The Dark Side of Epidural Steroid Injection: Understanding Hidden Dangers

When chronic back pain hits, epidural steroid injections come as a quick fix. But behind the promise of pain relief, there is a dark side to epidural steroid injections that is rarely talked about. From some risks to long-term complications, take a closer look at the downsides of these injections.

But First, What is Epidural Steroid Injection?

Epidural steroid injections, or ESI injections, are steroid injections used to treat lower back pain, compressed sciatic nerve, and other trapped nerves. These injections typically place steroids in the spine's epidural space to relieve pain caused by inflammation and irritation of spinal nerve roots. The epidural space is a sac that surrounds the spinal cord and contains nerves, blood vessels, and fat. Pain relief from an epidural steroid injection may last some days or months. 

What is the Dark Side of Epidural Steroid Injections?

Though safe and effective for use, there are some hidden dangers of epidural steroid injections that you need to be aware of before treatment: 

• The steroid medication may temporarily worsen your pain before it begins to work.

• You may experience bruising or tenderness at the injection site.

• Fluoroscopy X-rays used during the procedure could harm the growing child. So, before the treatment, it's crucial to discuss with a doctor if you are or are planning to get pregnant.

• An epidural steroid medication will probably result in high blood sugar if you have diabetes (hyperglycemia). It might go on for several hours or days.

• An ESI may suddenly raise your pulse rate and eye pressure if you have glaucoma.

• Any performance-enhancing drug medication has the propensity to make people gain weight on the back, stomach, shoulders, tummy, and face.

• The steroid may cause stomach ulcers if a person is predisposed to them.

• Lack of sleep and exhaustion due to the steroid injections’ temporary nature of pain relief and the need for repeated injections.

• Headache and lightheadedness due to dural puncture, where the needle mistakenly punctures the dura, an outer membrane that surrounds the spinal cord.

• Permanent nerve damage in extremely rare cases, from severe infection or spinal cord damage, which is caused by a steroid epidural injection. 

Side Effects of Epidural Steroid Injections

Though safe, epidural steroid injections can cause certain side effects:

Common Side Effects:

If these side effects last longer, see a doctor:

• Mild Injection Site Pain at the Injection Site

• Temporary Worsening of Pain

• Flushing of the face and chest

• Insomnia (Difficulty sleeping)

• Increased Blood Sugar Levels

• Nausea

• Dizziness

• Headaches

• Fatigue

Rare, Severe Side Effects:

Report these side effects immediately to the healthcare providers to reduce further complications:

• Severe Headache

• Infection at the Injection Site

• Nerve or Blood Vessel Damage

• Blood Pressure Changes

• Allergic Reactions

• Numbness and Tingling Sensations 

• Permanent Nerve Damage (Paralysis)

What Risks and Complications Could Epidural Steroid Injections Possess?

Though rare, the following are potential risks of epidural injections:

1. Bleeding Risk

• Bleeding can occur where the needle was injected, within the epidural space, soft tissues, or the spinal cord's membranes, due to damage to arteries.

• If blood starts accumulating, it can contribute to a hematoma or a blood clot within the arteries, blocking the blood supply to the spinal cord or brain. 

2. Dural Puncture 

• Accidental insertion of the needle into the outer membrane of the spinal cord, called "dura mater," may lead to dural puncture.

• This results in leakage of cerebrospinal fluid (CSF) that lowers CSF pressure in the brain, leading to a headache. This condition is known as a "wet tap".

3. Nerve Damage 

• Nerve damage from spine injections is rare but can occur due to severe infection, spinal cord damage, blood clotting, and direct nerve injury.

• This can lead to complications such as loss of sensation, abnormal sensations, or seizures. The annoyance may linger for just a few days but quickly passes.

4. Cauda Equina Syndrome 

• Due to damage to the cauda equina nerves present at the base of the spinal cord, Cauda Equina Syndrome can occur rarely.

• This syndrome may lead to loss of the ability to urinate or bowel, which should be treated immediately to prevent lower body paralysis.

5. Infection

• Infections can occur within the body, affecting the brain and spinal cord (in rare cases), or can occur in the injection area.

• Examples include:

• Epidural abscess, pus accumulated in the epidural space.

• Osteomyelitis, an infection of the vertebral disc or bone.

• Meningitis, an inflammation of the membrane and brain.

• Soft tissue abscess, a buildup of pus in the soft tissues present at the injection site.

6. Heart Complications

• Though rarely, epidural steroid injections may cause heart-related issues, which occur when the injection solution enters blood vessels.

