medilaw.tv - Cervical Spine Epidural Steroid Injection transforaminal pain management videos. This movie illustrates the technique for performing a cervical transforaminal epidural injection in the supine position. This movie shows patient positioning, skin preparation, local anesthetic injection, needle introduction into the epidural space, contrast injection to check needle tip position in the epidural space, steroid / anesthetic injection, and finally wound dressing. Cervical Spine Epidural Steroid Injection transforaminal pain management videos.

INTRODUCTION
An epidural injection is used to inject medication into the epidural space around irritated spinal nerves. Spinal nerves can be irritated by herniated or degenerative discs, facet joint osteophytes, enlarged ligaments or traumatic or infectious inflammation. The injected medication can include local anesthetic, slow-release anti-inflammatory steroid and opioid pain-relieving medication. Epidural injections can be diagnostic or therapeutic. The amount of immediate pain relief from the local anesthetic is diagnostic of the degree to which the nerves are a source of your pain. This information will assist with the selection of further treatment options. Once the source of the pain is known, therapeutic injections can be given to provide pain relief. Steroids act as an anti-inflammatory to decrease pain and swelling. Opioids increase the pain relief. In addition, the injection fluid also helps to flush out inflammatory pain-causing proteins. The injection can provide ongoing pain relief so that a rehabilitation program can be undertaken.

INDICATIONS
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
The indications for an epidural injection are
– to assist in the identification of the cause of neck or arm pain
– to provide relief of pain caused by disease of the intervertebral disc, spinal nerve root, or adjacent structures.

ALTERNATIVES
The non-surgical alternatives to epidural injection may be
– activity modification
– weight loss
– aerobic exercise, such as walking, cycling, and swimming
– strength and flexibility exercises
– physical therapy
– hydrotherapy
– heat and cold pads
– acupuncture
– oral pain-relieving medications such as acetaminophen or paracetamol, non-steroidal anti-inflammatory drugs, glucosamine, chondroitin

The surgical alternatives to epidural injection may be
– pain management injections or ablations
– surgical decompression and possibly fusion
– disc replacement surgery
– oral steroid medication (may not be as effective).

INFORMED REFUSAL
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
It is your right to delay or refuse the recommended treatment for your condition. However, this delay or refusal may lead to the worsening of your symptoms, such as increased neck pain, arm pain, pins and needles, weakness or numbness. You should ask your doctor what might happen should you choose not to undertake the recommended treatment.

BEFORE
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
Before the epidural injection
- cease blood thinners as instructed ie coumadin/warfarin, plavix, heparin, aspirin
- let your doctor know all the medications you are taking including herbal medications that can increase bleeding risk ie vitamin E, glucosamine, chamomile, danshen, garlic, gingko, devil’s claw, ginseng, fish oil, willow bark, feverfew, and goji berries
- you should take your routine medications, but stop any pain relievers or anti-inflammatory medication for the day. You need to have some pain, so you can assess whether the injection gives you any pain relief.
- you will be admitted into the hospital on the day of the procedure
- bring your radiological images and reports ie X-rays, CTs, MRIs
- don't eat or drink for a few hours before the procedure.
- wear loose-fitting clothes that are easy to take off and put on. Do not wear any jewelry.
- before the procedure, the skin on your neck will be cleaned and you will be given a general health check. The skin on your neck may be shaved.
- an intra-venous line may be placed in to a vein in your arm to administer fluid and medications
- let your doctor know if you develop a fever, cold or flu symptoms before your scheduled procedure.

GOALS
The goal of an epidural steroid injection is to provide pain relief by reducing the inflammation of the nerve roots as they leave the spine. An epidural steroid injection will not correct the pre-existing medical problem but may provide enough pain relief so that psychology, physical therapy and pharmacologic management can be optimized.

TECHNIQUE
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
Your neck will be cleaned. A local anesthetic injection will numb the skin. This may sting for a couple of seconds. A needle will enter the epidural space through the intervertebral foramen. Fluoroscopy, an X-ray TV, is often used to help guide the needle to the correct location. Some contrast dye may be injected to check the exact position of the needle tip. Then the medication will be injected, the needle removed and a small bandage placed on the skin.

NO SMOKING
Smoking damages every part of your body and decreases the chance of a successful procedure. If you smoke, you should stop now.

