What are epidural steroid injections. How do they work for bulging disc treatment. Who can benefit from these injections. What are the potential risks and side effects. How should patients prepare for the procedure. How long do the effects last for back pain relief.

Understanding Epidural Steroid Injections for Bulging Disc Treatment

Epidural steroid injections are a widely used medical procedure for managing various spinal conditions, particularly those causing back pain and nerve compression. These injections involve the administration of corticosteroid medication directly into the epidural space, which surrounds the spinal cord and nerves.

The primary purpose of these injections is to reduce inflammation and alleviate pain associated with conditions such as herniated discs, spinal stenosis, and radiculopathy. By delivering potent anti-inflammatory medication directly to the affected area, epidural steroid injections can provide significant relief for patients suffering from chronic back pain and related symptoms.

What exactly are epidural steroid injections?

Epidural steroid injections are a minimally invasive procedure that involves injecting a combination of corticosteroids, local anesthetics, and saline into the epidural space. This space is located between the protective covering of the spinal cord (dura mater) and the vertebral wall. The injected medication targets the inflamed nerves, reducing swelling and pain signals.

Common conditions treated with epidural steroid injections

• Herniated or bulging discs
• Spinal stenosis
• Sciatica
• Lumbar and cervical radiculopathy
• Degenerative disc disease
• Postherpetic neuralgia
• Facet and synovial cysts

The Science Behind Epidural Steroid Injections

Epidural steroid injections work by delivering a powerful anti-inflammatory medication directly to the site of nerve impingement in the spine. This targeted approach allows for maximum effectiveness with minimal systemic side effects.

How do epidural steroid injections provide pain relief?

The injected corticosteroids reduce inflammation around the affected nerves, which in turn decreases pain, numbness, and other neurological symptoms. Additionally, the local anesthetic provides immediate, short-term pain relief. The combination of these medications can offer both immediate and long-lasting benefits for patients suffering from various spinal conditions.

Types of steroids used in epidural injections

Several corticosteroids are commonly used in epidural injections, including:

• Dexamethasone
• Betamethasone
• Methylprednisolone
• Triamcinolone

The choice of steroid and dosage depends on various factors, such as the patient’s medical history, the specific condition being treated, and the physician’s preference.

Different Approaches to Epidural Steroid Injections

Epidural steroid injections can be administered using various techniques, depending on the affected area of the spine and the specific condition being treated. The three main approaches are:

1. Caudal
2. Interlaminar (also known as translaminar)
3. Transforaminal

Caudal epidural steroid injections

Caudal injections are performed through the sacral hiatus, a natural opening at the base of the spine. This approach is often used when multiple areas of the spine are affected or when post-surgical changes prevent other approaches. While it’s the least complicated method, it’s also the least specific in terms of targeting a particular spinal level.

Interlaminar epidural steroid injections

Interlaminar injections deliver medication directly into the epidural space at the affected spinal level. This technique allows for more targeted treatment and can address multiple levels or both sides of the spine simultaneously. It’s particularly useful for conditions affecting larger areas of the spine.

Transforaminal epidural steroid injections

Transforaminal injections target the specific nerve root as it exits the spine. This approach is often the first choice for lumbar spine injections, especially in cases of disc herniation causing nerve compression. It provides the most precise delivery of medication to the affected area.

Who Can Benefit from Epidural Steroid Injections?

Epidural steroid injections can be beneficial for a wide range of patients suffering from various spinal conditions. These injections are particularly effective for those experiencing acute or chronic pain due to nerve compression or inflammation.

Ideal candidates for epidural steroid injections

• Patients with herniated or bulging discs
• Individuals suffering from spinal stenosis
• Those experiencing radiculopathy or sciatica
• Patients with degenerative disc disease
• Individuals with persistent back pain unresponsive to conservative treatments

It’s important to note that while epidural steroid injections can provide significant relief for many patients, they may not be suitable for everyone. A thorough evaluation by a qualified healthcare professional is necessary to determine if this treatment is appropriate for a particular individual.

When are epidural steroid injections not recommended?

There are certain situations where epidural steroid injections may not be advisable, including:

• Pregnancy
• Active infections
• Bleeding disorders
• Allergies to the medications used
• Certain systemic health conditions

The Procedure: What to Expect During an Epidural Steroid Injection

Understanding the procedure can help alleviate anxiety and ensure proper preparation for patients undergoing epidural steroid injections.

How is an epidural steroid injection performed?

The procedure typically involves the following steps:

1. The patient is positioned appropriately, usually lying face down on an X-ray table.
2. The injection site is cleaned and sterilized.
3. Local anesthetic is applied to numb the area.
4. Using fluoroscopic (X-ray) guidance, the physician carefully guides the needle to the correct location in the epidural space.
5. A contrast dye may be injected to confirm proper needle placement.
6. The steroid medication is then slowly injected into the epidural space.
7. The needle is removed, and a small bandage is applied to the injection site.

Is anesthesia used during the procedure?

While general anesthesia is not typically required for epidural steroid injections, local anesthesia is used to numb the injection site. This helps minimize discomfort during the procedure. Some patients may experience mild pressure or discomfort as the medication is injected, but the procedure is generally well-tolerated.

Frequency and Duration of Epidural Steroid Injections

The frequency and duration of epidural steroid injections can vary depending on the individual patient’s condition and response to treatment.

How often can patients receive epidural steroid injections?

