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Dexamethasone first always in lumbar region??
http://jama.jamanetwork.com/article.aspx?articleid=2213785
http://www.ncbi.nlm.nih.gov/pubmed/25668411
The recently published recommendations8 included several important suggestions for improving the safety of epidural steroid injections (explanations, if needed, are in parentheses).
http://jama.jamanetwork.com/article.aspx?articleid=2213785
http://www.ncbi.nlm.nih.gov/pubmed/25668411
The recently published recommendations8 included several important suggestions for improving the safety of epidural steroid injections (explanations, if needed, are in parentheses).
- All cervical and lumbar interlaminar epidural steroid injections should be performed using image guidance, with appropriate anteroposterior, lateral, or contralateral oblique views and a test dose of contrast medium. (There has been a case report of lower extremity paralysis after lumbar interlaminar injection without fluoroscopy and a case report of paraplegia after thoracic interlaminar injection when fluoroscopy was used but contrast was not injected.)
- Cervical and lumbar transforaminal epidural steroid injections should be performed by injecting contrast medium under real-time fluoroscopy or digital subtraction imaging, before injecting any substance that may be hazardous to the patient. (The use of digital subtraction imaging has been shown to be more effective in detecting intravascular injection than syringe aspiration alone.)
- Cervical interlaminar epidural steroid injections are recommended to be performed at C7-T1, but preferably not higher than the C6-7 level. (The cervical epidural space is widest at the C6-T1 levels. Gaps in the ligamentum flavum are more frequent with ascending cervical levels.)
- No cervical interlaminar epidural steroid injection should be undertaken, at any segmental level, without preprocedural review of prior imaging studies demonstrating sufficient epidural spatial dimensions for needle placement at the target level.
- Particulate steroids should not be used in therapeutic cervical transforaminal injections. (Injuries following nonparticulate injections were temporary, whereas paraplegias after particulate steroids were permanent. If the nerve root involved is at a higher level, ie, C5, most pain medicine physicians perform an interlaminar injection at C6-7 or C7-T1, insert a catheter, and advance it to C5. For diagnostic injections, to help the surgeon identify the affected nerve root, pain physicians perform transforaminal injections using local anesthetic, with or without a nonparticulate dexamethasone.)
- A nonparticulate steroid (eg, dexamethasone)6 should be used for the initial injection in lumbar transforaminal epidural injections.
- There are situations in which particulate steroids could be used in the performance of lumbar transforaminal epidural steroid injections. (This is because the lumbar transforaminal area is wider than in the cervical regions. If relief from a nonparticulate steroid is of short duration, some physicians will inject a steroid containing smaller particles, either betamethasone or triamcinolone.)