Epidural Steroid Injection for Back Pain: Low Cost Technique for Rural Areas

By Dr. J. Gnanaraj and Dr.(Prof) Sekar Michael | Published: Sep 2017 Volume: 6

Epidural steroid injections have been used for low back pain and leg pain since 1952 and often the first line of minimally invasive treatment [1]. However, the benefit is often temporary lasting up to six weeks [2]. Hence the American Academy of Neurology’s recommendation is to use this treatment only for short term benefits and to be aware of the side effects and complications.


The injections can occasionally cause

  • “steroid flush,” a flushing of the face and chest with a feeling of warmth and increase of temperature over several days
  • headache
  • sleeping difficulties
  • anxiety
  • nausea
  • diarrhea
  • water retention
  • a temporary increase in pain for a few days

They are also contraindication in uncontrolled diabetes and hypertension and those taking medicines for anticoagulation or prevention of platelet adhesions.
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The techniques that are recommended use both fluoroscopy guidance and use of radio-contrast material [3]. The drawback is that fluoroscopy guidance requires “C“ arm unit that is expensive and available only in a few centers and the use of contrast materials have their own problems. Several reasons have been given for their mechanism of action and the efficacy depends on the technique, fluoroscopy and contrast guidance [4].


In rural areas where “C” arm fluoroscopy unit and contrast are not available we have used the ordinary x-ray machine and injection of air to confirm the position before epidural injections. The air appears dark in the x-rays and does not have the side effects of contrast material and helps in the correct placement of the needle.

The patient is placed supine on the x-ray table and the area is prepared for sterile placement. Then an injection of air and x-ray is taken to confirm the position of the needle tip and then the medicine is injected in the correct space.


As advocated by the American Academy of Neurology, epidural steroids provide short term benefits in back pain which is a very common condition. The fluoroscopy guidance is required for correct placement of the injection needle but has the drawback of being expensive and not available in rural and remote areas. Moreover, part of the side effects described could be attributed to contrast although one cannot be sure of this. Contrast is known to cause allergic reactions.

This method is a low-cost safe method that is possible in rural and remote areas.

Gnanaraj, J. and Sekar M., (2017), Epidural Steroid Injection for Back Pain: Low Cost Technique for Rural Areas, mdCurrent-India, Volume 6. Available online at: http://mdcurrent.in/primary-care/epidural-steroid-injection-back-pain-low-cost-technique-rural-areas/ This is a peer-reviewed article.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
sekar michael Dr. Sekar Michael, underwent post-graduate training in anaesthesiology and pain services at Christian Medical College, Vellore. His passion for chronic pain management led him to specialise in pain services and start a comprehensive interventional pain clinic at Coimbatore.

Besides being active Instructor in Essential Pain Management, he is also the Editor in chief of the Tamil Nadu Journal of Anaesthesia, and has many international and national publications to his credit.

References (click to show/hide)

  1. Available from: http://www.spine-health.com/treatment/injections/lumbar-epidural-steroid-injections-low-back-pain-and-sciatica
  2. Available from: http://www.healthcommunities.com/back-pain/steroid-injections-benefits-risks.shtml
  3. Available from: https://en.wikipedia.org/wiki/Epidural_steroid_injection
  4. Available from: http://emedicine.medscape.com/article/325733-overview#a3


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