Dexamethasone Dose for Lumbar TF ESI's

[APDoc]

For those of you using solely dexamethasone for your lumbar TF ESI's, what dose are you using for a unilateral single level injection? Thanks.

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[drf]

ive been using 10. Here is a paper i read a while back.

Lumbar Transforaminal Epidural Dexamethasone
A Prospective, Randomized, Double-Blind, Dose-Response Trial
Farshad M. Ahadian, MD,*Þ Kai McGreevy, MD,þ and Gerhard Schulteis, PhD*§

Background and Objectives: Serious adverse events related to particulate steroids have curtailed the use of transforaminal epidural steroid injections for radicular pain. Dexamethasone has been proposed as an alternative. We investigated the efficacy, dose-response profile, and safety of 3 doses of epidural dexamethasone.
Methods: A prospective, randomized, double-blind, dose-ranging de- sign was used. A total of 98 subjects were randomized to transforaminal epidural dexamethasone 4 mg (n = 33), 8 mg (n = 33), or 12 mg (n = 32). The primary outcome measure for this study was reduction in radicular pain according to the visual analog scale from baseline, with 30% re- duction or higher considered clinically meaningful. Secondary measures included the Oswestry Low Back Disability Scale, Subject Global Im- pression of Change, Subject Global Satisfaction Scale, and adverse events. Outcomes were assessed at 1, 4, 8, and 12 weeks after injection. Outcome measures, sample size, and statistical analysis were defined before enrollment.
Results: Mean radicular pain according to the visual analog scale compared with baseline was reduced 41.7%, 33.5%, and 26.6% at 4, 8, and 12 weeks, respectively, after injection. Oswestry disability ratings declined from ‘‘moderate'' at baseline to ‘‘minimal'' at 4, 8, and 12 weeks after injection. There was no statistical difference between groups for either measure (all P values G 0.05, Bonferroni-corrected). Parallel effects were observed in ‘‘impression of change'' and ‘‘satisfaction'' measures. No serious adverse events were noted.
Conclusions: Transforaminal epidural dexamethasone provides sta- tistically significant and clinically meaningful improvement in radicular pain at 12 weeks after injection, with parallel improvements in disability, impression of change, and satisfaction measures. There was no difference in efficacy for dexamethasone 4 mg compared with 8 or 12 mg. The optimal dose of epidural dexamethasone may be lower than 4 mg, further increasing the long-term safety and tolerability of this treatment. Current data are reassuring with regard to the safety of dexamethasone for transforaminal epidural steroid injection.
(Reg Anesth Pain Med 2011;36: 572Y578)

 

[PinchandBurn]

i've been using 8mg. That article in RAPM (reg ane and pain med) said using 4mg is just as good. Jury is still out for me on that one.


IF two levels, I use 16mg.

Only prob is that blood sugars shoot up pretty high.

In fellowship, all I used was kenalog or some would use depomedrol. given all the controversy around particulate steorids, i changd over to dex. I question whether it's effective.

Art of Adam is on the left. So personally, if I do right sided TFESI L4/5 and below I now sometimes use kenalog. If on the left, always use dex, unless I do a S1. This is also because of kenalog being 'of label'.

 

[powermd]

We've been using Solumedrol in my practice for TFs, and with a recent price spike in depo, we talked about switching over to SM for all epidurals. Less risk, less $$, and perhaps no difference in outcome- what's not to like?

I did a little trial of SM for caudals, lumbar, and cervical ESI in about 10-12 patients. Almost all had a moderate to severe pressure paresthesia in the low back or neck with onset about 30 seconds after injection, and lasting about 5-10 minutes. In one case (a crazy fibro) it lasted 30-60, and we had to recover the patient in one of the offices. My protocol is 5 mL total injectate (10 for caudal), 125 mg SM, stop injecting if the patient reports bothersome pressure. I switched to 3 mL on a few to see if that changed the paresthesia- it didn't. The pressure paresthesia was always felt axially, not in a radicular pattern.

I had previously noted these pressure paresthesias for the TFs when I would leave local out of the mix (no driver), but I attributed that to the injection location, HNP, scar tissue, etc.

Immediately on switching back to depo, no more pressure paresthesias (beyond the usual minor ones).

 

[Ducttape]

I use 4 mg dex for TF and 80mg depomedrol for il Lesi....

 

[Intubate]

i've been using 8mg. That article in RAPM (reg ane and pain med) said using 4mg is just as good. Jury is still out for me on that one.


IF two levels, I use 16mg.

Only prob is that blood sugars shoot up pretty high.

In fellowship, all I used was kenalog or some would use depomedrol. given all the controversy around particulate steorids, i changd over to dex. I question whether it's effective.

Art of Adam is on the left. So personally, if I do right sided TFESI L4/5 and below I now sometimes use kenalog. If on the left, always use dex, unless I do a S1. This is also because of kenalog being 'of label'.

There have been catastophic outcomes from particulate steroid injections on the left and right, and as low as S1. Don't fool yourself.

 

[Gauss]

is anyone using preservative free dex? I'm curious if there's any difference - there is benzyl alcohol in the solutions I get. I've been thinking about solumedrol, absolutely no worries if vascular. Are there different formulations IV vs IM, preservatives?