Lumbar Steroid Injection vs Facet Nerve Block

About 10 years ago, I had a torn rotator cuff in my right shoulder. Tried injections a couple of times but didn't get much relief. Finally had the orthoscopic surgery by Dr. Moskwa of Princeton Orthopedic. Four small holes. Not too long of a healing period, some PT and was throwing a softball with out pain the next summer. No pain since the operation.

Thanks. Was your surgery arthroscopic? I need a shoulder replacement due to severe arthritis plus rotator cuf repair. I’m so confused. Thanks for your supply.

Hi Babette. Sorry to hear you are in pain. I have had 67 epidural steroid injections & 11 nerve blocks.I've had very little success with any of them. I found an article (see below) that describes the difference between the 2. I hope the nerve block helps and that the article does the same.All the best

By Dr. Donald Corenman

What are Spinal Injections?

Injections in the cervical and lumbar spines have long been used to both diagnose and treat nerve irritation, canal stenosis and disc pain. These injections can be very helpful even in the long term to yield spine and extremity pain relief. Below, a detailed discussion is offered on epidural injections and selective nerve root blocks–diagnostic and therapeutic.
What is the difference between epidural steroid injections (ESI) and selective nerve root blocks (SNRB)?

The difference between epidural steroid injections (ESI) and selective nerve root blocks (SNRB) requires going back to anatomy. The dura is the membrane inside the spinal canal which makes up the long tube from the brain to the tailbone. This dural sac contains the nerves and the cerebrospinal fluid or CSF. The nerves then branch out from this sac like tree branches (one on each side) at every level to exit the spinal canal (see the anatomy section).

The Latin term “epi” means “above” so an epidural injection is an injection above the dura. This injection is normally placed around the center of the neck or back and the medication is deposited on top of the dura. The SNRB puts medication at the nerve root branch from the spine in the area called the foramen. With a small volume, only the exiting nerve root can be targeted. With a larger volume, the medication will enter the canal and cover more than one nerve root.
How Do You Choose Which One?

The choice of injection location depends upon the problem area suspected of causing pain. If the canal is stenotic (narrowed), a central injection or ESI would be used. If a nerve is suspected of causing pain, a SNRB would be used in the foramen that the nerve exits. Now to confuse the issue, you can introduce medication into the central canal through the foramen if you use enough volume. This would be called a trans-foraminal epidural steroid injection (TFESI). If disc pain is suspected, either route (ESI or TFESI) would be acceptable.
Diagnostic vs. Therapeutic

Epidural injections and selective nerve root blocks–diagnostic and therapeutic–which one to choose? There are two medications injected at the same time. One is a numbing agent and the other is a steroid. With both medications injected at the same time, the injection is called “diagnostic and therapeutic”. If just the numbing medication is injected, it would be called a diagnostic test. If only the steroid was injected- obviously the injection would be called a therapeutic injection.

The part of the test named “diagnostic” involves numbing the structure or structures thought to be involved in the pain generation. This can be a nerve root, a disc or the entire canal. This is just like a trip to the dentist. An injection into the jaw anesthetizes the sensory nerve and makes the jaw feel “numb and swollen”. After three hours, the feeling or sensation returns.

The same concept is used with the diagnostic injection into the structure thought to cause the pain. The first three hours after the injection will numb that area. If the region that is numbed is causing the symptoms, there should be relief of pain for about two to three hours while repeating the activity that causes pain (sitting, standing, walking bending or whatever action induces the pain). This of course means that if sedation is used during the injection-it must have worn off in a short period of time. If you are sedated for three hours and lie in the recovery room, the diagnostic portion of the injection will be lost and the injection will have to be repeated.
Pain Diary

The most important thing post injection is to get up and repeat the activity that causes the pain in the three hour diagnostic “golden window”. Do not just sit around after the injection! A pain diary needs to be kept both prior to the injection and after the injection. Please see the section on providing a pain diary to understand how to fill one out.
Steroids

The therapeutic portion of the injection is the steroid. The steroid medication is wonderful for nerve inflammation. Someone should develop a bumper sticker “Nerves Love Steroids”. These steroids are corticosteroids and not the anabolic type that body builders use to look like a puffed up balloon. The body manufactures about 8-10 mg/day of this in the adrenal glands.

There are multiple actions of steroids that benefit nerves. The main action of the steroid is to prevent the chemical cascade that causes inflammation. A cascade is an amplification system to get a small matter big attention. For example- a small inflammatory source (a cut or abrasion) will cause multiple amplifications in a cascade. The first step magnifies the response 100 times; the next step multiplies that step 100 more times and so on. There may be 7-8 steps for this cascade to continue. Breaking this cascade is the specialty of the steroid.

What the steroid prevents is swelling, breakdown and tissue destruction of the injured area (which is what inflammation really is). Normally the chemical cascade “calls” in white blood cells (WBCs) to do their work. When the white blood cells (WBCs) migrate to this area, they release their contents which cause more swelling and even some tissue destruction (normally designed to “clean up” the injured area but in this case, causes more nerve injury). Swelling occurs when the under the influence of the chemical mediators of inflammation- small blood vessel walls in the vicinity become more “leaky” and tissue fluid floods into the area. The WBCs literally dissolve and eat (phagocytize) the dead and dying tissue. This is great for healing a tendon or skin abrasion but not so good for the nerve root.

