Skip to main content
SpringerLink
Log in

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

  • Review Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

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.

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.

Institutional subscriptions

Similar content being viewed by others

References

  1. Wu A, March L, Zheng X, Huang J, Wang X, Zhao J, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020;8(6):299.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976). 2009;34(19):2077–84.

    Article  PubMed  Google Scholar 

  3. Manchikanti L, Falco FJ, Pampati V, Cash KA, Benyamin RM, Hirsch JA. Cost utility analysis of caudal epidural injections in the treatment of lumbar disc herniation, axial or discogenic low back pain, central spinal stenosis, and post lumbar surgery syndrome. Pain Physician. 2013;16(3):E129-143.

    Article  PubMed  Google Scholar 

  4. Manchikanti L, Boswell MV, Hirsch JA. Lessons learned in the abuse of pain-relief medication: a focus on healthcare costs. Expert Rev Neurother. 2013;13(5):527–43 (quiz 544).

    Article  CAS  PubMed  Google Scholar 

  5. Christelis N, Simpson B, Russo M, Stanton-Hicks M, Barolat G, Thomson S, et al. Persistent spinal pain syndrome: a proposal for failed back surgery syndrome and ICD-11. Pain Med. 2021;22(4):807–18.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ter Meulen BC, Weinstein H, Ostelo R, Koehler PJ. The epidural treatment of sciatica: its origin and evolution. Eur Neurol. 2016;75(1–2):58–64.

    Article  PubMed  Google Scholar 

  7. Kaye AD, Manchikanti L, Abdi S, Atluri S, Bakshi S, Benyamin R, et al. Efficacy of epidural injections in managing chronic spinal pain: a best evidence synthesis. Pain Physician. 2015;18(6):E939-1004.

    Article  PubMed  Google Scholar 

  8. MacVicar J, King W, Landers MH, Bogduk N. The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of the published data. Pain Med. 2013;14(1):14–28.

    Article  PubMed  Google Scholar 

  9. Helm Ii S, Harmon PC, Noe C, Calodney AK, Abd-Elsayed A, Knezevic NN, et al. Transforaminal epidural steroid injections: a systematic review and meta-analysis of efficacy and safety. Pain Physician. 2021;24(S1):S209–32.

    PubMed  Google Scholar 

  10. Kennedy DJ, Levin J, Rosenquist R, Singh V, Smith C, Stojanovic MP, et al. Epidural steroid injections are safe and effective: multisociety letter in support of the safety and effectiveness of epidural steroid injections. Pain Med. 2015;16(5):833–8.

    Article  PubMed  Google Scholar 

  11. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013;16(2 Suppl):S49-283.

    PubMed  Google Scholar 

  12. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NICE guideline NG59). Online 2016. Available at: https://www.nice.org.uk/guidance/ng59. Accessed 10 April 2022.

  13. Manchikanti L, Pampati V, Hirsch JA. Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014. BMJ Open. 2016;6(12):e013042.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Manchikanti L, Sanapati MR, Soin A, Manchikanti MV, Pampati V, Singh V, et al. An updated analysis of utilization of epidural procedures in managing chronic pain in the Medicare population from 2000 to 2018. Pain Physician. 2020;23(2):111–26.

    Article  PubMed  Google Scholar 

  15. Manchikanti L, Soin A, Mann DP, Bakshi S, Pampati V, Hirsch JA. Comparative analysis of utilization of epidural procedures in managing chronic pain in the Medicare population: pre and post affordable care act. Spine (Phila Pa 1976). 2019;44(3):220–32.

    Article  PubMed  Google Scholar 

  16. Olmarker K, Blomquist J, Strömberg J, Nannmark U, Thomsen P, Rydevik B. Inflammatogenic properties of nucleus pulposus. Spine (Phila Pa 1976). 1995;20(6):665–9.

    Article  CAS  PubMed  Google Scholar 

  17. Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI. Lumbar facet pain: biomechanics, neuroanatomy and neurophysiology. J Biomech. 1996;29(9):1117–29.

    Article  CAS  PubMed  Google Scholar 

  18. Manchikanti L, Knezevic E, Knezevic NN, Vangala BP, Sanapati MR, Thota S, et al. A comparative systematic review and meta-analysis of 3 routes of administration of epidural injections in lumbar disc herniation. Pain Physician. 2021;24(6):425–40.

    Article  PubMed  Google Scholar 

  19. Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag. 2015;5(2):129–46.

