A poster presentation of this research: Trends in Outcome for the Treatment of Intracranial Aneurysms in New York State: A 3-year Population Based Study

This study can be found in the August 2009, Vol. 65,  issue 2 of Neurosurgery

Using fluoroscopy guidance, the presumed pain-causing facet joint is injected with a steroid medication (to decrease inflammation) and/or a local anesthetic (to numb the area).

If the patient’s pain is relieved after the injection, the pain-generating facet joint is presumed to have been identified. A facet joint block may also be used therapeutically to provide pain relief.

Twisting injuries of the spine are the predominant cause of damage to the facet joints.

Epidural Steroid Injections are used to decrease the inflammation associated with a variety of spinal conditions, such as herniated disc, spinal stenosis, or degenerative disc disease, enabling the patient to pursue physical therapy/rehabilitation. While patients often experience a reduction in pain following an epidural steroid injection, there seems to be a better response when the injections are coupled with an organized therapeutic exercise program.

Before an Epidural Steroid Injection
An Epidural Steroid Injection usually takes between 15 and 30 minutes. The patient lies flat on an x-ray table on their abdomen. Prior to the epidural injection, the skin is numbed with lidocaine, which is similar to the Novocain that the dentist uses (a “local” anesthetic).

What to Expect During an Epidural Steroid Injection
An epidural steroid injection is generally administerd using the following process:

• Using fluoroscopy (live x-ray) for guidance, the physician injects steroids into the epidural space — that area that lies between the inner surface of the bony vertebral column and the outer, sleeve-like covering (the dura) of the spinal cord. Sometimes a flushing solution (either lidocaine or normal saline) is also used to help “flush out” inflammatory proteins from the region that is believed to be the source of pain.
• The Epidural Steroid Injection procedure is usually not uncomfortable; however, sedation is available for patient anxiety and comfort. Sedatives are rarely necessary. If a sedative is used, the patient will need to be monitored for a longer period following the injection.
• The procedure takes about 30 minutes, plus approximately forty-five minutes recovery time.
• Following the injection, the patient is usually monitored for 15 to 20 minutes before being discharged to go home. Patients are usually asked to rest on the day of the epidural steroid injection. Normal activities (those that were done the week prior to the epidural injection) may typically be resumed the following day.

Success Rates
An Epidural Steroid Injection is generally successful in relieving pain for approximately 50% of patients. If a patient does not experience any back pain or leg pain relief from the first epidural injection, further injections will probably not be beneficial. However, if there is some improvement in back pain or leg pain, one to two additional Epidural Steroid Injections may be recommended.

How Frequently Can Epidural Steroid Injections be Performed?
There is no definitive research to dictate the frequency of how often a patient should have Epidural Steroid Injections for low back pain and/or leg pain. In general, it is considered reasonable to perform up to three epidural injections within a six-month period.

Typically, Epidural Steroid Injections are done in two-week intervals. However, there is no general consensus in the medical community as to whether or not a series of three injections need always be performed. If one or two injections lessen the patient’s low back pain and/or leg pain, some physicians prefer to save the third epidural steroid injection for any potential recurrences of back pain later in the twelve-month period.

Potential Risks and Side Effects
As with all invasive medical procedures, there are potential risks associated with lumbar (lower back) Epidural Steroid Injections. Generally, however, there are few risks associated with epidural steroid injections and they tend to be rare. Risks may include:

• Infection. Minor infections occur in 1% to 2% of all injections. Severe infections are rare.
• Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
• Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or secondarily from infection or bleeding.
• Dural puncture (“wet tap”). A dural puncture occurs in 0.05% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually gets better within a few days. Although rare, a blood patch may be necessary to alleviate the headache.

Paralysis is not a risk since there is no spinal cord in the region of the epidural steroid injection.

