Improving safety of Epidural Steroid Injections--JAMA

[drusso]

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).

1. 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.)
   
   
2. 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.)
   
   
3. 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.)
   
   
4. 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.
   
   
5. 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.)
   
   
6. A nonparticulate steroid (eg, dexamethasone)6 should be used for the initial injection in lumbar transforaminal epidural injections.
   
   
7. 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.)
   

---

Members don't see this ad.

 

[nvrsumr]

Number 7 makes no sense as the old study by Tiso(I think) shows greater aggregation of betamethasone particles despite smaller size leading to possibly a larger embolus.

 

[SSdoc33]

so, we are not allowed to use depo medrol for LTFESI, but kenalog is OK? this really clears things up.....

 

[willabeast]

i use dex for all my TF now. IMHO it does not work that well, but i am at peace with it. A man has got to know his limitations.

 

[drusso]

i use dex for all my TF now. IMHO it does not work that well, but i am at peace with it. A man has got to know his limitations.

Just another day at the office...

 

[Stim4me]

Y

i use dex for all my TF now. IMHO it does not work that well, but i am at peace with it. A man has got to know his limitations.

you won't get repeat customers.... My question is what do you do with hundreds of patients that want particulate injections because it "worked well" in the past. I have to deal with that everyday.

 

[lobelsteve]

Y

you won't get repeat customers.... My question is what do you do with hundreds of patients that want particulate injections because it "worked well" in the past. I have to deal with that everyday.

Just inject them every 4 weeks for life.

 

[Taus]

Y

you won't get repeat customers.... My question is what do you do with hundreds of patients that want particulate injections because it "worked well" in the past. I have to deal with that everyday.

Paramedian interlaminar.

 

[PainDrain]

Safety is one thing but safety at the cost of effectiveness is just foolish. I have never seen a single person in which dex worked, not one. I understand the rationale behind not using a particulate in a cervical TFESI but I also think cervical TFESIs carry and unacceptable risk to begin with and I would never bother doing one. I did a brief review of the literature a while back and based on the case reports there have been about 12-15 reports of spinal cord infarcts following lumbar TFESIs and one paper was quoted as saying the Medicare alone is billed for 300K of these per year. So that is a very small risk in a rather huge patient pool. I think if you use good technique and shoot dye with a washout then it is safe to use kenalog; otherwise you are performing a sham procedure when using dex.

 

[willabeast]

Safety is one thing but safety at the cost of effectiveness is just foolish. I have never seen a single person in which dex worked, not one. I understand the rationale behind not using a particulate in a cervical TFESI but I also think cervical TFESIs carry and unacceptable risk to begin with and I would never bother doing one. I did a brief review of the literature a while back and based on the case reports there have been about 12-15 reports of spinal cord infarcts following lumbar TFESIs and one paper was quoted as saying the Medicare alone is billed for 300K of these per year. So that is a very small risk in a rather huge patient pool. I think if you use good technique and shoot dye with a washout then it is safe to use kenalog; otherwise you are performing a sham procedure when using dex.

in principle i agree with you. in practice, if a patient sues you, the plantifs will point to your use of kenalog as an example of carelessness. as unfair as that is, i do not need that sort of headache. OTOH if it was me wanting a TF ESI on myself , i would probably go for kenalog, at least for lumbar TF. medical practice is not based on science, it is more like the fashion industry, and you cannot sell clothes that are unfashionable if you want to survive. YMMV.

 

[lobelsteve]

Safety is one thing but safety at the cost of effectiveness is just foolish. I have never seen a single person in which dex worked, not one. I understand the rationale behind not using a particulate in a cervical TFESI but I also think cervical TFESIs carry and unacceptable risk to begin with and I would never bother doing one. I did a brief review of the literature a while back and based on the case reports there have been about 12-15 reports of spinal cord infarcts following lumbar TFESIs and one paper was quoted as saying the Medicare alone is billed for 300K of these per year. So that is a very small risk in a rather huge patient pool. I think if you use good technique and shoot dye with a washout then it is safe to use kenalog; otherwise you are performing a sham procedure when using dex.

Your experience with dex is discordant with the published literature comparing it to particulate.

Your number of injured for lumbar tfesi is at least 60% off.

Your thoughts on the subject are yhe exact reason those folks got paralyzed and we have guidelines preventing well meaning idiots from hurting people. And the guys writing the guidelines are both protecting patients from you and protecting you from those patient's attorneys.

 

[drusso]

Here is how it works : research changes policy, policy changes payment, payment changes practice.

