Epidural Steroid Injection (ESI)

WHAT IS AN EPIDURAL STEROID INJECTION?

Epidural Steroid Injection (ESI): is an injection performed in the lumbar (low back), thoracic (mid back), or cervical (neck) regions to relieve pain in your neck, arms/hands, legs, chest or lower back. Medications, like, anti-inflammatory steroid with or without a local anesthetic are commonly the drug of choice. The medication is injected into the epidural space, an area surrounding the spinal cord and nerves. The procedure is usually done under X-ray guidance.

• What is steroid: Steroid (short for Corticosteroid) is man-made drug that closely resemble cortisol, a hormone that your adrenal glands produce naturally. Steroid works by decreasing pain and reducing inflammation. Steroids generally take 48 – 72 hours to take effect.
• What are local anesthetics: Local anesthetics are medicines that block sensation of pain in the brain by acting on certain nerve pathways. Generally, the numbing effects of a local anesthetic last from anywhere between half an hour to four hours.

BEFORE THE PROCEDURE

• Please arrive 30 minutes before your scheduled appointment.
• First, you will meet with a Patient Access Representative (PAR) at the registration desk that will review your medical insurance, Emirates ID and perform your clinic registration. (Please bring your insurance card and Emirates ID).
• You will then see a nurse who will obtain your medical history and perform a nursing physical assessment.
• You will then meet with the pain physician for an evaluation and who will also explain the procedure in detail, including possible complications and side effects. Your physician will obtain the consent for procedure and also will answer any questions that you may have.
• Inform your pain physician: If you are taking any blood thinners (Abciximab or Integrelin, Aspirin, Aggrastat or Tirofiban, Alteplase or Actylise, Apixaban or Eliquis, Ardeparin or Indeparin, Argatroban or Arganova or Exembol, Bivalirudin or Angiomax, Coumadin or Warfarin, Dabigatran or Pradaxa, Dalteparin or Fragmin, Danaparoid or Orgaran, Eftifibatide or Integrelin, Fondaparinux or Arixtra, Heparin, Lovenox or Enoxaparin or Clexane, Plavix or Clopidogrel, Pletal or Cilostazol, Prasugrel or Effient, Rivaroxaban or Xarelto, Ticagrelor or Brilinta, etc). You will need to discontinue this medication prior to your procedure. Please note: Do not discontinue any medication without first consulting with your physician, who is prescribing these blood thinner medications.

  • If you are nursing or may possibly be pregnant.

  • If you have an active infection, flu, cold, fever or uncontrolled blood pressure.

  • If you ever had an allergic reaction to X-ray dye or shellfish.

  • You will be instructed, to bring a responsible adult with you to drive and accompany you home after the procedure.

  • Discontinue any pain medication four hours before the time of your scheduled procedure. Continue to take all other medications (when you are instructed) with a small sip of water before coming for the procedure. Bring all medications with you so that you can take it after your procedure (take only what is due after the procedure or as instructed by your primary or referring physician).

THE DAY OF THE PROCEDURE

• You must fast at least six hours before the procedure. You may have clear liquids until two hours before the procedure, but do not eat anything within six hours of your appointment. If you have diabetes and use insulin, you must adjust the dosage of your insulin the day of the procedure as instructed.

Diabetic Instructions

• Please be sure to check your glucose level in the morning of your injection. Also, you will need to check your glucose levels more frequently for the first two or three days following your injection. (Some patients may notice an increase in their glucose levels after their procedure).
• On the day before surgery, continue your usual diet, continue diabetic tablets, continue usual insulin regiment, and continue your insulin pump at the same rate.
• If you are instructed to fast before the procedure, then on the day of the procedure

• Check your blood sugar in the morning and if it is less than 70 mg/dl (3.8 mmol/l), drink half a cup of apple juice OR take four glucose tablets.
• Do not take diabetic tablets.
• If you are on Lantus, Levemir or NPH take half of your usual dose.
• If you use an insulin pump continue the same basal rate.
• If you take mixed insulin (70/30 or 75/25) please check your blood sugar in the morning. If your blood sugar is higher than 200 mg/dl (or 11 mmol/l) take half of your usual dose of mixed insulin. If your blood sugar is lower than 200 mg/dl (or 11 mmol/l) then DO NOT take your insulin. Your blood sugar will be rechecked at the hospital.

