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Thoracic epidural

If you are considering having a thoracic epidural or have a procedure planned, it is important to know all you can about it. This includes:

why you need this procedure
what it will be like
how it will affect you
what risks are involved
any alternatives.

The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

What is the problem?

You have an inflamed ‘intervertebral’ disc in your upper back. This causes pain running around from your back into your chest wall.

What is an intervertebral disc?

The vertebrae are the bones that make up the spine. The front of each vertebra is solid and is called the body. This is where the disc fits. There is an intervertebral disc between each vertebra. The intervertebral discs act like shock absorbers to let the spine bend and twist, and spread the impact when you jump up and down. Each disc can be considered as having two parts rather like a soft centred sweet. The tough outer rim is bound to the vertebra above and below. The middle of the disc is soft and it is this part that moves out of place (prolapses).

Behind the body of each vertebra is an arch of bone called the lamina. The arches form a channel, called the vertebral canal. The spinal cord runs down the vertebral canal from the brain, protected by the bony arches.

Spinal nerves run out from the spinal cord through gaps between the arches. These are the nerve roots. They run to different levels in the trunk, arms and legs. The lowest spinal nerves run to the buttocks and bladder.

The spinal cord only runs part way down the spine. It stops at the level of the lowest ribs. Below this spinal nerves run down the vertebral canal to the correct gaps between the arches. These nerves packed in the canal look like the tail of a horse and are called the cauda equina in Latin.

The spinal nerves and cord carry feeling impulses from the body up to the brain and impulses from the brain down to the muscles.

What is a thoracic epidural?

The upper back, between the shoulder blades is called the thoracic spine. Epidural injections in the upper back are used to treat a number of different painful conditions. The condition most often treated is pain coming around the chest wall and ribs.

Epidural injections are usually given into the back. The needle is inserted between the gaps of the vertebrae, into an area known as the epidural space. This is a space that surrounds the spinal cord. The nerves that carry painful sensations pass through this space. The injection is just outside the covering of the spinal cord, which is called the dura; hence the name epidural.

An epidural injection can target the painful area. The injection bathes the nerves and intervertebral discs in local anaesthetic and steroid solution. Only a small amount of steroid is needed and it will not cause any of the side effects sometimes associated with taking steroid tablets. They are not the same kind of steroids that athletes may take. This steroid injection relieves pain and inflammation. Pain, caused by inflamed nerves felt in the chest wall, can be treated in this way. Bathing the inflamed discs in this way may also reduce some upper back pain.

What has gone wrong?

You have suffered general wear and tear or damage from injury to the intervertebral discs in your spine. When the disc is inflamed, the nearby nerves become irritated. These nerves supply sensation to the chest wall and hence the brain is fooled into believing that the chest wall is injured. This is not the case; although you may feel pain in the chest the problem is in the spine.

The aims

The aim of the procedure is to reduce the inflammation of the disc. This reduces your chest wall pain and some of your back pain.

The benefits

Your pain should be reduced and you should be able to move around more easily. You can then exercise to prevent the problem happening again. If successful, this treatment can avoid the need for surgery.

Are there any alternatives?

By the time you consider a thoracic epidural you should have already tried other more simple treatments. These include rest, painkilling and anti-inflammatory tablets, and physiotherapy with exercise.

You may also have tried a transcutaneous electrical nerve stimulation (TENS) machine for your pain. This works by sending soothing pulses across the surface of the skin and along the nerve fibres. These pulses prevent pain signals reaching the brain. They also stimulate your body to produce higher levels of its own natural painkillers, called endorphins.

What if you do nothing?

If you do nothing there are several things that may happen:

With time and rest the inflammation and pain may settle on its own
The pain and difficulty in moving around may remain the same
The pain may increase
The disc may become further damaged and may injure the nerves that control movement. You may then develop weakness and difficulty in moving your legs. Some of this may be permanent
In rare and severe cases you may lose control of your bladder and bowels as the nerves that control these are damaged

Who should have it done?

The following groups of patients should have the procedure done:

Patients with chest wall pain caused by inflamed discs
Patients with upper back pain that has not settled by other means

Who should not have it done?

Each patient has the final decision as to whether to proceed or not. If you are unhappy about the procedure for any reason you should not continue.

There are specific medical situations when an epidural should not be done and they are as follows:

When a patient is on medication that prevents blood from clotting, such as warfarin. This would lead to more bleeding than normal. It may be possible to stop the medication a few days before the procedure. This will need to be discussed with your doctor
When a patient is suffering from an illness that prevents blood from clotting, such as haemophilia. This would also lead to more bleeding than normal
When there is infection of the skin over the site where the needle needs to be put in
When the patient has a bloodstream infection
When a patient has noticed a recent worsening of their symptoms, especially weakness and loss of bladder or bowel control