 

[willabeast]

Here is how it works : research changes policy, policy changes payment, payment changes practice.

the $$$ dollar question - who decides what research to reimburse.

Thus Conscience does make Cowards of us all,
And thus the Native hue of Resolution
Is sicklied o'er, with the pale cast of Thought,
And enterprises of great pitch and moment,
With this regard their Currents turn awry,
And lose the name of Action. [4]

 

[BobBarker]

Caudal cath to area near nerve root and spray it with you steroid of choice. Do these very frequently.

 

[Taus]

Safety is one thing but safety at the cost of effectiveness is just foolish. I have never seen a single person in which dex worked, not one. I understand the rationale behind not using a particulate in a cervical TFESI but I also think cervical TFESIs carry and unacceptable risk to begin with and I would never bother doing one. I did a brief review of the literature a while back and based on the case reports there have been about 12-15 reports of spinal cord infarcts following lumbar TFESIs and one paper was quoted as saying the Medicare alone is billed for 300K of these per year. So that is a very small risk in a rather huge patient pool. I think if you use good technique and shoot dye with a washout then it is safe to use kenalog; otherwise you are performing a sham procedure when using dex.

Not one patient improve with dex? I guess I've had a lot of patients lie to me when they said they were better.

 

[clubdeac]

I've said it before and will say it again, I've had numerous patients who got only transient relief from the spine surgeon's injectionist's TFESI come to me and get months relief from a paramedian ILESI w/depo or kenalog. It just works better

 

[PainDrain]

Your experience with dex is discordant with the published literature comparing it to particulate.

Your number of injured for lumbar tfesi is at least 60% off.

Your thoughts on the subject are yhe exact reason those folks got paralyzed and we have guidelines preventing well meaning idiots from hurting people. And the guys writing the guidelines are both protecting patients from you and protecting you from those patient's attorneys.

There is also published literature showing no difference between local and local plus steroid. Why don't you just abandon the steroid and use local?

As far as I could find, there were three cases out of Michigan and Bogduk reported two separate series. But if you want to take the number of 25 (as you say I am off by 60%) out of literally millions of procedure performed then got for it. It's still exceedingly small. Also, several of the incidents involved cervical and thoracic transforaminals, which are far riskier. And you do realize that simply placing a needle into the region of the foramen and causing vascular injury has been implicated in causing neurological damage in some of the reported cases? So merely performing any injection is dangerous.

 

[Taus]

...

 

[specepic]

I know what the papers say about Dex but it does not seem to help as much

 

[SSdoc33]

There is also published literature showing no difference between local and local plus steroid. Why don't you just abandon the steroid and use local?

As far as I could find, there were three cases out of Michigan and Bogduk reported two separate series. But if you want to take the number of 25 (as you say I am off by 60%) out of literally millions of procedure performed then got for it. It's still exceedingly small. Also, several of the incidents involved cervical and thoracic transforaminals, which are far riskier. And you do realize that simply placing a needle into the region of the foramen and causing vascular injury has been implicated in causing neurological damage in some of the reported cases? So merely performing any injection is dangerous.

you do realize that not all spinal cord infacts or adverse events make it to the journals, right?

 

[SSdoc33]

dex works. just not quite as long as particulate. i agree with the literature. to say it doesnt work is misguided

i still think a TFESI with dex is better than an ILESI with particulate in most cases.

 

[DOctorJay]

dex works. just not quite as long as particulate. i agree with the literature. to say it doesnt work is misguided

i still think a TFESI with dex is better than an ILESI with particulate in most cases.

when people say things like this I always wonder about this study...
http://www.ncbi.nlm.nih.gov/pubmed/18227326

SSdoc, interested in your response

 

[willabeast]

dex works. just not quite as long as particulate. i agree with the literature. to say it doesnt work is misguided

i still think a TFESI with dex is better than an ILESI with particulate in most cases.

this is IMHO the real question that needs to be explored with some good research.

 

[SSdoc33]

when people say things like this I always wonder about this study...
http://www.ncbi.nlm.nih.gov/pubmed/18227326

SSdoc, interested in your response

when you further lateral for an interlaminar, the risk of a PDPH goes up. if you look at the anatomy, the lateral interlaminar approach just gets you geographically closer to the TFESI approach. the benefit is that you can use particulate with the interlaminar. im not sure there is much difference, but if the above technique (lateral interlaminar) was used as much as TFESI, i'd bet you'd have some neurologic complications with the particulate. i dont really buy that it is "safer", but you do get to use the particulate, so i can see your rationale

 

[Stim4me]

I don't interprete from the comments above that dex doesn't work, just less long lived and effective. Sure this is based on personal experience, maybe a nation wide survey would be indicated in this debate. They surveyed pain specialists regarding anticoagulants with facet blocks and changed their guidelines a few years ago.....no randomized studies were performed for safety confirmation....