    Article  PubMed  Google Scholar 

  20. Brunner P, Amoretti N, Soares F, Brunner E, Cazaux E, Brocq O, et al. Approaches in injections for radicular pain: the transforaminal, epidural and transfacet approaches. Diagn Interv Imaging. 2012;93(9):711–22.

    Article  CAS  PubMed  Google Scholar 

  21. The British Pain Society. Outcome measures. Online: The Faculty of Pain Medicine of the Royal College of Anaesthetists, London 2019. Available at: https://www.britishpainsociety.org/static/uploads/resources/files/Outcome_Measures_January_2019.pdf. Accessed 10 April 2022.

  22. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):2940–52 (discussion 2952).

    Article  CAS  PubMed  Google Scholar 

  23. Reichardt SD, Amouret A, Muzzi C, Vettorazzi S, Tuckermann JP, Lühder F, et al. The role of glucocorticoids in inflammatory diseases. Cells. 2021;10(11):2921.

  24. Goppelt-Struebe M. Molecular mechanisms involved in the regulation of prostaglandin biosynthesis by glucocorticoids. Biochem Pharmacol. 1997;53(10):1389–95.

    Article  CAS  PubMed  Google Scholar 

  25. Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain. Spine J. 2009;9(6):509–17.

    Article  PubMed  Google Scholar 

  26. Bicket MC, Gupta A, Brown CH, Cohen SP. Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. Anesthesiology. 2013;119(4):907–31.

    Article  PubMed  Google Scholar 

  27. MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology. 2009;252(3):647–61.

    Article  PubMed  Google Scholar 

  28. Watkins TW, Dupre S, Coucher JR. Ropivacaine and dexamethasone: a potentially dangerous combination for therapeutic pain injections. J Med Imaging Radiat Oncol. 2015;59(5):571–7.

    Article  PubMed  Google Scholar 

  29. Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: a comprehensive review of the published data. Pain Med. 2020;21(3):472–87.

    Article  PubMed  Google Scholar 

  30. Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, McCormick ZL. The effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Med. 2020;21(1):41–54.

    Article  PubMed  Google Scholar 

  31. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. Thoracic interlaminar epidural injections in managing chronic thoracic pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Pain Physician. 2014;17(3):E327-338.

    Article  PubMed  Google Scholar 

  32. Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician. 2021;24(S1):S27–208.

    PubMed  Google Scholar 

  33. Manchikanti L, Benyamin RM. Key safety considerations when administering epidural steroid injections. Pain Manag. 2015;5(4):261–72.

    Article  PubMed  Google Scholar 

  34. Pörtner M, Möllmann H, Rohdewald P. Glucocorticoid receptors in human synovial tissue and relative receptor affinities of glucocorticoid-21-esters. Pharm Res. 1988;5(10):623–7.

    Article  PubMed  Google Scholar 

  35. Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, et al. Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion. Clin J Pain. 2007;23(7):551–7.

    Article  PubMed  Google Scholar 

  36. Park CH, Lee SH, Kim BI. Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain. Pain Med. 2010;11(11):1654–8.

    Article  PubMed  Google Scholar 

  37. Bensler S, Sutter R, Pfirrmann CWA, Peterson CK. Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: comparison of outcomes in 494 patients with lumbar radiculopathy. Eur Radiol. 2018;28(3):946–52.

    Article  PubMed  Google Scholar 

  38. Bensler S, Sutter R, Pfirrmann CWA, Peterson CK. Is there a difference in treatment outcomes between epidural injections with particulate versus non-particulate steroids? Eur Radiol. 2017;27(4):1505–11.

    Article  PubMed  Google Scholar 

  39. Donohue NK, Tarima SS, Durand MJ, Wu H. Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study. Korean J Pain. 2020;33(2):192–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Kennedy DJ, Plastaras C, Casey E, Visco CJ, Rittenberg JD, Conrad B, et al. 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. 2014;15(4):548–55.

    Article  PubMed  Google Scholar 

  41. Makkar JK, Singh PM, Jain D, Goudra B. Particulate vs non-particulate steroids for transforaminal epidural steroid injections: systematic review and meta-analysis of the current literature. Pain Physician. 2016;19(6):327–40.

    Article  PubMed  Google Scholar 

  42. Feeley IH, Healy EF, Noel J, Kiely PJ, Murphy TM. Particulate and non-particulate steroids in spinal epidurals: a systematic review and meta-analysis. Eur Spine J. 2017;26(2):336–44.

