Epidural steroids

[militarymd]

I'm friends with a couple of 100% pain management guys. I've asked the following question several times without getting any good answers, so I'll try here.

Is there any data to support the 3 injections only? Why only 3, and not more? I get the "we don't want to suppress the adrenal-pituiatry axis" a lot, but the fact of the matter is that patients with other diseases get more steroids for longer periods of time without difficulty with their adrenals.

Has there been any prospective randomized control trials comparing fluoro guided epidural steroid injections with IM steroids and/or systemic steroids?

Thanks

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[lobelsteve]

I'll fire the first shot.

Flame suit on:::

3 is an old standard based on doing these procedures blindly (without fluoroscopic guidance) because you would only get the medication to the right spot 1 in 3 times.

There is literature to support the rate of successful medication deployment at the desired level and side and within the epidural space. I cannot quote it directly, but pubmed can.

Pain relief is not the same as epidural anesthesia. The doses of medication are different and the outcomes desired are different. If I place an epidural under fluoroscopic guidance and the patient does not get adequate relief lasting several weeks to several months, then maybe their pain is coming from a different location- the medication did not reach the target, the pain is not relieved by steroids or local anesthetic, or secondary gain issues.

If a patient gets a week or 2 relief I believe that they either had a systemic effect of the steroid or I was too far away from the "pain generator" to make a lasting difference.

Flame suit off:::

 

[Aether2000]

There is absolutely no scientific evidence. The series of 3 was started by one of the seminal publications on epidural steroid injections in which 3 injections (every other day by the way) were administered. Period. No science...just the practice of one author. Medicare eventually adopted the 3 per year rule based on the fact that so many people were receiving a series of three injections. Again, no science, no data....
Doctors who practice by scheduling a series of 3 epidural steroid injections without re-evaluating the patient to determine the responsiveness and appropriate timing of subsequent injections, are practicing substandard care and are running block mills...ie. the mindless block jock.
There are no maximum number of epidural steroid injections per year supported by the scientific literature. It is as absurd to define a maximum number per year as it would be to tell a patient they can only have 3 asthma treatments per year. Nonsense, nonsense, nonsense. However, the obligatory fluid retention, hypertension, and hyperglycemia that often results should give one pause regarding overzealous use. There are also reports of avascular necrosis of the femoral head from overuse of steroids.

 

[militarymd]

of 3 epidural steroid injections without re-evaluating the patient to determine the responsiveness and appropriate timing of subsequent injections, are practicing substandard care and are running block mills...ie. the mindless block jock.

Seems that a lot of folks do that.

 

[lobelsteve]

Whew, thought I was going to get hosed for suggesting that a Pain physician actually diagnose the patient before treating them. I'm offended to see Rx's for LESIx3 from spine surgeons who I have never met. I understand it pays the bills and referrals are very important- but probably not as important as patient care.

 

[The A guy]

Hi,

I have had way over 20 epidurals in my spine adventure career (trying to avoid the 7 surgeries, which I had to have anyway), and wonder, also, why the three-some? AND why no attempt was made by my different pain docs to tally the total # of ESI I had, and try and limit them (God forbid) so that the total lifespan exposure to the A/P axis situation did not get out of control.

No one ever asked, or when I brought up the fact that I had already had dozens of epidurals before (not to mention that they did not help mitigate the pain, after # 15 or so), showed any concern that my exposure to steroids vis a vis A/P axis, might be an issue. Now that my stomach looks like the Pillsbury doughboy, I reflect on what on earth my body and brain, will be doing (besides exposure to adhesive arachnoiditis, which cannot be cured) in the future because of this many epidurals.

I would also like to hear any speculation as to what adrenal-pit axis results would be, given exposure to close to 30 ESI over 18 years or so might be expected to be.

Thanks, and appreciate any and all responses.

yankee echo
The A guy

I'm friends with a couple of 100% pain management guys. I've asked the following question several times without getting any good answers, so I'll try here.

Is there any data to support the 3 injections only? Why only 3, and not more? I get the "we don't want to suppress the adrenal-pituiatry axis" a lot, but the fact of the matter is that patients with other diseases get more steroids for longer periods of time without difficulty with their adrenals.

Has there been any prospective randomized control trials comparing fluoro guided epidural steroid injections with IM steroids and/or systemic steroids?

