Current Trends in Steroid Dose Choice and Frequency of Administration of Epidural Steroid Injections: A Survey Study

Association Between Corticosteroid Dose and Pain Reduction After Sacroiliac Joint Injections

OBJECTIVE

Sacroiliac joint-mediated back pain has proven therapeutic benefit from fluoroscopically guided sacroiliac joint corticosteroid injections. We examined corticosteroid dose and pain relief after fluoroscopically guided sacroiliac joint injections to better understand their relationship.

DESIGN

This is a retrospective observational cohort analysis of electronic health record data on 661 patients who received unilateral fluoroscopically guided sacroiliac joint intraarticular corticosteroid injection with 40 mg versus 80 mg of methylprednisolone from 2012 and 2019. Patients were injected by fellowship trained proceduralists after diagnosis by board-certified physiatrists in an academic physiatry practice. Absolute change in pain scores (postprocedure and first follow-up) was modeled using linear regression of methylprednisolone dosage (40 mg vs. 80 mg) controlling for age, sex, body mass index, baseline pain scores, and follow-up time.

RESULTS

Linear regression indicated that dosage of methylprednisolone, age, and body mass index were not statistically significantly associated with change in pain scores. Sex approached significance ( P = 0.0501) indicating that females may have a lower degree of pain resolution than males.

CONCLUSIONS

Practitioners should consider corticosteroid dose when performing these beneficial procedures. This could reduce cost and potential side effects associated with larger doses, while still providing therapeutic benefit. This pilot study can guide future research and dosing guidelines for fluoroscopic spine injections.

Effect of Preoperative Acupuncture and Epidural Steroid Injection on Early Postoperative Infection After Lumbar Spinal Fusion

BACKGROUND

Acupuncture and epidural steroid injection (ESI) are frequently performed in patients with degenerative lumbar disease. The purpose of this study was to explore preoperative acupuncture and ESI as risk factors for postoperative infection after elective lumbar fusion.

METHODS

Patients >50 years of age who underwent spinal fusion due to degenerative lumbar disease from 2010 to 2019 were identified by diagnostic and procedural codes using a nationwide database. The incidence of spinal infection within 90 days after surgery was identified. Patients who underwent acupuncture and/or ESI within 90 days prior to spinal surgery were identified using procedural codes. The infection rate was analyzed by dividing patients into 4 groups as follows: patients who underwent neither acupuncture nor ESI (unexposed group), patients who underwent acupuncture only (acupuncture group), patients who underwent ESI only (ESI group), and patients who underwent both acupuncture and ESI (combined group). Cox regression analysis was performed to identify risk factors for postoperative spinal infection.

RESULTS

A total of 207,806 patients were included in this study. The postoperative infection rate among all patients was 4.29%. The infection rates in the unexposed, acupuncture, ESI, and combined groups were 4.17% (4,342 of 104,106 patients), 3.90% (340 of 8,726 patients), 4.48% (3,761 of 83,882 patients), and 4.26% (473 of 11,092 patients), respectively. Increasing age, male sex, and ESI were demonstrated to be risk factors for postoperative spinal infection. ESI was no longer a risk factor when patients who received acupuncture or ESI within 2 weeks of spinal surgery were excluded. Preoperative acupuncture was not associated with postoperative spinal infection.

CONCLUSIONS

Acupuncture and ESI performed >2 weeks prior to spinal surgery did not increase the risk of postoperative infection.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Particulate Steroid Injection vs Nonparticulate Steroid Injection for Lumbar Radicular Pain: A Systematic Review and Meta-analysis

OBJECTIVE

The objective of this study was to identify the difference on pain intensity and disability between particulate and nonparticulate steroid injections in patients with lumbar radicular pain. Subgroup analysis by study design, type of particulate steroid, and follow-up duration were performed.

DATA SOURCES

We performed the literature search in the PubMed, Embase, and Cochrane Library up March, 2023.

STUDY SELECTION

Studies, including randomized controlled trials (RCTs) and nonrandomized studies, that compared particulate steroid injection and nonparticulate steroid injection in patients with lumbar radicular pain were independently reviewed by 2 reviewers for eligibility for inclusion.

DATA EXTRACTION

Outcomes of interest were pain intensity and disability. Two reviewers independently assessed the quality of included studies using the revised Cochrane Risk of Bias (RoB2.0) tool for RCTs and the Risk of Bias in Nonrandomized Studies of Interventions Tool (ROBINS-I) for nonrandomized studies. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD).

