Ep. 45 Pain Procedures: Epidurals

Episode Summary:

In this episode of "It's Not In Your Head" podcast, co-hosts Justine Feitelson and Dr. Dan Bates delve into the intricacies of epidurals. They discuss what epidurals are, how they work, various injectables used, potential complications, and what patients can expect during recovery. Give this episode a listen for a detailed explanation of different epidural techniques including interlaminar, transforaminal, and caudal epidurals, along with their applications in pain management and diagnostic procedures. 

Episode Overview:

Epidurals in this episode are explained as targeted injections into the “epidural space” around the spinal cord, used mainly for nerve-related pain, diagnosis, and calming a sensitized nervous system rather than as a quick cure for all back or leg pain.

What are Epidurals

Dan explains that the spinal cord sits inside a sac called the dura, and an epidural is an injection placed just outside that sac in the epidural space. Into this space, clinicians can inject local anesthetic and/or cortisone to reduce pain and inflammation around spinal nerves.

Main Types of Epidurals

They describe three main types:

• Interlaminar (the classic “labor epidural” from the back, washing over a broad area),

• Transforaminal (very targeted to a specific nerve root as it exits the spine), and

• Caudal (from the base of the spine, designed to “wash over” many lower nerves at once)

Choice of approach depends on whether the goal is precise diagnosis of a single nerve problem or broad pain calming when everything feels “out of control.”

What Gets Injected

Typical injectables include short-acting local anesthetics such as xylocaine/lidocaine and non‑particulate cortisone like dexamethasone. Dan deliberately avoids long‑acting locals and particulate steroid crystals (like certain brands used in joints) in epidurals because, if accidentally injected into a blood vessel or artery, they carry higher risks such as dangerous heart rhythm problems, stroke, or spinal cord injury.

Benefits and Uses

Epidurals are used to treat nerve root compression (radiculopathy), which can cause sharp, “electric” pain, numbness, pins and needles, and weakness in specific patterns down the arm or leg. They are also used after procedures (for example, after radiofrequency treatments) to dampen pain and to help calm both peripheral and central sensitization by targeting nerve roots and the dorsal root ganglion where nerve cell bodies sit.

Risks and Safety Measures

Common minor risks include bruising and temporary pain when a needle briefly irritates a nerve. Rare but serious complications include deep infection (epidural abscess), bleeding into the space (epidural hematoma), dural puncture causing a spinal fluid leak headache, and unintended “spinal block” where both legs go weak for a few hours until the anesthetic wears off. =

To minimize these risks, Dan uses imaging and contrast dye to confirm the needle is in the epidural space rather than a blood vessel or inside the dura, and he carefully manages blood thinners and even fish oil supplements before procedures. If you’re a patient, make sure you are aware of these considerations with this procedure.

Duration and Pulse RF extension

The immediate effect comes from the local anesthetic, then cortisone can give relief for several days, after which pain may partially return. Pulsed radiofrequency (a low‑heat electrical field at the nerve) can be used alongside epidurals to trigger longer‑term changes in inflammatory signaling, with a characteristic pattern: early relief, a plateau or slight worsening, then a clearer improvement around day 12 that can last 3–6 months.

Recovery and Activity After

On the day of the procedure, patients are encouraged not to “run home” or push themselves but also not to completely rest and do nothing. The advice is to live normal daily life within comfort, avoid new high‑load activities for the first days, and then build back toward bigger goals like running once the benefit is clear.