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Epidural Steroid Injections:
A Review of the Recent
Literature
J anette (J an) Elliott, RN-BC, MS, AOCN
September 9, 2011
What is an Epidural Steroid
Injection?
An injection of a steroid medication into
the epidural space with the intent to
alleviate pain
Epidural anatomy
Spinal meninges
Pia mater
Arachnoid
Dura
Epidural
outside the dura
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How is it administered?
Translaminar: lumbar or cervical
Needle
inserted via the
midline through
the spinal
ligament
Patel, V.B. (2009) Techniques for Epidural Injections. Techniques in Regional Anesthesia
And Pain Management, 13:217-228.
How is it administered?
Transforaminal: lumbar
Transforaminal
lumbar
Needle inserted via
a lateral approach to
the neuroforamin
Cervical
transforaminal
steroids no longer
recommended
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How is it administered?
Caudal
Needle
inserted thru
sacral hiatus
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How do steroids work?
Reduce inflammation by blocking
transmission of C fiber input.
Steroids decrease inflammation by
inhibiting phospholipase A
2
action.
Epidural steroid injection places the
medication at the site of inflammation
Indications for Epidural Steroid
Injection
Herniated nucleus pulposus with nerve root
irritation
Herniated nucleus pulposus with nerve root
compression
Annulus tearhasten recovery
Spinal stenosistransient relief
Post laminectomy syndrome
Contraindications of ESI
Uncontrolled diabetes
+/- epidural lipomatosis
Bleeding concerns
Anticoagulation
Bleeding disorders
Bleeding factor deficiencies
Von Willebrands disease
Idiopathic thrombocytopenic purpura (ITP)
Low platelet count
Severe liver dysfunction
Hemophilia
Infection
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Anticoagulants and ESIs
Warfarin (Coumadin)
Stop 5 days in advance of procedure
Clopidogrel (Plavix)
Stop 7 days in advance of procedure
Low Molecular weight heparin (Enoxaparin)
Last dose 24 hours prior
Ticlopidine (Ticlid)
Stop 14 days prior
Anticoagulants and ESIs (cont)
Platelet GP IIb/IIIa receptor antagonists
abciximab (Reopro)
iptifibatide (Integrilin)
tirofiban (Aggrastat)
Stop 5 days in advanceof procedure
Resumeon postop day
Enoxiparinbridge
Horlocker, T. et al, (2010) Regional AnesthesiainthePatient ReceivingAntithrombotic or
Thrombolytic Therapy: AmericanSociety of Regional AnesthesiaandPainMedicineEvidence-
BasedGuidelines(ThirdEdition). Regional Anesthesia and Pain Medicine. Volume
35(1), J anuary/February 2010, pp64-101, DOI: 10.1097/AAP.0b013e3181c15c70
Newer Anticoagulants
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)--investigational
Dabigatran and Rivaroxaban approved in
post-op total hip and knee patients
Research in other settings
Liau, J .V. andFerrandis, R. (2009) New Anticoagulatns andRegional Anesthesia.
Current OpinioninAnaesthesiology, 22:661-666.
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How is the procedure
performed?
Lumbar
PronePreferred
Sittingif person too heavy for procedure table, blind stick
Side lyingmore likely used with inpatients, blind stick
Caudal through sacral hiatus
Loss of resistance technique +/- contrast
Cervical
PronePreferred, may use fluoro
Sitting
Loss of resistance or hanging drop technique +/- contrast
Fluoroscopic guidancecurrent standard of care
Ultrasound guidancehelp determine depth
Potential complications
Dural puncturewet tap
Hematoma
Spinal injury
Direct nerve injury
Infection
Direct nerve injury from needle or pressure of
injectate
Vertebral artery dissection
Stroke
Death
Potential side effects of the
steroid medication
Localized increase in pain
Non-positional headaches resolving within 24 hours
Facial flushing
Anxiety
Sleeplessness
Fever the night of injection
High blood sugar
A transient decrease in immunity because of the
suppressive effect of the steroid
Stomach ulcers
Severe arthritis of the hips (avascular necrosis)
Cataracts
Staehler, R. (2007) Epidural Steroid Injections: Risks and Side Effects. Downloaded 8/10/11
fromhttp://www.spine-health.com/treatment/injections/epidural-steroid-injections-risks-and-
side-effects
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Epidural Space Identification
?? Liquid or air as mediumfor loss of resistance
5 publications included in a meta analysis
Hypothesis: LOR technique with liquid medium
associated with fewer epidural-related
complications
Results
Not statistically different in obstetric population
Small statistically difference (1.5%) in chronic pain
population for post dural puncture headache with fluid
Schier, R. et al, (2009) Epidural SpaceIdentification: A Meta-Analysis of Complications After Air
VersusLiquidastheMediumfor Lossof Resistance. Anesthesia& Analgesia, 109:2012-2021.
