What is the step-by-step procedure for treating a prolapsed intervertebral disc (PIVD) at the L4-L5 level using epidural steroid injections (Inj. Epidural Steroid)?

From the Guidelines

Epidural steroid injections for treating a prolapsed intervertebral disc at L4-L5 should be performed with caution, considering the potential risks and benefits, and ideally under fluoroscopic guidance to ensure accurate needle placement. The procedure involves positioning the patient prone on the procedure table with a pillow under the abdomen to flex the spine and widen the interlaminar space. After sterilizing the injection site, the physician administers local anesthesia (typically 1-2% lidocaine) to numb the skin and deeper tissues. Using fluoroscopic guidance for accurate needle placement, the physician inserts a 20-22 gauge epidural needle through the L4-L5 interlaminar space using either a midline or paramedian approach. Once the needle reaches the epidural space (confirmed by loss of resistance technique), a contrast medium is injected to verify proper needle placement. The steroid medication—commonly methylprednisolone (40-80mg), triamcinolone (40-80mg), or dexamethasone (8-12mg)—is then injected along with a local anesthetic like bupivacaine 0.25% (2-3ml) 1.

Key Considerations

• The entire procedure typically takes 15-30 minutes, and patients are monitored for 30-60 minutes afterward.
• Most patients receive a series of 1-3 injections spaced 2-4 weeks apart.
• These injections work by reducing inflammation around the compressed nerve roots, thereby decreasing pain and improving function.
• Patients should avoid strenuous activity for 24-48 hours post-procedure and may experience temporary numbness or increased pain before feeling relief.
• The potential risks of the procedure include a small risk of moderate to serious harms, such as deep infection, and temporary altered level of consciousness, as well as a very small risk of catastrophic harms, such as paralysis and death following epidural steroid injection 1.

Important Recommendations

• Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1.
• Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1.

From the Research

Step-by-Step Procedure for PIVD L4-L5 by Inj. Epidural Steroid

The procedure for treating a prolapsed intervertebral disc (PIVD) at the L4-L5 level using epidural steroid injections involves several steps:

• Preparation: The patient is prepared for the procedure by explaining the risks and benefits, and obtaining informed consent 2, 3.
• Positioning: The patient is positioned in a prone position on the fluoroscopy table to allow for easy access to the L4-L5 intervertebral space 4.
• Sterilization: The skin is sterilized with an antiseptic solution to minimize the risk of infection 5.
• Local Anesthesia: A local anesthetic is administered to numb the skin and reduce discomfort during the procedure 3, 4.
• Epidural Space Access: The epidural space is accessed using a needle, and the position is confirmed using fluoroscopy 2, 4.
• Injection: A mixture of steroid and local anesthetic is injected into the epidural space to reduce inflammation and relieve pain 2, 3, 4, 5.
• Post-Procedure Care: The patient is monitored for any adverse reactions and provided with post-procedure instructions 3, 5.

Routes of Injection

There are three common routes of injection for epidural steroid injections:

• Caudal route: The injection is administered through the sacral hiatus, which is located at the bottom of the spine 3, 6.
• Transforaminal route: The injection is administered through the intervertebral foramen, which is located on either side of the spine 2.
• Interlaminar route: The injection is administered through the interlaminar space, which is located between the laminae of two adjacent vertebrae 2, 4.

Efficacy of Epidural Steroid Injections

The efficacy of epidural steroid injections for treating PIVD at the L4-L5 level has been studied in several research papers:

• A study published in 2016 found that all three routes of injection (caudal, transforaminal, and interlaminar) were effective in improving pain and function in patients with lumbar disc prolapse 2.
• A study published in 2010 found that caudal epidural steroid injections were effective in relieving pain and improving function in patients with lumbar disc prolapse 3.
• A study published in 2017 found that interlaminar epidural steroid injections were effective in reducing pain and improving function in patients with multilevel lumbar disc disease 4.
• A study published in 2002 found that epidural steroid injections were effective in alleviating radicular symptoms from lumbar herniated discs for up to 12-27 months 5.
• A study published in 2007 found that there was no significant difference in the outcome of caudal epidural injections for patients with disc prolapse at L4-5 and L5-S1 levels 6.