Skip to main content
SpringerLink
Log in

Is there a difference in treatment outcomes between epidural injections with particulate versus non-particulate steroids?

  • Musculoskeletal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

To compare the outcomes of patients after interlaminar computed tomography (CT)-guided epidural injections of the lumbar spine with particulate vs. non-particulate steroids.

Methods

531 consecutive patients were treated with CT-guided lumbar interlaminar epidural injections with steroids and local anaesthetics. 411 patients received a particulate steroid and 120 patients received a non-particulate steroid. Pain levels were assessed using the 11-point numerical rating scale (NRS) and overall reported ‘improvement’ was assessed using the Patients Global Impression of Change (PGIC) at 1 day, 1 week and 1 month post-injection.

Descriptive and inferential statistics were applied.

Results

Patients receiving particulate steroids had statistically significantly higher NRS change scores (p = 0.0001 at 1 week; p = 0.0001 at 1 month).

A significantly higher proportion of patients receiving particulate steroids reported relevant improvement (PGIC) at both 1 week and 1 month post injection (p = 0.0001) and they were significantly less likely to report worsening at 1 week (p = 0.0001) and 1 month (p = 0.017).

Conclusion

Patients treated with particulate steroids had significantly greater pain relief and were much more likely to report clinically relevant overall ‘improvement’ at 1 week and 1 month compared to the patients treated with non-particulate steroids.

Key Points

• CT-guided epidural injections of the lumbar spine with particulate vs. non-particulate steroids.

• Good outcomes with particulate steroids.

• Less pain relief in patients with non-particulate steroids.

• Less improvement in patients with non-particulate steroids.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Manchikanti L, Pampati V, Boswell MV, Smith HS, Hirsch JA (2010) Analysis of the growth of epidural injections and costs in the Medicare population: a comparative evaluation of 1997, 2002, and 2006 data. Pain Physician 13:199–212

    PubMed  Google Scholar 

  2. Harkness EF, Macfarlane GJ, Silman AJ, McBeth J (2005) Is musculoskeletal pain more common now than 40 years ago?: two population-based cross-sectional studies. Rheumatology (Oxford) 44:890–895

    Article  CAS  Google Scholar 

  3. Karamouzian S, Ebrahimi-Nejad A, Shahsavarani S, Keikhosravi E, Shahba M, Ebrahimi F (2014) Comparison of two methods of epidural steroid injection in the treatment of recurrent lumbar disc herniation. Asian Spine J 8:646–652

    Article  PubMed  PubMed Central  Google Scholar 

  4. Friedly J, Nishio I, Bishop MJ, Maynard C (2008) The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery. Arch Phys Med Rehabil 89:1011–1015

    Article  PubMed  Google Scholar 

  5. Abdi S, Datta S, Trescot AM et al (2007) Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 10:185–212

    PubMed  Google Scholar 

  6. Krych AJ, Richman D, Drakos M et al (2012) Epidural steroid injection for lumbar disc herniation in NFL athletes. Med Sci Sports Exerc 44:193–198

    Article  CAS  PubMed  Google Scholar 

  7. Parr AT, Diwan S, Abdi S (2009) Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician 12:163–188

    PubMed  Google Scholar 

  8. Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S (2009) Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician 12:109–135

    PubMed  Google Scholar 

  9. Buenaventura RM, Datta S, Abdi S, Smith HS (2009) Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 12:233–251

    PubMed  Google Scholar 

  10. Price CM, Rogers PD, Prosser AS, Arden NK (2000) Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis 59:879–882

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP (2013) Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med 38:175–200

    Article  CAS  PubMed  Google Scholar 

  12. Abram SE (1999) Treatment of lumbosacral radiculopathy with epidural steroids. Anesthesiology 91:1937–1941

    Article  CAS  PubMed  Google Scholar 

  13. Derby R, Lee SH, Date ES, Lee JH, Lee CH (2008) Size and aggregation of corticosteroids used for epidural injections. Pain Med 9:227–234

