Epidural steroid injection · St. Louis

Epidural Steroid Injection (ESI)

An epidural steroid injection (ESI) places steroid medicine into the epidural space around an irritated spinal nerve root. It treats back pain and pain that spreads out from the spine. A selective nerve root block or a facet injection hits one spot. An ESI covers about three spinal levels on both sides of the spine.

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Overview

Back pain affects nearly everyone at some point in their adult life. Often the exact cause is not easy to see. Many things can feed back pain, including disc disease, referred pain, and psychological factors. That makes the exact spot and level of the pain harder to pin down. Imaging (X-RAYs, MRI and CT scans) helps screen the spine for causes of low back pain. But sometimes it does not show an exact cause.

Back pain can come from any part in or around the spine that has nerve endings and can send pain. These parts include discs, facet joints, muscle, nerves, ligaments and dura (the lining of the spinal canal). All of them touch or sit close to the epidural space. Pain may sit in the spine itself (‘axial’), or spread out from the spine (‘radicular’). The ESI is built to relieve both types.

The Epidural Injection (ESI) numbs the space around the spinal sac (dural sac). It can be done at any level of the spine. Most often it is done in the lumbar spine (low back) or cervical spine (neck). Compare it to a selective nerve root block, or a facet injection. Those target one nerve or joint on one side of the spine. The ESI treats several levels in a row on both sides of the spine.

The ESI delivers a small amount of strong medicine straight into part of the epidural space. It usually covers about 3 levels of the spine.

What Does ESI Stand For in Medical Terms?

ESI stands for epidural steroid injection — a procedure that places steroid medicine into the epidural space around an irritated spinal nerve root. You may see it written by the part of the spine treated: a cervical ESI (neck), a thoracic ESI (mid-back), or a lumbar ESI (lower back). The lumbar ESI is the most common.

ESI is also short for the Emergency Severity Index. That is the five-level triage scale used in hospital emergency rooms. The two are unrelated. Everything on this page is about the injection.

Related abbreviations you may see on a referral or an operative note

ILESI — interlaminar epidural steroid injection
TFESI — transforaminal epidural steroid injection
SNRB — selective nerve root block, a close cousin used more to find the pain than to treat it
ESI series — more than one injection over several weeks, when repeat treatment is truly needed

What Is The Epidural Space?

The dura membrane covers the spinal cord and nerve roots in your spine. The space around the dura is the epidural space. Nerves run through it to your back and into your legs. When these nerve roots get inflamed, they can hurt in those areas. The irritation comes from a damaged disc or from rubbing on the bony parts of the spine.

How Does an Epidural Steroid Injection Relieve Pain?

An epidural injection puts anti-inflammatory medicine into the epidural space. It reduces inflammation of the nerve roots and aims to ease the pain in your back or legs. By cutting inflammation, the epidural injection may help the injury heal. It may give lasting relief. Or it may give several months of relief while the injury/cause of your pain heals. Based on where you hurt, the spinal steroid injection can go in the neck (cervical), middle back (thoracic) or lower back (lumbar).

What Happens During an Epidural Steroid Injection?

No IV or sedation is used; you stay awake under local anesthetic. You will lie on your stomach on the x-ray table. You are placed so your doctor can see your back best with x-ray guidance. Your back is scrubbed with 2 types of sterile soap. Next, the doctor numbs a small patch of skin on your low back. This medicine stings for several seconds. Once the numbing sets in, your doctor guides a small needle with x-ray. It goes into the tiny bony opening (sacral hiatus) just above the crease in your buttocks. A small amount of contrast (dye) is then injected. It confirms the needle sits in the epidural space. If the medicine does not reach high enough, a small catheter (thin tube) is placed in the epidural space. It is moved up to the problem area.

What Are the Types of Epidural Steroid Injections?