Generally, it’s recommended that patients receive no more than three to six epidural steroid injections per year. In cases of acute conditions, such as a new disc herniation, injections may be administered more frequently, with only weeks between treatments. For chronic conditions, the interval between injections is typically three to six months or more.

How long do the effects of epidural steroid injections last?

The duration of pain relief from epidural steroid injections can vary significantly among patients. Some individuals may experience relief for several months, while others may have longer-lasting effects. On average, patients can expect pain relief to last anywhere from a few weeks to several months.

Factors that can influence the duration of relief include:

• The underlying condition being treated
• The severity of nerve compression or inflammation
• The patient’s overall health and lifestyle
• The specific medications used in the injection
• The individual’s response to the treatment

Potential Risks and Side Effects of Epidural Steroid Injections

While epidural steroid injections are generally considered safe when performed by experienced professionals, like any medical procedure, they carry some risks and potential side effects.

What are the common side effects of epidural steroid injections?

Most side effects associated with epidural steroid injections are mild and temporary. These may include:

• Temporary increase in pain at the injection site
• Headache
• Flushing of the face
• Insomnia
• Anxiety or mood changes
• Temporary increase in blood sugar levels (in diabetic patients)

Are there any serious risks associated with epidural steroid injections?

While rare, more serious complications can occur. These may include:

• Infection
• Bleeding or hematoma formation
• Nerve damage
• Allergic reactions to the medications
• Spinal cord injury (extremely rare)

It’s crucial for patients to discuss all potential risks with their healthcare provider before undergoing the procedure.

Preparing for an Epidural Steroid Injection

Proper preparation can help ensure a smooth and successful epidural steroid injection procedure.

What should patients do before their epidural steroid injection?

To prepare for an epidural steroid injection, patients should:

• Inform their doctor of all medications they’re taking, including blood thinners
• Disclose any allergies, especially to medications or contrast dyes
• Follow fasting instructions if provided by their healthcare provider
• Arrange for transportation home after the procedure
• Wear comfortable, loose-fitting clothing
• Avoid wearing jewelry or bringing valuables to the appointment

What type of doctor performs epidural steroid injections?

Epidural steroid injections are typically performed by physicians specializing in pain management, such as:

• Anesthesiologists
• Physical medicine and rehabilitation specialists (physiatrists)
• Neurologists
• Orthopedic surgeons
• Interventional radiologists

These specialists have extensive training in spinal anatomy and injection techniques, ensuring the safest and most effective administration of the treatment.

The Role of Epidural Steroid Injections in Comprehensive Pain Management

While epidural steroid injections can provide significant relief for many patients, they are often part of a broader pain management strategy.

How do epidural steroid injections fit into overall pain management?

Epidural steroid injections are typically used in conjunction with other treatment modalities to provide comprehensive pain relief and improve function. These may include:

• Physical therapy
• Exercise programs
• Medications (such as anti-inflammatories or muscle relaxants)
• Lifestyle modifications
• Ergonomic adjustments
• Weight management

The goal is to provide both immediate pain relief through the injections and long-term management of the underlying condition through complementary treatments.

Can epidural steroid injections help avoid surgery?

In many cases, epidural steroid injections can help patients avoid or delay the need for surgery. By reducing inflammation and pain, these injections may allow patients to participate more fully in physical therapy and other conservative treatments, potentially leading to long-term improvement without surgical intervention.

However, it’s important to note that while epidural steroid injections can be highly effective for many patients, they may not be suitable or successful for everyone. In some cases, surgery may still be necessary to address the underlying spinal condition.

What You Should Know About Epidural Steroid Injections

• What are epidural steroid injections?
• What are they used for?
• What steroids are used?
• Who can benefit from them?
• How do the injections work?
• How often can you get them?

• How long do they last for back pain?
• What are the risks?
• Are there side effects?
• How should I prepare for my procedure?
• Is any anesthesia used? Is it painful?




• What kind of doctor performs these injections?

What are epidural steroid injections?

Epidural steroid injections place corticosteroid medication directly around a pinched nerve as it exits the spine within the epidural space. The epidural space is located where the bones and discs of the spine surround the nerves and spinal cord. This is the space into which disc tissue can herniate and cause pressure and inflammation around spinal nerves.

What are epidural corticosteroid injections used for?

Epidural steroid injections are commonly used to treat back pain caused by a herniated disc (slipped disc), lumbar or cervical radiculopathy, spinal stenosis or sciatica. Corticosteroids are strong anti-inflammatory medications and, when placed into the epidural space, can significantly reduce inflammation around an irritated nerve that is causing back and leg pain and discomfort.

What kind of steroids are used in epidural steroid injections?

The most commonly used steroids in epidural injections are dexamethasone, betamethasone, methylprednisolone, and triamcinolone. The choice of agent and dose is based on patient factors, response to prior injections, the region of the spine being injected, and the epidural approach.

Who can benefit from an epidural steroid injection?

Patients with several common conditions – including lumbar disc herniation, degenerative disc disease, lumbar radiculopathy, sciatica, lumbar spinal stenosis, postherpetic neuralgia and facet/synovial cysts – may benefit from an epidural injection. An epidural steroid injection may be an effective nonsurgical treatment in itself or may aid in surgical planning.

How do epidural corticosteroid injections work?