    Article  CAS  PubMed  Google Scholar 

  43. Mehta P, Syrop I, Singh JR, Kirschner J. Systematic review of the efficacy of particulate versus nonparticulate corticosteroids in epidural injections. PM R. 2017;9(5):502–12.

    Article  PubMed  Google Scholar 

  44. Zhai J, Zhang L, Li M, Tian Z, Tian Y, Zheng W, et al. Epidural injection with or without steroid in managing chronic low-back and lower extremity pain: a meta-analysis of 10 randomized controlled trials. Am J Ther. 2017;24(3):e259–69.

    Article  PubMed  Google Scholar 

  45. Manchikanti L, Pampati V, Benyamin RM, Boswell MV. Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: local anesthetic alone vs. local combined with steroids. Int J Med Sci. 2015;12(3):214–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Manchikanti L, Knezevic NN, Parr A, Kaye AD, Sanapati M, Hirsch JA. Does epidural bupivacaine with or without steroids provide long-term relief? A systematic review and meta-analysis. Curr Pain Headache Rep. 2020;24(6):26.

    Article  PubMed  Google Scholar 

  47. Knezevic NN, Manchikanti L, Urits I, Orhurhu V, Vangala BP, Vanaparthy R, et al. Lack of superiority of epidural injections with lidocaine with steroids compared to without steroids in spinal pain: a systematic review and meta-analysis. Pain Physician. 2020;23(4S):S239–70.

    PubMed  Google Scholar 

  48. Manchikanti L, Knezevic E, Knezevic NN, Sanapati MR, Thota S, Abd-Elsayed A, et al. Epidural injections for lumbar radiculopathy or sciatica: a comparative systematic review and meta-analysis of Cochrane Review. Pain Physician. 2021;24(5):E539–54.

    PubMed  Google Scholar 

  49. El-Yahchouchi CA, Plastaras CT, Maus TP, Carr CM, McCormick ZL, Geske JR, et al. Adverse event rates associated with transforaminal and interlaminar epidural steroid injections: a multi-institutional study. Pain Med. 2016;17(2):239–49.

    PubMed  Google Scholar 

  50. Kainer MA, Reagan DR, Nguyen DB, Wiese AD, Wise ME, Ward J, et al. Fungal infections associated with contaminated methylprednisolone in Tennessee. N Engl J Med. 2012;367(23):2194–203.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Engel A, King W, MacVicar J, Society SDotISI. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014;15(3):386–402.

    Article  PubMed  Google Scholar 

  52. Manchikanti L, Candido KD, Singh V, Gharibo CG, Boswell MV, Benyamin RM, et al. Epidural steroid warning controversy still dogging FDA. Pain Physician. 2014;17(4):E451-474.

    Article  PubMed  Google Scholar 

  53. Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, et al. Safe use of epidural corticosteroid injections: recommendations of the WIP Benelux Work Group. Pain Pract. 2019;19(1):61–92.

    Article  PubMed  Google Scholar 

  54. Racoosin JA, Seymour SM, Cascio L, Gill R. Serious neurologic events after epidural glucocorticoid injection–the FDA′s risk assessment. N Engl J Med. 2015;373(24):2299–301.

    Article  PubMed  Google Scholar 

  55. Cohen SP, Greuber E, Vought K, Lissin D. Safety of epidural steroid injections for lumbosacral radicular pain: unmet medical need. Clin J Pain. 2021;37(9):707–17.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Schreiber AL, McDonald BP, Kia F, Fried GW. Cervical epidural steroid injections and spinal cord injuries. Spine J. 2016;16(10):1163–6.

    Article  PubMed  Google Scholar 

  57. Bao C, Bao S. Hemorrhagic infarction of cerebellum and brainstem due to cervical epidural steroid injection - case report and review of the literature. Acad Forensic Pathol. 2018;8(4):952–6.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep. 2015;19(5):482.

    Article  PubMed  Google Scholar 

  59. Ghaly RF, Zouki T, Pynadath A, Candido KD, Knezevic NN. Transforaminal epidural steroid injection can result in further neurological injury in a patient with severe foraminal stenosis and nerve impingement. Surg Neurol Int. 2018;9:159.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Gharibo CG, Fakhry M, Diwan S, Kaye AD. Conus medullaris infarction after a right L4 transforaminal epidural steroid injection using dexamethasone. Pain Physician. 2016;19(8):E1211–4.

