Caudal Epidural Spinal Injections: What You Need to Know – Ultrasound Guided Injections

Introduction

Caudal epidural spinal injections are a common treatment for relieving pain associated with inflamed spinal nerves These injections are particularly useful for alleviating sciatica, conditions often linked to nerve irritation or compression in the lumbar spine.

Our doctor specialises in administering caudal epidural injections with the aid of ultrasound guidance. This cutting-edge technology allows our doctors to precisely target the epidural space at the base of the spine, where the inflammation is located.

The use of ultrasound in caudal epidural injections offers several key benefits. By visualising the injection site in real-time, the doctor can ensure that the needle is placed in the exact location needed to achieve the best therapeutic outcome. This precision reduces the risk of complications and enhances the overall effectiveness of the procedure.

Our ultrasound guided injection services are designed to be cost-effective and straightforward for patients. We offer an easy-to-book process that allows for self-referral, meaning no prior referral from another healthcare provider is required. This streamlined approach ensures that you can access the care you need efficiently and without unnecessary delays, making the process both convenient and accessible

To learn more about caudal epidural spinal injections, we invite you to read the full article or contact our clinic to discuss if an epidural may be able to provide you fast, effective pain relief.

What is a caudal epidural spinal injection?

A caudal epidural is the most common injection for lower back pain and/or leg pain. Simply put, it’s a way to quickly deliver targeted pain relief using a small needle and syringe.

The injection is administered directly into the epidural space near the sacrum, or sitting bone, allowing the medication to spread throughout the lower back and around the nerves. These nerves supply sensation to the leg, so the injection can effectively help alleviate leg pain, commonly known as sciatica.This type of injection typically includes a mix of saline, corticosteroids (also known as steroid or cortisone) , and a local anaesthetic. The steroids help reduce inflammation and irritation around the nerves, which can break the pain cycle and promote healing and can provide rapid pain relief.

These injections are only ever given alongside physiotherapy to provide pain relief, making it easier for you to engage with a benefit from your rehabilitation.

What are corticosteroids?

Corticosteroids are medications that can be naturally found in the body or made synthetically to mimic these natural steroids. Unlike anabolic steroids used by bodybuilders, corticosteroids, when injected, are mainly used to reduce pain, inflammation, and swelling in or around joints caused by musculoskeletal conditions or injuries.

There are different types of corticosteroids available. Some offer quick relief but only last a few days, while those used in spinal epidural injections may take about a week to start working but can provide relief for several months.

It’s important to understand that the effectiveness of these injections can vary from person to person. While most people experience at least some relief, a few may not see any improvement at all.

Why would I need a caudal epidural injection?

Caudal epidural injections are primarily used to treat chronic pain that radiates from the spine into the legs, commonly known as radicular pain or ‘sciatica.’ This type of pain can be particularly debilitating, often affecting your ability to engage in daily activities and disrupting sleep, especially when other treatments have not provided sufficient relief.

The injection helps reduce irritation and inflammation in the affected area, providing significant pain relief. By breaking the cycle of pain, it offers a ‘window of opportunity,’ making it easier for you to participate in physiotherapy and other rehabilitative treatments.

Caudal, epidural steroid injections may help alleviate pain caused by the following conditions:

• A herniated or bulging disk that pinches nerves, causing pain.
• Spinal stenosis (the narrowing of one or more spaces within your spine).
• Degenerative disc disease (disc degeneration)
• Spinal cysts
• Vertebral bone spurs (osteophytes).
• Scoliosis (deformity of the spine) that causes nerve root irritation.
• Spondylolysis (spine degeneration).
• Other injuries to spinal nerves, vertebrae and surrounding tissues.

If you are suffering from pain affecting other areas in your spine your consultant may suggest that you combine an epidural with other types of injections to achieve the best pain relief and outcomes, such as facet joint injections  or nerve root injections.

Can I take other medicines along with the steroid injection?