    Article  PubMed  Google Scholar 

  14. FDA - US Food and Drug Administration. Shoulder. Kenalog-10 (triamcinolone acetonide) injection and Kenalog-40 (triamcinolone acetonide) injection. http://www.fda.gov/safety/medwatch/safetyinformation/ucm262876.htm. Accessed 15 Feb 2015

  15. US Food and Drug Administration FDA (2014) FDA drug safety communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. http://www.fda.gov/downloads/Drugs/DrugSafety/UCM394286.pdf. Accessed 15 Feb 2015

  16. Tinetti ME, Studenski SA (2011) Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med 364:2478–2481

    Article  CAS  PubMed  Google Scholar 

  17. Neumann PJ (2013) Communicating and promoting comparative-effectiveness research findings. N Engl J Med 369:209–211

    Article  CAS  PubMed  Google Scholar 

  18. Bensler S, Sutter R, Pfirrmann CW, Peterson CK (2015) Long term outcomes from CT-guided indirect cervical nerve root blocks and their relationship to the MRI findings - a prospective Study. Eur Radiol 25:3405–3413

    Article  PubMed  Google Scholar 

  19. Friedly JL, Comstock BA, Turner JA et al (2014) A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 371:11–21

    Article  PubMed  Google Scholar 

  20. Kim D, Brown J (2011) Efficacy and safety of lumbar epidural dexamethasone versus methylprednisolone in the treatment of lumbar radiculopathy: a comparison of soluble versus particulate steroids. Clin J Pain 27:518–522

    Article  PubMed  Google Scholar 

  21. Kennedy DJ, Plastaras C, Casey E et al (2014) Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial. Pain Med 15:548–555

    Article  PubMed  Google Scholar 

  22. Manchikanti L, Candido KD, Kaye AD et al (2014) Randomized trial of epidural injections for spinal stenosis published in the New England Journal of Medicine: further confusion without clarification. Pain Physician 17:E475–E488

    PubMed  Google Scholar 

  23. Manchikanti L, Candido KD, Singh V et al (2014) Epidural steroid warning controversy still dogging FDA. Pain Physician 17:E451–E474

    PubMed  Google Scholar 

  24. Denis I, Claveau G, Filiatrault M, Fugere F, Fortin L (2015) Randomized double-blind controlled trial comparing the effectiveness of lumbar transforaminal epidural injections of particulate and nonparticulate corticosteroids for lumbosacral radicular pain. Pain Med 16:1697–1708

    Article  PubMed  Google Scholar 

  25. Park CH, Lee SH, Kim BI (2010) Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain. Pain Med 11:1654–1658

    Article  PubMed  Google Scholar 

  26. Lee SE, Kim DS, Lee WK et al (2010) Application of the Epstein criteria for prediction of clinically insignificant prostate cancer in Korean men. BJU Int 105:1526–1530

    Article  PubMed  Google Scholar 

  27. Stanczak J, Blankenbaker DG, De Smet AA, Fine J (2003) Efficacy of epidural injections of Kenalog and Celestone in the treatment of lower back pain. AJR Am J Roentgenol 181:1255–1258

    Article  PubMed  Google Scholar 

  28. Shakir A, Ma V, Mehta B (2013) Comparison of pain score reduction using triamcinolone vs. dexamethasone in cervical transforaminal epidural steroid injections. Am J Phys Med Rehabil 92:768–775

    Article  PubMed  Google Scholar 

  29. Lee JW, Park KW, Chung SK et al (2009) Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy: a comparative study of particulate versus non-particulate steroids. Skeletal Radiol 38:1077–1082

    Article  PubMed  Google Scholar 

  30. Dreyfuss P, Baker R, Bogduk N (2006) Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med 7:237–242

    Article  PubMed  Google Scholar 

  31. Bose B (2005) Quadriparesis following cervical epidural steroid injections: case report and review of the literature. Spine J 5:558–563

    Article  PubMed  Google Scholar 

  32. Hodler J, Boos N, Schubert M (2013) Must we discontinue selective cervical nerve root blocks? Report of two cases and review of the literature. Eur Spine J 22:S466–S470

