Pain and symptom management
Simple analgesia in the form of over the counter medication may be enough, taken correctly, to control bouts of back pain. Always check with your pharmacist or GP if you are taking other medicines or have other medical conditions. If over the counter pain relief is not adequate see your GP who may be able to prescribe other types of anagelsia for you as appropriate. Some patients experience considerable relief from a group of medicines called antineuroleptics (reduce nerve pain). These include amitriptyline and gabapentin. These medicines need to be prescribed by your GP who will discuss their appropriateness with you depending on your other medications and past medical history.
See BackCare information sheet – go to fact sheets: number 507: drugs for pain relief:
for detailed information on individual drugs
Mr Chapple may ask you to keep a symptom diary following a procedure
Epidurals are used in spinal conditions for diagnostic assessment and therapeutic treatment. Epidurals come in various forms which are named by the area of the spine requiring treatment.
For unilateral sciatica, foraminal epidural steroids guided by image intensification have a higher success rate than caudal epidurals. If the patient has more generalised nerve entrapment then lumbar or caudal epidurals can be used to gain wider spread of the steroids in the spine. Caudal and lumbar epidurals can also be used to treat back pain as well as leg pain.
Epidural injections are performed as a day case. Lumbar and caudal epidurals are usually done without x-ray control while foraminal epidurals are done with image intensification guidance to the area of the spine.
What is injected in epidural injections?
All three use a local anaesthetic and a steroid, usually in the form of a suspension in solution which allows the solution to be absorbed while the suspended steroid stays in the position where it is injected. Normally the steroids used in Mr Chapple’s practice are triamcinolone or depo-medrone. These are strong locally acting steroids.
How do steroid injections work?
The function of the steroid is to reduce the local inflammation within the tissues it comes into contact with. Inflammation is a complicated biological pathway and the steroids have the ability to reduce certain stages within this pathway and to reduce the overall inflammatory products produced. Inflammation often causes pain producing biological products that stimulate the small pain fibres in the area of the inflammation. Steroids reduce the overall production of these pain products and therefore hopefully will produce a reduction in the patient’s symptoms.
The other constituent of epidural injections is local anaesthetic. There is usually a local applied to the skin plus a local anaesthetic which is injected with the steroids. The local anaesthetic has a more immediate effect to try to change the patient’s symptoms while it is in the area of the injection. It is absorbed and therefore it’s effect will be limited. Normally this will be in the region of 3-10 hours but sometimes this effect goes on for 24 hours or more.
What happens afterwards the epidural injection and when will I notice a difference?
It is very important after any injection to remember how the symptoms are over the first 24 hours, because this gives good diagnostic guidance to the condition as to whether the pain the patient is experiencing is being generated from the area where the injection was placed. It is therefore important that patients keep a pain and symptom diary (symptoms diary) for the hours and days after the injection to ascertain whether there is a therapeutic effect, by how much the symptoms are changed and for how long any change lasts.
There can be a rebound effect a day or so after the injections and the symptoms the patient experiences can be increased for a short while. This can be taken as a positive diagnostic sign that the injection was given in the area that was producing the patient’s symptoms, as there is a local aggravation once the local anaesthetic has worn off and before the local steroid has a chance to build up to a maximum therapeutic effect. The response is very varied from a proportion of patients who have no change from the injections to a proportion of patients who have a very good change.
As with any procedure there may be side-effects with epidural injection. These are always fully discussed by Mr Chapple with his patients before the decision is made. The main complications from epidural are: headache, worsening of pain and infection.
Who should have an epidural injection?
The indications for epidurals are very varied and some are best treated by caudal epidurals, others by lumbar epidurals and some by foraminal epidurals. Therefore if all the indications are put together the results will not be meaningful. It is important to separate out the indications for the steroids and then ascertain the role for the steroid for that condition, as to whether it is mainly diagnostic or aiming to be mainly therapeutic.
Contra-indications to epidural injections:
- people on warfarin, clopidogrel or other anti-coagulent medication
- people with a known allergic reaction to steroids or with blood/liver disease
- people with a skin infection on the back or in the natal cleft
Success rates for epidurals
The success rate for reduction in patients’ symptoms using foraminal epidural steroid injections targeted for patients with significant leg pain is in the region of 75%. ie 75% of patients undertaking the procedure will have a good enough reduction in their symptoms that they feel the injection was worthwhile.
The success rates for lumbar epidurals for patients with spinal stenosis is in the region of 50-60%.
The success rates for caudal epidurals undertaken for patients with L5/S1 generated sciatica is in the region of 50-60%.
Who performs epidurals and how are they done?
Foraminal epidurals are undertaken by the radiologists or the spinal surgeon or pain specialist, and are undertaken in the X-ray Department or in main theatre using image intensification for guidance of placement of the very fine needle as close as possible to the nerve root that is being compressed.