Sure there may be a few cases of spinal injuries NOT reported, but are likely minor with no registered legal settlements. But my estimate there are likely tens of thousands of workers comp, personal injury and commercial insurance epidurals not reported period..... Likely pushing the 4-6 million spinal injections per year to much higher levels (denominator) with a tinny numerator....

 

[SSdoc33]

Likely pushing the 4-6 million spinal injections per year to much higher levels (denominator) with a tinny numerator....

true.... but it really sucks if you are the numerator

 

[freddydpt]

An interesting observation from the radiology perspective. I've seen many strokes caused by cervical manipulation (supposedly "extremely safe" and low risk of morbidity/mortality) but never one infarct caused by any epidural injection.

 

[PainDrain]

true.... but it really sucks if you are the numerator

Sure, but it also sucks to be the case of Stevens-Johnsons from taking ibuprofen. It's an exceedingly rare event. It doesn't mean I am going to abandon the use of a safe and well tolerated medication for one of questionable efficacy.

 

[Ducttape]

you are (at least, you are wise) if you abandon the use of a supposedly "safe and well tolerated medication" if national, professional, and insurance based guidelines all suggest doing so.

 

[PainDrain]

Are they saying to do that? You guys are to much. These recs even say to move forward with TFESI with particulate if dex fails. Just use live dye study or DSA.

Please tell me where all national, prof and insurance companies are suggesting doin this?

 

[bedrock]

You guys are still missing the "bedrock" option-----------S1 TFESI with particulate steroid.

In the last 30 years, there have been 25-3o cases of SCI after lumbar TFESI out of approximately 40 million TFESI performed. Only one of those 25-30 SCI cases occurred after an S1 TFESI and that one S1 case occurred by a guy using bad technique injecting into a blogogram.
SCI is horrible, but 1 in 40 million are decent odds compared to the much higher odds of suffering permanent nerve damage, spinal infection, and permanent disability, etc, from spine surgery.

I can't tell you how many hundreds of patients I have seen that failed TFESI with dex, failed ILESI with depo (or were post lami), that I have since spared from lumbar fusions, SCS, or chronic narcs, by providing S1 TFESI with particulate steroid.

S1 TFESI consistently treats radiculopathy and stenosis up to L3. From S1 you can easily shoot particulate steroid right up the L3-S1 lateral recesses.

I always try a closer injection first, TFESI with dex usually, (+/- ILESI with depo, if not post lami). But I never let a patient suffering from radiculopathy or stenosis, go to a surgeon because of brief or no relief after an epidural, unless that patient has failed an S1 TFESI with particulate steroid.

(BTW-I don't ever offer particulate steroid in TFESI above S1)

 

[bedrock]

MODS-- please move this thread to private forum!

 

[Stim4me]

Are they saying to do that? You guys are to much. These recs even say to move forward with TFESI with particulate if dex fails. Just use live dye study or DSA.

Please tell me where all national, prof and insurance companies are suggesting doin this?

I agree here... The guidelines seem like a cop-out... Just trying to appease too many factions.
I would recommend a national consensus questionare gathering the current thought and opinion. I think it may shed light on what most of us are experiencing and doing in our practices... They did it for facets and anticoagulants and NO safety studies were performed that I know of...

 

[Doctodd]

Caudal cath to area near nerve root and spray it with you steroid of choice. Do these very frequently.

I see these coming back

 

[Taus]

I see these coming back

I do this every once in a while- but you eat cost of catheter and introducer needle. Approx half reimbursement from injection depending on insurer and cath brand. I do em when I can't do interlaminar at level of pathology (ie upper cervical) or had prior posterior surgery

 

[PinchandBurn]

You guys are still missing the "bedrock" option-----------S1 TFESI with particulate steroid.

In the last 30 years, there have been 25-3o cases of SCI after lumbar TFESI out of approximately 40 million TFESI performed. Only one of those 25-30 SCI cases occurred after an S1 TFESI and that one S1 case occurred by a guy using bad technique injecting into a blogogram.
SCI is horrible, but 1 in 40 million are decent odds compared to the much higher odds of suffering permanent nerve damage, spinal infection, and permanent disability, etc, from spine surgery.

