Many people might have heard the term epidural but must be unfamiliar as to what exactly it means. For the uninitiated lot, an epidural is a local anesthetic which helps reduce pain in your body, specifically backache. Epidural administration is usually done during childbirth to relieve the mother of labor pain. Different types of epidural are available and their usage depends on the purpose and preference of the anesthetist. Patient preference is also taken into consideration apart from the patient’s biological parameters.
Generally, epidural anesthesia involves injecting of pain medication in the backbone near the lower spine. With injecting of the anesthesia, the body below becomes numb to all the pain and all transmission of pain sensation is inhibited. There are a variety of epidurals, each type associated with its own pros and cons.
Here is a compilation of the different types of epidural:
This is the standard epidural and makes use of local anesthetics. They are generally used as they are quite effective and complete pain relief. They take around 15-30 minutes for complete pain relief, but pain relief starts after 10 minutes of administration. They can generally last for 1-2 hours. The potential cons of this type of epidural include:
- Lowering of blood pressure which requires administration of a large amount of fluids to counter the drop in B.P.
- Minimized sensation, especially in the legs resulting in limited mobility in patients.
- When used during labor, they can prolong the initial stages of labor often increase the chances of cesarean They also relax your pelvic floor which prevents rotation of baby from posterior to anterior position.
It makes use of narcotics like morphine etc. either alone or in combination with some anesthetic. They relieve pain without causing muscle weakness. They are often called walking epidurals as they relieve pain without immobilizing the patient. Pure narcotic epidurals relieve pain and you can walk after 30 minutes of administration. The duration of pain relief depends on the dose and type of narcotic used. Epidural morphine takes 30-45 minutes to take effect and pain relief lasts for 12-24 hours, while fentanyl is effective in 10 minutes and lasts for 4-6 hours. The side effects include:
- Skin rashes and itching is generally observed in women. The intensity can range from mild to severe.
- Eliminating the narcotic from a baby’s body takes a longer If this epidural is used for childbirth, your baby might be more prone to sleeping.
In this type, narcotic and local anesthesia is mixed and used in the same epidural. This combines the advantage of both previous ones; providing adequate pain relief without lowering your blood pressure or reducing mobility. The side effects can be a combination of both the drugs but the effect of local medication are slightly reduced in this mixed epidural.
As the name specifies, in this type of epidural, medication is given intermittently using an epidural catheter. Generally, the drugs are administered every 1.5-2.5 hours. Since it takes around 15-30 hours for the epidural to wear of, the subsequent doses are administered accordingly.
This type of administration has epidural medication being administered slowly and continuously via a catheter or an infusion pump. The rate is controlled and can be changed (increased or decreased) as per the requirement. Since it usually uses less medication and keeps the blood pressure more stable it is preferred by doctors. The patient is also more mobile and doesn’t have to bear the rollercoaster effect of the intermittent epidural.
Use of epidural for relieving chronic back pain
Apart from being used to relieve labor pain in expectant mothers, epidural has found use in relieving patients from chronic back pain. Since many people have desk jobs these days, with limited mobility, a wrong posture can lead to severe back ailments which results in a constant backache. The situation worsens when immediate treatment and rest is not done. A large population complains of severe and constant back pain. Doctors have taken to using the epidural administration of drugs to relieve people of backache. The patient’s parameters are checked and the dose of the anesthetic is calculated accordingly. The exact position of pain is located and the epidural is administered with precision. The area is numbed previously so that the patient does not undergo any discomfort. Depending on the drug injected via epidural administration, the patient can be pain-free for a specific period of time.
Many times instead of an anesthetic or a narcotic, steroid drugs are administered via epidural to relieve the patient of pain in leg or back. This is the case when inflamed spinal nerves press on discs causing unbearable pain to the patient. The medicines are injected in the epidural space (the fat-rich region between the bone and the defensive sac of spinal nerves). The effective of epidural steroid injection can last for months and sometimes even years, thus allowing the patient to live their life their way, pain-free.
How does epidural steroid injection (ESI) work?