You can usually take other medications along with local steroid injections. However, if you’re being treated for conditions like diabetes, high blood pressure, cancer, or HIV, it’s important to check with your GP or specialist first to ensure the injection is safe for you.

Also, if you’re on a blood thinner like warfarin, you might need a blood test to make sure your blood isn’t too thin before getting the injection, as there’s a risk of bleeding at the injection site.
These considerations are highlighted in the online consent form you’ll need to complete before booking your appointment.

Are there any reasons I can’t have a caudal epidural injection?

There are several conditions that may require caution before proceeding with this treatment. While not all of these are strict contraindications, they do warrant careful evaluation. Epidural steroids should be carefully considered and may not be recommended in the presence of the following conditions:

• Infection in any part of the body, including the site of injection
• Tumours or cancer
• Bleeding disorders
• Uncontrolled diabetes
• Heart problems, such as congestive heart failure
• Pregnancy or breastfeeding mothers
• Osteoporosis
• Known allergy to steroid medication on anaesthetic

The Procedure: What to Expect

Before your injection, you’ll be required to complete a medical screening and consent form. It is essential to provide your consultant with detailed information about any existing medical conditions and current medications before moving forward with the epidural spinal injection.

To ensure your safety, your clinician may recommend delaying the injection if you have certain conditions, such as unstable blood pressure or blood sugar levels related to diabetes. In such instances, approval from your GP might be necessary before proceeding.

Your specialist will provide you with specific instructions on how to prepare for your injection to ensure the best possible outcome.

Important Information

• An ultrasound guided caudal epidural steroid injection is performed as a day case in an outpatient clinic.
• You must have someone who is able to accompany you home following the procedure.
• You should not drive for 24 hours following the injection.
• You can eat and drink as normal before the procedure
• You should take your usual medications, however please advise us if you are diabetic or are on anticoagulants (blood thinning medication).
• You will need to have had an up to date MRI scan of your back before your injection to help determine the exact area that needs to be
• treated.Being asked not to eat or drink for a period of time before your injection.

How is the injection done?

The procedure starts with cleaning the skin over the injection site to minimise the risk of infection. You will typically be positioned lying prone (face down) on the examination table. To ensure your comfort, we’ll adjust your position as needed, and we will take steps to make sure you are as comfortable as possible throughout the procedure.

For a caudal epidural, the needle is inserted into the base of the spine just above your tailbone.
The doctor will use ultrasound guidance to accurately place a needle into the epidural space. Once the needle is in place, the medication is injected.

After the injection the area will be recleaned and a dressing applied to the site.
The entire process typically takes only 20-30 minutes.

Why Ultrasound-guided?

The use of ultrasound allows your doctor to see the area that needs to be injected and accurately place the needle.

The use of ultrasound technology provides significant advantages over traditional fluoroscopy. Ultrasound allows your doctor to see the area that needs to be injected in real time, enabling precise needle placement and enhancing the accuracy of the injection.

Research suggests (Andrzej Krol. 2022) that using ultrasound imaging improves both accuracy and safety of the injection. It has also been found to be equally as accurate as fluoroscopy guided spinal injections. (Elashmawy
et al. 2020)

Advantages of Ultrasound Imaging:

• Can be performed in an outpatient setting.
• No radiation is involved, making it safer for repeated use.
• Provides real-time imaging for quick and effective guidance.
• Allows for detailed visualisation of both soft tissues (e.g., ligaments, nerves) and bones.
• Enhances the accuracy of needle placement and overall procedural safety.

Is the Injection Painful?

While the injection can be uncomfortable, the use of a local anaesthetic helps minimise pain during the procedure. You might feel pressure or a mild burning sensation when the medication is injected.

Around 1 in 4 people may notice a temporary increase in their pain (a post injection flare) within the first 24-48-hours after injection.

Any discomfort following the procedure usually settles within a couple of days. Simple painkillers, such as paracetamol, and anti-inflammatories may be recommended by the doctor, applying a cold compress, may help. This will be discussed at your appointment.