Identification of Cervical Spinous Level
Control grouppalpate for C7 with patient
in anatomical position, N=48
Flex/Ex grouppalpate for C& for flexing
and extending patients neck, N=48
Used fluoro to confirm accuracy
Control37.5% accurate
Flex/Ex77.1% accurate
Shin, S., Yoon, D, andYoon, K.B. (2011) Identificationof theCorrect Cervical Level
by Palpationof SpinousProcesses. Anesthesia-Analgesia, 112(5): 1232-1235
Ultrasound Guidance
Advantages
Portability, cost, ability to see soft tissues, lack of
radiation
Help identify needle depth
100% lumbar L4/5, less at higher levels
Helpful in pediatric/infant populations
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Ultrasound Guidance (cont)
Limitations
Lack of contrast medium for visualization of
vascular structures
Small window for visualization of needle, injectate
and dura mater.
Requires 2 people
Shankar, H and Zainer, C. (2009) Ultrasound guidance for Epidural Steroid
Injections. Techniques is Regional Anesthesia and Pain Management,
13:229-235.
Quality of Evidence Developed by
U.S. Preventive Services Task Force
I: Evidence obtained from at least one properly randomized
controlled trial
II-1: Evidence obtained fromwell-designed controlled trials without
randomization
11-2: Evidence obtained fromwell-designed cohort or case-control analytic
studies, preferably frommore than one center or research group
II-3: Evidence obtained frommultiple time series with or without the
intervention. Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s) could also
be regarded as this type of evidence
III: Opinions of respected authorities, based on clinical experience
descriptive studies and case reports or reports of expert committees
Adapted fromBerg, A.O. and Allan, J .D. (2001) Introducing the Third U.S. Preventive
Services Task Force. American J ournal of Preventive Medicine, 20:21-35.
Outcome measures
Short termrelief--<6 months
Long termrelief-->6 months
Improvement in function or psychological status
This wasnt always commented on in thereviews
Return to work
Not commented on in thereviews
Reduction in opioid intake
Not commented on in thereviews
All of thesereviews doneby thesameclinical group
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Buenaventura--
Lumbar Transforaminal
Systematic Review4 randomized studied included
Results
Short term level II-1
Long termlevel II-2
Pain reduction64-81%
Disability reduction60-63%
Reducedepression56%
Buenaventura, R.M., Datta, S., Abdi, S. andSmith, H.W. (2009) Systematic Reviewof Therapeutic
Lumbar Transforaminal Epidural SteroidInjections. Pain Physician, 12:233-251.
Benyamin-Cervical Interlaminar
Systematic Review1,994 reviewed--3 systematic reviews, 3 randomized
studies and 5 observational studies included
Studies included multipleinjections
Someused local anesthetic aloneinstead of steroid
ResultsLevel II-1
Pain reduction68-79% at 6 months
Disability reductionnot reported
Reducedepressionnot reported
Limitationpaucity of availableresearch
Benyamin, R. et al (2009) Systematic Reviewof TheEffectiveness of Cervical Epiduralsinthe
Management of ChronicNeck Pain. Pain Physician, 12:137-157.
ParrLumbar InterLaminar
Systematic Review1,647 reviewed8 systematic
reviews, 20 randomized studies and 30 observational
studies included
Studies included multiple injections
Some used local anesthetic alone instead of steroid
Results
Level II-2 for short termand level III for long term--disc
herniation or radiculitis
Level III for short and long termspinal stenosis and
discogenic pain without radiculitis or hernation
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ParrLumbar InterLaminar (cont)
Pain reductionat 3, 6 and 12 months
no significant difference for disc herniation or
radiculitis
Significant difference in 1 study at 3 months,
no significant difference at 6 or 12 months
Disability reductionnot reported
Reduce depressionnot reported
Parr, A.T., Diwan, S., andAbdi, S. (2009) Lumbar Interlaminar Epidural Injectionsin
ManagingChronic Low back andLower Extremity Piana; A Systematic Review . Pain
Physician, 12:163-188.
ConnCaudal
Systematic Review3,387 reviewed18 randomized studies
and 20 observational studies included
Studies included multiple injections
Some used local anesthetic alone instead of steroid
ConnCaudal (cont)
Results
Level I for short and long termfor disc herniation and/ and/or
radiculitis and discogenic pain
Level II1 or II-2 for Post-laminectomy syndromeand spinal
stenosis
Painreduction
56-81% for disc herniation or radiculitis
65-77% post-laminectomy syndrome
Disability reductionnot consistently stated in thereview
Onestudy showed >40% decreasein 55-70% of patients
Conn, A., Buenaventura, R.M., Datta, S., Abdi, S andDiwan, S. (2009) Systematic Reviewof
Caudal Epdiural InjectionsintheManagement of ChronicLowBack Pain. Pain Physician, 12:109-
135.