The ESI consists of a mixture of a local anesthetic and a corticosteroid. The corticosteroid is much more effective when delivered exactly at the site of pain. When injected into the epidural space in the spine, between the vertebra and the dura sac of spinal cord and nerves, it flushes away the proteins which cause the swelling. Instead of making the herniated disc smaller, they remove the protein covering the spinal nerves, thereby relieving the extra pressure on the discs which ultimately results in pain for the patient. With pain relief, the patient can continue with their daily routine, participate in physiotherapy program and live a pain-free life for days, months or years. Subsequently, if and when the pain resurfaces, another ESI can be used. It is particularly effective for patients of chronic backache.
The ideal candidate for epidural
Epidural is used for pain relief in patients suffering from labor pains as well as chronic back or leg (sciatica), neck and arm. Patients with the following condition can benefit immensely from epidural:
- Sciatica – Severe pain courses through the leg from the buttocks along the sciatic nerve; generally caused by compression of 5th lumbar or 1st sacral spinal nerve.
- Disc degeneration – Ageing or breakdown of intervertebral discs which results in collapsing of the disc space, tearing of annulus and growth of bone spurs.
- Disc herniation – A gel-like material is present between disc spaces to protect them from wear and tear. The bulging of this material or a rupture through any weak area in the annulus (surrounding wall) can result in pain, irritation, and swelling when the material comes in contact with the spinal nerves.
- Spinal stenosis – Narrowing of the nerve root canal or spinal canal can result in leg and back pain, especially while walking.
- Spondylolisthesis – A rupture or weakness between the upper and lower surfaces of the vertebra can result in severe pain, especially if the vertebra slips forward to compress the nerve root.
Patients with painful inflammatory conditions can also benefit immensely from ESI. Many patients recovering from painful and corrective surgery, find it difficult to continue with their physiotherapy sessions due to the constant pain. ESI can help relieve them of this pain so that they can continue with their rehabilitative exercises.
Who should avoid using an epidural spinal injection?
Despite reading about the wonders of ESI and the advantage people have in managing their pain using this, it cannot be and should not be administered to everyone. Before opting for ESI, it is important for patients to discuss their medical history with the doctor. Care should be taken not to use ESI on patients having any infection or bleeding problems. It has also been observed that ESI can temporarily elevate blood sugar, blood pressure as well as eye pressure in patients. Thus people who are suffering from diabetes, hypertension, any heart ailment or glaucoma need to discuss with their physician before getting ESI administered. Patients who are pregnant also need to discuss with their doctors before going ahead with the procedure as fluoroscopy X-rays might harm the baby.
Different types of Epidural Spinal Injections (ESIs)
The different types of ESI are used to relieve patients of back, neck, arm, and legs:
- Lumbar ESI (for relieving pain in the back)
In this case, the needle is injected slightly off the midline of the back to reach the nerve canal. To reach the affected site, the needle is inserted from the back with a tracking dye to confirm the flow of medication.
- Cervical ESI (for relieving pain in neck and arm)
The needle is inserted from the side of the neck and reaches the neural foramen just above the opening of the nerve root, outside the epidural space. A contrast dye is injected to follow the flow of the medication. The steroid medication is delivered where the inflamed nerve root exits the spine.
- Caudal ESI (for relieving pain in legs)
In this case, the needle is inserted above the tailbone in the sacral hiatus in order to reach the lowest spinal nerves. This is helpful in relieving lower back pain and pain in the legs.
Risks associated with epidural usage
Though epidural is considered an ideal non-surgical method of treating chronic pain in patients, it comes with its own set of risks. Since it involves the insertion of a needle in the spine, the side effects include spinal headache from the dural puncture, allergic reaction, itching, bleeding, infection, nausea and vomiting, and nerve damage causing paralysis in a rare case. Effect of corticosteroid on the body includes weight gain, water retention, insomnia, mood swings, hot flashes, high blood sugar in diabetics, mild muscle weakness, etc. Some of the common side effects of the epidural injection are discussed below:
- Breathing problems are observed in patients when the anesthetic used affects the chest muscles and hampers breathing. Often it leads to slower breathing rate or other breathing related problems.
- Many patients observe severe headache if the epidural needle accidentally punctures the spinal cord covering membrane and the fluid leaks out. This is generally treated by oral painkillers, plenty of fluid and in severe cases epidural blood patch.
- Sometimes, a bacterial infection might occur in patients who have undergone ESI. Though the instances are extremely rare, it can occur. Once a bacteria enters the body, the infection can spread to other parts of your body.
