Skip to main content

Ideal Corticosteroid Choice for Epidural Steroid Injections: A Review of Safety and Efficacy

Current Physical Medicine and Rehabilitation Reports volume 3, pages 151–158 (2015)Cite this article

Abstract

Spine pathology and pain are common. Epidural injections for radicular pain are a common treatment option. While effective for certain populations, these injections have been associated with rare but significant complications including paralysis. The mechanism of injury is felt to be an embolic event following an injection of non-soluble particulate corticosteroids inadvertently into an artery that perfuses the spinal cord or brain. This dire complication has varying risks based on the anatomic considerations of a given route of injection and the corticosteroid utilized. This article will review the proposed mechanism of injury, anatomy principles of the routes of epidural injections, and the solubility and efficacy research on the different commonly utilized corticosteroid options.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

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

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Kennedy DJ, Baker RM, Rathmell JP. Use of spinal injections for low back pain. JAMA. 2013;310(16):1736.

    CAS  PubMed  Article  Google Scholar 

  2. Kennedy DJ, Levin J, Rosenquist R, Singh V, Smith C, 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;. doi:10.1111/pme.12667.

    PubMed  Article  Google Scholar 

  3. Karppinen J, Ohinmaa A, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, et al. Cost effectiveness of periradicular infiltration for sciatica: subgroup analysis of a randomized controlled trial. Spine. 2001;26(23):2587–95.

    CAS  PubMed  Article  Google Scholar 

  4. Ludwig MA, Burns SP. Spinal cord infarction following cervical transforaminal epidural injection: a case report. Spine. 2005;30(10):E266–8.

    PubMed  Article  Google Scholar 

  5. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10(8):1389–94.

    PubMed  Article  Google Scholar 

  6. Bose B. Quadriparesis following cervical epidural steroid injections: case report and review of the literature. Spine J. 2005;5(5):558–63.

    PubMed  Article  Google Scholar 

  7. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine. 2007;32(11):1249–56.

    PubMed  Article  Google Scholar 

  8. Suresh S, Berman J, Connell DA. Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block. Skeletal Radiol. 2007;36(5):449–52.

    CAS  PubMed  Article  Google Scholar 

  9. Beckman WA, Mendez RJ, Paine GF, Mazzilli MA. Cerebellar herniation after cervical transforaminal epidural injection. Reg Anesth Pain Med. 2006;31(3):282–5.

    PubMed  Article  Google Scholar 

  10. McMillan MR, Crumpton C. Cortical blindness and neurologic injury complicating cervical transforaminal injection for cervical radiculopathy. Anesthesiology. 2003;99(2):509–11.

    PubMed  Article  Google Scholar 

  11. Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol. 2003;24(4):351–5.

    PubMed  Article  Google Scholar 

  12. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001;91(3):397–9.

    CAS  PubMed  Article  Google Scholar 

  13. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11(8):1149–68.

    PubMed  Article  Google Scholar 

  14. • 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. A well done review of efficacy for a single procedure with appropriate stratification based on underlying pathology.

    PubMed  Article  Google Scholar 

  15. Depalma MJ, Stout A, Kennedy DJ. Corticosteroid choice for epidural injections. PM R. 2013;5(6):524–32.

    PubMed  Article  Google Scholar 

  16. Derby R, Lee S-H, Date ES, Lee J-H, Lee C-H. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227–34.

    PubMed  Article  Google Scholar 

  17. Benzon HT, Chew T-L, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology. 2007;106(2):331–8.

    CAS  PubMed  Article  Google Scholar 

  18. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4(4):468–74.

    PubMed  Article  Google Scholar 

  19. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005;117(1–2):104–11.

    PubMed  Article  Google Scholar 

  20. Alleyne CH, Cawley CM, Shengelaia GG, Barrow DL. Microsurgical anatomy of the artery of Adamkiewicz and its segmental artery. J Neurosurg. 1998;89(5):791–5.

    PubMed  Article  Google Scholar 

  21. Kroszczynski AC, Kohan K, Kurowski M, Olson TR, Downie SA. Intraforaminal location of thoracolumbar anterior medullary arteries. Pain Med. 2013;14(6):808–12.

    PubMed  Article  Google Scholar 

  22. Kroszczynski AC, Kohan K, Kurowski M, Olson TR, Downie SA. Intraforaminal location of thoracolumbar anterior medullary arteries. Pain Med. 2013;14(6):808–12.

    PubMed  Article  Google Scholar 

  23. Atluri S, Glaser SE, Shah RV, Sudarshan G. Needle position analysis in cases of paralysis from transforaminal epidurals: consider alternative approaches to traditional technique. Pain Physician. 2013;16(4):321–34.

    PubMed  Article  Google Scholar 

  24. Lo D, Valleé JN, Spelle L, Cormier E, Saillant G, Rancurel G, et al. Unusual origin of the artery of Adamkiewicz from the fourth lumbar artery. Neuroradiology. 2002;44(2):153–7.