DATA SYNTHESIS

A total of 10 studies were included in this meta-analysis. The results showed no significant difference in visual analog scale, disability score and the numbers of patients with 50% pain reduction between particulate and nonparticulate steroid injection groups (P>.05). Particulate steroid injections showed significant better effect in pain scale in RCTs (MD=0.62; 95% CI 0.08-1.16, P=.02). In subgroup analysis with steroid types, methylprednisolone showed better effect compared with dexamethasone, while dexamethasone showed better effect compared with betamethasone.

CONCLUSIONS

This meta-analysis suggested no significant differences between the particulate and nonparticulate steroid groups in pain or disability score. Therefore, considering the safety profile of nonparticulate steroids, nonparticulate steroid injection may be helpful in patients with lumbar radicular pain.

An update on epidural steroid injections: is there still a role for particulate corticosteroids?

Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.

Clinical Effectiveness of Single Lumbar Periradicular Infiltration in Patients with Sciatica

Periradicular therapy (PRT) is a minimally invasive radiological procedurein patients with chronic lumbar pain.The aim of the study is to identify clinical and radiological predictive factors for treatment success after a single PRT treatment in patients with sciatica.The study includes a prospective follow-up of 166 patients treated with PRT. The pain intensity is determined according to the VAS scale and the degree of improvement is presented as excellent (over 75%), good (50-70%), moderate (25-49%), and weak (less than 25%). The follow up of the treated patients was done at 2 weeks, 3 and 6 months. In patients with pain duration up to 3 months, the improvement was excellent in n=32 (58.18%) after 2 weeks, after 3 months n=41 (74.55%) and after 6 months n=41 (74.55%). This stands in contrast to patients with pain over 1 year. The percentage of improvement after 6 months, post-intervention, was highest in patients without nerve root compression (86.25±19.2),and the highest improvement after 6 months was in patients with localization of pain at the L4-L5 level (69.69±29.7), the greatest improvement after six months was in patients with extraforaminal hernia (62.82±34.3), and the lowest in patients with central stenosis (40.21±30.7).Our study results suggest that the shorter a pain duration, low-grade root compression, injection level and type of herniation area predictor the more favourable response patients have to transforaminal epidural steroid injection in patients with sciatica.

Flushing After Lumbar Epidural Steroid Injection with Dexamethasone

PURPOSE OF REVIEW

Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%).

RECENT FINDINGS

There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.

Agents Used for Nerve Blocks and Neurolysis

The recognition of pain and the treatments used for it are vital for all practitioners. Many types of pain can be treated in a locoregional fashion, which has significant implications not just for any individual patient but for society as a whole. These treatments are most effective when performed in a minimally invasive, image-guided fashion. Interventional radiologists should play a central role in providing these lifestyle-limiting treatments. This article describes the medications most typically used for spinal and extra-axial treatments in the management of patients in pain.

The Effect of a Multidisciplinary Spine Clinic on Time to Care in Patients with Chronic Back and/or Leg Pain: A Propensity Score-Matched Analysis

Chronic back and leg pain are leading causes of disability worldwide. The purpose of this study was to compare the care in a unidisciplinary (USC) versus multidisciplinary (MSC) spine clinic, where patients are evaluated by different specialists during the same office visit. Adult patients presenting with a chief complaint of back and/or leg pain between June 2018 and July 2019 were assessed for eligibility. The main outcome measures included the first treatment recommendations, the time to treatment order, and the time to treatment occurrence. A 1:1 propensity score-matched analysis was performed on 874 patients (437 in each group). For all patients, the most common recommendation was physical therapy (41.4%), followed by injection (14.6%), and surgery (9.7%). Patients seen in the MSC were more likely to be recommended injection (p < 0.001) and less likely to be recommended surgery as first treatment (p = 0.001). They also had significantly shorter times to the injection order (log-rank test, p = 0.004) and the injection occurrence (log-rank test, p < 0.001). In this study, more efficient care for patients with back and/or leg pain was delivered in the MSC setting, which was evidenced by the shorter times to the injection order and occurrence. The impact of the MSC approach on patient satisfaction and health-related quality-of-life outcome measures warrants further investigation.

One-year results from a randomized comparative trial of targeted steroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment of unilateral cervical radicular pain

OBJECTIVES

The objective of this study was to evaluate the long-term effectiveness of catheter-directed cervical interlaminar epidural steroid injection with triamcinolone compared with cervical transforaminal steroid injection with dexamethasone for the treatment of refractory unilateral radicular pain.