After the Injection: Recovery

Whilst we do not require a doctor to refer you for an injection, we will supply you with a report after the procedure which we suggest you forward to your GP for your medical records.

What happens after the procedure?

After the injection, you’ll rest in the clinic for about 20-30 minutes to ensure you don’t have any adverse effects from the procedure.

If you have local anaesthetic, you may feel some pain relief within minutes, but this will normally wear off after a few hours and you may experience some soreness at the injection site, which should subside within a few days.

It usually takes several days to a week for the effect of the steroid to work. On some occasions it can take even longer, up to 2-3 weeks to achieve the full effect.

Most patients are able to resume normal activities after a few days, although it’s recommended to take it easy on the day of the procedure and avoid strenuous exercise usually for two days or so.
This advice may vary according to your specific injury and circumstances. You should discuss this with your treating clinician to confirm.

Will I need another injection?

If you find the injection helpful and other treatments are unsuitable or haven’t helped, the injection may be repeated. However, injections are most often used to provide a window of opportunity to engage in exercise and rehabilitation. Once your pain is better controlled, the need for injection should be reduced. Guidelines suggest limiting to a maximum of 3 steroid injections into the same area in a 12-month period.

What are the benefits of having a caudal epidural steroid injection?

The primary benefits of caudal epidural steroid injections include:

Pain Relief

Many people experience significant temporary relief from pain, with some even enjoying long-term benefits.

Enhanced Quality of Life

Reduced pain often leads to a better quality of life, allowing you to perform daily activities more comfortably and without the limitations that pain previously caused.

Diagnostic Insights

These injections can help identify the specific source of your pain, which is especially useful if there are multiple potential causes.

Reduced Need for Invasive Procedures

By effectively managing pain, epidural steroid injections may decrease the likelihood of needing more invasive treatments for pain relief.

What are the risks of having a caudal epidural spinal injection?

Epidural injections are generally very safe, and most people have spinal steroid injections without any significant side effects. However, as with any medical procedure, there are potential risks.

Potential Side Effects:

• Local tenderness, bleeding and bruising at the site of the injection
• Weakness, tingling or numbness in limbs for a few hours to days
• Vasovagal episode (fainting)
• A temporary increase in pain for a few days.

More serious side effects – These are extremely rare:

Infection

Very occasionally, the area where the injection was given may become infected. Or In rare cases (about 1 in 50,000) a joint or tissue structure inside the body can become infected.

If the area becomes more painful, hot, red, and swollen, seek medical attention immediately. Other signs of infection include feeling generally unwell, such as having a fever or nausea.

Spinal Disc Infection

Infection of the spinal discs (discitis) is very rare but is a medical emergency that requires medical attention and prompt antibiotic treatment.

Anaphylaxis

It is extremely rare to have an allergic reaction to steroid or local anaesthetic (1:500,000). This would usually happen within the first few minutes of an injection and requires immediate medical attention. Very rarely the allergic reaction can be delayed. The symptoms you might experience are feeling lightheaded or faint, breathing difficulties (such as fast, shallow breathing and/or wheezing), a fast heartbeat, clammy skin, confusion and anxiety, collapsing or losing consciousness. You will be asked to remain in the clinic for 20 minutes following the injection to allow observation of possible adverse reactions.

Spinal Headache

Headaches following a caudal epidural injection are rare (<1%) and occur if the dura is accidentally punctured with the needle. This is more common during a transforaminal epidural or spinal epidural (used during labour), both of which are not performed in our spinal injection clinic. Headaches are usually benign and self-limiting, settling in 1-2 weeks.

Spinal Cord Damage

Spinal injections do not target the spinal cord directly and the chances of causing spinal cord damage is remote. Spinal cord injury can occur indirectly due to chemical injury (through steroid or local anaesthetic), bleeding (blood clot) or ischaemia (reduced spinal blood circulation). The rate of spinal cord injury is extremely low, estimated around 1:150,000.