    CAS  PubMed  Article  Google Scholar 

  25. Okubadejo GO, Talcott MR, Schmidt RE, Sharma A, Patel AA, Mackey RB, et al. Perils of intravascular methylprednisolone injection into the vertebral artery. An animal study. J Bone Joint Surg Am. 2008;90(9):1932–8.

    PubMed  Article  Google Scholar 

  26. Dawley JD, Moeller-Bertram T, Wallace MS, Patel PM. Intra-arterial injection in the rat brain: evaluation of steroids used for transforaminal epidurals. Spine. 2009;34(16):1638–43.

    PubMed  Article  Google Scholar 

  27. Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial. Reg Anesth Pain Med. 2011;36(6):572–8.

    CAS  PubMed  Article  Google Scholar 

  28. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J. 2002;2(1):70–5.

    PubMed  Article  Google Scholar 

  29. Huntoon MA, Martin DP. Paralysis after transforaminal epidural injection and previous spinal surgery. Reg Anesth Pain Med. 2004;29(5):494–5.

    PubMed  Article  Google Scholar 

  30. Karasek M, Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med. 2004;5(2):202–5.

    PubMed  Article  Google Scholar 

  31. Glaser SE, Falco F. Paraplegia following a thoracolumbar transforaminal epidural steroid injection. Pain Physician. 2005;8(3):309–14.

    PubMed  Article  Google Scholar 

  32. Muro K, O’Shaughnessy B, Ganju A. Infarction of the cervical spinal cord following multilevel transforaminal epidural steroid injection: case report and review of the literature. J Spinal Cord Med. 2007;30(4):385–8.

    PubMed  PubMed Central  Article  Google Scholar 

  33. Ruppen W, Hügli R, Reuss S, Aeschbach A, Urwyler A. Neurological symptoms after cervical transforaminal injection with steroids in a patient with hypoplasia of the vertebral artery. Acta Anaesthesiol Scand. 2008;52(1):165–6.

    CAS  PubMed  Article  Google Scholar 

  34. Lyders EM, Morris PP. A case of spinal cord infarction following lumbar transforaminal epidural steroid injection: MR imaging and angiographic findings. AJNR Am J Neuroradiol. 2009;30(9):1691–3.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  35. Wybier M, Gaudart S, Petrover D, Houdart E, Laredo J-D. Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature. Eur Radiol. 2010;20(1):181–9.

    PubMed  Article  Google Scholar 

  36. Manchikanti L. Role of neuraxial steroids in interventional pain management. Pain Physician. 2002;5(2):182–99.

    PubMed  Article  Google Scholar 

  37. Benzon HT, Gissen AJ, Strichartz GR, Avram MJ, Covino BG. The effect of polyethylene glycol on mammalian nerve impulses. Anesth Analg. 1987;66(6):553–9.

    CAS  PubMed  Article  Google Scholar 

  38. Craig DB, Habib GG. Flaccid paraparesis following obstetrical epidural anesthesia: possible role of benzyl alcohol. Anesth Analg. 1977;56(2):219–21.

    CAS  PubMed  Article  Google Scholar 

  39. Ackerman WE 3rd, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg. 2007;104(5):1217–22 tables of contents.

    PubMed  Article  Google Scholar 

  40. Engel A, King W, MacVicar J, Standards Division of the International Spine Intervention Society. 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.

    PubMed  Article  Google Scholar 

  41. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336(23):1634–40.

    CAS  PubMed  Article  Google Scholar 

  42. Valat J-P, Giraudeau B, Rozenberg S, Goupille P, Bourgeois P, Micheau-Beaugendre V, et al. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003;62(7):639–43.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  43. Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine. 1991;16(5):572–5.

    CAS  PubMed  Article  Google Scholar 

  44. Lee JW, Park KW, Chung S-K, Yeom JS, Kim K-J, Kim H-J, et al. Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy: a comparative study of particulate versus non-particulate steroids. Skeletal Radiol. 2009;38(11):1077–82.

    PubMed  Article  Google Scholar 

  45. Shakir A, Ma V, Mehta B. Comparison of pain score reduction using triamcinolone vs. dexamethasone in cervical transforaminal epidural steroid injections. Am J Phys Med Rehabil. 2013;92(9):768–75.

    PubMed  Article  Google Scholar 

  46. Kim D, Brown J. 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. 2011;27(6):518–22.

    PubMed  Article  Google Scholar 

  47. •• El-Yahchouchi C, Geske JR, Carter RE, Diehn FE, Wald JT, Murthy NS, et al. The noninferiority of the nonparticulate steroid dexamethasone vs. the particulate steroids betamethasone and triamcinolone in lumbar transforaminal epidural steroid injections. Pain Med. 2013;14(11):1650–57. This is a largest study to date comparing the outcomes after receiving various steroid options.

    PubMed  Article  Google Scholar 

  48. 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.

