Spinal Injections
Spinal injections are commonly used to localize and treat painful tissues in the cervical, thoracic and lumbosacral spine. Indications for treatment with spinal injections and the type of injection to be performed differ among individual patients. The physicians at the Virginia Spine Institute rely on a thorough patient history combined with a physical exam and appropriate imaging studies and other diagnostic tests in order to determine if an injection (and what type of injection) is warranted.
When spinal injections are being performed, x-ray guidance (i.e. fluoroscopy) is commonly utilized to ensure that the proper tissue (nerve root, nerve branch, joint, etc.) is being targeted, and more importantly, to ensure that the injection is performed safely (i.e. avoiding injury or injection into adjacent nerves, blood vessels, and the spinal cord) [Figure 1].
Figure 1: Fluoroscope
The most commonly performed spinal injections at the Virginia Spine Institute include epidurals, intra-articular facet injections or medial branch blocks, sacroiliac joint injections and radiofrequency ablations.
Epidural injections are typically used to treat pain that is emanating from an inflamed nerve root. The cause of the inflamed nerve root can be from multiple sources (e.g. herniated disc, arthritic changes in the spine, etc.). Symptoms usually include shooting, burning, electric-like pain in the affected extremity sometimes associated with numbness, tingling and weakness along the course of the inflamed nerve root. Epidural injections can be performed via several different approaches (e.g. caudal, interlaminar, transforaminal) [Figure 2], and the approach your clinician chooses is based on each individual patient’s clinical presentation, the personal preference and experience of the practitioner performing the injection, the desired outcome, and most importantly, the risks versus benefits of performing one type of epidural over another. Clinically, the purpose of all epidural injections (independent of the approach used) is to place a mixture of steroid and local anesthetic at the purported source of the problem in order to decrease inflammation that is causing pain, and to promote healing and progression with the established treatment plan.
Figure 2: Epidural Steroid Injection
If the facet joints [Figure 3] or the sacroiliac joints [Figure 4] are suspected as a potential source of pain, then an injection of steroid and anesthetic into the joint is commonly used to confirm the diagnosis and also relieve pain emanating from these joints. Another way to determine if the facet joints are a causing pain is to block the nerve supply (i.e. medial branches) to individual joint(s). If either of these approaches confirms that the facet joint and/or the sacroiliac joint is a significant source of pain, then a procedure called radiofrequency ablation may be utilized to provide longer term treatment and pain relief.
Figure 3: Cervical Facet Joint Injection Figure 4: Sacroiliac Joint Injection
Risks of spinal injections may include a very small chance of bleeding, infection or injury to local neurovascular structures in the vicinity of the structures being targeted. You should make your physician aware of any anti-inflammatory, blood thinning and herbal medications you are taking that may increase your risk of bleeding during and immediately after the procedure. Many of these medications will need to be temporarily discontinued for a given period of time prior to the injection to decrease the risk of bleeding.
Patients should be aware of potential side effects associated with steroid injections. Symptoms such as headache, flushing, sweating, mild temporary weight gain, dizziness and a short-lived flare-up of pain (called a post-injection flare) are commonly associated side effects of local steroid injections. Furthermore, patients with diabetes typically experience a short-term increase in blood glucose levels and patients with congestive heart failure need to be aware that steroids may increase water retention and lead to an exacerbation of symptoms. Thus it is imperative that your clinician checks for these conditions and determine if you are a safe candidate for injection with steroid.
The majority of patients do extremely well and experience significant relief of pain and suffering following appropriately prescribed spinal injections. Sometimes injections need to be repeated or a different type of injection needs to be performed once your symptoms are better localized and controlled. Here at the Virginia Spine Institute, the decision to perform additional injections is made only after careful observation and follow up regarding how prior injections have impacted the your pain and quality of life.
