#treatment - Spine

Spinal Injections

Types of injection

There are 3 main types of injections in the spine:

  1. Facet joint injections,
  2. Nerve root injections and
  3. Caudal epidurals.

The injections can be in the lumbar, thoracic, and cervical spine (caudal epidural is only in the lower spine region). “Lumbar” indicates that the injection is in the lower back region, “cervical” indicates that it is in the neck region, and “thoracic” indicates that it is between the neck and the lower back.

You may be having one or more of these. Which one(s) you have will depend on your symptoms, and your MRI scan.

You may be having one or more of these. Which one(s) you have will depend on your symptoms, and your MRI scan.

Facet Joint Injections

The facet joints are paired joints in the back and neck, with one pair at each vertebral level (one joint on each side of each vertebra). These joints have opposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule that is filled with synovial (joint) fluid, which reduces the friction between bones that rub together.

Facet joints link each segment of the spine. They provide stability and help to guide motion. The facet joints can become painful due to ‘wear and tear’ (degenerative change, or arthritis), back injury or mechanical stress to the back. The reason for injecting your facet joint is both for diagnostic and therapeutic purposes.

A lumbar facet joint injection involves injecting a small amount of local anaesthetic (numbing agent) and steroid (cortisone) anti-inflammatory. This can anaesthetise the facet joint and block the pain. The pain relief from a facet joint injection is intended to help you better tolerate a physiotherapy program to rehabilitate your injury or back condition.

Facet joint injections usually have two goals: to help diagnose the cause and location of pain, and also to provide pain relief.

Note: Facet joint pain can sometimes temporarily worsen in the first few days following the procedure.

Nerve Root Injection

Nerve roots are branches of nerves that leave the main spinal canal and supply sensation and power to the leg and foot region (from the lumbar spine), the chest (from the thoracic spine), and the arms and head (from the cervical spine). Which nerve root you have injected will depend on your symptoms and your MRI results.
The nerve root is identified on X-ray using dye, which is injected to visualise the nerve itself. The procedure is otherwise the same as for a facet injection, where the local anaesthetic and steroid is injected around the nerve.

Caudal Epidurals

A caudal epidural is a steroid and local anaesthetic injection into the epidural space. The epidural space is the space outside the dura (the covering of the spinal cord). This space runs the length of the spine. A caudal epidural is given for pain arising from irritation from a damaged discs or for pain due to pressure on / pinching of the nerves by the bone or ligaments of the spine. An epidural injection places anti-inflammatory drugs into the epidural space to decrease inflammation of the nerve roots, reducing the pain in the back or legs.

Potential Risks and Complications

As with all medication and procedures, there are potential risks associated with spinal injections. However, in general, the risks are low and complications are rare.

Potential complications that may occur include:

  • Bruising or discomfort at the point of the injection or worsening of pain symptoms. These symptoms are usually mild and short-lived. Long lasting increases in pain are rare.
  • Allergic reaction. The allergy may be from the X-ray contrast or steroid. It is rare to get a reaction to local anesthetic. Life threatening or severe allergies are very rare indeed.
  • Bleeding. A rare complication, bleeding is more common for patients with underlying bleeding disorders or in patients on blood thinners.
  • Infection. Minor infections occur in less than 1% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
  • Nerve or spinal cord damage or paralysis. Whilst extremely rare, damage to the spinal cord or nerves can occur from direct trauma from the needle, or secondarily from infection, bleeding resulting in compression, or injection into an artery causing blockage.
  • Headache occurs infrequently due to the nerve coverings being breached by the needle tip, causing leakage of CSF (cerebrospinal fluid). This normally lasts just a day or two.
  • Facial flushing for a few days.
  • Temporary alteration of your usual menstrual cycle (females).
  • Temporary increase in your sugar levels if you are diabetic.

Before Your Procedure

Please inform your surgeon if you are:

  • Diabetic
  • Have a cough, cold, or any kind of infection.

You must also inform us (before attending the hospital for your injection) if you are taking any of the following medications:

  • Aspirin, warfarin, or clopidogrel (as some of these may need to be stopped some days before).
  • Antibiotics

Information for females: We will need to know the start date of your last menstrual period due to the use of X-ray equipment. If you think you might be pregnant, please contact us for advice.

On The Day Of Your Procedure

Bring a list of your medications with you.