I can't tell you how many hundreds of patients I have seen that failed TFESI with dex, failed ILESI with depo (or were post lami), that I have since spared from lumbar fusions, SCS, or chronic narcs, by providing S1 TFESI with particulate steroid.

S1 TFESI consistently treats radiculopathy and stenosis up to L3. From S1 you can easily shoot particulate steroid right up the L3-S1 lateral recesses.

I always try a closer injection first, TFESI with dex usually, (+/- ILESI with depo, if not post lami). But I never let a patient suffering from radiculopathy or stenosis, go to a surgeon because of brief or no relief after an epidural, unless that patient has failed an S1 TFESI with particulate steroid.

(BTW-I don't ever offer particulate steroid in TFESI above S1)

This makes a lot of sense.

i do a modification of what you stated. For example, IF i have to do a 2 level TFESI. Let's say L4/5 and L5/s1. I will use 4mg dex at L4/5 and depomedrol at L5/s1. Sure you can have the Art of Adam or radicular arteries ANYWWHERE, but they are MORE likely 'higher' in the L spine.

 

[bedrock]

This makes a lot of sense.

i do a modification of what you stated. For example, IF i have to do a 2 level TFESI. Let's say L4/5 and L5/s1. I will use 4mg dex at L4/5 and depomedrol at L5/s1. Sure you can have the Art of Adam or radicular arteries ANYWWHERE, but they are MORE likely 'higher' in the L spine.

Up to you, but there have been several cases of SCI after L5-S1 TFESI with particulate steroid vs only one case at S1.
One case (particularly one S1 case with bad technique), is a freak singular occurrence, vs several cases at particular level(s) is a pattern, as there have been several SCI cases at every lumbar level above S1.

Everyone chooses what they are comfortable with. For me, I can accept one singular random freak SCI case, 1 out of 40 million TFESI, occurring at S1, and continue that S1 procedure, but I can't accept the risk of SCI using using particulate steroid at higher lumber levels than S1, as there have been multiple SCI events with TFESI above S1 using particulate steroid.

For recalcitrant L4-L5 pathology, I sometimes perform L4-L5 TFESI w dex and S1 with Depo.

 

[joshmir]

Why not do an interlaminar approach and thread a catheter? I speculate the answer is that we are thinking/hoping that the catheter from the caudal approach gets it more anterior , but just wanted to check; i havve never done a lateral after Im in with the touhy when I do a caudal with cath, so I dont know if they get anterior

 

[Stim4me]

catheters cost 30-75$ bucks, medicare barely covers cost for a caudal epidural as is. That's why no catheter usage regularly....
are people using epidural catheters that are reasonably priced? (ie. $10)...would be helpful info. I pay $35 for epimed brevi catheters...

 

[bedrock]

Besides the cost of the catheter, you also eat the extra "cost" of the extra time spent to try to manipulate the catheter vs just doing an efficient injection-only epidural.

When you add it all up, you make basically nothing on those catheter cases, which is why hardly anyone does them outside of academics.

 

[lobelsteve]

EC 05000 Arrow theracath. Cheapest cath I know of. Of course when you are not buying or have to worry about it....

 

[Taus]

Caudal with cath really only takes an extra minute or so. Cervicals def take longer as I come in like a stim trial. I like to keep a few on hand for the rare cases ill use them on... 3 total in last year.

 

[PinchandBurn]

I know guys around where I prcticed always used Catheters beacuse they could 'bill more'. Obviously they cant anymore. I personally never saw a difference if you used them or not. So why use more fluro and time, and get the same results?

 

[Taus]

I know guys around where I prcticed always used Catheters beacuse they could 'bill more'. Obviously they cant anymore. I personally never saw a difference if you used them or not. So why use more fluro and time, and get the same results?

Last one was a big c3-4 hnp w unilateral foraminal stenosis. Surgeon wanted c4 TFESI. I did it like an snrb, barely entering foramen given stenosis degree and spinal level leading to higher incidence ( >30%) vertebral artery in posterior foramen per literature . Got good root flow, min epidural. Only had a touch, 0.2cc local w my dex. Got 1 week moderate relief. Patient was miserable despite time meds and pt. wanted to avoid surgery. I did a T1-2 interlaminar and drove catheter to c34, got great epidural flow at target with depo. Will be worth my time and cost if can get enough relief to avoid surgery.

I'm not convinced it makes that big of a difference for caudals (usually fbss w radic not responsive to TFESI or ancient spine).

 

[BobBarker]

You can do them in the HOPD.