Epidural steroid injections work by delivering a potent anti-inflammatory to the site of nerve impingement in the spine. Injected medications may include steroids, local anesthetics, and saline, and they can vary in volume and concentration on an individual basis. While epidural injections for other applications may not require image guidance, epidural steroid injections for pain management are routinely performed with fluoroscopic or X-ray guidance to ensure correct, effective, and safe deposition of the injected medications. In select cases, CT or ultrasound guidance may be used as an alternative if indicated.

Cervical and thoracic epidural steroid injections

Epidural steroid injections in the cervical and thoracic spine can be used to treat cervical or thoracic herniated discs, radiculopathy, degenerative disc disease, or spinal stenosis. In the cervical region (neck), these conditions cause pain and neuropathies that radiate to the arm and hand. In the thoracic region (upper back and chest), pain can radiate to the ribs or flank. Injections may be done using an interlaminar or transforaminal technique as described below.

Caudal, interlaminar and transforaminal epidural corticosteroid injections

Three routes may be used for epidural injections in the lumbosacral spine (the vertebrae in the lumbar spine and sacrum of the lower back)

• caudal
• interlaminar (also known as translaminar)
• transforaminal

Your physician will choose which method is right for you based on your diagnosis and if you have had any prior spine surgeries.

• A caudal epidural steroid injection is the least complicated way to access the epidural space but is also the least specific. It can be useful if multiple areas of the spine are involved or if post-surgical changes prevent other approaches.
• An interlaminar or translaminar epidural steroid injection delivers the medication directly into the epidural space at the affected level, can be targeted to one side or the other, and can treat multiple levels or both sides at once.
• A transforaminal epidural steroid injection delivers the medication to the area where the specific affected nerve root exits the spine and is compressed by a disc herniation. It is the usual first choice approach for an epidural injection in the lumbar spine.

How often can you get epidural steroid injections?

Epidural steroid injections are recommended to be administered up to three to six times per year. In the case of a new disc herniation, injections may be only weeks apart with a goal of quick and complete resolution of symptoms. For chronic conditions, three to six months or more between injections is common.

How long do epidural injections last for back pain?

Epidural steroid injections can help resolve pain permanently in patients with a new disc herniation who respond favorably. For patients with chronic pain or recurrent disc herniations, the desired duration of effect is three to six months or more.

What are the risks of epidural steroid injections?

The risks in any procedure involving a needle include bleeding, infection and nerve damage. When performed properly, the risk of any of these is exceedingly low and usually outweighed by the potential benefit of the procedure.

Some contraindications for performing epidural steroid injections include:

• bleeding disorders or anticoagulation
• medication allergies (rare)
• systemic infection or localized infection overlying the area

Risks and benefits of repeated epidural steroid injections should be weighed on a case-by-case basis for patients who have or are at-risk for osteoporosis, as some evidence suggests repeated steroid injections can accelerate bone loss.

What are the side effects of epidural steroid injections?

Common side effects include mild injection site pain, temporary worsening of usual pain, flushing, insomnia, or increased blood sugar. These are usually self-limited and resolve within one to three days. A less common side effect is headache.

Is any preparation required? Can I eat before and after my epidural steroid injection?

Your doctor will give you specific instructions and these will vary by facility and type of epidural (lumbar, thoracic or cervical). Because the procedure is usually performed with local anesthetic rather than sedation, fasting guidelines are not overly prohibitive.

Is any anesthesia used? Are epidural steroid injections painful?

A local anesthetic is injected into the skin, numbing the area where the epidural needle is then placed. Patients may experience mild discomfort but should not experience severe pain during the procedure.

Will I have to lie flat on my stomach for long during or after the procedure?

The procedure can last anywhere from 10 to 20 minutes and requires the patient to lie prone, if possible, to allow for X-ray guidance (fluoroscopy). After the procedure, you can sit, stand, and walk as usual after a short period of monitoring.

What kind of doctor performs epidural steroid injections?

Epidural steroid injections at HSS are performed by several types of doctors – pain management physicians, physiatrists and interventional radiologists – all of whom are trained to safely perform this procedure, often with additional subspecialty fellowship training.

References

Updated: 6/1/2023

Authors

Anuj Malhotra, MD

Director, Pain Management Division, Hospital for Special Surgery
Assistant Attending Anesthesiologist, Pain Management, Hospital for Special Surgery

Related articles

References

• Connolly TM, Nadav D, Gungor S. Ultrasound-guided caudal epidural steroid injection for successful treatment of radiculopathy during pregnancy. Pain Manag. 2020 Mar;10(2):67-71. doi: 10.2217/pmt-2019-0044. Epub 2020 Mar 12. PMID: 32162584.
• Cozowicz C, Wilson LA, Poeran J, Liu J, Fiasconaro M, Zhong H, Girardi F, Conwell C, Memtsoudis SG. Trends in the Use of Epidural Steroid Injections to Treat Back Pain Before Spine Surgery. Pain Med. 2022 Dec 1;23(12):2089-2091. doi: 10.1093/pm/pnac095. PMID: 35708661.
• Gungor S, Aiyer R, Erkan D. Cervical Epidural Injection in the Management of Refractory Pain and Stiffness in Spondyloarthropathy: A Case Report Series. Pain Pract. 2018 Apr;18(4):532-538. doi: 10.1111/papr.12616. Epub 2017 Nov 20. PMID: 28742241.
• Krez A, Liu Y, Kanbour S, Clare S, Waldman S, Stein EM. The skeletal consequences of epidural steroid injections: a literature review. Osteoporos Int. 2021 Nov;32(11):2155-2162. doi: 10.1007/s00198-021-05986-4. Epub 2021 Jun 4. PMID: 34089066.
• Malhotra A, Mackey S. Outcomes in pain medicine: a brief review. Pain Ther. 2012 Dec;1(1):5. doi: 10. 1007/s40122-012-0005-4. Epub 2012 Sep 29. PMID: 25134934; PMCID: PMC4107859.
• Lee JJ, Nguyen ET, Harrison JR, Gribbin CK, Hurwitz NR, Cheng J, Boachie-Adjei K, Bogner EA, Moley PJ, Wyss JF, Lutz GE. Fluoroscopically guided caudal epidural steroid injections for axial low back pain associated with central disc protrusions: a prospective outcome study. Int Orthop. 2019 Aug;43(8):1883-1889. doi: 10.1007/s00264-019-04350-w. Epub 2019 Jun 5. PMID: 31168645.