Thanks

 

[Aether2000]

Insanity is the endless repetition of the same process over and over, each time hoping for a different result. A Einstein

You were treated by insane doctors my friend. To many old school anesthesiologists that were sent pain patients, there were but three choices: narcotics, epidural steroid injections, trigger points. Since they don't want to be bothered by the patient maintenance issues regarding narcotics, they revert to trigger points. Since Medicare and insurers pay so little for trigger points, they revert to epidural steroids. Even if they have been tried many times before and without success.....
The AHA is suppressed for about a month after a bolus epidural steroid injection. There is no evidence of long lasting suppression.

 

[Mister Mxyzptlk]

A series of 3 ESI's will suppress the response to cosyntropin for more than a month, up to almost 3 months. Interestingly, the concomittant use of midazolam seems to make it worse.

I thought the source of the series of 3 came from Bonica's observatiion that if three don't work, don't pursue it. So 3 was intended as the "ceiling". It has since been turned around to become the "floor", i.e, that you need to do 3.

In reality nobody knows the right number to do, and chances are that since the pathology can be so variable there will never be a single value for the floor or the ceiling.

For that matter, where is the magic in 40 mg or 80 mg of steroid? Maybe 10 mg is all you need. Applied locally that is still a colossally supra-physiological dose.

 

[Aether2000]

Perhaps the number also eminated from the adage, "If at first you don't succeed, try try again" that was applied by physicians doing blind epidurals with such variable results that they continued the insanity. Of course fluoroscopy has been widely available for over a decade and a half, so all those errant placements and probably billions of dollars worth of crappy medicine could have been saved.

 

[wonthurtabit1]

A series of 3 ESI's will suppress the response to cosyntropin for more than a month, up to almost 3 months. Interestingly, the concomittant use of midazolam seems to make it worse.

I thought the source of the series of 3 came from Bonica's observatiion that if three don't work, don't pursue it. So 3 was intended as the "ceiling". It has since been turned around to become the "floor", i.e, that you need to do 3.

In reality nobody knows the right number to do, and chances are that since the pathology can be so variable there will never be a single value for the floor or the ceiling.

For that matter, where is the magic in 40 mg or 80 mg of steroid? Maybe 10 mg is all you need. Applied locally that is still a colossally supra-physiological dose.

gorback
do you have the original references for these effects, I want to start archiving these classic studies which often become urban legend. I also wanted to get actual numbers on % flushing, rash, HTN, hyperglycemia etc, so I could write up a good informed consent form.

 

[wonthurtabit1]

There is absolutely no scientific evidence. The series of 3 was started by one of the seminal publications on epidural steroid injections in which 3 injections (every other day by the way) were administered. Period. No science...just the practice of one author. Medicare eventually adopted the 3 per year rule based on the fact that so many people were receiving a series of three injections. Again, no science, no data....
Doctors who practice by scheduling a series of 3 epidural steroid injections without re-evaluating the patient to determine the responsiveness and appropriate timing of subsequent injections, are practicing substandard care and are running block mills...ie. the mindless block jock.
There are no maximum number of epidural steroid injections per year supported by the scientific literature. It is as absurd to define a maximum number per year as it would be to tell a patient they can only have 3 asthma treatments per year. Nonsense, nonsense, nonsense. However, the obligatory fluid retention, hypertension, and hyperglycemia that often results should give one pause regarding overzealous use. There are also reports of avascular necrosis of the femoral head from overuse of steroids.

algos,
same question to you. copy of an original article for the master files? this would be a great article to scan into pdf. I always find it extremely intriguing in regard to medical folklore. Insurance companies will fight you tooth and nail on diagnostic lumbar z-joint blocks, but will wave you on through w/ 3 epidurals.

 

[wonthurtabit1]

For that matter, where is the magic in 40 mg or 80 mg of steroid? Maybe 10 mg is all you need. Applied locally that is still a colossally supra-physiological dose.

Didn't I hear a figure like 540 mg/year of kenalog max per ISIS? or is that urban legend? a study to back it up?

 

[Mister Mxyzptlk]

"Perhaps the number also eminated from the adage, "If at first you don't succeed, try try again" that was applied by physicians doing blind epidurals with such variable results that they continued the insanity. Of course fluoroscopy has been widely available for over a decade and a half, so all those errant placements and probably billions of dollars worth of crappy medicine could have been saved."


Wow. I hope history doesn't judge us quite so harshly regarding our own little efforts to address today's conundrums. In a few years we too will look hopelessly quaint to our successors.

