A lumbar epidural steroid injection is a common procedure to treat low back pain and sciatica. It involves injecting a steroid medication into the epidural space around the spinal nerves in the lower back. This can help reduce inflammation and irritation of the nerves that may be causing pain. But how painful is the injection itself?
What is a lumbar epidural steroid injection?
An epidural steroid injection goes into the epidural space surrounding the spinal cord. When it is done in the lower back it is called a lumbar epidural steroid injection or LESI. The medication used is typically a corticosteroid that has strong anti-inflammatory effects. It works by reducing inflammation and swelling of tissues around the spinal nerves, which can provide significant pain relief.
Some key facts about lumbar epidural injections:
- They are most commonly used to treat low back pain and sciatica
- The medication used is typically a steroid like cortisone or dexamethasone
- It is injected into the epidural space in the lower back, around the lumbar nerves
- It can provide significant short-term pain relief that may last for weeks or months
- LESIs are generally very safe but do have some risks like infection or bleeding
What causes the pain during the injection?
The injection is usually only mildly to moderately painful for most patients. There are a few reasons why it can hurt:
- Inserting the needle – The doctor has to insert a small needle through skin and tissues to access the epidural space. This can cause a temporary stinging sensation.
- Hitting a nerve – There are many nerves in the low back, and sometimes the needle may come into contact with one, causing a shooting pain.
- Injecting the medication – When the steroid medication is injected, it can briefly cause pressure and aching as it fills the epidural space.
- Inflammation – If there is a lot of existing inflammation around the spinal nerves, this can make the procedure more painful due to irritation.
Pain level during lumbar epidural steroid injection
On a pain scale from 0-10, with 0 being no pain and 10 being the worst pain, most patients report the lumbar epidural injection as:
- 1-3 during administration of local anesthetic to numb the area
- 2-5 during insertion of the needle into the epidural space
- 0-2 during injection of the steroid medication
However, some patients may experience more significant pain, in the range of 5-8 on the scale, if there is difficulty accessing the epidural space or the needle hits a nerve. Overall though, most patients tolerate the injection relatively well.
What is done to minimize pain during the injection?
Physicians take a few key steps to make the lumbar epidural injection as comfortable as possible:
- Local anesthetic – The injection site is numbed with a local anesthetic like lidocaine. This prevents feeling the initial needle insertion.
- Thin needle – A very thin needle is used to minimize discomfort.
- Fluoroscopy guidance – The needle is guided using live x-ray (fluoroscopy) for precise placement without multiple passes.
- Slow injection – The steroid medication is injected slowly to minimize pressure.
- Positioning – Proper positioning helps open up the epidural space to make the injection easier.
Relaxation techniques like deep breathing are also encouraged during the procedure. If significant pain is experienced, additional local anesthetic can be injected through the needle as well.
Does the size of the needle matter?
Needle size can make a difference in the amount of pain experienced during a lumbar epidural steroid injection. Larger needles are more rigid and can potentially cause more tissue trauma and discomfort upon insertion. Here is how needle size impacts pain:
- Smaller needle (25-27 gauge) – A very thin needle around 1 inch long causes the least tissue disruption and is generally the least painful option.
- Larger needle (21-23 gauge) – A thicker needle may cause more pain with insertion but can allow for faster injection of medication.
- Length of needle – Longer needles are harder to insert accurately and may increase discomfort.
Because of this, most physicians prefer using the thinnest 25-27 gauge needle in the 1.5 inch range for epidural steroid injections to minimize discomfort while still allowing effective medication delivery.
Common concerns about pain with the procedure
Some common concerns patients have about potential pain with a lumbar epidural steroid injection include:
- The needle hitting bone or nerves – This can happen in some cases, especially if bony spinal anatomy is distorted. Fortunately it is rare with experienced physicians using fluoroscopy guidance.
- Discomfort during medication injection – As noted earlier, this may cause some dull pressure but generally not severe pain.
- Soreness afterwards – Some lingering soreness at the injection site is common after the numbing medication wears off.
- Multiple injections needed – If pain relief is not sufficient after the first injection, a second or even third injection may be recommended, which means undergoing the procedure again.
However, while these concerns are understandable, severe pain is uncommon during an epidural injection performed by an experienced doctor. Let your physician know in advance about any pain concerns you may have.