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Epidural Steroid Injection, ESI, spine injections Cincinnati, Ohio Mayfield Brain & Spine

Overview

An epidural steroid injection (ESI) is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by inflamed spinal nerves due to spinal stenosis or disc herniation. Medicines are delivered to the epidural space, which is a fat-filled area between the bone and the protective sac of the spinal nerves. Pain relief may last for several days or even years. The goal is to reduce pain so that you may resume normal activities and a physical therapy program.

What is an epidural steroid injection (ESI)?

A steroid injection includes both a corticosteroid (e.g., triamcinolone, methyl-prednisolone, dexamethasone) and an anesthetic numbing agent (e.g., lidocaine or bupivacaine). The drugs are delivered into the epidural space of the spine, which is the area between the bony vertebra and the protective dura sac surrounding the spinal nerves and cord (Fig. 1).

Figure 1. Side view of the spine. The epidural space is a fat-filled area that lies between the bony vertebra and the dura sac, which surrounds and protects the spinal cord and nerve roots.

Corticosteroid injections can reduce inflammation and can be effective when delivered directly into the painful area. Unfortunately, the injection does not make a herniated disc smaller; it only works on the spinal nerves by flushing away the proteins that cause swelling. The pain relief can last from days to years, allowing your spinal condition to improve with physical therapy and an exercise program.

Who is a candidate?

Patients with pain in the neck, arm, low back, or leg (sciatica) may benefit from ESI. Specifically, those with the following conditions:

• Spinal stenosis: A narrowing of the spinal canal and nerve root canal can cause back and leg pain, especially when walking.
• Spondylolisthesis: A weakness or fracture between the upper and lower facets of a vertebra. If the vertebra slips forward, it can compress the nerve roots causing pain.
• Herniated disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall (annulus). Irritation, pain, and swelling occur when this material squeezes out and comes in contact with a spinal nerve.
• Degenerative disc: A breakdown or aging of the intervertebral disc causing collapse of the disc space, tears in the annulus, and growth of bone spurs.
• Sciatica: Pain that courses along the sciatic nerve in the buttocks and down the legs. It is usually caused by compression of the 5th lumbar or 1st sacral spinal nerve.

ESI has proven helpful for some patients in the treatment of painful inflammatory conditions. ESI can also help determine whether surgery might be beneficial for pain associated with a herniated disc. When symptoms interfere with rehabilitative exercises, epidurals can ease the pain enough so that patients can continue their physical therapy.

ESI should NOT be performed on people who have an infection or have bleeding problems. The injection may slightly elevate the blood sugar levels in patients with diabetes. It may also temporarily elevate blood pressure and eye pressure for patients with glaucoma. You should discuss this with your physician.

If you think you may be pregnant, tell the doctor. Fluoroscopy x- rays may be harmful to the baby.

Who performs the procedure?

Physicians who perform epidural steroid injections include physiatrists (PM&R), radiologists, anesthesiologists, neurologists, and surgeons.

What happens before treatment?

The doctor who will perform the procedure reviews your medical history and previous imaging studies to plan the best approach for the injections. Be prepared to ask any questions at this appointment.

Patients who take take blood thinning medication (Coumadin, Plavix, etc.) may need to stop taking it several days before the ESI. Discuss any medications with your doctors, including the one who prescribed the medication and the doctor who will perform the injection.

The procedure is usually performed in an outpatient center using x-ray fluoroscopy. Make arrangements to have someone drive you to and from the center the day of the injection.

What happens during treatment?

At the time of the procedure, you will be asked to sign consent forms, list medications you are presently taking, and if you have any allergies to medication. The procedure may last 15-45 minutes, followed by a recovery period.

The goal is to inject the medication as close to the painful nerve as possible. The type of injection depends on your condition and if you have metal rods or screws from previous surgery. The doctor will decide which type is likely to produce the best results.

Step 1: prepare the patient
The patient lies on an x-ray table. Local anesthetic is used to numb the treatment area so discomfort is minimal throughout the procedure. The patient remains awake and aware during the injection to provide feedback to the physician. A low dose oral sedative, such as Valium or Versed, may be offered depending on the center.

Step 2: insert the needle
With the aid of an x-ray fluoroscope, the doctor directs a hollow needle through the skin and between the bony vertebrae into the epidural space. Fluoroscopy allows the doctor to watch the needle in real-time on the x-ray monitor, ensuring that the needle goes to the desired location. Some discomfort occurs, but patients more commonly feel pressure than pain.

There are several types of ESIs:

• Cervical ESI (neck). The needle entry site is from the side of neck to reach the neural foramen, just above the opening for the nerve root and outside the epidural space (Fig. 2). Contrast dye is injected to confirm where the medication will flow.