Lumbar epidurals under Mr Chapple’s care are undertaken by the consultant anaesthetist and mainly used for patients with spinal stenosis at L4/5 or L3/4 with bilateral leg symptoms/neurogenic claudication.
Caudal epidurals are undertaken by Mr Chapple in main theatre or in the anaesthetic room so that if there is a reaction to the injection patients are in an environment with support available instantaneously. It is possible to undertake these procedures under sedation or general anaesthetic, in which case the chances of nerve injury are very slightly higher.
What are the possible rare complications of spinal injection procedures?
Complications of injection therapies are rare but include complications of:
- Infection (any needle through the skin can potentially introduce an infection but the rate is less than 1/1000 injections).
- There is risk of allergic or adverse type reaction to the injection which again is very rare, and in the region of 1/200 – 1/500 who will possibly have an allergic type response to the injected substance.
- 1/100 patients could have a vaso-vagal or fainting syncope episode.
- There is a potential risk for CSF leak, which is a leak of the fluid surrounding the nerve by puncture of the dura. This risk is very rare and between 1/200 – 1/600. Consequences are usually very benign as the leak usually spontaneously closes. It might require one to two days of bed rest.
- The chances of a nerve injury by misplacement of the needle are very rare as in my practice the procedures are done under local anaesthetic and any placement of the needle too close to the nerve produces warning signs that the patient alerts us to.
What can I do after spinal injection?
After foraminal injections most patients are able to walk immediately. They can sometimes experience some weakness or numbness in the leg in the region of the distribution for the nerve that has been injected. Therefore all patients must have a relative or friend to drive them away from the hospital, but they can leave virtually immediately.
Patients having undertaken caudal or lumbar epidurals are normally asked to rest for a while on their front and then their back, which allows the steroids to settle in the area of the injection around the nerve roots. After 1-1½ hours patients are mobilised and when they are safe mobilising they are able to return home, again with a friend or relative to drive them.
Follow up arrangements
Follow up is usually between 2-3 weeks after foraminal injections and 4-6 weeks after lumbar and caudal epidurals. Patients are asked to keep a pain and symptom diary which they bring to their review appointment.
Facet joint injection
The facet joints (see Your Back)
Can be a pain source for some patients with back pain due to many conditions occurring within the joints.
The patient often experiences pain on a spinal extension (arching the back backwards) and on twisting.
The injections deliver a small dose of local anesthetic and steroid to the facet joint and its covering capsule.
If the patient experiences a good reduction in pain while the local is working then it indicates that the injected facet joints are the patient’s likely pain source. About one third of patients have a prolonged therapeutic reduction in symptoms, on third a short lasting change and one third no change. Depending on the results the next possible treatment options will be discussed with the patient.
Trochanteric Bursa Injection
The trochanter is past of the thigh bone (femur) that can be felt on the outside of the upper thigh near the hip and buttock. A bursa is a small fluids filled sac which acts as a cushion to allow the smooth passage of the tendons (facialata) which run over the bony prominence. The bursa can become inflamed for various reasons for example; direct trauma, extended pressure (lying on that hip) and repetitive motion.
Once inflamed it is known as Trochanteric Bursitis and can cause extended periods of pain and discomfort over the bursa with referred pain to the buttock, thigh and knee. The pain may be worse when lying on the hip and getting in and out of cars with low seats.
Trochanteric Bursitis can settle with rest and time, and can respond to therapy. If resistant to therapy treatment then simple injections of steroids to the area can be diagnostic and therapeutic. The condition often settles with repeated injections, however, very rarely, the bursa needs to be excised and the tendon (facialata) released.
Sacro-iliac joint injections
The sacro-iliac joints are the large joints that connect the spine to the pelvic bones. They are surrounded by extremely strong ligaments which restrain their movement. They can become painful due to arthritis, trauma and inflammatory conditions.
They are investigated with X-rays, bone scans and CT/MRI scans. If the sacro-iliac joints are the possible source of the patient’s pain they are injected with local anaesthetic and steroids. The Sacroiliac joint can be treated with rhysolysis to ablate the painful nerves. In extremely rare circumstances the joints can require fusion procedures.
Sacro-coccygeal joint and coccyx
The coccyx (tail bone) can be a pain source after local trauma to the area or inflammation. The coccyx is painful to sit on and requires avoidance of direct pressure by sitting on one buttock or using pillows. Anti-inflammatory medications help some patients. Most acute episodes settle within a few weeks.
If the pain continues then an injection to the coccyx and sacro-coccygeal joint are offered. This is usually performed under a brief general anaesthetic to allow adequate volumes of local anaesthetic and local steroid to the joint and bone surface.