Managing Pain ESI
Epidural Steroid Injection—a treatment for short-term relief of certain types of pain. ESI is sometimes prescribed for pain in the hands, arms, legs, back, or neck.

Among the growing number of alternative pain-management options available through healthcare providers is "epidural steroid injection" (ESI)—a treatment for short-term relief of back and neck pain. ESI is sometimes prescribed by physicians for pain felt in the hands, arms, legs, back, or neck that results from spinal disk problems or spinal stenosis. It involves injecting a small amount of medication into the "epidural space" surrounding the spinal canal, which contains the spinal cord and spinal nerve roots.

How it works

ESIs usually consist of steroid medications placed next to nerve roots as they exit the spinal cord around the vertebrae.

Figure 1: ESI injection into the spinal cord

Steroid medications reduce inflammation and sometimes, by association, pain. In some cases, image guidance techniques such as fluoroscopic guidance (continuous X-ray) and ultrasound are used to provide more accurate needle placement to reduce side effects. A 2015 publication from the American Medical Association recommends that all ESI in the lumbar or cervical space should use image guidance.

Spinal pain

ESIs are helpful for certain types of spinal conditions. For example, ESIs appear to be better for neck pain from herniated disks (when the disks between the spinal bones rupture) than for spinal stenosis (narrowing of the space around the spinal cord). Combining anesthetic ESI with anti-inflammatory medication seems to relieve neck pain better than either medication alone. However, one study found that ESI treatment with a combination of steroid and lidocaine did not relieve lumbar spinal stenosis pain. There is some—but not enough—evidence to support the use of ESIs with mid-back pain, but more research is needed.

Figure 2: Normal disk versus herniated disk

Low-back pain

Many people find ESIs helpful for low-back pain, especially when related to low-back herniated disks and spinal stenosis, although the effectiveness might be temporary. A systematic review of ESIs for low back pain found ESIs did not reduce chronic low back pain or the need for surgery. As mentioned above, ESIs appear to be more effective for pain from herniated disks rather than spinal stenosis. In fact, some evidence suggests that for people with pain from spinal stenosis, those who have ESIs performed have worse outcomes than those who do not.

Effectiveness

For herniated disks, ESIs don't work as well as other treatments such as diskectomy. There isn't enough research yet to know how well ESIs work for general low-back pain. Many doctors do not recommend ESIs for non-specific back pain, because of the risks associated with the procedure (see below).

Overall, ESIs sometimes offer short-term relief for certain back and neck pains, but their long-term effects and cost-effectiveness are uncertain. However, ESIs are frequently combined with various other types of treatments for chronic pain. The National Institutes of Health reports that ESIs are generally safe when performed by doctors who are trained pain specialists. In fact, ESIs are the most common procedure performed in pain clinics throughout the United States.

Risks

In 2014, FDA issued a safety warning that ESIs can produce rare adverse events. Severe side effects reported include infection, bleeding around the spinal cord, and when done in the neck, spinal cord damage. In addition, spinal cord ischemia, damage to the central nervous system, and death after ESI have also been reported.  Common, less severe side effects of ESIs include soreness, redness, and bruising around the injection site. Minor side effects also include dizziness, headache, nausea, and allergic reactions to the injected medication.
In most cases, ESIs are used after less-invasive pain treatments, such as oral medications and physical therapy, have not provided sufficient relief. ESIs with steroids should never be given more than a few times a year because too much steroid can cause bone, fat, and muscle loss and can disrupt hormone balances. ESIs should always be "administered cautiously, with careful monitoring for systemic side effects." Consult your healthcare provider about possible negative side effects of receiving ESIs.

ESIs and SOF

Back, shoulder, and knee pain are common among Operators because of the significant physical demands of SOF training and missions, and high OPTEMPO. ESIs are used in military facilities to treat back and neck pain as part of a comprehensive pain-management plan. In combination with other pain treatments, they appear to be helpful at getting operators and enablers back to duty. Overall, ESIs provide at least short-term relief that allows service members to engage in longer-term pain management techniques such as stretching, exercising, acupuncture, and physical therapy.

Because this treatment method is used in many military treatment facilities, SOF family members can benefit from ESIs too, if the need arises.