    PubMed  Article  Google Scholar 

  49. DePalma MJ, Stout A, Kennedy DJ. Corticosteroid choice for epidural injections. PM R. 2013;5(6):524–32.

    PubMed  Article  Google Scholar 

  50. •• 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. This reference is among the best prospective studies comparing the steroid choices in a single homogenous patient population with appropriate outcomes over an appropriate time frame.

    PubMed  Article  Google Scholar 

  51. Lennard TA. Pain procedures in clinical practice. 3rd ed. Philadelphia: Elsevier/Saunders; 2011.

    Google Scholar 

  52. Dreyfuss P, Baker R, Bogduk N. Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med. 2006;7(3):237–42.

    PubMed  Article  Google Scholar 

  53. Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial. Reg Anesth Pain Med. 2011;36(6):572–8.

    CAS  PubMed  Article  Google Scholar 

  54. Stanczak J, Blankenbaker DG, De Smet AA, Fine J. Efficacy of epidural injections of Kenalog and Celestone in the treatment of lower back pain. AJR Am J Roentgenol. 2003;181(5):1255–8.

    PubMed  Article  Google Scholar 

  55. Noe CE, Haynsworth RF. Comparison of epidural Depo-Medrol vs. aqueous betamethasone in patients with low back pain. Pain Pract. 2003;3(3):222–5.

    PubMed  Article  Google Scholar 

  56. Blankenbaker DG, De Smet AA, Stanczak JD, Fine JP. Lumbar radiculopathy: treatment with selective lumbar nerve blocks–comparison of effectiveness of triamcinolone and betamethasone injectable suspensions. Radiology. 2005;237(2):738–41.

    PubMed  Article  Google Scholar 

  57. Park JW, Nam HS, Cho SK, Jung HJ, Lee BJ, Park Y. Kambin’s triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med. 2012;25(1):833–43.

    Google Scholar 

  58. McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PM R. 2009;1(7):636–42.

    PubMed  Article  Google Scholar 

  59. Bogduk N, International Spine Intervention Society, Standards Committee. Practice guidelines for spinal diagnostic and treatment procedures. San Francisco: International Spine Intervention Society; 2004.

    Google Scholar 

  60. Chang Chien GC, Candido KD, Knezevic NN. Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminal epidural steroid injection. Pain Physician. 2012;15(6):515–23.

    PubMed  Google Scholar 

  61. 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. doi:10.1097/ALN.0000000000000614.

    CAS  PubMed  Article  Google Scholar 

  62. Kennedy DJ, Schneider B, Casey E, Rittenberg J, Conrad B, Smuck M, et al. Vasovagal rates in flouroscopically guided interventional procedures: a study of over 8,000 injections. Pain Med. 2013;14(12):1854–9.

    PubMed  Article  Google Scholar 

  63. Schneider BJ, Smuck M, Plastaras C, Nahm LS, Maus TP, Kennedy DJ. Poster 458 delayed complications following interventional pain procedures. PM R. 2014;6(9):S346.

    Article  Google Scholar 

  64. Nahm LS, Smuck M, Plastaras C, Schneider BJ, Kennedy DJ. Poster 457 next day adverse events from interventional pain procedures. PM R. 2014;6(9):S346.

    Article  Google Scholar 

  65. McCormick Z, Plastaras C, Garvan C, Macron DS, Joshi A, Chimes GP, et al. Poster 460 fluoroscopically guided lumbosacral transforaminal epidural steroid injections: adverse events and predictive factors. PM R. 2014;6(9):S347.

    Article  Google Scholar 

  66. Schneider B, Kennedy DJ, Casey E, Smuck M, Conrad B, Plastaras C. Trainee involvement in transforaminal epidural steroid injections associated with increased incidence of vasovagal reactions. PM&R. 2014. http://linkinghub.elsevier.com/retrieve/pii/S1934148214001713.

  67. Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, et al. Complications of spinal diagnostic and treatment procedures. Pain Med. 2008;2(9):S11–34.

    Article  Google Scholar 

  68. Shetty SR, Shankaranarayana RU, Mehandale SG. Paraplegia following caudal block in a child with Burkitt’s lymphoma. Paediatr Anaesth. 2011;21(10):1087–8.

    PubMed  Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopedics, Stanford University, 450 Broadway St, Redwood City, CA, 94063, USA

    Byron Schneider, Neal Varghis & David J. Kennedy

Authors
  1. Byron Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Neal Varghis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David J. Kennedy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Byron Schneider.

Additional information

This article is part of the Topical Collection on Interventional Pain Management.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Schneider, B., Varghis, N. & Kennedy, D.J. Ideal Corticosteroid Choice for Epidural Steroid Injections: A Review of Safety and Efficacy. Curr Phys Med Rehabil Rep 3, 151–158 (2015). https://doi.org/10.1007/s40141-015-0086-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40141-015-0086-1

Keywords

  • Epidural
  • Steroid
  • Injections
  • Particulate
  • Non-particulate
  • Radiculopathy