45 year old female with 6-month history
of right leg pain.
Despite nonoperative treatment with physiotherapy, NSAIDs, neuromodulatory medication she complained of severe right leg pain in the L5 nerve distribution
MRI confirmed a para-central right disc herniation impinging the right L5 nerve.
We have decided to proceed with a right transforaminal nerve root injection.The pre-injection score was 9/10 on the Visual Analogue Scale.
The patient remained in the hospital for about 2 hours and her husband drove her home. The post-injection pain was reported to be 1/10.
The injection is performed as a day-case procedure and may be performed with you awake or under light sedation. Epidural glucocorticoid injections are commonly given to patients with leg and/or back pain to relieve such pain and improve mobility without surgery. These steroid injections are used to buy time to allow healing to occur, as an attempt to avoid surgery after other conservative (non-surgical) treatment approaches have failed or for diagnostic purposes.
During a transforaminal injection, a small-gauge blunt needle is inserted into the epidural space under fluoroscopic guidance through the bony opening of the exiting nerve root (Figure 1).
The needle is smaller in size than that used during a conventional epidural approach. The procedure is performed with the patient lying on their belly using fluoroscopic (real-time x-ray) guidance, which helps to prevent damage to the nerve root. A radiopaque dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed (See Figure 1). This technique allows the glucocorticoid medicine to be placed closer to the irritated nerve root than using conventional interlaminar epidural approach. The exposure to radiation is minimal.
Indications include large disc herniations, foraminal stenosis, and lateral disc herniations. Patients with disc herniations and leg pain in most of the studies attained maximal improvement in 6 weeks. Interestingly, long-term success rates for transforaminal epidural glucocorticoid injections ranged from 71% to 84%.
The effectiveness of the injections is variable. For some people it can get rid of their leg pain permanently, and for others for weeks or months.
As a rule, patients who obtained little relief from the first injection got little benefit from a second or third injection. Those patients with degenerative lumbar canal stenosis and patients who failed previous therapies may significantly improve standing and walking tolerance following transforaminal lumbar steroid injections.
Complications Complications are rare but may include headaches, infections, blood pressure changes, bleeding, and discomfort at needle insertion site. Use of steroids rarely causes an increase in blood sugar and blood pressure, as well as leg swelling. The major complication, that being damage to a nerve root is very rare. However, using a blunt needle may even more reduce the risk of this complication.
You will be required to stay in the hospital for a few hours after the procedure. Sometimes, after having a nerve block procedure, your back or leg may feel stiff, weak or numb for a few hours. Please ask one of the staff to help you get up after the operation. You should not drive on the day of the injection. A follow up appointment will be arranged, so that the doctor / nurse can review the effects of the treatment. We would like you to gradually return to your normal activities after the injection and you should return to work as soon as possible, and if you were working up until the time of the injection, you should be able to return to work the following day. If you were taking tablets for pain relief before the injection, please continue to do so afterwards until you are able to tell if the injection has helped you. If it has, please discuss reducing your use of painkilling tablets with your GP. We will usually see you again in the outpatient clinic a few weeks later to find out if the procedure has helped. It is important that you keep a record of whether you feel the injection helped, both on the day it was performed and also over the next few weeks.
It is very important that you inform the Mr Annis`s or Secretary, at least a week before the injection:
If you are allergic to any medications
If you are on blood thinning medication such as Warfarin, Aspirin, Clopidogrel (Plavix), Ticlopidine (Ticlid)
If you have an infection near the injection site.
If you have had a recent steroid / cortisone injection.
If you think you might be pregnant
If you are a Diabetic and have poorly controlled blood sugars, a steroid injection could aggravate this.
Caution should be exercised if you have had a recent heart attack or vaccination. Please inform the pain clinic.
The information contained in this leaflet is for educational purposes only, please discuss with Mr Annis if you require further information.
If there are any concerns or queries please contact Mr Annis`s Secretary.