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Transforaminal Epidural Steroid Injection



What is a transforaminal epidural injection ?

A transforaminal epidural injection is an injection of medications typically including a local anesthetic and a steroid into the opening at the side of the spine where a nerve root exits. This opening is known as a foramen. There is a small sleeve of the epidural space that extends out over the nerve root for a short distance. This epidural root sleeve is just outside the spinal canal. Sometimes these injections are referred to as root sleeve blocks, root blocks or transforaminal epidural blocks.


Am I a candidate for a transforaminal epidural injection?

Transforaminal epidural injections are commonly offered to patients with narrowing of the spinal canal or the foramen causing compression of the spinal nerves. This compression can lead to radicular pain which is typically described as burning, numbness and or tingling radiating to the area where the specific injured nerve innervates. A classic example of this is sciatica, where a patient may experience these symptoms down the legs into the feet.


What are the benefits of transforaminal epidural injections?

The long acting steroid that is injected reduces the inflammation and swelling of spinal nerve roots and other tissues surrounding the spinal nerve root. This may in turn reduce pain, tingling and numbness and other symptoms caused by such inflammation, irritation or swelling. Transforaminal injections can also be used to identify a specific spinal nerve root level in the process of evaluating the source of pain.


How long does a transforaminal epidural injection take?

Depending on the area to be treated, the actual procedure typically takes five to fifteen minutes.


How is a transforaminal epidural injection performed?

The procedure is performed in different positions depending on the area treated. They are done either with the patient laying on their side or back for most neck injections and with the patient typically on their stomach for back injections. Occasionally other positions are used to optimize the X-ray view. All patients are monitored with heart rate, blood pressure, and an oxygen monitoring device. The skin overlying the treatment area is cleaned with antiseptic solution and numbed with local anesthetic. The injection needle is then placed under live X-ray (fluoroscopy) guidance. Once the needle is in the correct location, the medication will be injected which can often feel like the normal pain that the patient feels in the distribution of that particular spinal nerve root. The needle is then removed and a sterile bandage is applied.


Will the transforaminal epidural injection hurt?

The procedure involves inserting a needle through skin and deeper tissues which can sometimes be painful. We do numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the spinal needle. Once numbed, placing the spinal needle often feels like more of a strong pressure and pinching than a sharp pain. Some patients choose to receive intravenous sedation that can make the procedure easier to tolerate. Many patients choose to undergo the transforaminal injection without sedation and do well with very little pain throughout the procedure.


Will I be “put out” for the transforaminal epidural injection?

This procedure is done under local anesthesia only, or with the assistance of a anesthesia provider using IV medications providing light sedation. The sedation can make the procedure more tolerable for some patients. The amount of sedation given generally depends upon the patient. Some patients have enough sedation that they have amnesia and might not remember parts or all of the actual procedure.


What should I expect after the transforaminal epidural injection?

Immediately after the injection, you may feel like your arm or leg is heavy and may be numb, depending on where the injection was done and how much local anesthetic was used. You may notice that your pain may be less immediately following the procedure. This immediate effect is also due to the local anesthetic injected. This will last only for a few hours. Your pain may return and you may have some soreness, worsening pain, or aching for a a few days following. This is due to the mechanical process of the needle insertion, as well as the irritation from the steroid injected. Typically, you should start obtaining pain relief starting the third to fourth day.


What should I do after the transforaminal epidural injection?

Due to the possibility that there may be numbness or weakness in the extremity treated, it may make driving following the procedure both difficult and dangerous. All patients must have a ride home prior to undergoing the procedure. Most patients are advised to take it easy for a day or so after the procedure until the medication has a chance to work. Typically you can perform any activity that you were able to perform before the procedure without further limitations.


Can I go back to work the next day?

You should be able to go back to work the next day. Usually you will feel some soreness or aching at the injection site only.


How long does the effect of the medication last?

The steroid starts working in about 3 to 5 days and the effect can last for several days to several months with some cases lasting for several years.

How many transforaminal epidural injections do I need to have?

If the first transforaminal injection does not relieve your symptoms within two weeks, you might be recommended to have a second injection. Similarly, if the second transforaminal injection does not completely relieve your symptoms in about a week to two weeks, you may be recommended to have a third injection. If there was no improvement after two injections, it is unlikely that a third transforaminal injection will help.


Can I have more than three transforaminal epidural injections?

In a six-month period, most patients do not receive more than three injections. This is because the effect of the medication injected frequently lasts for six months or more. If three injections have not helped you much, it is not too likely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from the steroid medications injected.


Will the transforaminal epidural injection help me?

It is sometimes difficult to predict if the injection will help you or not. Patients who have pain radiating from the spine down into the arms or legs respond better to the injections than the patients who have only pure neck or back pain. Similarly, the patients with a recent onset of pain may respond much better than patients with longstanding pain.


What are the risks and side effects?

Generally speaking, transforaminal injections are safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effect is pain from the actual injection once the local anesthetic wears off and this pain is temporary. Uncommon risks involve spinal puncture, infection, bleeding inside the epidural space, nerve damage, or worsening of symptoms. Other risks which are related to the side effects of the long acting steroid include weight gain, increase in blood sugar in diabetics, water retention and suppression of body’s own natural production of steroids when steroids are overused

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