Epidural steroid injection

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Epidural steroid injection
Blausen 0354 EpiduralSteroidInjection.png
Steroids are injected into the cerebrospinal fluid in the canal surrounding the spine. Nerves branch out from the spine. The nerve roots, which may be compressed, are at the base of the nerves.
Specialty Pain medicine

Epidural steroid injection (ESI) is a technique in which corticosteroids and a local anesthetic are injected into the epidural space around the spinal cord in an effort to improve spinal stenosis, spinal disc herniation, or both. It is of benefit with a rare rate of major side effects. [1] [2] The Food and Drug Administration (FDA) has not approved ESI for pain management, and has raised concerns about rare, but serious, side effects. [3]

Contents

Medical uses

Epidural steroid injection for sciatica and spinal stenosis is of unclear effect. [1] The evidence to support use in the cervical spine is not very good. [4] When medical imaging is not used to determine the proper spot for injection, ESI benefits appear to be of short-term benefit when used in sciatica. [5] It is unclear if ESI is useful for chronic pain after spinal surgery. [6]

Steroid effectiveness

Steroids are included in ESI based on the belief that steroids reduce inflammation, but clinical practice has indicated that steroids plus lidocaine (anesthetic) produces no greater reduction in pain than lidocaine alone. [7] The fact that there is no association between quantity of steroid and reported pain reduction has caused speculation of a placebo effect for steroids. [8]

Side effects

Major side effects are rare. [2] These include loss of vision, stroke, paralysis, or death when the corticosteroids are infected, as in a 2012 meningitis outbreak. [2] [9] Another study found an increased odds of developing epidural lipomatosis, independent of body mass index (BMI) or other factors. [10]

Locally injected glucocorticoids can have systemic effects, including loss of bone mineral density, suppression of the immune system as well as effects on the central nervous system and cardiovascular system. [11]

Technique

Elective spinal injections should be performed with imaging guidance, such as fluoroscopy or the use of a radiocontrast agent, unless that guidance is contraindicated. [12] Imaging guidance ensures the correct placement of the needle and maximizes the physician's ability to make an accurate diagnosis and administer effective therapy. [12] Without imaging, the risk increases for the injection to be incorrectly placed, and this would in turn lower the therapy's efficacy and increase subsequent risk of need for more treatment. [12]

References

  1. 1 2 Shaughnessy, AF (15 February 2016). "Epidural Steroid Not Better Than Placebo Injection for Sciatica and Spinal Stenosis Pain and Function". American Family Physician. 93 (4): 315–6. PMID   26926820.
  2. 1 2 3 Schneider, B; Zheng, P; Mattie, R; Kennedy, DJ (August 2016). "Safety of epidural steroid injections". Expert Opinion on Drug Safety. 15 (8): 1031–9. doi:10.1080/14740338.2016.1184246. PMID   27148630. S2CID   27053083.
  3. ↑ "FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain". Food and Drug Administration . Retrieved 4 March 2025.
  4. ↑ Cohen, SP; Hooten, WM (14 August 2017). "Advances in the diagnosis and management of neck pain". BMJ (Clinical Research Ed.). 358: j3221. doi:10.1136/bmj.j3221. PMID   28807894. S2CID   29500924.
  5. ↑ Vorobeychik, Y; Sharma, A; Smith, CC; Miller, DC; Stojanovic, MP; Lobel, SM; Valley, MA; Duszynski, B; Kennedy, DJ; Standards Division of the Spine Intervention, Society (December 2016). "The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data". Pain Medicine (Malden, Mass.). 17 (12): 2185–2202. doi: 10.1093/pm/pnw091 . PMID   28025354.
  6. ↑ Wylde, V; Dennis, J; Beswick, AD; Bruce, J; Eccleston, C; Howells, N; Peters, TJ; Gooberman-Hill, R (September 2017). "Systematic review of management of chronic pain after surgery". The British Journal of Surgery. 104 (10): 1293–1306. doi:10.1002/bjs.10601. PMC   5599964 . PMID   28681962.
  7. ↑ Manchikanti L, Knezevic NN, Hirsch JA (2016). "Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis" (PDF). Pain Physician . 19 (3): E365-410. PMID   27008296.
  8. ↑ Whynes DK, McCahon RA, Hardman J (2012). "Cost effectiveness of epidural steroid injections to manage chronic lower back pain". BMC Anesthesiology . 12: 26. doi: 10.1186/1471-2253-12-26 . PMC   3468401 . PMID   23016755.
  9. ↑ Kauffman, CA; Malani, AN (April 2016). "Fungal Infections Associated with Contaminated Steroid Injections". Microbiology Spectrum. 4 (2): 359–374. doi:10.1128/microbiolspec.EI10-0005-2015. ISBN   978-1-55581-944-6. PMID   27227303. S2CID   42550449.
  10. ↑ Jaimes, Rafael; Rocco, Angelo (August 2014). "Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a case series". BMC Anesthesiology. 14 (70): 70. doi: 10.1186/1471-2253-14-70 . PMC   4145583 . PMID   25183952.
  11. ↑ Stout A, Friedly J, Standaert CJ (2019). "Systemic Absorption and Side Effects of Locally Injected Glucocorticoids". PM&R . 11 (4): 409–419. doi:10.1002/pmrj.12042. PMID   30925034.
  12. 1 2 3 North American Spine Society (February 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, North American Spine Society, retrieved 25 March 2013
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