Advertisement

Epidural Steroid Injections

  • Thomas Suchy
  • Jack Diep
  • Jianguo ChengEmail author
Chapter

Abstract

The incidence of lower back or neck pain and related radicular pain has become increasingly common throughout the industrialized and developing world. Epidural injections for management of back pain and radicular pain have been performed for decades. It is the most commonly utilized intervention for managing chronic and acute lower back pain. Improvement in anatomic knowledge, coupled by major advances in medical equipment and imaging devices, has led to rapid growth in use of epidural steroid injections beyond the lower back pain treatment. Cervical, thoracic, and sacral anatomic sites are becoming more utilized to target spine pain by interventional clinicians. This chapter describes patient selection; indications and contraindications; techniques and anatomic considerations for interlaminar, transforaminal, and caudal approaches; complications; and the scientific evidence behind these procedures.

Keywords

Interlaminar Transforaminal Epidural steroid injection Disc herniation Impingement Lumbar herniated disc Nerve root irritation Radiculopathy Radicular pain Spinal stenosis 

References

  1. 1.
    Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353–71.Google Scholar
  2. 2.
    Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783–92.PubMedGoogle Scholar
  3. 3.
    Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR, North Carolina Back Pain Project. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med. 1995;333(14):913–7.PubMedGoogle Scholar
  4. 4.
    Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:1462–9: annrheumdis-2013.PubMedGoogle Scholar
  5. 5.
    Nyman T, Grooten WJ, Wiktorin C, Liwing J, Norrman L. Sickness absence and concurrent low back and neck–shoulder pain: results from the MUSIC-Norrtälje study. Eur Spine J. 2007;16(5):631–8.PubMedGoogle Scholar
  6. 6.
    Montgomery W, Sato M, Nagasaka Y, Vietri J. The economic and humanistic costs of chronic lower back pain in Japan. Clinicoecon Outcomes Res: CEOR. 2017;9:361.Google Scholar
  7. 7.
    Deyo RA. Back Pain Patient Outcomes Assessment Team (BOAT). US Department of Health & Human Services-Agency of Healthcare Research; 1994.Google Scholar
  8. 8.
    Sinnott PL, Dally SK, Trafton J, Goulet JL, Wagner TH. Trends in diagnosis of painful neck and back conditions, 2002 to 2011. Medicine. 2017;96(20):e6691.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Sicard A. Les injections medicamenteuses extra-durales par voie sacrococcygienne. Compt Rend Soc De Biol. 1901;53:396–8.Google Scholar
  10. 10.
    Hollander JL. The local effects of compound F (hydrocortisone) injected into joints. Bull Rheum Dis. 1951;2(2):3.PubMedGoogle Scholar
  11. 11.
    Robecchi A. L’idrocortisone (composto F). Prime experienze cliniche in campo reumatologico. Minerva Med. 1952;98:1259–63.Google Scholar
  12. 12.
    Gharibo C, Koo C, Chung J, Moroz A. Epidural steroid injections: an update on mechanisms of injury and safety. Techn Reg Anesth Pain Manag. 2009;13(4):266–71.Google Scholar
  13. 13.
    Vidyasagar KY. Assessment of the growth of epidural injections in the Medicare population from 2000 to 2011. Pain Physician. 2013;16:E349–64.Google Scholar
  14. 14.
    Benditz A, Brunner M, Zeman F, Greimel F, Florian V, Boluki D, et al. Effectiveness of a multimodal pain management concept for patients with cervical radiculopathy with focus on cervical epidural injections. Sci Rep. 2017;7(1):7866.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Center P, Director MP, Manchikanti L. 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:E327–38.Google Scholar
  16. 16.
    Costandi SJ, Azer G, Eshraghi Y, Zeyed Y, Atalla JE, Looka ME, et al. Cervical transforaminal epidural steroid injections: diagnostic and therapeutic value. Reg Anesth Pain Med. 2015;40(6):674–80.Google Scholar
  17. 17.
    Leung SM, Chau WW, Law SW, Fung KY. Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy. Hong Kong Med J. 2015;21(5):394–400.PubMedGoogle Scholar
  18. 18.
    Narouze S, Benzon H, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2015;40(3):182–212.PubMedGoogle Scholar
  19. 19.