Figure 2. An ESI injection in the cervical spine for neck or arm pain. The needle is inserted from the side of the neck to reach the neural foramen to deliver the steroid medication (green) where the inflamed nerve root exits the spine.

• Lumbar ESI (low back). The needle entry site is slightly off midline of the back to reach the nerve canal (Fig. 3). Contrast dye is injected to confirm where the medication will flow.

Figure 3. An ESI injection in the lumbar spine for leg or low back pain. The needle is inserted from the back on the affected side to reach the epidural space to deliver steroid medication (green) to the inflamed nerve root.

• Caudal ESI (tailbone). The needle is placed in the sacral hiatus above the tailbone to reach the lowest spinal nerves. Contrast dye is injected to confirm where the medication will flow.

Step 3: inject the medication
When the needle is correctly positioned, the anesthetic and corticosteroid medications are injected into the epidural space around the nerve roots. The needle is then re­moved. Depending on your pain location, the procedure may be repeated for left and right sides. One or several spinal levels may be injected.

What happens after treatment?

Most patients can walk around immediately after the procedure. After being monitored for a short time, you usually can leave the center. Rarely temporary leg weakness or numbness can occur; therefore someone should drive you home.

Typically patients resume full activity the next day. Soreness around the injection site may be relieved by using ice and taking a mild analgesic (Tylenol).

You may want to record your levels of pain during the next couple of weeks in a diary. You may notice a slight increase in pain, numbness, or weakness as the numbing medicine wears off and before the corticosteroid starts to take effect.

Patients should schedule a follow-up appointment with the referring or treating physician after the procedure to document the efficacy and address any concerns the patient may have for future treatments and expectations.

What are the results?

Many patients experience some pain relief benefits from ESI [1,2]. For those who experience only mild pain relief, one to two more injections may be performed, usually in 1-4 week intervals, to achieve full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with a physical therapy and/or home exercise program to strengthen the back muscles and prevent future pain episodes.

What are the risks?

With few risks, ESI is considered an appropriate nonsurgical treatment for some patients. The potential risks associated with inserting the needle include spinal headache from a dural puncture, bleeding, infection, allergic reaction, and nerve damage / paralysis (rare).

Corticosteroid side effects may cause weight gain, water retention, flushing (hot flashes), mood swings or insomnia, and elevated blood sugar levels in people with diabetes. Any numbness or mild muscle weakness usually resolves within 8 hours in the affected arm or leg (similar to the facial numbness experienced after dental work). Patients who are being treated for chronic conditions (e.g., heart disease, diabetes, rheumatoid arthritis) or those who cannot temporarily discontinue anti-clotting medications should consult their personal physician for a risk assessment.

Sources & links

If you have more questions, please contact Mayfield Brain & Spine at 800-325-7787 or 513-221-1100.

Links
Spine-health.com
Spineuniverse.com

Sources

1. Weinstein SM, Herring SA: NASS. Lumbar epidural steroid injections. Spine J 3(3 Suppl):37S-44S, 2003.
2. Lutz GE, VAd VB, Wisneski RJ: Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil 79:1362-1366, 1998.

anesthetic: an agent that causes loss of sensation with or without the loss of consciousness.

chronic: a condition of slow progression that continues over a long period of time, opposite of acute.

corticosteroid: a hormone produced by the adrenal gland or synthetically made. Regulates salt and water balance and reduces inflammation.

epidural space: the area between the membrane surrounding the spinal cord and the vertebral wall that is filled with fat and small blood vessels.

fluoroscopy: an imaging device that uses x-ray or other radiation to view structures in the body in real time, or “live. ” Also called a C-arm.

sciatica: pain that courses along the sciatic nerve in the buttocks and down the legs. Usually caused by compression of the 5th lumbar or 1st sacral spinal nerves.

updated > 7.2018
reviewed by > Marc Orlando, MD, Mayfield Clinic, Cincinnati, Ohio

Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic. This information is not intended to replace the medical advice of your health care provider.

Treatment of protrusion of the lumbar spine in Moscow at the Dikul clinic: prices, appointments

Treatment of protrusions of the lumbar spine in Moscow at the Dikul clinic: prices, appointments | Center Dikul

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• org/ListItem”> Main
• Treatment of the back
• Treatment of protrusion of the intervertebral discs
• Treatment of protrusion of the lumbar spine

Back pain can come from the intervertebral disc, nerves, muscles, bones and facet joints. A bulging disc is the most common cause of lower back and leg pain in all age groups. A small disc protrusion is often asymptomatic. At the same time, a large disc protrusion can protrude into both the foramen and the spinal canal and lead to the impact on the nerve structures with the development of radicular syndrome or spinal canal stenosis with the development of such a serious condition as Cauda equine.

Most back pain caused by a small disc protrusion resolves on its own.

Small disc protrusions are often poorly visualized on both radiography and MRI.

Chronic back pain caused by a bulging disc after injury has a major impact on work performance. Treatment of protrusion of the lumbar spine is usually conservative, but in the presence of compression of the nerve structures, surgical treatment may be recommended.