When you arrive at the hospital you will be taken to the ward and a nurse will complete your admission details and check that you are fit for your procedure. You will be asked to sign a consent form by your surgeon, which details the risks and benefits of your procedure. You will also have a chance to speak to your surgeon and ask any further questions you may have at this time.

The anaesthetist will see you prior to the procedure to explain the sedation and to answer any questions you might have about this. A mark will be placed on your back to indicate the part of the body being injected. Although this is obvious, it is a routine requirement.

The Procedure

Injections are a relatively simple and straightforward procedure. Injections are best performed using fluoroscopy (live X-ray) for guidance, to properly target and place the needle in the correct position.

The injection procedure includes the following steps:

  • The procedure is performed with sedation to varying degrees, based on your level of comfort and your choice.
  • An i.v. (intravenous) line will be inserted in your arm to deliver the sedation.
  • You will lie stomach down on the procedure table. The skin over the area to be injected will be cleaned with antiseptic (chlorhexidine), which temporarily gives an orange stain to the skin. You will then be covered with sterile drapes to keep the field clean.
  • Local anaesthetic agent is then injected into a small area of skin to numb it. This may sting for a few seconds.
  • X-ray guidance (fluoroscopy) is always used to direct a small needle to the relevant area.
  • For a nerve root injection and caudal epidural, contrast dye is then injected to give an image that confirms the correct position.
  • The technique used for caudal epidural is to inject in the ‘soft spot’ above the coccyx (lower spine between your buttocks). This provides a path to the epidural space, which is confirmed following the injection of dye.
  • Following this confirmation, a small mixture of anaesthetic (normally 0.5% Marcaine) and anti-inflammatory medication (steroid/cortisone) is then slowly injected.

The injection itself only takes a few minutes, but the entire procedure usually takes between fifteen and thirty minutes.

Immediately Following the Injection

After the procedure, patients typically remain resting in the recovery area for twenty to thirty minutes. You will then be asked to demonstrate that you can move all of your limbs to ensure that all the nerves are functioning well.

On occasion, you may feel some numbness, pins and needles or even slight weakness in the legs (lumbar injection), or arms and hands (cervical). This normally settles down over a few hours.

You will then be taken back up to the ward. Once you have been to the toilet and had something to eat, and once the nurses feel that you are safe and ready, you will be allowed home. This is likely to be 1 to 2 hours after the procedure.

It is our policy that you should have someone come and pick you up. You should be fit to return to work the following day.

It is possible that your pain may be worse in the first few days after the injection. The steroid/cortisone is slow acting and can take up to six weeks to work.

It is likely that you will be asked to commence your physiotherapy three weeks after your injection, if you are sufficiently comfortable by this point. If you do not have an assigned physiotherapist, we will arrange this for you. All you need to do is contact our office (details on your clinic and admission letter) with your details and your preferred area.

An outpatient appointment will be arranged for 4 to 6 weeks after your injection. Please contact our office if you do not have an appointment arranged following your procedure.

When you get home

Avoid doing any strenuous activities.

Avoid driving or operating any manual equipment on the day of the procedure. If sedation was used, you should not drive for 24 hours afterwards.

Remove the dressing the next morning.

The week after the injection

You may notice an increase in pain in the first few days following the procedure, as the local anaesthetic wears off and before the steroid starts to take effect.

If the area is uncomfortable in the first two to three days after the injection, carefully applying an ice pack to the general area of the injection site will typically provide pain relief.

You may continue to take your regular pain medicine after the procedure.

On the day after the procedure, you may return to your regular activities.

Summary

Overall, injections are relatively simple and safe procedures to perform. The injection is done to check that your pain is actually coming from the specific site being injected and to provide pain relief. The overall chance of success is about 75%. The injection may be effective for days, months, or occasionally permanently. The aim is to allow a pain-free period while the cause of the pain is allowed to resolve naturally.

What if my symptoms return?

Patients are routinely followed up in the clinic 4 to 6 weeks after the procedure. If your symptoms return after this, we will review your symptoms in the clinic again and make further recommendations to you based on a re-assessment. This could involve a further injection, or advice about further interventions. You would need to contact our office again to arrange this appointment.

Infomation

CLICK HERE to get this advice sheet in printable PDF format

This advice sheet is intended specifically for patients of Mr Alexander Montgomery, and is intended as an aid for patients either undergoing or considering spinal injection treatments. The information in this sheet is specifically to supplement the advice that you either will or have received from your consultant in clinic. If you have any queries or concerns arising from the guidance in this advice sheet then you should discuss this directly with your consultant.