Epidural Dexamethasone induced periscapular pain?

[Ligament]

Ever since switching to Dex from Kenalog for cervical interlaminar epidurals, about 50% of my patients complain of significant but transient interscapular pain immediately after injection of dex. Injection of contrast immediately prior to this produces no such pain.

I read that IV dex can cause immediate and sever rectal spasms(?!). I wonder if this is a similar mechanism?


The pharmacological mechanism explaining this phenomenon remains poorly understood, but could be related to the phosphate ester of the corticosteroid since perineal irritation has been described with hydrocortisone-21-phosphate sodium and prednisolone phosphate [11,12]. No detailed explanation is mentioned even on extensive medline search. It has been explained that the pathogenesis of perineal pruritus /pain has been may be related to corticosteroid phosphate esters such as the dexamethasone sodium phosphate (as used in our cases) to cause perineal pain and irritation. Both the incidence and severity may increase as the organic phosphate content of the injection increases. The lesser duration of pain might be due to hydrolysis of compound to phosphate ions and dexamethasone. However, the pathophysiology of this rare

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[DOctorJay]

I'm not sure I'm seeing 50% but certainly at least a third or so of the CESIs I do with dex have similar complaints.

Steve says we're wrong.
Betamethasone for TFESIs?

 

[lobelsteve]

I'm not sure I'm seeing 50% but certainly at least a third or so of the CESIs I do with dex have similar complaints.

Steve says we're wrong.
Betamethasone for TFESIs?

I agree. I use Celestone for ILESI. Never had a complaint except the typical warmth in chest from contrast.

 

[SSdoc33]

that "warmth" is from the pressure of the fluid, IMHO. also, that "warmth" is probably what ligament is talking about.

as far as the tenesmus, i have no idea.

 

[Ligament]

Maybe 5% of my patients had this issue when I used Kenalog. Now about 50%. Only change is to Dex.

 

[emd123]

Ever since switching to Dex from Kenalog for cervical interlaminar epidurals, about 50% of my patients complain of significant but transient interscapular pain immediately after injection of dex. Injection of contrast immediately prior to this produces no such pain.

I read that IV dex can cause immediate and sever rectal spasms(?!). I wonder if this is a similar mechanism?


The pharmacological mechanism explaining this phenomenon remains poorly understood, but could be related to the phosphate ester of the corticosteroid since perineal irritation has been described with hydrocortisone-21-phosphate sodium and prednisolone phosphate [11,12]. No detailed explanation is mentioned even on extensive medline search. It has been explained that the pathogenesis of perineal pruritus /pain has been may be related to corticosteroid phosphate esters such as the dexamethasone sodium phosphate (as used in our cases) to cause perineal pain and irritation. Both the incidence and severity may increase as the organic phosphate content of the injection increases. The lesser duration of pain might be due to hydrolysis of compound to phosphate ions and dexamethasone. However, the pathophysiology of this rare

I agree with not using kenalog for epidurals due to the labeling, but why not use celestone or depomedrol for IL CESIs?

 

[Dr. Ice]

I use depo

 

[Ligament]

I agree with not using kenalog for epidurals due to the labeling, but why not use celestone or depomedrol for IL CESIs?

Lawyers.

 

[Dr. Ice]

What is the concentration of Dex you are using for interlams?

 

[Taus]

What about Depo or Beta on a cervical interlam causes the theoretical/potential medicolegal concerns more then dex? The generalization from dex on tfesi? The preservative vs commercial pf dex?

 

[emd123]

Lawyers.

Other than the fact that lawyers can sue you for any bad outcome, what's special about lawyers and particulates for interlaminar CESIs?

 

[Tapspatellas]

Other than the fact that lawyers can sue you for any bad outcome, what's special about lawyers and particulates for interlaminar CESIs?

Particulate intrathecal. Experts can't even always agree that something wasn't definitively epidural vs intrathecal. I've seen a couple patients who told me they had arachnoiditis from an epidural. Just need a good lawyer, with a symapthetic jury or a wimpy attorney on the insurance side.

 

[clubdeac]

I'm still using particulates for my interlaminars..I'm at the VA though as well. Less liability