In addition to risks from the injection, there are also potential side effects from the steroid medication. These side effects tend to be rare, though they become more common when steroids are taken daily for several months. These risks and side effects may include:

• A transient decrease in immunity
• High blood sugar
• Stomach ulcers
• Severe arthritis of the hips (avascular necrosis)
• Cataracts
• Transient flushing
• Increased appetite

Who Should Avoid Epidural Steroid Injections?
Lumbar Epidural Steroid Injections should not be performed on patients who:

• Have a local or systemic bacterial infection
• Are pregnant (if fluoroscopy is used)
• Have bleeding problems
• May be suffering from a tumor or infection (if suspected, an MRI scan should be done prior to the injection to rule out these conditions)
• Are suspected of having allergies to the injected solution, uncontrolled medical problems (such as congestive heart failure and diabetes)
• Are taking aspirin or other antiplatelet drugs/blood thinners (epidural steroid injections can be given once these medications have been stopped; however, patients need to consult with their physician before discontinuing them)

We’ve posted a video of Dr. Solomon, Chair of the Department of Neurological Surgery, discussing risk factors and treatment for brain aneurysm on Youtube.

Outstanding patient care from an exceptional, multidisciplinary team

More than 20 surgical specialists and sub-specialists, a dedicated nursing team for neurosurgery patients, labs performing cutting-edge research, and CUMC’s world-class hospital facilities (including a Neuro ICU and unique amenities at our Children’s Hospital), combine to deliver outstanding care, making clear communication about complicated conditions a priority so that patients and their families are equipped to make wise decisions.

Unparalleled technical expertise

The size of our department (more than 20 doctors) enables individual surgeons to focus on their diverse specialties, offering patients extraordinary technical expertise in fields as diverse as aneurysm, pediatric epilepsy, and spinal tumors. As a group, our surgeons are leaders in their fields. Many have published articles in their specialties and perform research that explores new approaches for treating neurological conditions.

Conservative treatment philosophy

We are committed to providing patients with the best, proven approaches for addressing their neurological conditions. As a professional academic practice, we are routinely engaged in clinical research that pushes the envelope. However, our treatment philosophy is essentially conservative: surgery is not always the right solution. Cutting-edge treatments may be minimally invasive or non-invasive.

Better outcomes

Studies have consistently shown that high-volume hospitals deliver better outcomes for surgical patients. The degree of specialization of our surgeons, who perform high volumes of procedures in their areas of expertise, helps secure those better outcomes. In addition, our dedicated nursing team coordinates exemplary pre-op education and post-op care, often resulting in quicker-than-expected recovery times.

A true team effort

The Department of Neurosurgery is not only one of the top practices in the United States; we are also one of the top academic programs, and the great majority of our faculty started out as students here. An advantage of our academic setting and our focus on specialized expertise is that patients are directed to the most appropriate specialist rather than the first available surgeon. We don’t provide incentives for doctors to work outside their specialties; we do promote cross-discipline consultation.

And when we hire new surgeons, we are choosing from the best-of-the-best. We have considerable experience with prospective additions to our group, since they have been students here, so we can easily determine how well they will fit the professional practice, and gauge their commitment to excellence and outstanding patient care. As a result, our doctors work together unusually well, and patients benefit from a true team effort.

Cutting-edge research

Our academic setting provides patients with access to the cutting-edge research being performed at multiple department labs. Patients may have the opportunity to participate in clinical studies and learn how new developments in medicine and technology may apply to their conditions.

Endowed Chairs/Professorships

Research is a large part of our mission here at the Department of Neurological Surgery. This is founded on a tradition that goes back to the early days of the Neurological Institute, a hundred years ago. A number of our neurosurgeons carry on this important work today. Their research is largely funded by private donors and the creation of Endowed Chairs or Professorships.

Meet our Endowed Chairs and learn more about their namesakes here: Our Endowed Chairs

World-class hospital facilities

CUMC, part of New York Presbyterian Hospital, has long been recognized as one of the top hospitals in the U.S. For neurosurgery in particular, CUMC offers a 16-bed Neuro ICU unit, dedicated nursing staff, anesthesiologists, and radiologists, all focused on addressing the unique needs of patients with neurological conditions. At the associated, top-rated Children’s Hospital, New York-Presbyterian Morgan Stanley Children’s Hospital, young patients receive top-notch care in a compassionate environment tailored to their unique developmental and emotional needs.