What is a selective nerve root injection and why is it helpful?

Your doctor has decided to treat your pain by referring you for a fluoroscopically guided selective epidural injection of corticosteroid medicine. Corticosteroids reduce inflammation around nerve roots and, thereby, help reduce pain in shoulder/arm and buttocks/leg. Cervical selective epidural injections are given along the side of the neck. Thoracic and lumbosacral injections are given in the mid and lower spine.

What will happen to me during the procedure?

All injections provided at the Kaiser Fremont/Hayward Spinal Diagnostics Center are performed by specialty-trained spine physicians under fluoroscopic (x-ray) guidance. Using fluoroscopy allows the physician performing the injection to place the medicine precisely into the epidural space. Immediately prior to the procedure an IV will be started and you will be positioned on the exam table. A nurse may administer some intravenous medication to help you relax during the procedure, but you will be awake at all times. For cervical injections you will lie on your back during the procedure. For thoracic and lumbar procedures you will lie on your abdomen.

Once you have been positioned on the exam table the physician will clean your skin with iodine or alcohol. After your spine has been cleaned thoroughly a sterile drape will be placed. Then the physician will view the bones in your spine using the fluoroscope. This will allow him to identify the proper location for the injection. After viewing the bones in your spine the physician will use numbing medicine to anesthetize the skin of your back. After the skin has been adequately anesthetized a small needle will be directed into the epidural space. When the needle is in proper position a small amount of iodine based dye will be injected. Visualization of the dye in the epidural space confirms that the medicine will go near the nerve roots. When the cortisone is injected you may feel a slight burning sensation in your back or down either your legs or arms. This is normal, and it suggests that the cortisone is migrating along your nerve roots.

Pain relief from the epidural injection may not become noticeable until a few days or up to a week after the injection. Occasionally your physician may schedule two or three injections at two to five week intervals. Some experience relief for only one or two weeks while others may have good relief for many months. If you do not receive lasting pain relief you will need to speak to your referring doctor about other treatment options.

Potential Complications

With any procedure there are potential complications. You and your doctor should discuss these before being referred for an epidural. We believe that in carefully selected patients the potential benefits from an epidural outweigh the potential harms. Potential complications or risks may include, but are not limited to:

1. If you are a diabetic your blood sugar will increase for 48 hours after the cortisone injection and you will need to monitor this.
2. If the spinal needle punctures the spinal sack and spinal fluid escapes this is referred to as a ‘wet tap’. A wet tap is not dangerous, but it will result in postponement of the epidural. Approximately 25% of patients who have a wet tap will develop a spinal headache. This may require treatment with an “epidural blood patch”. The incidence of wet taps with fluoroscopically guided procedures is less than 1%.
3. Infection is a remote possibility whenever a needle is introduced under the skin. To prevent this complication your skin will be disinfected and carefully prepared using strict sterile technique. If an infection in the spinal canal or vertebrae occurs, this is a serious complication and it will require intensive antibiotic treatment and possibly surgery.
4. Local bleeding can rarely be serious and require further treatment.
5. There is potential for nerve injury which can lead to permanent pain and /or weakness.
6. You may have an allergic/adverse reaction to medications and substances used during the procedure: Betadine (contain iodine), anesthetics, contrast agents, corticosteroids. Side effects of corticortisteroids include increased blood sugar, increased blood pressure, mood swings, fluid retention that can exacerbate existing heart failure, local fat atrophy, facial flushing, skin discoloration, gastritis or peptic ulcer disease, bone demineralization and necrosis of the hip.
7. For cervical procedures, on rare occasions, there is a risk of spinal cord injury that may result in quadriplegia/paraplegia, impaired breathing, prolonged headaches, seizures, stroke, and possible death associated with the procedure.
8. For thoracic (mid-back) procedure, there is a risk of lung puncture and collapse of the lung(s), which may require placement of a chest tube to re-expand your lungs.
9. Risk of conscious sedation, which include, but not limited to allergic reactions to medications, post-procedure psychological problems such as hallucination, potential for over sedation, potential breathing problems, lack of blood flow and oxygen to vital organs such as the brain and the heart, which creates the risk of major complications such as stroke, heart attack or potentially even death.
10. Although most patients will benefit from the procedure, there is no guarantee of the desired results. Some patients will have a severe flare up in their pain for 1-2 weeks after an injection. In some individuals, this increase in pain can last longer, or in rare cases, even be permanent.

