Epidural Steroids A Comprehensive, Evidence-Based Review
†Pain Management Center, Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD Regional anesthesia and pain medicine
(Impact Factor: 3.09).
05/2013; 38(3):175-200. DOI: 10.1097/AAP.0b013e31828ea086
Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.
Available from: PubMed Central
- "Transforaminal epidural steroid injection (TFESI) is one of the most widely used interventional treatment for the relief of radicular pain secondary to lumbar spinal stenosis, lumbar discogenic disease, or failed back surgery syndrome. The mechanism of treatment is believed to be the attenuation of inflammation around the irritated nerve root [1,2]. Moreover, TFESI has the benefit of delivering therapeutic medication closer to the ventral epidural space, which is known to have abundant pain substances [3,4]. "
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ABSTRACT: Recently, there have been several case reports and retrospective studies about the incidence of intradiscal (ID) injection during transforaminal epidural steroid injection (TFESI). Inadvertent ID injection is not a rare complication, and it carries the risk of developing diskitis, although there has been no report of diskitis after TFESI. We prospectively evaluated the incidence of inadvertent ID injection during lumbar TFESI and analyzed the contributing factors.
Ten patients received 2-level TFESI, and the remaining 229 patients received 1-level TFESI. When successful TFESI was performed, 2 ml of contrast dye was injected under real-time fluoroscopy to check for any inadvertent ID spread. A musculoskeletal radiologist analyzed all magnetic resonance images (MRIs) of patients who demonstrated inadvertent ID injection. When reviewing MRIs, the intervertebral foramen level where ID injection occurred was carefully examined, and any anatomical structure which narrowing the foramen was identified.
Among the 249 TFESI, we identified 6 ID injections; thus, there was an incidence of 2.4%. Four patients had isthmic spondylolisthesis, and the level of spondylolisthesis coincided with the level of ID injection. We further examined the right or left foramen of the spondylolisthesis level and identified the upward migrated disc material that was narrowing the foramen.
Inadvertent ID injection during TFESI is not infrequent, and pain physicians must pay close attention to the type and location of disc herniation.
Available from: Jee Youn Moon
- "The effects of epidural administered steroids stem from their ability to inhibit the synthesis of prostaglandins, their anti-inflammatory effects, and their ability to inhibit ectopic discharge from an injured sensory nerve [14,27]. However, data evaluating different types of steroid injections are mostly limited to underpowered, randomized or retrospective studies comparing particulate to nonparticulate steroids . Among three randomized comparative-effectiveness studies comparing different steroid preparations, two studies reported there was no evidence that nonparticulate steroids such as dexamethasone at 10 mg were less effective than particulate steroids such as methylprednisolone, TA or betamethasone in lumbar transforaminar epidural injections [29,30]. "
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ABSTRACT: Epidural steroid injection (ESI) is one of the most common procedures for patients presenting low back pain and radiculopathy. However, there is no clear consensus on what constitutes appropriate steroid use for ESIs. To investigate optimal steroid injection methods for ESIs, surveys were sent to all academic pain centers and selected private practices in Korea via e-mail.
Among 173 pain centers which requested the public health insurance reimbursements for their ESIs and were enrolled in the Korean Pain Society, 122 completed questionnaires were returned, for a rate of 70.5%; also returned were surveys from 39 academic programs and 85 private practices with response rates of 83.0% and 65.9%, respectively.
More than half (55%) of Korean pain physicians used dexamethasone for ESIs. The minimum interval of subsequent ESIs at the academic institutions (3.1 weeks) and the private practices (2.1 weeks) were statistically different (P = 0.01).
Although there was a wide range of variation, there were no significant differences between the academic institutions and the private practices in terms of the types and single doses of steroids for ESIs, the annual dose of steroids, or the limitations of doses in the event of diabetes, with the exception of the minimum interval before the subsequent ESI.
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ABSTRACT: The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, the numerous modalities of treatments applied in managing these patients continue to increase as well. In the period from 2000 to 2011 interventional techniques increased 228%. In addition, analysis of utilization trends and expenditures for spinal interventional techniques alone from 2000 to 2008 illustrated an increase in Medicare fee-for-service expenditures of 240% in terms of dollars spent in the United States. The Office of Inspector General (OIG) of the Department of Health and Human Services showed an increase in facet joint and transforaminal epidural injections, with a significant proportion of these services did not meet the medical necessity criteria.The increasing utilization of interventional techniques is also associated with significant variations among specialty groups and regional variations among states. Overall procedures have increased by 173%, with rate of 130% per 100,000 Medicare beneficiaries for epidural injections; 383%, with a rate of 308% for facet joint interventions; and overall 410%, or a rate of 331% for sacroiliac joint interventions. Certain high volume interventions such as lumbar transforaminal epidural injections and lumbar facet joint neurolysis have actually increased a staggering 806% and 662%.Coverage policies across ambulatory settings and by multiple payers are highly variable. Apart from variability in the development of coverage policies, payments also substantially vary by site of service. In general, amongst the various ambulatory settings the highest payments are made to hospital outpatient departments (HOPDs) the lowest to in-office procedures, and payment to ambulatory surgery centers (ASCs) falling somewhere in the middle.This manuscript describes the many differences that exist between the various settings, and includes suggestions for accountable interventional pain management with coverage for techniques with evidence, addressing excessive use of specific techniques, and equalizing payments across multiple ambulatory settings.
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