Viewed through the prism of contemporary knowledge it's easy to mistakenly judge our predecessors as being stupid. If you read the medical literature from the 1800s you can see the same types of thought processes and arguments that we engage in here. All that was lacking was the information. They struggled with the medical issues of their day as we struggle with ours.

 

[Mister Mxyzptlk]

gorback
do you have the original references for these effects, I want to start archiving these classic studies which often become urban legend. I also wanted to get actual numbers on % flushing, rash, HTN, hyperglycemia etc, so I could write up a good informed consent form.

Kay J, et al. Epidural triamcinolone suppresses the pituitary-adrenal axis in human subjects. Anesth Analg. 1994 Sep;79(3):501-5.

 

[Aether2000]

Ah, but therein lies the rub. I am not talking about our predecessors, but the blind interlaminar methodology that continues to predominate today's epidural injections, even when there is unequivocal evidence of inaccuracy of placement....

 

[wonthurtabit1]

"Perhaps the number also eminated from the adage, "If at first you don't succeed, try try again" that was applied by physicians doing blind epidurals with such variable results that they continued the insanity. Of course fluoroscopy has been widely available for over a decade and a half, so all those errant placements and probably billions of dollars worth of crappy medicine could have been saved."


Wow. I hope history doesn't judge us quite so harshly regarding our own little efforts to address today's conundrums. In a few years we too will look hopelessly quaint to our successors.

Viewed through the prism of contemporary knowledge it's easy to mistakenly judge our predecessors as being stupid. If you read the medical literature from the 1800s you can see the same types of thought processes and arguments that we engage in here. All that was lacking was the information. They struggled with the medical issues of their day as we struggle with ours.

a insightful thought indeed -- perhaps the most memorable quote i heard in medical school was the following: "50% of what you are learning in medical school is wrong, the problem is, we don't know which 50%." yup, some young turk is going to be calling us doddering in a few decades to be sure.

 

[wonthurtabit1]

Ah, but therein lies the rub. I am not talking about our predecessors, but the blind interlaminar methodology that continues to predominate today's epidural injections, even when there is unequivocal evidence of inaccuracy of placement....

maybe our new credo should change from:
primum no nocere to primum no stupido

 

[Aether2000]

lol...funny.

 

[Doctodd]

Guys/gals, i remember a specific study that supported the use of around 2. I would waste more than a day looking for it, but from what i remember 80% of patients received about 12 months significant relief(>50%) when they had 2.2 or somewhere around there. Maybe someone has a secretary with some free time.

T

 

[Mister Mxyzptlk]

Ah, but therein lies the rub. I am not talking about our predecessors, but the blind interlaminar methodology that continues to predominate today's epidural injections, even when there is unequivocal evidence of inaccuracy of placement....

Do you really think that blind IL is still the predominant technique? Not in my neighborhood, although there have been a few holdouts - mostly older orthos referring to the hospital anesthesia group for blind ESI's.

I'm seeing the opposite problem here - radiologists doing fluoro-guided ESI's with post-ESI CT scans.

 

[Aether2000]

I will try to check on the numbers. Anesthesiologists have a superior numerical advantage in their population relative to us pain physicians...
The opposite problem you cite is probably overkill...a CT obtained post epidural injection as a routine is way outside the normal standard of care...

 

[wonthurtabit1]

Guys/gals, i remember a specific study that supported the use of around 2. I would waste more than a day looking for it, but from what i remember 80% of patients received about 12 months significant relief(>50%) when they had 2.2 or somewhere around there. Maybe someone has a secretary with some free time.

T

Okay, I think I found the article we are looking for, the magic # was 1.8 tfesis

Arch Phys Med Rehabil. 1998 Nov;79(11):1362-6.

Fluoroscopic transforaminal lumbar epidural steroids: an outcome study.
• Lutz GE,

Department of Physical Medicine and Rehabilitation, Hospital for Special Surgery, New York, NY 10021, USA.

OBJECTIVES: To determine the therapeutic value and long-term effects of fluoroscopic transforaminal epidural steroid injections in patients with refractory radicular leg pain.

BACKGROUND DATA: Although numerous studies have evaluated the efficacy of traditional transsacral (caudal) or translaminar (lumbar) administration of epidural steroids, to our knowledge no studies have assessed specifically the therapeutic value of fluoroscopic transforaminal epidural steroids.

STUDY DESIGN: A prospective case series that investigated the outcome of patients with lumbar herniated nucleus pulposus and radiculopathy who received fluoroscopic transforaminal epidural steroid injections.