• This contributes to several issues, such as vasovagal response, a sudden drop in blood pressure and heart rate, takotsubo cardiomyopathy, a temporary weakening of the heart muscles, or cardiac accelerator fiber blockage causing a slow heart rate. 

7. Local Anesthetic Risks

• Epidural steroid injections containing a local anesthetic can pose a risk if the solution enters the blood or if the needle is not placed precisely.

• This may result in toxicity of the cardiovascular system or the central nervous system and cause dizziness, seizures, confusion, or tremors, and even cardiac arrest (in severe cases).

8. Particulate Steroid Risks

• Particulate steroid injections used in the procedure may lump together and block the small blood vessels, which can lead to a risk of lowering the blood flow to the spinal cord.

• This can disrupt the sufficient supply of blood to the spinal cord, contributing to tissue damage and severe neurological issues. 

Can Long-term Complications Result From Receiving an ESI injection?

Even though they are extremely uncommon, yes, long-term effects from epidural steroid injections might occur. Those include:

• Epidural injection-induced spinal cord or neurological dysfunction damage that results in a lifelong neurologic deficit.

• Chronic pain is brought on by epidural injection-induced spine or nerve root damage.

• Hematomas, which develop when an accumulation of blood occurs between the dermal layer and the spinal cord, can result in permanent paralysis.

Prognosis (Outlook) for Epidural Steroid Injection Therapy

There are different stages of outcomes for epidural steroid injections (ESIs) because there are numerous chronic pain causes, and each person is unique. However, the success rate ranges from 50% to 84%, based on the specific issue, severity of pain, and response of an individual to the treatment.

How Long Do the Effects of Epidural Steroid Injections Last?

Epidural cortisone injections are effective at relieving pain, but the duration of that relief may vary depending on what is causing the pain in the first place. Their effects may last for a few weeks or months. Some people might experience immediate pain relief, while others might feel an improvement in a few days or weeks. In some cases, the individuals may have pain relief for several months or longer.

When to See the Doctor?

After receiving your ESI injection and returning home, call your health professionals or head straight to the hospital if you notice any symptoms like:

• Having an intense headache while sitting or standing that gets better when you lie down. This might indicate a dural puncture.

• Experiencing a viral infection, which could indicate an infection.

• Having diminished or lost urethral or bowel control completely.

• Noticing weakness or numbness in one's legs may indicate a nerve injury.

Black Box Warning for Epidural Steroid Injections

In 2014, the US Food and Drug Administration (FDA) gave the following warnings to the people regarding the use of epidural steroid injections:

• These injections may cause rare but severe negative effects such as stroke, loss of vision, paralysis, and death.

• As the safety and effectiveness of injecting these corticosteroid injections into the spinal cord's epidural space have not been established, so FDA has not approved their use.

• Patients need to discuss all the benefits and risks of these injections with a doctor, and also the benefits and risks related to other treatment options.

• Seek medical help immediately in case of unusual symptoms associated with epidural corticosteroid injections, like tingling sensations in the arms or legs, vision changes, severe headache, sudden numbness of the face, leg, or arm, or on one or both sides of the body, dizziness, or seizures.

• Consult and report the side effects associated with these injections to the FDA MedWatch program. 

Tips to Reduce the Potential Risks of Epidural Steroid Injections

Consider these tips:

• Choose an experienced anaesthetist: Look for qualified and experienced anaesthetists who have great knowledge and skills in performing the procedure correctly.

• Ask them about the procedure: Ask the anaesthetist to tell you all the exact details of what will happen during the procedure. This can let you know what to expect.

• Review your medical history: Discuss all your medical issues, especially diabetes, infections, or bleeding disorders, with your doctor, as they can interfere with the procedure.

• Reduce the number of injections: Avoid using the injections frequently or repeatedly (basically not more than 3 or 4 a year).

• Rest after the procedure: Getting enough rest helps steroids to stay in the targeted area for a longer time, which gives effective relief from pain.

• Monitor the potential side effects: Take a close look at side effects such as worsening pain, fever, or numbness and report them immediately to your doctor to prevent further complications.

Summing Up 

With advantages, there is also a dark side to epidural steroid injections that you need to be aware of before starting the treatment. Those downsides include temporary pain relief, bruising or tenderness at the injection site, high pulse rate and eye pressure, increased blood sugar levels, stomach ulcers, headaches, and nerve damage. Some people have observed that the procedure loses some effectiveness after repeated use. If you experience any complications, report them immediately to a doctor.back