    Article  PubMed  Google Scholar 

  33. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P (2007) Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. AJR Am J Roentgenol 188:1218–1221

    Article  PubMed  Google Scholar 

  34. Rozin L, Rozin R, Koehler SA et al (2003) Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol 24:351–355

    Article  PubMed  Google Scholar 

  35. Ludwig MA, Burns SP (2005) Spinal cord infarction following cervical transforaminal epidural injection: a case report. Spine (Phila Pa 1976) 30:E266–E268

    Article  Google Scholar 

  36. Meyer HJ, Monticelli F, Kiesslich J (2005) Fatal embolism of the anterior spinal artery after local cervical analgetic infiltration. Forensic Sci Int 149:115–119

    Article  PubMed  Google Scholar 

  37. Popescu A, Lai D, Lu A, Gardner K (2013) Stroke following epidural injections–case report and review of literature. J Neuroimaging 23:118–121

    Article  PubMed  Google Scholar 

  38. Ziai WC, Ardelt AA, Llinas RH (2006) Brainstem stroke following uncomplicated cervical epidural steroid injection. Arch Neurol 63:1643–1646

    Article  PubMed  Google Scholar 

  39. US Food and Drug Administration FDA (2011) FDA - US Food and Drug Administration. Shoulder. Kenalog-10 (triamcinolone acetonide) injection and Kenalog-40 (triamcinolone acetonide) injection. http://www.fda.gov/safety/medwatch/safetyinformation/ucm262876.htm. Accessed 15 Jan 2015

  40. Wybier M, Gaudart S, Petrover D, Houdart E, Laredo JD (2010) Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature. Eur Radiol 20:181–189

    Article  PubMed  Google Scholar 

  41. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR (2007) Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology 106:331–338

    Article  CAS  PubMed  Google Scholar 

  42. Tiso RL, Cutler T, Catania JA, Whalen K (2004) Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J 4:468–474

    Article  PubMed  Google Scholar 

  43. Rathmell JP, Aprill C, Bogduk N (2004) Cervical transforaminal injection of steroids. Anesthesiology 100:1595–1600

    Article  PubMed  Google Scholar 

  44. Huntoon MA (2005) Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain 117:104–111

    Article  PubMed  Google Scholar 

  45. Rathmell JP, Benzon HT (2004) Transforaminal injection of steroids: should we continue? Reg Anesth Pain Med 29:397–399

    PubMed  Google Scholar 

  46. Lechmann M, Peterson CK, Pfirrmann CW, Hodler J (2013) Lumbar nerve root injections: a prospective cohort outcomes study comparing age- and gender-matched patients who returned an outcomes-based postal questionnaire with patients who did not return the postal questionnaire. Skeletal Radiol 42:1429–1435

    Article  PubMed  Google Scholar 

  47. Kremer S, Pfirrmann CW, Hodler J, Peterson CK (2012) Imaging-guided lumbar facet injections: is there a difference in outcomes between low back pain patients who remember to return a postal questionnaire and those who do not? Insights Imaging 3:411–418

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

The scientific guarantor of this publication is Susanne Bensler. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional review board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. Methodology: retrospective, diagnostic or prognostic study, performed at one institution.

Author information

Authors and Affiliations

  1. Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland

    Susanne Bensler, Reto Sutter, Christian W. A. Pfirrmann & Cynthia K. Peterson

  2. Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland

    Susanne Bensler, Reto Sutter, Christian W. A. Pfirrmann & Cynthia K. Peterson

Authors
  1. Susanne Bensler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Reto Sutter
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christian W. A. Pfirrmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cynthia K. Peterson
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Susanne Bensler.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bensler, S., Sutter, R., Pfirrmann, C.W.A. et al. Is there a difference in treatment outcomes between epidural injections with particulate versus non-particulate steroids?. Eur Radiol 27, 1505–1511 (2017). https://doi.org/10.1007/s00330-016-4498-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-016-4498-9

Keywords

Search

Navigation