EXPECTATIONS
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
The expectations of the procedure are
– the procedure will take about ten to thirty minutes
– immediately after the injection of local anesthetic, you should feel that your pain is much less
– your arms and hands may feel weak or numb for a few hours
– after a few hours, your pain will return and you may have a sore neck for a couple of days. This is due to the needle insertion. Simple pain relief and ice packs for ten minutes every couple of hours will help.
– about half of clients receive longer term pain relief from a steroid injection. It will take two to ten days for the pain relief to commence. The relief may be permanent, or temporary, but it will permit a rehabilitation program to be commenced.
– clients with shorter symptom duration tend to achieve better pain relief that also tends to last for longer.

REHABILITATION
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
Rehabilitation from an epidural injection
- you will be observed for half to one hour before being discharged
– you may have slight bruising from the needle, this will settle
– take your usual medication as required.
– take simple pain relief medication if required. You can ice the area for up to ten minutes every couple of hours for additional pain relief. Use ice cubes or frozen peas in a damp towel.
– you are usually discharged to home on the same day. You will need to be taken home and supervised for the rest of the day by a friend.
– you will be able to resume your normal activities the following day, however no driving or operating heavy machinery for twenty-four hours
– you can remove the bandage after twenty-four hours and wash as usual
– check your wound twice a day. If you notice any redness, swelling, green or yellow discharge, or opening of the wound, see your family doctor immediately and call your surgeon
– you may be asked to complete a pain diary for the next week to help your doctor assess the benefits of the injection
– you will have a follow-up appointment with your doctor to assess the effect of the injection, and to determine future treatment.

ON-GOING CARE
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
You have a weak spot in your neck, and surgery can never return it to full strength. You will need to engage in lifelong neck care to reduce the risk of further neck problems. You should always maintain correct posture, lose any excess body fat, continue your daily exercise program and avoid unnecessary stresses on your neck.
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POTENTIAL COMPLICATIONS OF A CERVICAL EPIDURAL INJECTION
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
ACCIDENTAL SPINAL CANAL INJECTION
Accidental injection of medication into the spinal canal can cause an unexpected decrease in nerve function. The effect varies, depending on the type and amount of medication, and its location in the spinal canal. The effect will eventually wear off. If the effect is in the upper neck, it can interfere with breathing and may require breathing assistance.

ADHESIVE ARACHNOIDITIS
Adhesive arachnoiditis is a rare complication of cervical surgery. It starts as an inflammation of the arachnoid membrane surrounding the spinal cord and nerve roots. It can be triggered by surgery, trauma such as a dural tear (membrane around spinal cord), chemical irritants such as radiographic contrast dye (mainly older ones), infection or hemorrhage. The inflammation can lead to scar tissue and adhesions that stick the nerve roots together. This tension on the nerve roots interferes with local blood flow and nerve function, leading to back or leg pain, numbness, cramps and stiffness. Arachnoiditis often develops gradually, over one to six or more months. There is no cure. The treatment is physical therapy and pain management medications and techniques.

ADRENAL SUPPRESSION
It is normal for some of the steroid medication injected into joints or muscles to spread around the body. This can cause a decrease in the adrenal gland's production of adrenal steroid hormones, called adrenal suppression, and a decrease in the size and capacity of the adrenal glands, called adrenal atrophy. This effect depends on the number of steroid doses, the amount of each dose, and the type of steroid used. When the steroid injections cease, the decreased adrenal hormone production can appear. It is particularly noticeable during times of stress when the normal 'fight or flight' mechanism fails to activate. Symptoms of adrenal suppression include fatigue, anxiety, depression, muscle pain and tenderness, joint pain, and irritable bowel syndrome. Similarly, if you take steroids regularly, you should not stop them suddenly, as you can reveal your underlying adrenal suppression, causing an ‘addisonian crisis’ – severe vomiting and diarrhoea, low blood pressure/sugar, tiredness, confusion, fainting, convulsions, fever, death.

ALLERGIC REACTION TO MEDICATION
Cervical Spine Epidural Steroid Injection transforaminal pain management videos.
An allergic reaction to the medications used can occur. This can cause a rash, swelling of the eyelids, hands, joints and throat, difficulty breathing, low blood pressure and death. These reactions are easily controlled with the right equipment and medications.

ANESTHESIA
Anesthesia is used so you will feel no pain during the procedure. Anaesthesia can be
Local – where the medication is injected into the skin around the site of the surgery to numb only surrounding tissues
Regional – where the body part is anesthetized by numbing a major nerve or part of the spinal cord.
Conscious sedation – where a full anesthetic is not given, rather, medications are used to create a near-sleep relaxed state.
General – where you are rendered unconscious and temporarily paralyzed. In this instance, medication is given to you through an IV line, and machines breath for you and monitor you, along with your Anesthesiologist. Most epidural injections use a local anesthesia, so that you won’t feel pain during the procedure.