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Abdi--Epidural Steroids
Combines all types of ESIs
<6 weeks short termand >6 weeks long term
Concludes:
Moderate evidence for interlaminar cervical and lumbar for
long termrelief
Moderate for cervical and lumbar transforaminals for long
termrelief in nerve root pain
Moderate evidence for caudal for long termrelief in nerve
root pain and chronic LBP
Adbi, et al. (2007) Epidural SteroidsintheManagement of Chronic SpinalsPain: A
Systematic Review. PainPhysician, 10:185-212
Boswell-Practice Guidelines-2007
Includes all spinal procedures but puts into
separate procedures
Caudal--states the reviews come to different
conclusions from the same studies
Concludes
Chronic LBP and radicular pain
Short term benefit--strong
Long term--moderate
Post laminectomy syndrome and spinal stenosis
Limited evidence
Boswell-Practice Guidelines
Concludes
Interlaminar in lumbar radiculopathy
Short term--strong
Long term--limited
Interlaminar in postlaminectomy syndrome
Limited
Interlaminar in cervical radiculopathy
Short term & long term--moderate
Transforaminal lumbar
Short-term--strong
Long term--moderate
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Boswell-Practice Guidelines (cont)
Transforaminal cervical
Short and long term--moderate
Evidence is indeterminate in managing
axial LBP, axial neck pain, and lumbar disc
extrusions
Boswell et al, (2007) Interventional Techniques: Evidence-based Practice
Guidelines in the Management of Chronic Spinal Pain. Pain Physician:
10:7-111.
ASIPP IPM Guidelines-2009
Chronic Spinal Pain Interventional
Techniques
Comprehensive review
Manchikanti, L. et al (2009) Comprehensive Evidence-Based Guidelines for
interventional Techniques in the Management of Chronic Spinal Pain. Pain
Physician: 12:699-802.
ASIPP--Caudal
Level 1caudal for disc herniation or
radiculitis and discogenic pain
Level II-1 or II-2 for post-laminectomy
and spinal stenosis
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ASIPPCervical, Lumbar &
Thoracic Interlaminar
Level II-1 or II-2
ASIPP
Common Indications for ESIs
Chronic pain poorly responsive to non-
interventional or non-surgical therapy
Disc herniation or radiculitis
Spinal Stenosis
Post spinal surgery syndrome
Epidural fibrosis
DDD/discogenic pain
Absence of facet pain
Pain causing functional disability
Average pain level >6
Other causes
Transforaminal Cervical ESIs
Fallen into disfavor
Catastrophes
Cerebellar and cerebral infarcts
Spinal cord injury and infarction
Massive cerebral edema
Visual defects r/t vascular occlusion
Persistent neurological deficits
Transient quadriplegia
Subdural hematoma
Unknown incidence, but rare
Adbi, et al. (2007) Epidural Steroids in theManagement of Chronic Spinals
Pain: A Systematic Review. Pain Physician, 10:185-212
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Frequency of ESIs
One week apart if in diagnostic phase, 2
weeks preferred in cancer pain
2 months or longer in therapeutic phase
provided > 50% pain relief ofr 6-8
weeks
Repeated only as necessary according
to medical necessity criteria
Limit to a max of 4-6 per year
Manchikanti, L. et al (2009) Comprehensive Evidence-Based Guidelines for interventional
Techniques in the Management of Chronic Spinal Pain. Pain Physician: 12:699-802.
What steroid does one use?
Depends on the type of ESI to be performed
Cerebral/cerebellar complications occur mainly
through intravascular embolization of the
particulate steroid in transforaminal ESIs
No CNS events reported with interlaminar ESIs
No CNS events reported with non-particulate
steroid
Medications
Methylprednisolone (Depo-medrol)
Triamcinolone (Kenalog)
Dexamethasone (Decadron)
Betamethasone (Celestone)
Betamethadone sodiumphosphate/betamethasone acetate
Betamethasone repository (compounded drug)
Betamethadone sodiumphosphate/betamethasone acetate
Betamethasone sodium phosphate
No study has directly compared efficacy
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Comparison of Drugs
Measured using laser scanning confocal
microscope
Compared diluted vs non-diluted drug
Compared to size of blood vessels
Derby measured size of blood vessels
Steroid Medications
Methylprednisone 80mg/ml with more particles than
40mg/ml
Compounded betamethasone with more particles than
commercial betamethasone
No statistical difference between methylprednisolone and
triamcinolone and compounded betamethasone
INCREASED proportion of particles in MORE HIGHLY
DILUTED methylpredsinolone 80mg/ml
Otherwise dilution decreased % larger particles
Dexamethasone and betamethasone phospate were pure
liquid
Steroid Medications Recommended
Benzon recommends non-particulate steroid
betamethasone phospate for transforaminal ESIs
Benzon states dexamethasone should be used with
caution until further studies clarify safety and efficacy
Derby states interventionalists might consider using a
nonparticulate steroid when performing cervical transforaminal
injections
Derby states Dexamethasone is less likely to cause arterial or
capillary obstruction
Benzon, H.T. et al. (2007) Comparison of the Particle Sizes of Different Steroids and the
Effect of Dilution. Anesthesiology, 106:331-8
Derby, R. et al (2008) Size and Aggregation of Corticosteroids Used for Epidural Injections.