    PubMed  Google Scholar 

  61. Eworuke E, Crisafi L, Liao J, Akhtar S, Van Clief M, Racoosin JA, et al. Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population. Reg Anesth Pain Med. 2021;46(3):203–9.

    Article  PubMed  Google Scholar 

  62. Food and Drug Administration. FDA drug safety communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain; 2014. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-label-changes-warn-rare-serious-neurologic-problems-after. Accessed 10 April 2022.

  63. Food and Drug Administration. Anesthetic and Analgesic Drug Products Advisory Committee meeting. Epidural steroid injections (ESI) and the risk of serious neurologic adverse reactions; 2014. Available at: https://wayback.archive-it.org/7993/20170404144310/https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndAnalgesicDrugProductsAdvisoryCommittee/UCM429414.pdf. Accessed 10 April 2022.

  64. American Patient Defense Union. APDU warning to Pfizer—unsafe and inappropriate use of depo-medrol in spinal pain management; 2017. Available at: https://medium.com/@patientdefenseunion/apdu-warning-to-pfizer-unsafe-and-inapprop riate-use-of-depo-medrol-in-spinal-pain-management-cdf8a2f797 c9. Accessed 10 April 2022.

  65. Krez A, Liu Y, Kanbour S, Clare S, Waldman S, Stein EM. The skeletal consequences of epidural steroid injections: a literature review. Osteoporos Int. 2021;32(11):2155–62.

    Article  CAS  PubMed  Google Scholar 

  66. Friedly JL, Comstock BA, Heagerty PJ, Bauer Z, Rothman MS, Suri P, et al. Systemic effects of epidural steroid injections for spinal stenosis. Pain. 2018;159(5):876–83.

    Article  CAS  PubMed  Google Scholar 

  67. Electronic Medicines Compendium. Kenalog Intra-articular/Intramuscular Injection. Summary of Product Characteristics (last updated on the eMC:11/10/2021).

  68. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974–84.

    Article  CAS  PubMed  Google Scholar 

  69. Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. 2020;20(7):998–1024.

    Article  PubMed  Google Scholar 

  70. Doan LV, Narvaez F, Fakhry M, Padjen K, Gharibo CG. Variations of technique in transforaminal epidural steroid injections and periprocedural practices by interventional pain medicine physicians in the United States. Pain Physician. 2019;22(5):E435–40.

    Article  PubMed  Google Scholar 

  71. Doan L, Patel H, Aronova Y, Gharibo C. Variations in interlaminar epidural steroid injection practice patterns by interventional pain management physicians in the United States. Pain Physician. 2018;21(5):E493–9.

    Article  PubMed  Google Scholar 

  72. Vydra D, McCormick Z, Clements N, Nagpal A, Julia J, Cushman D. Current trends in steroid dose choice and frequency of administration of epidural steroid injections: a survey study. PM R. 2020;12(1):49–54.

    Article  PubMed  Google Scholar 

  73. Gupta S, Sharma M. Interventional Pain Medicine practice in the UK and the USA: a survey of 242 pain physicians. Pain Physician. 2020;23(2):127–34.

    Article  PubMed  Google Scholar 

  74. Gupta S, Sharma M. Top 5 Abstracts from the 11th Annual North England Pain Medicine Group Meeting, 2019. Abstract No: 5 - Survey of Awareness of the Guidelines. Faculty of Pain Medicine and the British Pain Society. Br J Pain. 2019;13:5–6.

  75. Dietrich TJ, Sutter R, Froehlich JM, Pfirrmann CW. Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update. Skeletal Radiol. 2015;44(2):149–55.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland

    Francis T. Delaney & Peter J. MacMahon

  2. School of Medicine, University College Dublin, Dublin, Ireland

    Peter J. MacMahon

Authors
  1. Francis T. Delaney
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter J. MacMahon
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Francis T. Delaney.

Ethics declarations

Ethical treatment of human subjects

Not applicable.

Informed consent

Not applicable.

Disclosures

The authors have nothing to disclose.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Delaney, F.T., MacMahon, P.J. An update on epidural steroid injections: is there still a role for particulate corticosteroids?. Skeletal Radiol 52, 1863–1871 (2023). https://doi.org/10.1007/s00256-022-04186-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-022-04186-3

Keywords

Search

Navigation