- In rare instances, if the pain medication enters a vein, it may result in seizure or convulsions due to abnormal brain activity.
- If the needle used for ESI hits a nerve, it can lead to temporary or permanent loss of feeling in that particular part of the body. Alternately, any bleeding taking place around the spinal cord; use of incorrect medication in epidural may also cause nerve damage.
- Getting too many injections in the same area may result in the nearby tissue (bone or joint cartilage) to breakdown. Constant use of corticosteroid can cause the skin or the soft tissue beneath to become thin.
What happens if the epidural procedure goes wrong?
Many hospitals treat patients with chronic lumbar, leg, neck or back pain using ESI. Mostly extensive care is taken while epidural administration so that the patient is relieved of pain. Patients may experience any of the minor side effect mentioned above, which are generally resolved within 24 hours. However, in some rare cases, ESI might be administered in a negligent manner. In case of patient history is not taken properly, or the crucial facts like an allergy to any medication, bleeding disorder, diabetes, etc. then the patient might have an allergic reaction or bleed extensively to cause severe damage. This might result in a case of epidural malpractice.
Rare epidural injuries sustained during botched ESI include:
- Infarction of spinal cord
- Decreased bone density
- Partial or complete paralysis
- Respiratory arrest
- Heightened pain in and around the injection site
- Formation of an epidural abscess (infection between the outer covering of the brain and spinal cord and bones of spine or skull)
- Nerve damage resulting in lifelong pain
If after an ESI procedure the patient experiences any of the above-mentioned symptoms, you should consult an expert medical malpractice attorney. Farahi Law Firm has expert attorneys who have successfully handled cases of medical malpractice including epidural malpractice. If you wish to consult your case with experts before filing it, Call – (310) 620-9791 to speak with one of the best legal hands.
Proving medical negligence is easier said than done
Proving medical malpractice or negligence on the part of a medical practitioner is not easy. During an ESI procedure, care must be taken that the injection should not penetrate more than 1.75 inches in the tissue. In case the doctor strayed from the standard and penetrated the needle 2 inches or more, the needle might damage a nerve resulting in any of the long-lasting damage to the patient. In order to prove medical malpractice, you need to ensure that:
- There was a breach in standard care established for ESP procedure.
- There was negligence in the medical duty imparted to the patient by the medical staff.
- That the breach in duty is responsible for the cause of harm to the patient.
- That physical manifestation of the neglect is visible (actual damage is seen in the patient)
Epidural is also often used for helping expectant mothers go through severe labor pains. Sometimes, inaccurate administration of epidural anesthesia can cause irreversible damage in not just the patient (expectant mother) but also to the newborn child. Lack of oxygen during childbirth may cause irreversible damage to the child which may include heart and respiratory diseases, brain injury, stroke, Cerebral and Erb’s palsy or sometimes even death. In case, an epidural error causes major medical issues effect in mother, it is bound to affect the newborn. In severely unfortunate cases, it may result in the death of either mother or child or both.
Can you sue your medical practitioner in case your epidural procedure results in severe damage to health or quality of life?
There are numerous advantages associated with the use of epidural. People who have been living with constant pain swear by the benefits of ESI. They are able to live their life comfortably, do all their jobs without any worries of pain hindering their daily activity. Even expectant mothers choose to opt for epidural anesthesia to get away from the severe constant labor pain while undergoing childbirth. However, if the procedure goes wrong, a joyful moment may turn into extreme sadness. Though this is no time to think of monetary compensation or lawsuits, yet it would help many other patients about to go through the same process some respite if their doctor is careful and follows standard procedure.
If you have gone through a painful ESI only to come out in a worse condition, it is important that you consult an expert medical malpractice attorney like Farahi Law Firm. Experienced lawyers can help prove if the procedure done by the doctor was improperly performed or if they failed to notify you of the various side effects and the risks involved with the procedure. In case the epidural was used to assist the birth, it is important to address questions like was ESI responsible for the child’s injury or it could have been caused by any other injury.
Since every case is different, the lawyer can get you adequate compensation depending on the severity of injury sustained, nature of injuries, medical and convalescence expenses occurred due to wrongful procedure, loss of wages due to inability to work (including any future loss of income), non-economic damage caused including pain, trauma, suffering and PTSD.