1905 Clint Moore Rd. Suite #309
Boca Raton, Florida 33496
Phone: (561) 988-8988
Fax: (561) 988-7075
Injections
Epidural

WHAT ARE THEY?
Epidurals are specific fluoroscopically guided (x-ray) needle injections placed into the spinal canal (interlaminar) or into the foramen of the spine (transforaminal), enabling delivery of 100 mg of Depo-Medrol medication. This is a slow releasing and long acting form of steroid or cortisone, which provides the strongest anti-inflammatory medication. This reduces swelling, inflammation, and symptomatic pain from nerve compression, spinal stenosis, herniated disks or inflamed degenerative disks. A 20 gauge, special blunt tipped spinal needle is utilized for this purpose. We specifically do not give general anesthesia or sedating medications for this procedure. We believe that an alert patient (not sedated) can notify the physician of any increased pain or nerve injury produced by the injection. When necessary, the physician may stop the injection or make an adjustment to the level of injection for maximum patient benefit.

Epidural injections have been shown to reduce the inflammation and can actually eliminate the need for surgery in a large study, recently published. Epidurals are not a cure, but bring pain to a more tolerable level; thereby allowing patients to function better on a daily basis. Even though the condition is still present, it is less painful and much more tolerable. There is no absolute maximum number of injections despite anecdotal opinions. We feel that a series of two or three injections can be repeated in three to four months relatively safely with the risks understood and agreed to by the patient. These are not the same epidural catheter injections as given for childbirth anesthesia. Our injections do not invole a narcotic or an anesthesia placed directly in the spinal canal.
INDICATIONS:

Epidural injections are indicated typically for spinal stenosis, herniated disks, degenerated disks and occasionally vertebral fractures. All of these conditions have one similarity and that is inflammation. This typically is characterized and experienced as a sharp, aching or electric shock sensation of pain typically in the buttocks or legs, but can be in the back as well. We do not feel epidural injections are indicated for painless leg weakness or foot drop where there is no pain or obvious inflammation noted.
BENEFITS:

The main benefit is relief of pain. This can vary from no relief to 100% relief and can last from a day to several years. The longer-term relief is probably due to a break in the pain cycle and quieting the nerve down, and then without re-aggravating the condition, the relief persists. More than 60% of patients with herniated disks treated with epidural injections have avoided surgery in published studies. Improved function, quality of life, and reduced pain are the main benefits of epidural injections.
RISKS:

1. Spinal fluid leak. This is estimated at 1 to 2% of injections. Spinal fluid leaks are usually noted by a headache upon sitting up or standing, and relieved by flat bedrest. Occasionally the leak may require an epidural blood patch, which is administered here at our office.

2. Bleeding in the spinal canal. This is extremely rare, but is more common in patients on blood thinning medications. This has not occurred in our practice, but is a theoretical risk, and could cause paralysis requiring surgical decompression. NOTE: If you are taking Plavix, Coumadin, aspirin, or over-the-counter anti-inflammatory drugs such as Motrin, Advil, Ibuprofen and others, notify your doctor.

3. Avascular necrosis of the hip. This is an extremely rare condition, probably less than 1 in 10,000. This condition involves a serious collapse of the hip joint, usually requiring surgery.

4. Adverse reaction to steroid medication. This is extremely rare, as steroids are the medication of choice for treatment of adverse reactions to other drugs.

5. Infection. Very rare for epidural steroid injections. The odds are less than 1:1,000. Sterile technique is utilized to avoid infection.

6. Elevated blood sugar in diabetics. This is a temporary effect lasting one to two weeks. Contact your diabetic doctor if elevated sugar becomes a problem.

7. Fluid retention. This is unusual and, again, is temporary effect.
SPECIAL CIRCUMSTANCES:

BLOOD THINNERS
Certain patients are on medication such as Plavix, Coumadin or other blood thinners. These patients are at an increased risk of bleeding in the spinal canal during the epidural procedure. Therefore, a patient must STOP all blood thinners 5 to 7 days prior to an epidural. First and foremost, the patient must discuss the safety of discontinuing these blood thinners with the doctor who originally prescribed the medication. If the patient and ordering physician allow the discontinuation of the blood thinner a protime and INR (blood tests) must be checked if the patient is on Coumadin. This is done after the patient has been off Coumadin five days, and usually done the morning of an injection at an outside laboratory. For patients on Plavix, a PFT (platelet function test) is also drawn the morning of the day of the injection to be sure the platelet function has returned to normal prior to the injection. If the results are to our satisfaction, the epidural will be administered. If you are taking any of the following medications, vitamins or herbs, please notify the doctor.

1. Aspirin
2. Vitamin E
3. Motrin
4. Advil
5. Ibuprofen
6. Aleve
7. Naprosyn
8. Ecotrin
9. Baby Aspirin
10. Feldene
11. Lodine
12. Voltaren
13. Arthrotec
14. Daypro
15. Excedrin
16. Indocin
17. Cataflam
18. Relafen
19. Trilisate
20. Ticlid
21. Persantine
22. Orudis
23. Fiorinal
24. Agrylin
25. Pletal
26. Aggrenox
27. Effient
28. Pradaxa
29. Coumadin
30. Warfarin
31. Plavix
32. Xarelto

Confirm that your prescribing doctor has allowed you to be off aspirin/Ecotrin/baby aspirin/Plavix/Aggrenox/ Effient for one week (7 days), or off Coumadin/Warfarin for 3 to 5 days, or off Pradaxa/Xarelto for 3 doses in a row, in preparation for the epidural injection.

SCAR TISSUE
Previous surgery causes scar tissue in the epidural space and causes difficulty administering an interlaminar epidural injection. Therefore, the epidural injection would usually be given above or below the previous surgery level or the injection type could be changed. The doctor could perform a transforaminal block, which is administered outside the spinal canal, therefore avoiding the scar tissue.

DIABETES
If you are diabetic, you should contact your doctor who manages this and obtain recommendations for any medication management changes, which may become necessary. Oftentimes, the insulin has to be increased due to the steroid effect.

If you have any other questions, please discuss them with your physician prior to the injection. We thank you for your confidence in selecting Florida Back Institute for your spine care.