    Shulman M. Treatment of neck pain with cervical epidural steroid injection. Reg Anesth. 1986;11:92–4.Google Scholar
  20. 20.
    Purkis IE. Cervical epidural steroids. Pain Clin. 1986;1:3–7.Google Scholar
  21. 21.
    Rowlingson JC, Kirschenbaum LP. Epidural analgesic techniques in the management of cervical pain. Anesth Analg. 1986;65:938–42.PubMedGoogle Scholar
  22. 22.
    Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012;15:E363–404.PubMedGoogle Scholar
  23. 23.
    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;91:397–9.PubMedGoogle Scholar
  24. 24.
    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;24:351–5.PubMedGoogle Scholar
  25. 25.
    Costandi S, Eshraghi Y, Mekhail N, Azer G, Zeyed Y, Looka M, et al. Cervical transforaminal epidural steroid injections diagnostic and therapeutic value. Reg Anesth Pain Med [serial on the Internet]. n.d. [cited February 16, 2018];40(6):674–680.PubMedGoogle Scholar
  26. 26.
    Lee JW, Park KW, Chung SK, Yeom JS, Kim KJ, Kim HJ, et al. Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy: a comparative study of particulate versus non-particulate steroids. Skelet Radiol. 2009;38:1077–82.Google Scholar
  27. 27.
    Lee SH, Kim KT, Kim DH, Lee BJ, Son ES, Kwack YH. Clinical outcomes of cervical radiculopathy following epidural steroid injection: a prospective study with follow-up for more than 2 years. Spine (Phila Pa 1976). 2012;37:1041–7.Google Scholar
  28. 28.
    Razzaq AA, O’Brien D, Mathew B, Bartlett R, Taylor D. Efficacy and durability of fluoroscopically guided cervical nerve root block. Br J Neurosurg. 2007;21:365–9.PubMedGoogle Scholar
  29. 29.
    Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir. 2005;147:1065–70.PubMedGoogle Scholar
  30. 30.
    Cohen SP, Hayek S, Semenov Y, Pasquina PF, White RL, Veizi E, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121(5):1045–55.PubMedGoogle Scholar
  31. 31.
    Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine. 2002;27:509–14.PubMedGoogle Scholar
  32. 32.
    Landa J. Outcomes of interlaminar and transforaminal spinal injections. Bull NYU Hosp Joint Dis. 2012;70:6–10.Google Scholar
  33. 33.
    Okmen K. The efficacy of interlaminar epidural steroid administration in multilevel intervertebral disc disease with chronic low back pain: a randomized, blinded, prospective study. Spine J. 2017;17:168–74.PubMedGoogle Scholar
  34. 34.
    Sharm AK. The effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections: a systematic review with comprehensive analysis of the published data. Pain Med. 2017;18:239–51.Google Scholar
  35. 35.
    DePalma MJ. Evidence-informed management of chronic low back pain with epidural steroid injections. Spine J. 2008;8:45–55.PubMedGoogle Scholar
  36. 36.
    Roberts ST. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PMR. 2015;1:756–68.Google Scholar
  37. 37.
    MacVicar J, King W, Landers MH, Bogduk N. The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of published data. Pain Med. 2013;14:14–28.Google Scholar
  38. 38.
    Bhatia A, Flamer D, Shah PS, Cohen SP. Transforaminal epidural steroid injections for treating lumbosacral radicular pain from herniated intervertebral discs: a systematic review and meta-analysis. Anesth Analg. 2016;122(3):867–70.Google Scholar
  39. 39.
    Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: a comprehensive literature review. J Back Musculoskelet Rehabil. 2011;24(2):67–76.PubMedGoogle Scholar
  40. 40.
    Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, Christo PJ, Ward SP. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199–245.PubMedGoogle Scholar
  41. 41.
    Fish DE, Lee PC, Marcus DB. The S1 “Scotty Dog”: report of a technique for S1 transforaminal epidural steroid injection. Arch Phys Med Rehabil. 2007;88(12):1730–3.PubMedGoogle Scholar
  42. 42.
    Kim D-H, Yoon DM, Yoon KB. Incidence of intravascular injection and the spread of contrast media during S1 transforaminal epidural steroid injection by two approaches: anteroposterior vs oblique. Anaesthesia. 2015;70(8):975–84.PubMedGoogle Scholar
  43. 43.
