pedicle. To confirm the exact depth of the needle, the doctor may take a lateral X-ray. This is done to prevent any damage to the underlying nerve root. Then, the needle is inserted further until it reaches the outer part of the intervertebral foramen. Next, steroid like dexamethasone is injected into the epidural space without a local anaesthetic. When the needle is withdrawn, the doctor may keep the area pressed to prevent bleeding from the injection site.

A person having a spinal injection

Prolotherapy

Many structures in the back have a poor blood supply, which is why they can struggle to heal on their own. It is the oxygen and nutrients in our blood supply that help to heal these structures.

Prolotherapy involves the injection of a regenerative solution into these structures to provide a direct supply of what is needed to heal them and provide pain relief.

As the treatment is helping to treat the root cause of the problem, it is deemed to be a permanent fix.

Frequently Asked Questions About Spinal Injections for Back Pain

How Long do Spinal Injections last?

Spinal injections like lumbar epidural steroid injections usually provide pain relief for as long as three months. However, this may be more or less depending on the patient’s factors and the technique used. While some people may experience immediate pain relief, others report no improvement in symptoms.

What are the Side Effects of Steroid Injections for Back Pain?

The common side effects experienced by individuals after steroid injections include sleeping problems, changes in their menstrual cycles, anxiety, increased water retention, and a steroid flush. Steroid flush is a temporary warmth and redness of the skin that may last for a few days.

How long does it take for Back Injections to work?

Steroid injections may take a few days to start showing effects. This time is usually reported to be within 1 to 5 days. However, the pain relief from the injection may last for months.

Do You Need to Rest after a Cortisone Injection in Back?

The procedure of injection administration in pain can be a source of mild to moderate pain for the patient. Moreover, the pain relief effects of cortisone are also not immediate and may take a few days to show full effect. This is why it is recommended to take a break for at least a day after administering steroid injection; however, after this, the individual may continue with their daily physical activity.

What is the Success Rate of Spinal Injections?

The spinal injection may work in 40 to 80%of the patient by improving more than 50% of their symptoms. Moreover, studies have shown these results to last for at least three months in most cases.

What is the Difference between a Cortisone Shot and an Epidural Steroid Injection?

The cortisone shot is delivered to the bloodstream, while the epidural steroid injection is administered to the site of the nerve pain. Hence Epidural steroid injections provide a more targeted relief.

References

1.       Patrick, N., Emanski, E., & Knaub, M. A. (2014). Acute and chronic low back pain. The Medical clinics of North America, 98(4), 777–xii. https://doi.org/10.1016/j.mcna.2014.03.005

2.       Patel K, Chopra P, Upadhyayula S. Epidural Steroid Injections. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470189/

3.       Miller, R., Beck, N. A., Sampson, N. R., Zhu, X., Flynn, J. M., & Drummond, D. (2013). Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. Journal of pediatric orthopedics, 33(3), 282–288. https://doi.org/10.1097/BPO.0b013e318287fffb

4.       Wang, H., Cheng, J., Xiao, H., Li, C., & Zhou, Y. (2013). Adolescent lumbar disc herniation: experience from a large minimally invasive treatment centre for lumbar degenerative disease in Chongqing, China. Clinical neurology and neurosurgery, 115(8), 1415–1419. https://doi.org/10.1016/j.clineuro.2013.01.019

5.       Buell, K. G., Sivasubramaniyam, S., Sykes, M., Zafar, K., Bingham, L., & Mitra, A. (2019). Expediting the management of cauda equina syndrome in the emergency department through clinical pathway design. BMJ open quality, 8(4), e000597. https://doi.org/10.1136/bmjoq-2018-000597

6.       Musich, S., Wang, S. S., Slindee, L. B., Keown, K., Hawkins, K., & Yeh, C. S. (2019). Using Pain Medication Intensity to Stratify Back Pain Among Older Adults. Pain medicine (Malden, Mass.), 20(2), 252–266. https://doi.org/10.1093/pm/pny007

7.       Owen, P. J., Miller, C. T., Mundell, N. L., Verswijveren, S., Tagliaferri, S. D., Brisby, H., Bowe, S. J., & Belavy, D. L. (2020). Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British journal of sports medicine, 54(21), 1279–1287. https://doi.org/10.1136/bjsports-2019-100886

8.       Lee, J. H., Sim, K. C., Kwon, H. J., Kim, J. W., Lee, G., Cho, S. S., Choi, S. S., & Leem, J. G. (2019). Effectiveness of lumbar epidural injection in patients with chronic spinal stenosis accompanying redundant nerve roots. Medicine, 98(9), e14490. https://doi.org/10.1097/MD.0000000000014490

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