DESIGN

Prospective, randomized, comparative trial.

METHODS

The primary outcome was the proportion of participants with ≥50% Numeric Rating Scale 'dominant pain' (the greater of arm vs neck) reduction from baseline. Secondary outcomes included ≥30% Neck Disability Index reduction and Patient Global Impression of Change response indicating 'much improved' or 'very much improved'.

RESULTS

Data from 117 participants (55.6% women; 52.3±12.5 years of age; body mass index, 28.2±6.5 kg/m²) were analyzed. The proportion of participants who experienced ≥50% pain reduction at 1 month, 3 months, and 6 months has been previously reported. At 1 year, 61.2% (95% CI, 46.9% to 73.9%) of the catheter group compared with 51.9% (95% CI, 38.4% to 65.2%) of the transforaminal group reported ≥50% 'dominant' pain reduction (p=0.35). The proportion of participants who experienced ≥30% improvement in Neck Disability Index score was 60.4% (95% CI, 45.9% to 73.3%) and 47.1% (95% CI, 33.7% to 60.8%) in the catheter and transforaminal groups (p=0.18). Patient Global Impression of Change improvement was similar in both groups: 60.5% (95% CI, 44.2% to 74.8%) and 57.5% (95% CI, 41.7% to 71.9%) of the catheter and transforaminal groups reported being 'much improved' or 'very much improved', respectively (p=0.79).

CONCLUSION

Both cervical catheter-directed interlaminar epidural injection and cervical transforaminal steroid injection were effective in reducing pain and disability in the majority of participants with refractory unilateral cervical radiculopathy for up to 1 year.

Comparative safety review of current treatment options for chronic low back pain and unmet needs: a narrative review

Introduction: The healthcare expenditures in the United States are substantial for the management of refractory, chronic low back pain (CLBP). The objective of this review is to summarize and evaluate the safety profiles of different pharmacological treatment options used in the management of CLBP.Areas covered: The authors conducted a search of randomized controlled trials (RCTs) assessing the safety profiles of different pharmacological agents used in the management of CLBP. This narrative review covered corticosteroids, opioids, antidepressants, gabapentinoids, nonsteroidal anti-inflammatory drugs, muscle relaxants, anti-nerve growth factor antibodies and topical agents, as monotherapy or in combination.Expert opinion: The risk-benefit ratio of a particular treatment is a subject driving the ongoing development of pharmaceuticals. The most commonly reported AEs across all drug classes are of gastrointestinal nature, followed by neurological and skin-related. These AEs include nausea, dizziness, constipation, arthralgia, headache, dry mouth, pruritus, etc. The majority of the AEs reported are not life-threatening, although they may lower patients' quality of life, thus, affecting their compliance. One of the biggest limitations of our review stems from the paucity of safety assessments in published RCTs. Advances in our understanding of the neurobiology of pain will promote development of new therapeutic strategies.

Safety of epidural steroids: a review

Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.

Corticosteroid and Local Anesthetic Use Trends for Large Joint and Bursa Injections: Results of a Survey of Sports Medicine Physicians

BACKGROUND

Physician decision-making surrounding choices for large joint and bursa injections is poorly defined, yet influences patient safety and treatment effectiveness.

OBJECTIVE

To identify practice patterns and rationale related to injectate choices for large joint and bursal injections performed by physician members of the American Medical Society for Sports Medicine (AMSSM).

DESIGN

An electronic survey was sent to 3400 members of the AMSSM. Demographic variables were collected: primary specialty (residency), training location, practice location, years of clinical experience, current practice type, and rationale for choosing an injectate.

PARTICIPANTS

A total of 674 physicians responded (minimum response rate of 20%).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Outcomes of interest included corticosteroid type and dose, local anesthetic type, and total injectate volume for each large joint or bursa (hip, knee, and shoulder).

RESULTS

Most respondents used triamcinolone (50% to 56% of physicians, depending on injection location) or methylprednisolone (25% to 29% of physicians), 21 to 40 mg (53% to 60% of physicians), diluted with lidocaine (79% to 87%) for all large joint or bursa injections. It was noted that 36.2% (244/674) of respondents reported using >40 mg for at least one injection type. Most (90.5%, 610/674) reported using an anesthetic other than ropivacaine for at least one type of joint or bursa injection. Physicians who reported lidocaine use were less likely to report that their injectate choice was based on the literature that they reviewed (odds ratio [OR] 0.41 [0.27-0.62], P < .001). Respondents predominantly used 5 to 7 mL of total injectate for all large joints or bursae (45% to 54% of respondents), except for the pes anserine bursa, where 3-4 mL was more common (51% of physicians).

