A Caudal Epidural Steroid Injection (CESI) is a medical procedure that alleviates pain in the lower back and legs. It involves delivering anti-inflammatory medication directly to specific areas around the spinal nerves. This targeted approach reduces inflammation and discomfort, offering relief for persistent lower spine pain.
What is a Caudal Epidural Steroid Injection?
A Caudal Epidural Steroid Injection targets the caudal epidural space, the lowest part of the epidural space near the tailbone, accessed through an opening called the sacral hiatus. This space is a fat-filled area surrounding the dura mater, the protective membrane of the spinal cord and nerve roots. Nerves travel through this space from the spine into the legs.
The injection contains a corticosteroid, such as dexamethasone or methylprednisolone, combined with a local anesthetic like lidocaine or bupivacaine. The corticosteroid reduces inflammation and swelling around irritated nerve roots, while the local anesthetic provides immediate, temporary pain relief by blocking nerve signals. This dual action mitigates pain by reducing nerve pressure and interrupting signals.
This procedure treats chronic pain in the lower back, buttocks, and legs. It treats conditions such as sciatica, radiating pain along the sciatic nerve pathway. It also addresses lumbar radiculopathy, chronic low back pain, and discomfort from disc herniation or spinal stenosis. CESI can also treat pain following spinal surgery, known as “failed back surgery syndrome.”
The Procedure Steps
The Caudal Epidural Steroid Injection is an outpatient procedure, allowing patients to go home the same day. The entire process usually takes about 15 minutes. Patients should plan to be at the clinic for about one hour to accommodate pre- and post-procedure protocols.
During the procedure, the patient lies face down on an X-ray table, sometimes with a pillow under the abdomen. The healthcare provider cleans the lower back injection site with a sterile solution, such as chlorhexidine, and applies a sterile drape. A local anesthetic is administered to numb the skin and underlying tissues at the injection site to minimize discomfort.
Imaging guidance ensures precise needle placement into the sacral hiatus and caudal epidural space. Fluoroscopy, a type of real-time X-ray, allows the physician to visualize the needle’s path. Ultrasound guidance also offers real-time visualization without radiation exposure. A small amount of contrast dye may confirm correct needle position before the corticosteroid and local anesthetic mixture is injected. After medication delivery, the needle is removed, and a small bandage is applied.
Before and After the Injection
Preparation involves discussing current medications with the healthcare provider. Patients may need to temporarily stop certain blood-thinning medications, like Coumadin or Plavix, to reduce bleeding risks. Fasting instructions include avoiding food for six hours before the appointment; clear liquids may be allowed up to two hours beforehand. Patients should wear loose, comfortable clothing and arrange for a responsible adult to drive them home, as driving is not permitted on the procedure day.
Immediately following the injection, patients are observed for a short period, often resting in a reclined position for at least two hours. Mild soreness, tenderness, or bruising at the injection site is common. Temporary numbness or weakness in the legs may occur for a few hours due to the local anesthetic.
Patients should avoid strenuous activity and driving for the first 24 hours. Most can resume normal activities the day after. While some may experience immediate pain relief, it often takes two to seven days for the corticosteroid to reduce inflammation and for full effects to become noticeable. Physical therapy may be recommended as part of a comprehensive pain management plan to promote long-term relief and strengthen muscles.
Risks and Important Considerations
While generally safe, Caudal Epidural Steroid Injections carry potential risks. Common, temporary side effects include a temporary increase in pain before the steroid takes effect, tenderness or bruising at the injection site, and a feeling of warmth or flushing in the face and chest, sometimes with a mild fever. For individuals with diabetes, the injection may temporarily increase blood sugar levels for hours or days. Those with glaucoma might experience a temporary rise in blood pressure and eye pressure.
Rare, more serious complications can occur. These include infection at the injection site or within the epidural space, bleeding around the spinal column (hematoma), and allergic reactions to the medications. Nerve damage, though extremely rare, is a risk if the needle inadvertently strikes a nerve, potentially leading to temporary or, in very infrequent cases, permanent nerve dysfunction. Dural puncture, where the needle penetrates the dura mater, can lead to a spinal headache due to spinal fluid leakage, occurring in less than 1% of people.
Pain relief from a CESI is typically temporary, lasting from several weeks to several months, or over a year. The procedure is not a cure for chronic pain but a tool to manage symptoms. The number of injections a patient can receive in a year is generally limited (often two to four) to minimize systemic steroid side effects. Individuals with active infections, uncontrolled diabetes, certain bleeding disorders, or those unable to lie in the prone position may not be suitable candidates. Discussing all health concerns and medical history with a healthcare provider before the injection is recommended to determine if CESI is appropriate.