• You will meet with the Patient Access Representative (PAR) who will review your Emirates ID, medical insurance and registration. (Please bring your insurance card and Emirates ID).
• You will then meet with a nurse who will review your medical history, medication and obtain your pre-procedure vital signs.
• Before the procedure, an intravenous (IV) line may be placed in a vein in your arm by a nurse or physician.
• You will then be taken to the procedure room and be assisted to get on the procedure table.
• A mild sedative may be given through your IV to relax you, if needed.

DURING THE PROCEDURE

The procedure takes approximately 20 minutes.

• You will be lying face down on the table. The procedure area (neck, upper, middle or lower back) will be cleansed with an antiseptic solution and then the area will be numbed using a local anesthetic.
• The physician will use an X-ray equipment to guide in the placement of a thin needle to the area in your back.
• After correct needle placement in the epidural space is confirmed by X-ray, a small amount of steroid with or without local anesthetic medications will be administered.
• A nurse will monitor your vital signs during your procedure.
• A plaster will be placed over the injection site when the procedure is completed.

AFTER THE PROCEDURE

• You will be transferred to the recovery room and will remain in the recovery room for about 20 – 30 minutes for observation. The length of stay in the recovery room may vary.
• A nurse will check your vital signs.
• You may feel some soreness of the back or neck at the point where the needle enters the skin after the procedure.
• There may be some temporary numbness in the involved extremity.
• When indicated, a nurse will give you a beverage and review your discharge instructions.
• A responsible adult must accompany you home.
• You will meet back with the Patient Access Representative (PAR) at the registration desk who will review your follow up appointment schedule.

DISCHARGE INSTRUCTIONS

• Do not drive or operate machinery for at least 24 hours after the procedure.
• You may resume your normal diet.
• Do not engage in strenuous activity.
• Do not take a bath, swim or use the hot tub for at least 24 hours; you may take a shower.
• You may remove the plaster in the evening before you go to bed.
• Smoking cessation is an important part of your rehabilitation and prevention of further deterioration of your joints and spine.

WHAT ARE THE COMMON SIDE EFFECTS OF THE MEDICATION?

Side effects with the epidural medications can last about 4 – 6 hours after the procedure:

• Arm/Leg or feet muscle weakness or numbness. If you have any leg weakness or numbness, walk only with assistance, as your legs may buckle when trying to walk.

SIDE EFFECTS OF FACET JOINT MEDICATIONS AND PROCEDURE

• Bleeding, nerve injury, infection or allergic reaction to medications used.
• Leg/arm muscle weakness or numbness. If you have any leg weakness or numbness, walk only with assistance, as your legs may buckle when trying to walk.
• Worsening of pain symptoms.
• Mild discomfort on injection site when the local anesthetic wears off. This usually lasts two or three hours. If it occurs, apply ice to the area the day of the procedure and moist heat the day after the procedure if the discomfort persists.
• Some patients might not experience pain relief in the immediate first few hours after the injection, depending upon whether or not the joints that were injected are the main source of pain.

WHEN I SHOULD CALL FOR HELP?

Contact your physician or come to the nearest Emergency Room if you have any of the problems stated below. Inform the Emergency Room staff that you just had a facet nerve block. The physician must evaluate you for the injection complication.

• If the weakness and numbness of your arms, legs or feet does not resolve after eight hours.
• Increased pain on injection site even after applying ice or moist heat pack.
• Onset of new fever, chills, nausea and vomiting.
• If your blood sugar or blood pressure is out of control.