CONCLUSIONS

It appears that triamcinolone and methylprednisolone are the most commonly used corticosteroids for sports medicine physicians; most physicians use 21 to 40 mg of corticosteroid for all injections, and lidocaine is the most-often used local anesthetic; very few use ropivacaine. Over one-third of respondents used high-dose (>40 mg triamcinolone or methylprednisolone) for at least one joint or bursa.

A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results

Objectives

Compare the effectiveness of catheter-directed cervical interlaminar epidural steroid injection (C-CIESI) with triamcinolone to cervical transforaminal steroid injection (CTFESI) with dexamethasone for the treatment of refractory unilateral radicular pain.

Design

Prospective, randomized, comparative trial.

Methods

Primary outcome: proportion of participants with ≥50% numeric rating scale pain score reduction from baseline “dominant pain” (the greater of arm vs neck) at one month postinjection. Secondary outcomes: ≥30% Neck Disability Index (NDI-5) reduction and Patient Global Impression of Change (PGIC) response indicating “much improved” or “very much improved.”

Results

One hundred twenty participants (55.6% females, 52.3 ± 12.5 years of age, BMI 28.2 ± 6.5 kg/m2), were enrolled. The proportions of participants who experienced ≥50% pain reduction at one, three, and six months were 68.5% (95% CI = 54.9–79.5%), 59.3% (95% CI = 45.7–71.6%), and 60.8% (95% CI = 46.7–73.2%), respectively, in the C-CIESI group compared with 49.1% (95% CI = 36.4–62.0%), 46.4% (95% CI = 33.8–59.6%), and 51.9% (95% CI = 38.4–65.2%), respectively, in the CTFESI group. The between-group difference at one month was significant (P = 0.038). The proportions of participants who experienced a ≥30% NDI-5 score improvement were 64.0% (95% CI = 49.8–76.1%) and 54.9% (95% CI = 41.1–68.0%) in the C-CIESI and CTFESI groups (P = 0.352). Participants reported similar PGIC improvement in both groups: At six months, 53.2% (95% CI 38.9–67.1%) and 54.5% (95% CI = 39.7–68.7%) of the C-CIESI and CTFESI groups reported being “much improved” or “very much improved,” respectively (P = 0.897).

Conclusions

Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.

Effect of low-dose lidocaine on objective upper extremity strength and immediate pain relief following cervical interlaminar epidural injections: a double-blinded randomized controlled trial

Background

Low-dose lidocaine is a common diluent for analgesia following cervical interlaminar epidural steroid injection (CIESI). Concerns with this practice exist. A single-arm cohort reported that 20% of patients develop postprocedural upper extremity weakness when using lidocaine as a diluent. Furthermore, a high-cervical spinal block with unintended intrathecal or subdural administration is possible.

Objective

Determine if low-dose lidocaine as a diluent during CIESI causes clinically meaningful (1) upper extremity weakness and (2) immediate pain relief when compared with saline.

Design

Double-blinded randomized control trial.

Methods

Patients with cervical radicular pain scheduled for CIESI were enrolled. Participants received lidocaine (CIESI-L) or saline (CIESI-S) as a diluent for the epidural injectate. Myotomal strength was measured with dynamometry before and between 20 and 30 min after CIESI. Pre-pain and post-pain scores were obtained. Primary and secondary outcomes were post-CIESI weakness of ≥20% (minimal clinically important difference (MCID)) in >1 myotome and ≥50% pain reduction on the numerical scale.

Results

120 participants (64 females (53%), mean age, 56 (SD 13.7) years) completed the study and were analyzed (CIESI-L n=60; CIESI-S n=60). There was no significant between-group difference in the proportion of participants with postprocedural weakness, CIESI-L 41.7% (95% CI, 29.8% to 54.5%), CIESL-S 50% (95% CI, 37.5% to 62.5%). Between-group comparison showed no significant difference in pain reduction, relative risk 1.53 (95% CI, 0.82 to 2.86).

Conclusion

Low-dose lidocaine as a diluent in CIESI does not significantly increase the risk of post-CIESI myotomal weakness when compared with saline, but also does not substantially increase the likelihood of immediate, meaningful pain relief.

Trial registration details

ClinicalTrials.gov (NCT03127137); December 26, 2017.