Causes

Aging and wear are usually the main causes of disc protrusion. However, many additional factors can stimulate or accelerate this degenerative spinal condition, including:

• Sudden injuries such as those that may occur during sports, a car accident, or a severe fall
• Genetic predisposition to degenerative disc disease (osteochondrosis)
• Congenital malformations of the spine
• Obesity or weight bearing
• Lack of sufficient and regular physical activity
• Malnutrition
• Smoking
• Impact of the person’s position or repetitive pressure on the discs of the lumbar spine
• As shown in the diagram above, the least pressure on the discs in the lumbar spine occurs in the supine position, while the greatest pressure on the discs occurs in the sitting position, with the torso leaning with the weight, with the center of gravity shifted forward along the axial line.
• It is important to note that while sitting, the impact on the lumbar discs is greater than when standing.
• Another cause of a protrusion of a disc in the lumbar region is excessive force when the vertebrae slide excessively, usually from overstretching or from lifting heavy objects with improper technique.

The muscles of the back try to prevent the spine from bending forward and causing compression, but the applied force vector is significant for them, and therefore the vertebrae slide too much in relation to each other.

Force vectors acting on the lumbar spine during sitting

Symptoms

General symptoms

• Insomnia – secondary to pain
• Weight loss secondary to chronic pain and loss of appetite. Loss of appetite observed in patients suffering from back pain due to spinal stenosis or cancer

Back pain

• Discogenic pain. Lumbar discogenic pain is felt in the region of the lumbar dermatome L1-L5.

Lumbar radicular pain

• The nature of the pain is sharp and shooting pain.
• Pain is provoked by certain movements (for example, bending or twisting the torso, coughing and sneezing).
• Time and intensity of pain – pain worse at night
• Pain radiates to the lower extremity – along the dermatome of the nerve roots L1, L2, L3, L4, L5 or S1.
• Dermatomal pain caused by root compression

Compression of the L1 root – pain spreads to the area of ​​the inguinal dermatome.

L2 root compression – Pain is felt along the anterior and lateral surface of the mid-thigh, mid-thigh and lateral thigh.

L3 root compression – Pain is felt along the inner and anterior-lower part of the thigh.

L4 root compression P- The pain is localized in the lower leg, mainly on the front and back side.

L5 P Compression – Pain is felt on the front lateral side of the lower leg and dorsal part of the foot in the region of the middle three toes.

S1 root compression – Pain is felt on the lateral side of the feet.

Compression S2 – Pain is felt on the back of the thigh and back of the upper 2/3 of the leg.

Tingling radiating along the dermatome of nerve roots L1-S2

Numbness radiating along the dermatome of nerve roots L1-S2

Other symptoms of disc protrusion

Paravertebral muscle spasm

• Pair vertebral muscle spasm is observed between the vertebrae L1 and L5.
• Muscle spasm is often permanent and causes severe pain secondary to muscle fatigue and accumulation of lactic acid in the muscles.

Muscle weakness in the lower limb

• Motor nerve ischemia. Strong pressure within the foraminal intervertebral foramen causes ischemic changes in the motor nerve, resulting in weakness in the leg.
• Movements in the spine. Flexion, extension, abduction, and extension of the lower limb become weak, depending on the level of root involvement in the lumbar spine.
• Change of position. The patient has difficulty getting in and out of a sitting or lying position.
• Motor disorders at the level of root damage

L1 – causes hip flexion weakness.

L2 – causes hip flexion weakness.

L3 – causes weakness of hip flexion and knee extension.

L4 – Impossibility of extension at the knee and dorsiflexion at the ankle.

L5 – Unable to perform big toe extension, plantar extension, inability to lift the big toe up.

S1 – Causes weakness in knee extension.

Reduced knee and ankle reflexes

• Patella reflex – L2 and L3. Damage to the root causes an abnormal reflex of the knee joint.
• Achilles reflex – reduced or absent with damage to the nerve roots L4-5 and S1.

Muscle atrophy

• Decrease in muscle mass observed on the side of the protrusion of the disc
• Muscle atrophy or thinning of the leg is associated with weakness in the leg.

Since the symptoms of lumbar protrusion are similar to many other more serious conditions, it is important to make a full diagnosis before starting treatment.

Diagnostics

Treatment of lumbar protrusion

Medication

• OTC analgesics – Designed for mild to moderate pain.
• Anti-inflammatory drugs – Designed to reduce nerve root inflammation caused by irritation and pinching (aspirin, ibuprofen (Motrin, Advil) and naproxen (Aleve).

Prescription analgesics

• Tramal – prescribed for persistent pain.
• Opiates are recommended when other drugs fail to relieve pain.
• Opioids are useful in the treatment of chronic intense pain.

Muscle relaxants

Antidepressants

• Effective as an analgesic in the treatment of chronic neuropathic pain.
• Used as an analgesic when other pain medications (NSAIDs, tramadol or opioids) cause severe side effects.
• For neuropathic pain associated with depression – used as an analgesic and antidepressant.
• Most commonly prescribed antidepressants
• Duloxetine
• Milnacipran
• Tricyclic antidepressants (Elavil)

Sedatives

• Sedatives (such as benzodiazepines) are prescribed to reduce anxiety caused by pain. In addition, they can to some extent reduce muscle spasm and normalize sleep.

Antiepileptic drugs

• The analgesic action of these drugs is used in the treatment of chronic neuropathic pain.
• Indicated as an analgesic if NSAIDs, tramadol, or opioids are associated with severe side effects.

The most commonly prescribed antiepileptics for pain:

• Gabapentin (Neurontin).
• Pregabalin (Lyrica).