General Pre/Post Procedure Instructions

1. You should REFRAIN FROM EATING AND DRINKING 8 HOURS prior to the procedure EXCEPT for taking sips of plain water with medication (see below).
2. If you are taking oral (pill form) diabetes medication, DO NOT take this medication the morning of the procedure.
3. Take all other routine medications before the procedure (such as high blood pressure medication and insulin injection), including the morning of the procedure, with sips of water. If you are taking insulin injection, inject only HALF of the usual scheduled dose the morning of the procedure.
4. STOP ASPIRIN and any medication that contains aspirin, such as Excedrin, 7 DAYS PRIOR to the prodecure.
5. STOP ALL ANTI-INFLAMMATORY MEDICATIONS (e.g. Motrin/Ibuprofen, Naprosyn/Naproxen, Aleve, Relafen/nabumetone, Lodine/etodolac, Daypro, Indocin, Celebrex, Trilisate, Feldene etc.) 5 DAYS PRIOR to the procedure.
6. If you are taking St. John’s Wort, Ginkgo, Ginseng, or Garlic supplements, you will need to stop these 5 days prior to the procedure. All of your routine medicines and supplements can be re-started after the procedure on the same day. You may take your regular pain medicine as needed before/after the procedure.
7. If you are taking Coumadin/Warfarin, heparin, Lovenox/Enoxaparin, please call the Coumadin Clinic at your local Kaiser facility or the physician who prescribed the medication prior to your visit.
8. If you are taking Plavix/Clopidogrel, Ticlid/Ticlopidine, or Pletal/Cilostazol, you must notify our office no later than 2 weeks prior to the procedure so that the timing of stopping these medicines can be explained.
9. You will need to bring a driver with you who is available to wait for you during the procedure. You may return to your current level of activities the next day, including return to work.
10. If you are on antibiotics, please notify our office, we may postpone the procedure until you have finished the medicine.
11. If you have an active infection or fever, we will not perform the procedure.
12. If you are a woman of childbearing age and you know or suspect that you may be pregnant, we will not perform the procedure.
13. If you have a known allergy – rash, hives, or anaphylaxis – to iodinated contrast agents, please contact our office 1week prior to your procedure.
14. You will be in the hospital for 2-3 hours even though you will see the physician for only 20 to 30 minutes.
15. You may return to your current level of activities the next day, including return to work.
16. If you have a recent spine MRI which was performed outside Kaiser Permanente you must hand carry it with you to your visit. Failure to do so may result in rescheduling of the procedure.

Cortisone inhibits the body’s response to fight infection. Cortisone injections should not be given if there is an active infection elsewhere in your body. This is an elective procedure. If you have fever, chills, have a cold or flu or any infection, you should call to cancel the procedure. You should also call to cancel the procedure if you have recent (since booking this procedure) exacerbation of heart failure, heart attack, stroke or transient ischemic attack.

For cancellation or rescheduling procedures: Call (510) 675-4540

IF YOU NEED TO CANCEL THE PROCEDURE THE DAY OF YOUR APPOINTMENT, PLEASE CALL THE KAISER FREMONT AMBULATORY SURGERY CENTER DIRECTLY AT (510) 248-5650.

Place of Procedure

Your procedure will be performed at the Kaiser Fremont Ambulatory Surgery Center, located on the ground floor of the Embarcadero Building, Kaiser Fremont Hospital, 39400 Paseo Padre Parkway, Fremont, CA 94538.

Appointment Date:_____________________________________________________

Appointment Time:_____________________________________________________

Physician: ____________________________________________________________

NOTE: Please arrive ONE HOUR PRIOR to the appointment time to allow necessary preparation for the procedure. Failure to do so will result in rescheduling of the procedure.