BackgroundEpidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown.ObjectiveIdentify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures.MethodsCross-sectional survey study of 314 physician members of the Spine Interventional Society.Results41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs.ConclusionCurrent trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.

Background: Epidural steroid injections (ESI) are commonly used to treat refractory radicular spinal pain. Although evidence suggests that an increasing cumulative dose of exogenous corticosteroid may be harmful, knowledge of current practice patterns is limited regarding the choice of dose and frequency of epidural steroid injections (ESIs). Objective: Describe current practice trends in the dose selection and frequency of administration of transforaminal ESIs (TFESIs) and interlaminar ESIs (ILESIs). Design: Cross-sectional survey study. Setting: Not applicable. Participants: Three hundred fourteen physician members of the Spine Intervention Society (SIS). From May to June 2018, an online survey was distributed to 5907 physician members of the SIS. Interventions: Not applicable. Main Outcome Measures: Corticosteroid dose used by practitioners and the number of annual ESIs administered per patient. Results: Three hundred fourteen physicians responded to the survey. For single cervical or lumbar injections of dexamethasone, most physicians (56.0%) reported using 10 mg; 17% of physicians reported use of doses greater than 10 mg, with 6% using a dose of 20 mg per injection level. The most common particulate corticosteroid dose used during both cervical and lumbar ILESIs was 80 mg (cervical = 55.4%, lumbar = 54.7%). During cervical and lumbar ILESIs, 17% and 12.7% of physicians reported using doses greater than 80 mg, respectively. Almost 10% of physicians reported performing cervical TFESIs with particulate steroids. Forty percent of physicians reported allowing four ESIs at a given spinal segmental level per year (cervical/thoracic/lumbosacral). A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%). Conclusions: There is considerable variability among this large cohort of interventionists with regard to corticosteroid dose selection and epidural steroid injection frequency. A small proportion of respondents reported Mulitsociety Pain Workgroup guideline-discordant use of particulate steroids during cervical TFESIs. These findings demonstrate a need for additional research regarding both the reasons for such variation in care and the reasons for guideline-discordant practice in a subset of physicians. Level of Evidence: IV.

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