 

[lobelsteve]

Randomized Double-Blind Controlled Trial Comparing the Effectiveness of Lumbar Transforaminal Epidural Injections of Particulate and Nonparticulate Corticosteroids for Lumbosacral Radicular Pain

1. Isabelle Denis MD, FRCPC, BSc1,*,
2. Geneviève Claveau MD, FRCPC2,
3. Marc Filiatrault MD, FRCPC1,
4. François Fugère MD, FRCPC3 and
5. Luc Fortin MD, FRCPC, MSc4

Article first published online: 22 JUN 2015

DOI: 10.1111/pme.12846

Pain Medicine

Abstract
Objective
To compare equivalent doses of a nonparticulate (dexamethasone) with a particulate (betamethasone) corticosteroid in lumbar transforaminal epidural steroid injections (TFESIs) in terms of pain, function, and complications.

Design
Fifty-six patients presenting with debilitating radicular pain were randomized in a double-blind controlled trial to receive a lumbar transforaminal injection of either dexamethasone 7.5 mg (n = 29) or betamethasone 6.0 mg (n = 27).

Setting
A pain clinic and physical medicine and rehabilitation department in two academic hospital centres.

Outcome Measures
Data were collected at 1-, 3-, and 6-month follow-ups. The primary outcome was pain reduction on a visual analog scale (VAS) at 3 months. Secondary outcomes were functional improvement, as measured by the Oswestry Disability Index (ODI), and number and type of complications.

Results
No differences on the VAS, analyzed either as a continuous (P = 0.209) or categorical variable (≥50% (P = 0.058) or ≥75% (P = 0.865) improvement) and ODI (P = 0.181) were found between the two groups at 3 months. At 6 months, improvement of ODI score was at the limit of statistical significance in favor of dexamethasone (P = 0.050). Multivariate regression analysis, adjusting for potential confounding variables, showed that differences on the ODI became statistically significant at the 6 month follow-up, also in favor of dexamethasone (adjusted P = 0.003). No serious complications were observed in either group.

Conclusion
According to this study, pain relief and functional improvement are similar for both dexamethasone and betamethasone at 3 months. Considering its safety profile, dexamethasone could be considered as first choice for TFESI. However, given that the study was underpowered, more research is needed to support a recommendation of systematically using dexamethasone in TFESI.

 

[ampaphb]

http://www.ncbi.nlm.nih.gov/pubmed/26873103

Sent from my SAMSUNG-SM-G920A using SDN mobile app

 

[bedrock]

None of these studies were done on spinal stenosis or chronic/recurrent radiculopathy, just one the one thing that's easy to study- acute radiculopathy.

Should we use TFESI with dex for acute radiculopathy? Yes.

Do any of these studies prove what we should do for the more common things we see in chronic pain management, such as spinal stenosis, chronic/recurrent radiculopathy, annular tears, etc? No they do not.

I can see the rationale for the first intervention for these diagnoses to be TFESI with dex. However, I can't see the rationale for not trying ILESI/Caudal with depo, if the patient only gets 1-2 weeks of relief after TFESI with dex.

Someone really really needs to publish a study on that.

 

[ampaphb]

The Feeley study was a meta-analysis, with inclusion criteria not limited by procedure or time from injury to injection

Sent from my SAMSUNG-SM-G920A using SDN mobile app

 

[Ligament]

You guys are still missing the "bedrock" option-----------S1 TFESI with particulate steroid.

In the last 30 years, there have been 25-3o cases of SCI after lumbar TFESI out of approximately 40 million TFESI performed. Only one of those 25-30 SCI cases occurred after an S1 TFESI and that one S1 case occurred by a guy using bad technique injecting into a blogogram.
SCI is horrible, but 1 in 40 million are decent odds compared to the much higher odds of suffering permanent nerve damage, spinal infection, and permanent disability, etc, from spine surgery.

I can't tell you how many hundreds of patients I have seen that failed TFESI with dex, failed ILESI with depo (or were post lami), that I have since spared from lumbar fusions, SCS, or chronic narcs, by providing S1 TFESI with particulate steroid.

S1 TFESI consistently treats radiculopathy and stenosis up to L3. From S1 you can easily shoot particulate steroid right up the L3-S1 lateral recesses.

I always try a closer injection first, TFESI with dex usually, (+/- ILESI with depo, if not post lami). But I never let a patient suffering from radiculopathy or stenosis, go to a surgeon because of brief or no relief after an epidural, unless that patient has failed an S1 TFESI with particulate steroid.

(BTW-I don't ever offer particulate steroid in TFESI above S1)

I'm tempted. I only use dex now in the epidural space...but I hate dex. I'm tempted.