Epidural Fat and Resultant Narrowing of the Lumbar Canal: A Complication of Epidrual Steroids

Epidural steroid injections are a common treatment for back and extremity pain.  Steroid injections have been associated with complications with include  changes in blood glucose and cortisol levels, infection. apotosis( programmed cellular death), damage to cartilage and the development of  avascular necrosis .   At the Centeno-Schultz Clinic platelet derived growth factors are been used  successfully in the treatment of cervical and lumbar pain.  A  patient who failed traditional epidural steroidshad signficant improvement after Regenexx PL epidural injections.

accumulation of fat around the epidural space can occur as the result of epidural steroid injections.  Narrowing the canal can cause  compression of spinal nerves with resultant pain and restriction in level of activity,

Tok reported a case where a patient developed neurologic symptoms secondary to abnormal epidural fat after a single epidural injection. Sandberg reports symptomatic compression of the neural elements from  excessive epidural fat after repeated epidural steroid injections.

 McCullen reported a similar case   after multiple steroid injections.

Fogel in at literature review and meta analysis demonstrated that exogenous steroid use, obesity and endogenous steroid excess are all associated with symptomatic epidural fat accumulation.

RW is a 45 y/o patient with chronic lower back pain who had received a larger number of lumbar epidural steroid injections from a local pain practice.  He transferred his care to the Centeno-Schultz Clinic.   RW’s lower back pain had escalated in severity.  His most recent lumbar spine MRI was significant for two level narrowing of the spinal canal in part due to a large accumulation of  epidural fat which was not present years prior.  The image below is RW’s most recent MRI.  The blue arrow identities the narrowing of the spinal canal at the L5/S1 level due to multiple steroid injections.

Another Strike Against Big Pharma

Zonegran, a commonly used medication for arm and leg pain secondary to nerve root irration was placed on the FDA medication watch list due to its significant life threatening side effects.  Updated clinical data has demonstrated that Zonegran can cause significant changes in acid-base balance (metabolic acidosis).  The list of medications with significant side effects continues to get longer.  In an earlier blog, I referenced the flouroquinolones, a class of antibiotics, which demonstrated the increase the risk of tendon rupture.  Sode et. al.,  demonstrated that the antibiotic tripled the risk of Achilles rupture.

Illustration of Nerve Root Irritation

Rather than masking the arm and leg pain associated with nerve irritation, at the Centeno-Schultz Clinic we are committed to identifying the cause of the pain and correcting it.  When a lumbar disc protrudes or herniates, often times there is compression of the nerve root with resultant lancinating electrical pain down the extremity. 

Nerve Root Irritation Due to Disc Herniation

 Treatment options include x-ray guided injections of local anesthetic and steroid in an attempt to decrease the pain and inflammation along the disc and nerve root. 

Epidural Injection Under X-Ray

 Another option is the injection of concentrated growth factors derived from a patient’s own platelets in an attempt to increase the blood supply to the damaged disc.  This therapy would aid in repairing the disc as opposed to simply decreasing the inflammation.

Before and 3 Months After Stem Cell Therapy

A novel new technique allows injection of expanded bone-marrow-derived mesenchymal stem cellsinto the disc to repair the damaged lumbar disc.  Please review MRI below of a patient who underwent injection of stem cells into his L5/S1 disc.   On the left, the arrow points the disc protrusion before treatment.  Three months after the Regenexx therapy there was a  reduction of his disc bulge as seen on image on the right, along with complete elimination of his leg pain.

Lumbar Disc Bulges and Leg Pain

Lumbar disc bulges are a common cause of lower back and leg pain.  Common therapies for lumbar disc bulgesinclude physical therapy, lumbar traction, inversion table therapy and lumbar epidural steroid injections.  The goal of therapy is to decrease the disc bulge and its compressive effect on the nerve root.  If nerve compression is left untreated, it can result in permanent leg pain and weakness.

Lumbar epidurals steroid injections should always be performed under x-ray to ensure accurate placement of the medication. The epidural space is the area immediately outside the spinal cord and is adjacent to the lumbar disc.

 

 

 If a lumbar epidural steroidis performed without x-ray there is no guarantee that the medication will get into the epidural space let alone on the irritated nerve root and disc.  At the Centeno-Schultz Clinic all lumbar epidurals are performed under x-ray.  Injection of contrast prior to the injection medication, ensures accurate placement. The x-ray below demonstrates contrast flowing along the right L5 nerve root with extension into the epidural space.

If conservative therapy or lumbar epidural steroid injections fail to provide sustained pain relief, patients now have the option of using their own stem cells to repair their lumbar disc bulges using the Regenexx procedure.  Regenexx is a simple needle in-needle out procedure which affords patients the opportunity to avoid the risks of surgery and anesthesia and repair disc bulges.

Review the video below on how stem cells can be used to treat disc bulges.

[youtube=http://www.youtube.com/watch?v=zI7TQzV