Improving safety of Epidural Steroid Injections--JAMA

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Patients often ask what is in the epidural. I tell them they have a choice they can have Celestone with a one in a million chance of paralysis or they are going to have dexamethasone with no chance of paralysis. I have had no takers in my S1 TFESI for the one in a million chance of paralysis.
 
I'm tempted. I only use dex now in the epidural space...but I hate dex. I'm tempted.

At a bare minimum, you gotta try ILESI/caudal with depomedrol if they only get a few weeks relief after TFESI with dex.

Performing S1 with Depo could be debated , but very useful IMHO.
I've even had patients with L2 or L3 radics due to foraminal stenosis and were post lami, and they got 1-2 weeks of relief after TFESI with dex, but 3 months or more relief after S1 with depo.

What's not debatable is that you absolutely must try ILESI/caudal with depomedrol if your patients only get a few weeks relief after TFESI with dex.
 
At a bare minimum, you gotta try ILESI/caudal with depomedrol if they only get a few weeks relief after TFESI with dex.

Performing S1 with Depo could be debated , but very useful IMHO.
I've even had patients with L2 or L3 radics due to foraminal stenosis and were post lami, and they got 1-2 weeks of relief after TFESI with dex, but 3 months or more relief after S1 with depo.

What's not debatable is that you absolutely must try ILESI/caudal with depomedrol if your patients only get a few weeks relief after TFESI with dex.

I used to use Kenalog for everything, I miss it. I would not use depomedrol for anything simply because it is lawyer feed (arachnoiditis bullcrap). I use dex for everything now due to CYA medicine.
 
Patients often ask what is in the epidural. I tell them they have a choice they can have Celestone with a one in a million chance of paralysis or they are going to have dexamethasone with no chance of paralysis. I have had no takers in my S1 TFESI for the one in a million chance of paralysis.
Steve to be fair I would phrase it this way "I tell them they have a choice they can have Celestone with a one in a million chance of paralysis and several months relief or they are going to have dexamethasone with no chance of paralysis with only several weeks relief. "
 
I used to use Kenalog for everything, I miss it. I would not use depomedrol for anything simply because it is lawyer feed (arachnoiditis bullcrap). I use dex for everything now due to CYA medicine.

I also miss kenalog. I only stopped using it due to the FDA specific warning against kenalog for epidural use. Now that is lawyer bait.

On the flip side, do you know if there been a successful lawsuit against a physician in this century for using depomedrol in an ILESI or caudal?
 
Last edited:
Steve to be fair I would phrase it this way "I tell them they have a choice they can have Celestone with a one in a million chance of paralysis and several months relief or they are going to have dexamethasone with no chance of paralysis with only several weeks relief. "

The literature refutes that notion.
 
The literature refutes that notion.

Show me the literature that dexamethasone works as long as particulate steroid for lumbar stenosis and chronic/recurrent radiculopathy. Study literature comparing different steroids doesn't exist for those two diagnoses.

The only studies have been done on acute radiculopathy secondary to disc herniation, because those patients are the easiest to find and stratify. Unfortunately, a nice acute radiculopathy from a simple disc herniation represents maybe 15% of my patients.
 
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.

I use only dex. I've seen it work A LOT of patients with clear cut radiculopathy, and obviously less so on the ones with a mix of pain generators. Even on some very big extrusions. Works fine IMO unless pt has severe foraminal stenosis.
 
Show me the literature that dexamethasone works as long as particulate steroid for lumbar stenosis and chronic/recurrent radiculopathy. Study literature comparing different steroids doesn't exist for those two diagnoses.

The only studies have been done on acute radiculopathy secondary to disc herniation, because those patients are the easiest to find and stratify. Unfortunately, a nice acute radiculopathy from a simple disc herniation represents maybe 15% of my patients.
ESI is not indicated unless it's for radiculopathies these days anyway. I'm not saying I have the answers though.
 
Show me the literature that dexamethasone works as long as particulate steroid for lumbar stenosis and chronic/recurrent radiculopathy. Study literature comparing different steroids doesn't exist for those two diagnoses.