“Epidural steroid injection” describes where the medicine goes — not how the needle gets there. There are three proven routes into the epidural space. The right one depends on your anatomy, which nerve root is involved, and whether you have had spine surgery before. All three are done under fluoroscopic (live X-ray) guidance with contrast dye. So we confirm the needle is in the right place before any steroid goes in.

Interlaminar (ILESI)

The needle goes in at the midline, between the laminae (bony plates) of two neighboring vertebrae. It puts medicine into the back part of the epidural space. The medicine tends to spread across several spinal levels. That suits a central disc herniation or symptoms in both legs.

Transforaminal (TFESI)

The needle travels through the neural foramen — the bony opening where the nerve root exits the spine — and puts medicine right next to the affected root. This is the most targeted of the three. It treats one root, so it also helps with diagnosis. How you respond helps confirm which nerve root is really causing your pain.

Caudal

The needle enters through the sacral hiatus at the very base of the spine. It fills the lowest part of the epidural space. It comes in from below, not through an old surgery site. So it is often chosen when past low back surgery or epidural scarring makes the other routes hard.

For more on what the steroid does once it reaches an inflamed nerve root — and what it cannot do — see why an inflamed nerve root burns, and what an epidural steroid injection actually does.

What Happens After an ESI Injection?

You will rest in a recovery area or in the procedure room. We watch you for 15-30 minutes. Then you track how much relief you get over the next week. You also get a follow-up visit for a repeat block if needed. The number of shots you need depends on how you respond, not a fixed schedule. There is no magic in a series of three. If a repeat block is needed, it is usually one to three weeks later. We recheck after each one. You may not be able to drive on the day of your epidural steroid injection. Your legs may feel weak or numb for a few hours, but that should clear fast. If it does not, go to the nearest ER.

Lasting Relief With Epidural Steroid Injections

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General Pre/Post Instructions

Eat a light meal a few hours before your procedure. If you are a diabetic on insulin, do not change how you normally eat before the procedure. Take your usual medicines (i.e. blood pressure and diabetes medicines). Are you on Coumadin, Heparin, Plavix or any other blood thinner (including Aspirin)? Or the diabetes drug Glucophage? Then you must tell this office, so we can explain when to take them. We do not use sedation, so most patients drive themselves home. If your legs feel weak or numb, wait until that clears before driving. You can go back to normal activity, including work, within two to four hours. Soreness from the epidural may take several days to fade. Your doctor may prescribe pain medicine. Treat your back with care while it heals. Your doctor will give you activity and rehab guidelines. You will need a special physical therapy and rehab program for several weeks after your procedure. You may need a back brace, plus electrical stimulation to ease spasms. You may need a nerve conduction study and EMG to show how bad the back injury is and how long it has lasted. Your usual pain may flare for a while, including muscle soreness where the needles went in. Use ice packs three or four times a day and take your usual pain medicines.

Duration of Relief

Most patients get 2-3 months of relief from some of their symptoms. Results range from no relief to near total relief. Relief can last from days to many months. Some patients get no relief from the first shot but do after one or two more in the next weeks. Many doctors give these shots in cycles (series) of one, two or three epidural injections over a couple of weeks. Cycles should be about two to three months apart. Giving steroids more often could cause more serious side effects. A transforaminal epidural steroid injection series often lasts 4-6 months or even longer.

Insurance, Cost and Getting Back to Normal

What it costs

Most plans cover an epidural steroid injection when it is medically needed. What you pay depends on your own policy. As a courtesy, we file insurance claims for you. You still owe your co-pays, co-insurance and deductibles. Some plans deny a procedure, or pay less, even when we believe the care is right for you. If money is tight, tell us early — we can sometimes make special arrangements. The full terms are in our office policy FAQs.

Getting back to normal

You go home the same day. We watch you for 15 to 30 minutes afterward. Most patients get back to normal activity — including work — within two to four hours. We do not use sedation, so you can usually drive yourself home. The exception is short-term leg weakness or numbness, which can last a few hours. Soreness where the needle went in is common. Ice and your usual pain medicine help. The full before-and-after instructions are in the section above. They cover blood thinners and diabetes medicine. Read them before your visit, because the timing of those medicines must be planned ahead.