Interventional pain management

• Translaminar epidural corticosteroid injection. An epidural injection of corticosteroids helps reduce disc and nerve root inflammation.
• Caudal Corticosteroid Injection – Caudal epidural injection is an alternative method of delivering corticosteroids into the epidural space.
• Trans-foraminal epidural injection – targeted injection of cortisone into the area of ​​root compression due to disc protrusion.

Chiropractic

This treatment is effective for small to medium disc protrusions.

Manual therapy often avoids invasive treatments such as interventional pain therapy and surgery.

• Osteopathic manual therapy is often used in the treatment of lumbar disc protrusion and can be effective within the first month after the onset of symptoms.
• Massage . The use of therapeutic massage helps to relieve pain in the superficial and deep layers of muscles and connective tissue. Massage helps to improve the blood supply to the muscles, as well as reduce muscle spasm.
• LFK
• Stretching and flexibility exercises help to restore the mobility of the motor segments of the lumbar spine. Weight training is essential for strengthening muscles and strengthening spinal stability.
• Physiotherapy (cryotherapy, ultrasound, electrical stimulation, magnetotherapy, TENS (Transcutaneous Electrical Nerve Stimulation). These and other physiotherapy methods are widely used in the treatment of lumbar disc protrusion.
• Acupuncture. The method of treatment is useful if necessary to reduce pain and restore conduction along the nerve fibers.

Surgical treatment

Surgical nerve decompression. These operations are performed to relieve pressure on the nerves:

• Microdiscectomy – Microscopic surgery leads to a quick recovery.
• Percutaneous nucleoplasty . Minimally invasive surgical treatment ensures rapid recovery
• Discectomy – After a skin incision and surgery, the disc is removed.
• Laminectomy – the bony part of the vertebra (lamina) is removed to widen the bone tunnel
• Fusion operation – this surgical treatment is used after unsuccessful operations to decompress the nerves.

Treatment

• Neurology
• Physiotherapy
• Device therapy
• Traumatology and Orthopedics
• Arthrology
• Podiatry
• Rheumatology
• Manual therapy
• Osteopathy
• Reflexology
• Carboxytherapy
• Therapeutic massage
• Dietetics
• Gynecology
• Pediatrics
• ENT (otorhinolaryngology)
• Urology

Appointments

Department of Neurology

• All Specialists
• Center Belyaevo
• Center Losiny Ostrov
• Maryino Center
• Center Krylatskoe

Fedotova Anastasia Valerievna

MRC Belyaevo

Shabunin Andrey Aleksandrovich

MRC Vodny Stadium

Podyablonskaya Maria Yuryevna

MRC Belyaevo 90 003

Teslenko Elena Leonidovna

MRC Belyaevo

Mikhalcheva Tatyana Vladimirovna

MRC Losiny Ostrov

Kursakina Elena Vladimirovna

MRC Krylatskoe

Malkova Valentina Rifovna

MRC Belyaevo

Nesterova Irina Nikolaevna

MRC Maryino

Kazakova Svetlana Sergeevna

MCC Krylatskoe

Kolobkova Maria Yuryevna

MRC Losiny Ostrov

Chernetsova Ksenia Andreevna

MRC Vodny Stadium Anastasia Aleksandrovna

MRC Belyaevo

Rodionova Nadezhda Viktorovna

MRC Losiny Ostrov

Bobrova Yulia Pavlovna

MRC Maryino

Shepeleva Irina Vasilievna

MRC Belyaevo

Bagdasaryan Manush Rubenovna

MRC Losiny Ostrov

Bakanova Larisa Maratovna 9 0003

CCC Krylatskoe

Musorina Vera Leonidovna

CCC Maryino

Slobozhaninova Marina Yurievna

CCC Maryino

Antonenko Nadezhda Sergeevna

MRC Krylatskoe

Polevoda Olga Andreevna

MRC Losiny Ostrov

Andrey Ermolin

Water Sports Center

Disc protrusion – treatment, symptoms, causes, diagnosis

Disc protrusion – the most common form of disc degeneration, which can lead to back pain. As a rule, it occurs with trauma or age-related changes in the disc and can proceed unnoticed until irritation of nearby nerves occurs. During normal functioning, the movements of the vertebrae are cushioned by intervertebral discs , having a spongy structure and an oval shape. Over time, discs wear out and begin to bulge beyond their normal position. Disc degeneration usually goes through several stages.

• Stage of damage (swelling). The inner part of the disc, called the nucleus pulposus, begins to move beyond its usual location and bulges towards the annulus fibrosus. The bulge may take up more than half (more than 180 degrees) of the circumference of the disc.
• Disc protrusion . The protrusion of the nucleus pulposus is still within the fibrous ring, but already protrudes into the spinal canal. The disc protrusion may be 180 degrees or less circumferential (more pointed protrusion).
• Herniated disc. When a disc herniation occurs, damage to the fibrous ring occurs, in which the contents of the nucleus pulposus can escape outside the ring.

It is important to remember that the terms protrusion and disc herniation are used by some doctors as similar conditions to each other and sometimes it is necessary to detail the diagnosis. The spine contains the spinal cord and dozens of nerve roots that emerge from the spine and innervate various areas of the body. When the disc bulges (protrusion) into a very small space of the spinal canal, this leads to an effect on the spinal cord or roots, which leads to the appearance of symptoms:

• Chronic back pain
• Muscle weakness
• Sciatica
• Pain, numbness and tingling in limbs
• Stiffness or soreness
• Loss of elasticity and mobility

Symptoms are quite individual and depend on the cause of disc damage and location. For example, a protruded disc in the cervical region can cause problems in the shoulder, and a protrusion in the lumbar region can cause weakness in the legs. Protrusions in the thoracic region are rare, but still occur. The genesis of protrusion affects the volume and intensity of symptoms. Imaging techniques (MRI or CT) are necessary for the correct diagnosis of protrusion. As a rule, conservative methods of treatment are quite effective for disc protrusions (exercise therapy, physiotherapy, massage, drug treatment).