The steroid also seems to “toughen” the nerve root. The lack of swelling and irritation reduces the size of the herniation but also probably makes the root less susceptible to compression. Remember that the disc herniation material is toxic to nerves. The steroid stabilizes the membrane that surrounds the root itself- making it less susceptible to chemical contamination.

Of course, there are potential risks of steroids and they need to be discussed with your physician but the global benefits of the steroid injection cannot be underestimated. Many times, it is the only substance that can give such immediate relief and continue that relief for a longer period of time. Steroid should be thought of as a management tool for the spinal generated pain. The procedure should be simple for a skilled and meticulous physician.

Wow! That’s horrible! I was told by a doctor I was seeing for pain (long ago) that I needed to see a physiatrist! He couldn’t help me and blamed that on my mental health!
Don’t let that doctor or nurse keep you from seeing another doctor! I left the doctor I mentioned who preformed my epidurals. Not so much because he didn’t prepare me for the painful procedure, but because of his attitude towards me after simply telling him the previous epidural didn’t help my pain. I asked him for a referral to a well known pain doctor who treated patients with fibromyalgia and instead of referring me he called that doctor and black listed me from seeing him. There are bad doctors and nurses! Bad attitudes, bad bedside manors, bad staff, bad, bad, bad! But there are excellent doctors too! I think I’ve found a good pain doctor. After years on pain medication but no treatment, I’m willing to try something to see if it will help. From what I’ve learned, it seems that these injections and treatments help some people, but not forever! I’ve had that experience myself. A medication works great for a period of time then stops working. I use a lot of natural techniques for distraction from pain. I’m fully aware my mental attitude about my pain is important. I have depression and see a therapist, but that doesn’t mean my pain has anything to do with my mental health. I choose to learn and apply the things that assist me living with pain. I believe in the mind body connection to pain. What that means to me is that my mental outlook and what I do to live with pain are an important part of treatment! Relaxation techniques, meditation, stretching, tolerable exercise, hobbies, art, music. I prop myself up with pillows and watch a good movie when I’m fatigued from pain. I eat foods that help with inflammation, smoothies, etc. Educating myself about what might help is a distraction itself!
You’re not alone! I’ve seen some real winners! I’ve also seen doctors who do care and give me hope. Pain is a tricky thing! The past 10 years for me has been about balance. I realize doctors may not be able to treat all my pain.
I want some kind of warning or preparation if an injection is going to be so painful that I scream in pain and am traumatized afterward! Doctors should know from experience if this might happen, that’s all I ask!

A physiatrist is different from a psychiatrist. If your doctor actually recommended a physiatrist, he was recommending a doctor who, in a sense, specializes in musculoskeletal issues. I was referred to one when I had a bad back injury that resulted in four herniated lumbar discs. The doctor who recommended me was an orthopedic surgeon who wanted to help me avoid surgery, thank heavens. The physiatrist put together the physical therapy program that helped me heal fully.

I am glad that I was able to ease your anxiety about the Cervical Branch Block.
Yes to the physical therapy. I have my first appointment for assessment for reconditioning water therapy on Thursday to see what I can do, that I am nervous about but I know that I do need help to get my strength back. I have damage from my cervical spine to my lumbar. I am in constant pain from my head to my toes. I just slept three and a half hours straight which is unusual.It took over two years to get a doctor that didn’t tell me that it was fibromyalgia and basically suck it up even though CTSCAN showed the damage in my spine.
I have tried over a dozen different topicals to help ease the pain and lidocaine patches and the most effective has been Two Old Goats Essential Oil Lotion that I have been using for at least fifteen years. I even tried CBD cream which was ninety dollars for four ounces that didn’t work at all.
I finally have hope. I know that it is going to be a long process. Keep in touch, I would love to hear about your journey so far I have felt alone in this battle with pain. I hope all the best for you.

I am glad that I was able to ease your anxiety about the Cervical Branch Block.
Yes to the physical therapy. I have my first appointment for assessment for reconditioning water therapy on Thursday to see what I can do, that I am nervous about but I know that I do need help to get my strength back. I have damage from my cervical spine to my lumbar. I am in constant pain from my head to my toes. I just slept three and a half hours straight which is unusual.It took over two years to get a doctor that didn’t tell me that it was fibromyalgia and basically suck it up even though CTSCAN showed the damage in my spine.
I have tried over a dozen different topicals to help ease the pain and lidocaine patches and the most effective has been Two Old Goats Essential Oil Lotion that I have been using for at least fifteen years. I even tried CBD cream which was ninety dollars for four ounces that didn’t work at all.
I finally have hope. I know that it is going to be a long process. Keep in touch, I would love to hear about your journey so far I have felt alone in this battle with pain. I hope all the best for you.