Thoracic Epidural Steroid Injection

Abstract

Epidural spinal injections (ESI) are one of the most common treatments for chronic back pain. Injections are performed with local anesthetics with or without corticosteroids and can reduce inflammation providing pain relief, restoring function, and improving participation in a physical therapy program. They are most commonly performed at the lumbosacral level to treat lumbosacral radicular pain caused by lumbosacral disc herniation. Though thoracic back pain is less common than cervical or lumbosacral back pain it can still cause significant limitations for patients who suffer from it. Thoracic epidural steroid injections are an effective treatment for several thoracic chronic pain conditions to include disc herniation, spinal stenosis, and post thoracic surgery and thoracotomy pain (Benyamin et al., Pain Physician 15(4):E497–E514, 2012; Manchikanti et al., Pain Physician 17(3):E327–E338, 2014; Manchikanti et al., Pain Physician 24(S1):S27–S208, 2021).

Lumbar epidural steroid injections can be performed via a transforaminal, interlaminar, or caudal approach with mixed data regarding the superiority of any one approach (Ghai et al., Pain Physician 17(4):277–290, 2014; Manchikanti et al., Clin Orthop Relat Res 473(6):1940–1956, 2015; Parr et al., Pain Physician 12(1):163–188, 2009). Many physicians choose the transforaminal approach due to the ability to better target the ventral epidural space (Lee et al., Spine J 18(12):2343–2353, 2018). Risks of the transformational approach include including paraplegia and pain, with caudal ESIs being considered a safer though less targeted approach. The caudal approach carries a lower risk of thecal sac puncture and can be done fluoroscopically, with ultrasound guidance, or with a combination of both—mainly with fluoroscopy being used to check contrast spread in patients with prior low back surgery.

When isolated lumbar nerve root irritation is suspected, selective nerve root blocks can be performed for diagnosis and to better target the affected nerve root. Causes of nerve root irritation can include disc herniation, ligamentum flavum hypertrophy, facet hypertrophy, and osteophytes leading to nerve root irritation (Stafford et al., Br J Anaesth 99(4):461–473, 2007).

Lumbar epidural steroid injection and selective nerve root blocks are considered temporizing treatments and recurrence of low back pain is expected. They do not alter prognosis for patients with certain condition in whom surgery is indicated.