Cervical disc protrusion

Disc protrusion is a condition in which the disc bulges and impacts on the roots, causing neck pain and other symptoms. Protrusion occurs, as a rule, as a result of age-related changes. There are seven vertebrae in the cervical spine, between which there are intervertebral discs . The cervical region is a very mobile structure and discs provide mobility and elasticity of movements in the neck, and stability of the head position. When the discs wear out, protrusions appear, which can cause compression of the spinal cord or roots. Effects on spinal structures and causes symptoms:

• Chronic, local pain in the neck
• Muscle weakness in shoulder, arm, elbow
• Numbness and tingling in the arm
• Pain radiating along the arm

Specific symptoms depend on the location of the protrusion and the degree of change in the disc. Therefore, effective treatment is possible only after an accurate diagnosis of the cause using neuroimaging (MRI or CT) and differentiation from other diseases that give similar symptoms. The possibilities of conservative treatment for protrusions in the cervical spine are quite high.

Protrusion in the thoracic spine

Protrusion in the thoracic spine is quite rare. The fact is that the ribs are attached to the thoracic vertebrae and, thus, the mobility of the vertebrae in the thoracic region is significantly reduced. And therefore, unlike the cervical or lumbar regions, the possibility of excessive impact on the discs is much less. But, nevertheless, there is still a certain amount of movement, and with degeneration of the discs, protrusions appear that bulge into the spinal canal and cause certain symptoms. Symptoms depend on the location of the protrusion and the degree of impact on nearby nerve formations.

• Pain inside or in the middle of the back
• Abdominal weakness
• Pain, numbness and/or tingling in chest, abdomen
• Back stiffness or soreness
• Pain in the intercostal space. As a rule, conservative methods of treatment are quite effective for such protrusions.

Protrusion in the lumbar spine

Most often, protrusions appear in the lumbar spine and cause back pain. The lumbar spine is most prone to problems due to the large load on one side (the center of gravity is in the lumbar region) and the large range of motion on the other side. As a result, the lumbar discs are more prone to damage and protrusion. In addition, age-related degenerative processes in the discs exacerbate changes in the discs. When the disc bulges, irritation of nearby spinal structures occurs, which leads to the appearance of symptoms.

Symptoms depend on the location and degree of pathological changes in the disc.

• Pain in the lower back of a chronic nature.
• Soreness or stiffness in the small of the back.
• Sciatica
• Muscle weakness in thighs and calves
• Pain, numbness or tingling in feet, toes
• Urination dysfunction (in rare, emergency cases)

Treatment is usually conservative. But sometimes, with large protrusions and severe persistent symptoms, surgical treatment is necessary.

Protrusion types

• Lateral
• Posterolateral
• Central (median)
• Rear

Lateral (lateral) protrusions

The term lateral protrusion means that the protrusion is on the side (right or left) of the spinal column. When the protrusion (bulging) is located on the side, then the probability of pressure on the roots of the spinal cord is quite high. This type of protrusion occurs quite rarely (in 10% of cases) and is often asymptomatic until the protrusion presses on nearby roots and causes symptoms.

Posterolateral protrusions

The most common type of protrusion. The term means that the location of the protrusion is back and sideways in relation to the spinal column. With this location of the protrusion, there is a high probability of not only affecting the roots (as with lateral protrusions) on the right or left, but also on other structures of the spinal cord. As well as lateral, this protrusion can be asymptomatic until there is a physical impact on the nervous structures.

Central protrusion (median)

The term refers to the direction of the protrusion towards the center of the spinal canal. With this arrangement, there is a risk of impact on the spinal cord. As a rule, such protrusions are asymptomatic and rarely need treatment.

Posterior protrusion

The term refers to the topical direction of the bulge (protrusion) back from the abdomen to the back. Most often, such an arrangement of protrusion leads to a direct effect on the spinal structures and leads to pain syndromes, sensitivity disorders, motor disorders, and dysfunction of the pelvic organs.

Symptoms of a bulging disc

The symptoms of a bulging disc are very variable and depend on the specific pathology of the disc. Symptoms range from numbness in the fingers to chronic back pain. By itself, the protrusion is asymptomatic. As long as there is no effect on the spinal structures (irritation of nerve fibers or roots), protrusion does not manifest itself in any way. And the person feels absolutely healthy until the protrusion comes into contact with the nerves. Depending on the topic of protrusion (median, posterior, lateral), certain anatomical regions of the spinal cord and roots are affected. The degree and severity of symptoms directly depend on the pathology that led to protrusion, topics and the degree of compression on the nerve roots and spinal cord. The most typical symptoms are:

• Chronic local pain in the back (usually in the neck or lower back)
• Radiating or migratory pains
• Lumbosacral sciatica (with localization of protrusion in the lumbar spine)
• Muscle weakness
• Feeling of numbness or tingling in the legs and arms
• Burning sensation (in the form of diffuse heat or hot spots)
• Stiffness

Symptoms can usually be managed with conservative treatment.