METHODS: Patients who met our inclusion criteria received fluoroscopically guided, contrast-enhanced transforaminal epidural administration of anesthetic and steroid directly at the level and side of their documented pathology. Patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, activity level, and patient satisfaction.

RESULTS: Sixty-nine patients met our inclusion criteria and were followed for an average period of 80 weeks (range, 28 to 144 weeks); 75.4% of patients had a successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, as well as an ability to return to or near their previous levels of functioning after only 1.8 injections per patient (range, 1 to 4 injections). Of our patients, 78.3% were satisfied with their final outcomes.

CONCLUSIONS: Fluoroscopic transforminal epidural steroids are an effective nonsurgical treatment option for patients with lumbar herniated nucleus pulposus and radiculopathy in whom more conservative treatments are not effective and should be considered before surgical intervention.
PMID: 9821894 [PubMed - indexed for MEDLINE]

 

[wonthurtabit1]

Do you really think that blind IL is still the predominant technique? Not in my neighborhood, although there have been a few holdouts - mostly older orthos referring to the hospital anesthesia group for blind ESI's.

I'm seeing the opposite problem here - radiologists doing fluoro-guided ESI's with post-ESI CT scans.

FYI: well, rheumatologists in france* still think this is impt to study. And americans ain't much smarter, I am aware of lots of CRNAs and docs in the community who just set up for 3 blinds in the office.... yes in 2006.
*BTW, there is that term "discal radiculgia" ... still can't pronounce it.

Clin Rheumatol. 2003 Oct;22(4-5):299-304.

Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia - a prospective, randomised, double-blind study.

• Thomas E,
• Cyteval C,
• Abiad L,
• Picot MC,
• Taourel P,
• Blotman F.

Lapeyronie Hospital, Montpellier, France.

A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months' duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober's index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland-Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.
PMID: 14579160 [PubMed - indexed for MEDLINE]

 

[wonthurtabit1]

lol...funny.

hey gang:

are there any studies comparing interlaminar (i refuse to call it translaminar bc Pauza says not too) vs. transforaminal? any studies comparing blind interlaminar vs. flouro-guided interlaminars

 

[Doctodd]

hey gang:

are there any studies comparing interlaminar (i refuse to call it translaminar bc Pauza says not too) vs. transforaminal? any studies comparing blind interlaminar vs. flouro-guided interlaminars

that sounds about right....great job finding it. Now our lives are justified....lol ;-)

T

 

[paz5559]

FYI: well, rheumatologists in france* still think this is impt to study. And americans ain't much smarter, I am aware of lots of CRNAs and docs in the community who just set up for 3 blinds in the office.... yes in 2006.
*BTW, there is that term "discal radiculgia" ... still can't pronounce it.

Clin Rheumatol. 2003 Oct;22(4-5):299-304.

Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia - a prospective, randomised, double-blind study.

• Thomas E,
• Cyteval C,
• Abiad L,
• Picot MC,
• Taourel P,
• Blotman F.

Lapeyronie Hospital, Montpellier, France.

A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months' duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober's index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland-Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.
PMID: 14579160 [PubMed - indexed for MEDLINE]

Hmm ... blind interlaminars are not at good as fluro-guided transforaminals. Does that mean it was the TF approach that improved the results? or the fluro?

The problem with the study is that it doesnt answer any specific question we need the answer to.

 

[Aether2000]

Paz, you are correct...we really need a blind vs fluoro guided ESI trial, but pain physicians are perhaps too ethical to perform such given the reported rates of not hitting the epidural space 15-30% of the time, not hitting the correct level 50% of the time, and the medication not making it to the target 75% of the time with interlaminars. With these stats, it is unconscionable that any self respecting physician would continue with blind epidural injections. It is unethical, sloppy medicine, and is tantamount to fraud when a simple solution exists: use the fluoroscope that is available at nearly every surgical hospital in the US to do the blocks.

 

[Mister Mxyzptlk]

...we really need a blind vs fluoro guided ESI trial, but pain physicians are perhaps too ethical...

I have never seen "pain physicians" and "too ethical" used in the same sentence before.

 

[The A guy]

Hi algosdoc,

YOu are so right. THe odd thing is, I have been treated by all 5 of this area's largest and most prestigious pain centers. They EACH have the same exact policy: accept our ESIs or you are fired as a patient. Chronic pain patients have no choice than to submit to epidural after epidural, or leave, or be tossed out. I have been chucked from 3 of those centers and left another 2 myself, after being read the riot act about refusing blocks # 30, 31 and 32. Here, the old school rules- you do procedures or you are done. Very sad.