Cauda Equina Syndrome

Cauda equina syndrome (CES) occurs when the nerves in the lower back become severely compressed, causing bilateral leg pain, bladder dysfunction (urinary retention), and faecal incontinence. Usually this is caused by a large disc prolapse, but some cases of CES have been reported following caudal epidural injections. The mechanism of this complication is unclear, but it is thought to be due to ischaemia (reduced spinal blood circulation), infection, chemical injury (through steroid or local anaesthetic) or blood clots. The incidence of CES after caudal epidural is estimated at 1:50,000 (<0.002%).

Worsening Pain or Paralysis

Spinal injections in extremely rare occasions can cause a persistent worsening of the pain, or paralysis of one or more limbs. Cases have been reported of where this was due to post-infection complications (e.g. arachnoiditis). The rate of these complications is extremely low and estimated at 1:50,000-150,000.

Summary of Risks and Side Effects

More common (<10%):

• A change in sensation in both your legs (this should resolve quickly if it occurs).
• Vasovagal reaction – Dizziness/fainting due to blood pressure drop (this typically resolves within 15-30 minutes after the injection).
• Bruising/bleeding in & around the injection site.
• Temporary loss of bladder control and sensation of a full bladder.
• Steroid flare – increase in pain for a few days after the injection.

Rare (<1%):

• Severe allergic reaction that requires emergency treatment (anaphylaxis).
• Headache.
• Spinal cord or nerve damage.
• Infection.
• Facial flushing.
• Vomiting.
• Skin discolouration or skin fat reduction (atrophy) at site of injection.
• If you are diabetic, your blood sugar may be slightly higher for one to two weeks.
• Irregular menstrual cycle (usually for 1-2 months).

Extremely Rare (<0.1%):

• Pain is permanently worse.
• Paralysis.
• Cauda equina syndrome.
• Loss of consciousness, respiratory depression, respiratory or cardiac arrest.
• Blindness.
• Hiccups.

Your spinal specialist will take every necessary precaution to reduce the risk of complications and will discuss these with you.

How to contact us

If you have any questions regarding the information contained in this leaflet, please call 02074823875 or email injections@complete-physio.co.uk and we will arrange for one of our clinical specialists to speak with you.

Frequently Asked Questions (FAQs)

1. What is an epidural space?

• Answer: The epidural space is a small area that surrounds the spinal cord and nerves, filled with fat and blood vessels. It acts as a cushion, protecting the nerves.

2. What conditions can be treated with an epidural injection?

• Answer: Conditions like herniated discs, spinal stenosis, and sciatica are commonly treated with epidural injections.

3. How long does the pain relief last?

• Answer: Pain relief can vary from person to person, lasting from a few days to several months, sometimes even longer term.

4. Are epidural injections safe?

• Answer: Yes, epidural injections are considered safe, though they do come with some risks, such as infection or nerve damage, which are rare.

5. Can I drive myself home after the injection?

• Answer: It’s recommended to have someone else drive you home, as you may feel some temporary weakness or dizziness after the procedure.

6. How many injections will I need?

Answer: This depends on your condition. Some patients experience relief after one injection, while others may require a series of injections.

7. Will I need to take time off work?

• Answer: Most patients can return to work the day after the procedure, depending on the nature of their job. If you have a manual job that involves lots of bending and lifting then please discuss this at your appointment; you may require a short period off work.

8. What should I do if my pain doesn’t improve?

• Answer: If you don’t experience any pain relief, or if your pain relief is very short lived, then please get back in contact with us straight away.

9. Can the injection be repeated?

• Answer: Yes, if you respond well to the first injection, it can be repeated if the pain returns.

10. What should I do to prepare for the injection?

• Answer: Before your injection, you’ll need to complete a medical screening and consent form. You’ll also need an up-to-date MRI scan of your back.