The only studies have been done on acute radiculopathy secondary to disc herniation, because those patients are the easiest to find and stratify. Unfortunately, a nice acute radiculopathy from a simple disc herniation represents maybe 15% of my patients.
Show me literature that shows ESIs are effective for lumbar stenosis.
http://www.ncbi.nlm.nih.gov/pubmed/26302454
http://www.ncbi.nlm.nih.gov/pubmed/24988555

As for radicular pain: http://www.spinalinjection.org/?page=PVNPLFF
 
Last edited:
To be fair, that's only one of the two articles that I cited

Sent from my SAMSUNG-SM-G920A using SDN mobile
 
Patients often ask what is in the epidural. I tell them they have a choice they can have Celestone with a one in a million chance of paralysis or they are going to have dexamethasone with no chance of paralysis. I have had no takers in my S1 TFESI for the one in a million chance of paralysis.
Probably closer to 1:250,000 chance...
That why I've switched to dex as well.
The article doesn't provide risk stats.
 
Last edited:
Probably closer to 1:250,000 chance...
That why I've switched to dex as well.
The article doesn't provide risk stats.

Where are you getting this? There have been only about 20 reported in the literature and most involved cervical TFESIs. There were 14 in the closed claims database from 1970-1999. There has been one reported case of an interlaminar epidural resulting in paralysis. How many spinal injections are performed annually? Your math doesn't add up.
 
Where are you getting this? There have been only about 20 reported in the literature and most involved cervical TFESIs. There were 14 in the closed claims database from 1970-1999. There has been one reported case of an interlaminar epidural resulting in paralysis. How many spinal injections are performed annually? Your math doesn't add up.
This is an interesting topic, with varied analyses and the outcomes are varied as well; permanent harm, paralysis, etc. I don't believe there is enough reporting/data to give you an answer for specific tfesi V's CESI complications. Most analyses combine spinal and epidural complications. I stated 1:250k, this large analysis shows more like 1:150k . Closed claims ASA data is another good source. Epidural hematoma with neurological harm, 1:200k per aana journal 2007.

http://www.oxfordjournals.org/our_journals/bjaint/press_releases/epidurals.pdf
 
Last edited:
This is an interesting topic, with varied analyses and the outcomes are varied as well; permanent harm, paralysis, etc. I don't believe there is enough reporting/data to give you an answer for specific tfesi V's CESI complications. Most analyses combine spinal and epidural complications. I stated 1:250k, this large analysis shows more like 1:150k . Closed claims ASA data is another good source. Epidural hematoma with neurological harm, 1:200k per aana journal 2007.

http://www.oxfordjournals.org/our_journals/bjaint/press_releases/epidurals.pdf


You are talking about total risk of paralysis. That is taking into account all neuraxial blocks, regardless of whether it's a labor epidural or a LESI. We are talking about neuraxial techniques for chronic pain and the fact that there are relatively few cases of neurological injury compared to the number performed in the US total.
 
You are talking about total risk of paralysis. That is taking into account all neuraxial blocks, regardless of whether it's a labor epidural or a LESI. We are talking about neuraxial techniques for chronic pain and the fact that there are relatively few cases of neurological injury compared to the number performed in the US total.
I bundle all neurological risks( stroke, blindness, it inj, arachnoiditis, hematoma formation, embolus infart, blindness, etc) for my patients, 1:200-250k. Transient neurological issues 1-10k risk. I don't simple say there's a 6-90/1.3 mm / per year risk of paralysis as you correctly indicated for catastrophic damage. An epidural hematoma has a 1:200k risk for any approach alone(goodman 2008 IL and TFEsI approach). What are others telling their patients.

http://link.springer.com/article/10.1007/s12178-008-9035-2/fulltext.html
 
Last edited:
The only TFESI I still do with particulate steroid is S1, and there has been only one case of major neurologic injury after an S1 TFESI, and over 10 million S1 TFESI performed in the medicare era, so I use the number 1 in 10 million when discussing this risk with patients.
 
The only TFESI I still do with particulate steroid is S1, and there has been only one case of major neurologic injury after an S1 TFESI, and over 10 million S1 TFESI performed in the medicare era, so I use the number 1 in 10 million when discussing this risk with patients.
Yup, you are more likely to get an incidental hematoma, with or without neurological injury, before you cause anterior spinal cord infarction.
 
Yup, you are more likely to get an incidental hematoma, with or without neurological injury, before you cause anterior spinal cord infarction.

1/10mil vs 0/10mil.... I still like zero. If I wanna use particulate I simply go paramedian interlam (or occasional +/- cath).


Sent from my iPhone using SDN mobile app
 
Top