Thanks,

Yankee

 

[wonthurtabit1]

Paz, you are correct...we really need a blind vs fluoro guided ESI trial, but pain physicians are perhaps too ethical to perform such given the reported rates of not hitting the epidural space 15-30% of the time, not hitting the correct level 50% of the time, and the medication not making it to the target 75% of the time with interlaminars. With these stats, it is unconscionable that any self respecting physician would continue with blind epidural injections. It is unethical, sloppy medicine, and is tantamount to fraud when a simple solution exists: use the fluoroscope that is available at nearly every surgical hospital in the US to do the blocks.

algos,
do you have these references for blind ESIs?

 

[wonthurtabit1]

Hmm ... blind interlaminars are not at good as fluro-guided transforaminals. Does that mean it was the TF approach that improved the results? or the fluro?

The problem with the study is that it doesnt answer any specific question we need the answer to.

this looks like a study of convenience -- comparing 2 clinical approaches.

Ideally, I was looking for a study comparing flouro guided tfesis vs. ilesis. my point being that how strange in 2006 that docs or crnas are even doing blind interlaminars.

 

[Aether2000]

I am actually in the midst of writing a paper on the subject...

 

[paz5559]

I am actually in the midst of writing a paper on the subject...

On which subject?

Dr Dreyfuss mentioned at ISIS that there are no RCTs for interlaminar ESI's with regard to axial back pain, but that ISIS was about to start an initiative to look into that


On the other hand, there are lots of studies that look at blind vs fluro:, the most recent of which is

Am J Neuroradiol 26:502–505, March 2005: Incorrect Needle Position during Lumbar Epidural Steroid Administration: Inaccuracy of Loss of Air
Pressure Resistance and Requirement of Fluoroscopy and Epidurography during Needle Insertion; Walter S. Bartynski, Stephen Z. Grahovac, and William E. Rothfus

 

[Aether2000]

On the unethical use of blind spinal injections for interventional pain when fluoroscopy is readily available.

 

[wonthurtabit1]

On which subject?

Dr Dreyfuss mentioned at ISIS that there are no RCTs for interlaminar ESI's with regard to axial back pain, but that ISIS was about to start an initiative to look into that


On the other hand, there are lots of studies that look at blind vs fluro:, the most recent of which is

Am J Neuroradiol 26:502–505, March 2005: Incorrect Needle Position during Lumbar Epidural Steroid Administration: Inaccuracy of Loss of Air
Pressure Resistance and Requirement of Fluoroscopy and Epidurography during Needle Insertion; Walter S. Bartynski, Stephen Z. Grahovac, and William E. Rothfus

paz

do you mean interlaminars for radicular pain/radiculopathy, not just axial back pain?

 

[wonthurtabit1]

On which subject?

Dr Dreyfuss mentioned at ISIS that there are no RCTs for interlaminar ESI's with regard to axial back pain, but that ISIS was about to start an initiative to look into that


On the other hand, there are lots of studies that look at blind vs fluro:, the most recent of which is

Am J Neuroradiol 26:502–505, March 2005: Incorrect Needle Position during Lumbar Epidural Steroid Administration: Inaccuracy of Loss of Air
Pressure Resistance and Requirement of Fluoroscopy and Epidurography during Needle Insertion; Walter S. Bartynski, Stephen Z. Grahovac, and William E. Rothfus

Interesting, their results showed 26% inaccurate placement w/o flouro -- maybe we should do 2 more and then get it in the right place. Sure is cheaper!! and crnas can do it. aaack... I actually thought the numbers were worse than missing only approx 25% of the time.


is there a smile for troublemaker?

 

[The A guy]

hey gang:

are there any studies comparing interlaminar (i refuse to call it translaminar bc Pauza says not too) vs. transforaminal? any studies comparing blind interlaminar vs. flouro-guided interlaminars

This is an interesting post. I would like to see any studies myself. I had one blind cervical and one flouro trans, and could tell very little difference, except maybe with the discomfort level. Is it true that tactile feel is the key to blind trans?

THanks

THe A guy

 

[drusso]

This is an interesting post. I would like to see any studies myself. I had one blind cervical and one flouro trans, and could tell very little difference, except maybe with the discomfort level. Is it true that tactile feel is the key to blind trans?

THanks

THe A guy

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