Pain Medicine, 9(2): 227-234.
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Summary
ESIs most used interventional technique
Many patients achieve significant benefit
Conflicting results from systematic reviews
None reach Level I evidence
No specific medication recommendations for interlaminar
ESIs
Non-particulate medications recommended for
transforaminal ESIs
Debate as to whether to do cervical transforaminal
injections
ASRA recommendations for anticoagulation
Use of fluoroscopy is standard of care
References:
Adbi, et al. (2007) Epidural Steroids in the Management of Chronic Spinals Pain: A
Systematic Review. Pain Physician, 10:185-212
Benyamin, R. et al (2009) Systematic Reviewof The Effectiveness of Cervical Epidurals
in the Management of Chronic Neck Pain. Pain Physician, 12:137-157.
Benzon, H.T. et al. (2007) Comparison of the Particle Sizes of Different Steroids and the
Effect of Dilution. Anesthesiology, 106:331-8
Berg, A.O. and Allan, J .D. (2001) Introducing the Third U.S. Preventive Services Task
Force. American Journal of Preventive Medicine, 20:21-35.
Boswell et al, (2007) Interventional Techniques: Evidence-based Practice Guidelines in
the Management of Chronic Spinal Pain. Pain Physician: 10:7-111.
Buenaventura, R.M., Datta, S., Abdi, S. and Smith, H.W. (2009) Systematic Reviewof
Therapeutic Lumbar Transforaminal Epidural Steroid Injections. Pain Physician, 12:233-
251.
Conn, A., Buenaventura, R.M., Datta, S., Abdi, S and Diwan, S. (2009) Systematic
Reviewof Caudal Epdiural Injections in the Management of Chronic LowBack Pain. Pain
Physician, 12:109-135.
Derby, R. et al (2008) Size and Aggregation of Corticosteroids Used for Epidural
Injections. Pain Medicine, 9(2): 227-234.
Horlocker, T. et al, (2010) Regional Anesthesia in the Patient Receiving Antithrombotic or
Thrombolytic Therapy: American Societyof Regional Anesthesia and Pain Medicine
Evidence-Based Guidelines (Third Edition). Regional Anesthesia and Pain Medicine.
Volume 35(1), J anuary/February 2010, pp 64-101, DOI:
10.1097/AAP.0b013e3181c15c70
References (cont)
Liau, J .V. and Ferrandis, R. (2009) NewAnticoagulatns and Regional Anesthesia.
Current Opinion in Anaesthesiology, 22:661-666.
Manchikanti, L. et al (2009) Comprehensive Evidence-Based Guidelines for interventional
Techniques in the Management of Chronic Spinal Pain. Pain Physician: 12:699-802.
Parr, A.T., Diwan, S., and Abdi, S. (2009) Lumbar Interlaminar Epidural Injections in
Managing Chronic Lowback and Lower Extremity Piana; A Systematic Review. Pain
Physician, 12:163-188.
Patel, V.B. (2009) Techniques for Epidural Injections. Techniques in Regional
Anesthesia And Pain Management, 13:217-228.
Schier, R. et al, (2009) Epidural Space Identification: A Meta-Analysis of Complications
After Air Versus Liquid as the Mediumfor Loss of Resistance. Anesthesia & Analgesia,
109:2012-2021 Shankar, H and Zainer, C. (2009) Ultrasound guidance for Epidural
Steroid Injections. Techniques is Regional Anesthesia and Pain Management, 13:229-
235.
Shin, S., Yoon, D, and Yoon, K.B. (2011) Identification of the Correct Cervical Level by
Palpation of Spinous Processes. Anesthesia-Analgesia, 112(5): 1232-1235
Staehler, R. (2007) Epidural Steroid Injections: Risks and Side Effects. Downloaded
8/10/11 fromhttp://www.spine-health.com/treatment/injections/epidural-steroid-injections-
risks-and-side-effects