Epidural steroid injections: an updated review on recent trends in safety and complicationsEpidural steroid injections ESIs what is anabolic steroids made out of, which can provide significant but temporary pain relief consideratins well-selected patients, are the most commonly performed procedure in pain management. The anatomy of the epidural space provides a framework for understanding risks associated with Sacety, a topic relevant to both patients and physicians in interventional pain, surgery and primary care. Safety considerations of epidural steroids include drug preparation and myriad physiological effects stemming from steroid exposure. Although major complications associated with ESI occur rarely, potentially catastrophic events resulting from infectious, hematologic and neurologic morbidity may lead to permanent injury. The safety profile safety considerations in epidural steroid injections ESIs may improve with development and dissemination of sound injection technique, safer compounds manufactured in a sterile manner and deficient of thromboembolic potential and the application of existing technology. N2 - Epidural steroid injections ESIssafety considerations in epidural steroid injections can provide significant but temporary pain relief in well-selected patients, are the most commonly performed procedure in pain management.
Key safety considerations when administering epidural steroid injections. - PubMed - NCBI
Copyright American Medical Association. Epidural steroid injections are used to treat patients with low back or neck pain with a radicular component. The 2 approaches used to access the epidural space are 1 the interlaminar approach, in which the tip of the needle is placed in the posterior epidural space similar to epidural catheter placement in surgery and obstetrics, and 2 the transforaminal approach, in which the tip of the needle is placed in an intervertebral foramina where the spinal nerve exits the spinal canal.
With the interlaminar approach, most of the injected drug remains in the posterior epidural space, whereas with the transforaminal approach, the drug is placed in close proximity to the inflamed spinal nerve and dorsal root ganglion and spreads into the lateral and anterior epidural space, the interspace between the spinal nerve and the herniated disk.
Practitioners usually use the transforaminal approach when a single nerve root in one extremity is affected from a single lateral herniated disk and use the interlaminar approach when several spinal nerves are involved in one leg or in both legs, as in the case of central disk herniation.
Recent studies, however, suggest the duration of relief to be comparable. Published reports seem to demonstrate the safety of epidural steroid injections, with only mild and transient adverse effects, in large clinical trials. However, rare occurrences of catastrophic central nervous system injuries, including paraplegia, quadriplegia, medullary infarct, cerebellar infarct, and death after epidural steroid injections, have been reported as isolated case reports.
Epidural injections in the cervical epidural space, especially when performed while the patient is under sedation and without appropriate precautionary steps, such as injection of radiographic contrast medium under fluoroscopy, have resulted in spinal cord injury. Transforaminal injections of particulate steroid, such as methylprednisolone, triamcinolone, or betamethasone, have resulted in cerebrovascular occlusion, likely from intravascular injection of the particulate steroid through 1 of the arteries ascending or deep cervical artery or the radicular artery accompanying the spinal nerve that communicates with the anterior spinal artery, resulting in a segmental cord infarct.
A multidisciplinary working group, consisting of specialists who had previously published research related to epidural steroid injections, discussed the adverse effects posed by the procedures and recommended safety improvements. The recommendations of the working group were voted on by representatives of an initial list of several national organizations. The recently published recommendations 8 included several important suggestions for improving the safety of epidural steroid injections explanations, if needed, are in parentheses.
All cervical and lumbar interlaminar epidural steroid injections should be performed using image guidance, with appropriate anteroposterior, lateral, or contralateral oblique views and a test dose of contrast medium. There has been a case report of lower extremity paralysis after lumbar interlaminar injection without fluoroscopy and a case report of paraplegia after thoracic interlaminar injection when fluoroscopy was used but contrast was not injected.
Cervical and lumbar transforaminal epidural steroid injections should be performed by injecting contrast medium under real-time fluoroscopy or digital subtraction imaging, before injecting any substance that may be hazardous to the patient. The use of digital subtraction imaging has been shown to be more effective in detecting intravascular injection than syringe aspiration alone.
Cervical interlaminar epidural steroid injections are recommended to be performed at C7-T1, but preferably not higher than the C level. The cervical epidural space is widest at the C6-T1 levels.
Gaps in the ligamentum flavum are more frequent with ascending cervical levels. No cervical interlaminar epidural steroid injection should be undertaken, at any segmental level, without preprocedural review of prior imaging studies demonstrating sufficient epidural spatial dimensions for needle placement at the target level.
Particulate steroids should not be used in therapeutic cervical transforaminal injections. Injuries following nonparticulate injections were temporary, whereas paraplegias after particulate steroids were permanent.
If the nerve root involved is at a higher level, ie, C5, most pain medicine physicians perform an interlaminar injection at C or C7-T1, insert a catheter, and advance it to C5.
For diagnostic injections, to help the surgeon identify the affected nerve root, pain physicians perform transforaminal injections using local anesthetic, with or without a nonparticulate dexamethasone. A nonparticulate steroid eg, dexamethasone 6 should be used for the initial injection in lumbar transforaminal epidural injections.
There are situations in which particulate steroids could be used in the performance of lumbar transforaminal epidural steroid injections. This is because the lumbar transforaminal area is wider than in the cervical regions.
If relief from a nonparticulate steroid is of short duration, some physicians will inject a steroid containing smaller particles, either betamethasone or triamcinolone. The advisory committee members voted 15 to 7 with 1 abstention that they could envision a situation in which epidural steroid injections should warrant a contraindication warning in the labeling of injectable corticosteroids. As of March 26, , the FDA has yet to take formal action on the recommendations provided by the advisory committee.
Epidural steroid injections will continue to be used for short-term relief of radicular pain. More research is needed to determine whether nonparticulate steroids have equal efficacy compared with particulate steroid formulations and to know the lowest dose that will lead to meaningful reduction in pain while minimizing adverse effects, such as elevations in blood glucose. The recommendations of the working group and the national organizations 8 are intended to help reduce or eliminate the occurrence of these rare but devastating neurological injuries associated with epidural steroid injections.
Conflict of Interest Disclosures: Dr Benzon reported that he is the deputy editor in chief of Pain Practice , and is a member of the board of directors of the American Society of Regional Anesthesia and Pain Medicine. Dr Rathmell reported that he is the executive editor of Anesthesiology and a director of the American Board of Anesthesiology. Improving the Safety of Epidural Steroid Injections. The Future of Epidural Steroid Injections.
Back to top Article Information. Assessment of the growth of epidural injections in the Medicare population from to Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: PubMed Google Scholar Crossref.
Intra-arterial injection in the rat brain: Spine Phila Pa Anatomy of the cervical intervertebral foramina: Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Comparison of the particle sizes of different steroids and the effect of dilution: Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate.
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