Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians

Abstract

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.

Comparison of treatment outcomes in lumbar central stenosis patients treated with epidural steroid injections: interlaminarversusbilateral transforaminal approach

“…Because of the risk of accidental intravascular injection and consequent neurological injuries, non-particulate steroids have been recommended, instead of a particulate steroid, in recent years. Clements et al [26] designed a cross-sectional survey study composed of 314 physicians, who were members of the Spine Interventional Society, and approximately 41% reported using particulate steroids for lumbar TFESI, and 74% for lumbar ILESI, indicating the variability in clinical practice. Chatterjee et al [27] reported that using methylprednisolone, a particulate steroid, provides significantly longer pain relief than dexamethasone, a non-particulate steroid.…”

Epidural steroids – are we following the guidelines?

“…Even though there are consensus and recommendations from the regulatory bodies or professional organisations, current practice in choosing steroids and diluents for epidural injection varies considerably between workgroups and centres. A recent study showed that 41% and 9% of physicians still use particulate steroids for lumbar and cervical transforaminal epidural injections, respectively . The choice of steroids and diluents may indeed influence safety.…”

“…Moreover, one of the aims of diluting steroids with local anaesthetics is to provide immediate pain relief for diagnostic purposes . The local anaesthetic can also help to reduce the discomfort or pain arising from the pressure or volume effects on the sensitive tissues inside the spinal cord . Corticosteroid preparations may also contain excipients such as polyethylene glycol (a drug vehicle) or benzyl alcohol (a preservative) that can be toxic .…”

Fluoroscopy-guided spine injections: establishing a successful service in your radiology department or practice

“…In terms of efficacy, there has been conflicting data in the literature regarding the use of particulate versus non-particulate steroids for ESI [4][5][6][7]. A recent survey of spine interventionalists demonstrated considerable variability with respect to choice of steroid for transforaminal ESI, underscoring the significant difference of opinion and level of comfort that still exists regarding utilization of these agents [8].…”