Aftercare and recovery following the injection
Once the lumbar epidural steroid injection is complete, here is what typically occurs:
- You will be monitored for up to 30 minutes to ensure no adverse effects like significant numbness in the legs.
- The numbing medicine will wear off after a few hours. You may have some residual soreness at the injection site for a day or two.
- You should take it easy for the rest of the day. No strenuous activities.
- The steroid medication can take 1-2 weeks to start working. Pain relief often peaks in 1-2 months.
- Some patients may require a series of 2-3 injections spaced out by several weeks for optimal pain relief.
While you may feel completely back to normal the day after the injection, it’s important not to overexert yourself and rest as much as possible as the steroid medication starts to take effect.
Risks and side effects
Lumbar epidural steroid injections are generally safe, but like any procedure there can be some risks and side effects including:
- Bleeding or bruising at the injection site
- Temporary numbness or weakness in the legs after the procedure
- Worsening of certain medical conditions like diabetes or congestive heart failure
- Spinal headache from leakage of cerebrospinal fluid
- Nerve damage or spinal cord injury (extremely rare)
- Skin discoloration or changes like thinning or dimpling (rare)
- Allergic reaction to the steroid or numbing medication
Make sure to discuss any specific health concerns with your doctor. Serious risks and complications are not common but can occur in a very small percentage of cases.
When should you follow up after the injection?
It’s a good idea to follow up with your doctor within 2-3 weeks after a lumbar epidural steroid injection to discuss your response. They will want to know:
- If you experienced any benefits in terms of pain relief
- How long the relief lasted
- If any numbness or weakness occurred
- If you had any worrisome side effects
Based on your response, your physician may recommend trying a second or third injection if the first did not provide sufficient pain relief. Follow-up appointments allow adjusting the treatment plan as needed.
Other treatments if the injection does not help
If you do not get adequate pain relief from one or more lumbar epidural steroid injections, there are some other options your doctor may suggest including:
- Oral steroids – Steroid pills or Medrol dose pack for inflammation
- Physical therapy – Stretching, exercises and modalities like heat or ice therapy
- Chiropractic treatment – Spinal manipulation and mobilization techniques
- Acupuncture – Fine needle stimulation of specific body points
- Massage therapy – Manual soft tissue techniques to reduce muscle tightness
- Radiofrequency ablation – Use of heat or cold to disable irritated spinal nerves
- Surgery – Laminectomy, discectomy or spinal fusion if conservative therapies fail
The right treatment plan depends on each patient’s specific condition and symptoms. Make sure to discuss alternative options with your physician if you do not get the desired results from epidural steroid injections.
When to consider surgery
Surgery like laminectomy or spinal fusion may be warranted if:
- Severe or progressive neurological deficits occur like leg weakness
- Cauda equina syndrome with loss of bowel or bladder control develops
- Unrelenting pain continues after multiple injections and extensive conservative treatment
- There is significant worsening of symptoms or development of new symptoms
- Spinal instability or deformity with risk of further damage is identified
Surgery has its own risks so it is generally reserved for severe cases that are unlikely to improve with other therapies. Most low back and leg pain can be managed without surgery. But it is an option if non-surgical options are unsuccessful after several months.
Preparing for a lumbar epidural steroid injection
Some things you can do to prepare for your lumbar epidural steroid injection include:
- Discuss any medications you take with your doctor, especially blood thinners
- Arrange for a driver to take you home afterwards
- Wear loose comfortable clothing to the appointment
- Eat a light meal prior to the procedure
- Ask questions and address any concerns you may have about potential pain
- Practice relaxation techniques like deep breathing
Thorough preparation helps minimize anxiety and ensures the procedure goes smoothly. Let your doctor know about any concerns upfront so they can take extra steps as needed for your comfort.
Conclusion
In conclusion, while lumbar epidural steroid injections can cause some mild to moderate discomfort during the procedure, significant pain is relatively uncommon. With adequate numbing medication, use of a thin needle, and a skilled physician utilizing fluoroscopy guidance, most patients tolerate the injections quite well with only minor soreness afterwards. Knowing what to expect and taking steps to prepare for the procedure can help minimize any pain concerns. If more invasive treatments like surgery can be avoided through the use of epidural steroid injections as part of a comprehensive treatment plan, then minor discomfort during the injection is usually an acceptable trade-off for most patients.