    Park SJ, Kim SH, Kim SJ, Yoon DM, Yoon KB. Comparison of incidences of intravascular injection between medial and lateral side approaches during traditional S1 transforaminal epidural steroid injection. Pain Res Manag. 2017;2017:6426802.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Ferris HA, Kahn CR. New mechanisms of glucocorticoid-induced insulin resistance: make no bones about it. J Clin Invest. 2012;122(11):3854–7.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Lansang M, Farmer T, Kennedy L. Diagnosing the unrecognized systemic absorption of intra-articular and epidural steroid injections. Endocr Pract. 2009;15(3):225–8.PubMedGoogle Scholar
  46. 46.
    Moon HJ, Choi KH, Lee SI, Lee OJ, Shin JW, Kim TW. Changes in blood glucose and cortisol levels after epidural or shoulder intra-articular glucocorticoid injections in diabetic or nondiabetic patients. Am J Phys Med Rehabil. 2014;93(5):372–8.PubMedGoogle Scholar
  47. 47.
    Younes M, Neffati F, Touzi M, Hassen-Zrour S, Fendri Y, Béjia I, Amor AB, Bergaoui N, Najjar MF. Systemic effects of epidural and intra-articular glucocorticoid injections in diabetic and non-diabetic patients. Joint Bone Spine. 2007;74(5):472–6.PubMedGoogle Scholar
  48. 48.
    Kim S, Hwang B. Relationship between bone mineral density and the frequent administration of epidural steroid injections in postmenopausal women with low back pain. Pain Res Manag. 2014;19(1):30–4.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Windsor RE, Storm S, Sugar R. Prevention and management of complications resulting from common spinal injections. Pain Physician. 2003;6(4):473–84.PubMedGoogle Scholar
  50. 50.
    Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. 2004;79(5):682–6. Elsevier.PubMedGoogle Scholar
  51. 51.
    Zhang JH, Wang ZL, Wan L. Cervical epidural analgesia complicated by epidural abscess: a case report and literature review. Medicine. 2017;96(40):e7789.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Simopoulos TT, Kraemer JJ, Glazer P, Bajwa ZH. Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar epidural steroid injection. Pain Physician. 2008;11(5):693–7.PubMedGoogle Scholar
  53. 53.
    Martin RJ, Yuan HA. Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis. Orthop Clin N Am. 1996;27(1):125–36.Google Scholar
  54. 54.
    Kabbara A, Rosenberg SK, Untal C. Methicillin-resistant Staphylococcus aureus epidural abscess after transforaminal epidural steroid injection. Pain Physician. 2004;7(2):269–72.PubMedGoogle Scholar
  55. 55.
    McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726–31.Google Scholar
  56. 56.
    Goodman BS, Bayazitoglu M, Mallempati S, Noble BR, Geffen JF. Dural puncture and subdural injection: a complication of lumbar transforaminal epidural injections. Pain Physician. 2007;10(5):697.PubMedGoogle Scholar
  57. 57.
    Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, Riew KD, 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.PubMedGoogle Scholar
  58. 58.
    Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage: two case reports. Spine. 1998;23(19):2137–40.PubMedGoogle Scholar
  59. 59.
    Tripathi M, Nath SS, Gupta RK. Paraplegia after intracord injection during attempted epidural steroid injection in an awake-patient. Anesth Analg. 2005;101(4):1209–11.PubMedGoogle Scholar
  60. 60.
    Windsor RE, Storm S, Sugar R, Nagula D. Cervical transforaminal injection: review of the literature, complications, and a suggested technique. Pain Physician. 2003;6(4):457–66.PubMedGoogle Scholar
  61. 61.
    Ludwig MA, Burns SP. Spinal cord infarction following cervical transforaminal epidural injection: a case report. Spine. 2005;30(10):E266–8.PubMedGoogle Scholar
  62. 62.
    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.PubMedGoogle Scholar
  63. 63.
    Suresh S, Berman J, Connell DA. Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block. Skelet Radiol. 2007;36(5):449–52.Google Scholar
  64. 64.
    Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections. Expert Opin Drug Saf. 2016;15(8):1031–9.PubMedGoogle Scholar
  65. 65.
    Pountos I, Panteli M, Walters G, Bush D, Giannoudis PV. Safety of epidural corticosteroid injections. Drugs R&D. 2016;16(1):19–34.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Pain MedicineCleveland Clinic FoundationClevelandUSA
  2. 2.Department of Pain Management and NeurosciencesCleveland ClinicClevelandUSA

Personalised recommendations