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Epidural Steroid Injection FAQs

The skin and deeper tissue are numbed first with local anesthetic. That is the part most patients notice. Pressure during the injection is common. Most call it uncomfortable, not painful. It takes only a few minutes once you are in position and the imaging is set.

The local anesthetic (numbing medicine) can give relief within hours, but it wears off. The steroid kicks in over about two to seven days. How long it lasts varies a lot, from weeks to several months. It depends on how much of your pain comes from inflammation around the nerve versus physical pressure on it.

There is no single fixed number. Shots are spaced out to limit total steroid exposure, and we recheck after each one. If two well-placed shots do nothing useful, a third is unlikely to help. We hunt for a different pain source instead of repeating. More on what decides how often epidural injections are repeated.

No — we do not use sedation for epidural steroid injections. The skin and deeper tissue are numbed with local anesthetic. You stay awake and alert the whole time. With no sedation, most patients drive themselves home. The exception is short-term leg weakness or numbness, which can last a few hours. If you have that, wait until it fully clears before driving. Tell us ahead of time if you take a blood thinner such as warfarin, clopidogrel, apixaban or rivaroxaban. That is because the timing must be worked out with the doctor who prescribes it.

That is useful information, not a dead end. If an epidural does not relieve your pain, the nerve root is likely not the main source. That points the search toward the facet joints, the sacroiliac joint, or the disc itself.

They use the same family of medicine, but not the same target. A “cortisone shot” usually means a steroid placed into a joint or soft tissue — a shoulder, a knee, a bursa. An epidural steroid injection puts the medicine into the epidural space around an irritated spinal nerve root. It is done under fluoroscopic (live X-ray) guidance. It calms inflammation at the root itself. Same drug class, different body part, different problem. More on what the steroid does at the nerve root.

Most are short-lived: soreness where the needle went in, a brief flare of your usual pain, a flushed face, a night or two of poor sleep, and a brief rise in blood sugar that matters if you are diabetic. Less common risks include a post-dural-puncture headache. Rarely, there is bleeding, infection or nerve irritation. That is why we review your blood thinners and diabetes medicine before scheduling. Side effects and the diabetic question, in more detail.

We watch you for 15 to 30 minutes and then you go home. We do not use sedation, so most patients drive themselves home. Legs can feel weak or numb for a few hours, and that should clear fast — if it does not, go to the nearest emergency room. Most patients get back to normal activity, including work, within two to four hours. Soreness at the shot site can last several days. Ice helps. Office policies and what to expect.

Do not drive while your legs feel weak or numb. Wait until that fully clears. Do not skip the activity and rehab guidelines your doctor gives you. Treat your back with care while it heals. Most patients get back to normal activity, including work, within two to four hours. Ice the spot where the needle went in if it is sore. If leg weakness does not clear fast, go to the nearest emergency room.

An ESI treats pain caused by an inflamed spinal nerve root. That includes pain in the spine itself (axial pain). It also includes pain that shoots from the spine into the legs (radicular pain). The irritation usually comes from a damaged disc or from rubbing on the bony parts of the spine. It can be given in the neck, the mid-back or the lower back. The lower back is the most common site.

Most plans cover an epidural steroid injection when it is medically needed. What you pay depends on your own policy. We file the claim for you as a courtesy. You still owe co-pays, co-insurance and deductibles. Some plans deny a procedure, or pay less, even when the care is right. If money is tight, tell us early.

The shot itself takes only a few minutes once you are in position and the X-ray is set. The skin is numbed first. A small amount of contrast dye confirms the needle is in the epidural space. Then the medicine goes in. We watch you for 15 to 30 minutes, then you go home. There is no sedation, so most patients drive themselves.

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