ARTERY INJURY - VERTEBRAL
The vertebral artery passes close to the vertebral bodies in the neck. Injury during surgery is uncommon. Laceration causes bleeding that can usually be controlled by topical agents, repair or blockage of the artery. If the blood supply to the brain from the other vertebral artery is functioning, then full recovery is likely if the bleeding is quickly treated. Injury may however lead to paralysis or death.

ARTERY PERFORATION
Arteries are large blood vessels that can carry blood under pressure throughout the body. Your doctor will be very careful to avoid injuring arteries near your operation site. An artery perforation can result in significant bleeding and blood loss. This is very uncommon. If an artery is perforated, the artery can usually be repaired and the lost blood can be replaced by a blood transfusion. A specialist vascular surgeon is often asked to repair arteries. Late consequences of artery injury include fistula, hemorrhage, pseudo-aneurysm, thrombosis and emboli.

CEREBROSPINAL FISTULA
A tear in the dura, which contains the spinal cord and the cerebrospinal fluid, can allow cerebrospinal fluid to leak out through the wound, and onto the skin. This is called a cerebrospinal fistula. It may cause headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. There is a risk of infection and meningitis. The dural tear may reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or surgery to repair.

DEATH
No physician can guarantee a risk-free procedure. All operations and procedure have some risks. Some risks are minor inconveniences, while some are major disabilities. The risks increase with repeat operations on the same area of your body. Your entire medical staff will do their best to eliminate all risks to you, before, during and after your surgery. However sometimes, even after the surgery goes well, serious problems can arise that can result in death. These include pneumonia, pulmonary emboli, heart attack and stroke. You should discuss these risks with your Physician and your Anesthesiologist.

DUROTOMY
The dura is a thin layer of tissue that forms a sac containing the brain, spinal cord and nerve roots. The sac is filled with cerebrospinal fluid or CSF. The dura can be punctured during an epidural injection leading to a leak of the fluid from the sac. This complication is more difficult to avoid when operating on severe spinal narrowing. A dural puncture with the leakage of cerebrospinal fluid, can cause a headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. A continuing leak can lead to a cerebrospinal fluid cyst under the skin, or a leakage of fluid from the wound. Dural punctures can reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or an additional operation to repair. Cervical Spine Epidural Steroid Injection transforaminal pain management videos.

EPIDURAL ABSCESS
Epidural abscess is a collection of pus that has formed in the epidural space of the spinal canal due to a bacterial infection. It can occur spontaneously, or occur one to two days after a spine procedure. As well as the usual signs of infection, the abscess can place pressure on the spinal cord and block its blood supply. Antibiotics may resolve the infection. If not, aspiration with a needle or a surgical drainage procedure may be required.

EPIDURAL FIBROSIS
Epidural steroid injections can lead to the formation of excessive amounts of scar tissue in the epidural space that can compress or tether adjacent tissues. This can cause pain and nerve irritation symptoms. Prevention involves post-operative physical therapy. Treatment may require physical therapy, pain medications, pain management techniques or further surgery.

EPIDURAL HEMATOMA
If bleeding occurs into the epidural space around the spinal cord, it may form a collection of blood, called an epidural hematoma. If the hematoma is large, it can compress the spinal cord and nerve roots leading to pain, weakness, numbness and bowel and bladder problems. A surgical procedure may be required to stop the bleeding and remove the hematoma.

EPIDURAL LIPOMATOSIS
Enlargement of the fat tissue in the epidural space is called epidural lipomatosis. While rare, it usually happens in people receiving long-term oral steroid medication. Cervical Spine Epidural Steroid Injection transforaminal pain management videos. There have been cases occurring after epidural steroid injections. As the fat tissue enlarges, it compresses the spinal cord causing back pain, leg weakness and sensation changes. Treatment can include decreasing steroid medication, weight loss and surgery to remove the fat tissue.

FLUOROSCOPY
Fluoroscopy uses X-rays to obtain instant pictures of the inside of a patient during a surgical procedure. This is very useful when needle tips need to be accurately positioned. X-rays are a form of ionising radiation. They can potentially cause cancer, reproductive abnormalities, cataracts and radiation dermatitis. Any effect depends on the amount and duration of exposure to the X-rays. During surgical procedures, the exposure is usually not significant. Your doctors will minimize the radiation dose to yourself and themselves by minimising the intensity and duration of exposure and by using lead.

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