number of steroid injections

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smarterchild

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hey everyone. i was wondering if you could point me towards any articles regarding how many steroid injections is safe in a 12 month time period?

if no formal articles, what are your thoughts about how many injection is safe? and i mean, total steroid (epidurals, joints, bursa...)

thanks
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there are multiple older threads, some 8-10 years ago.

there is no great data, but most ppl seem to take the number of 3 mg/kg of depomedrol in a 6 month period of time as usually baseline. one of the initial articles detailing cushings from overjudicious use of steroids was written in the 1960s I believe.

6 per year seems to be what most ppl state. I usually will do only 4.

https://forums.studentdoctor.net/threads/procedures-steroid-dose-per-year.1295608/
 
smarterchild said:
hey everyone. i was wondering if you could point me towards any articles regarding how many steroid injections is safe in a 12 month time period?

if no formal articles, what are your thoughts about how many injection is safe? and i mean, total steroid (epidurals, joints, bursa...)

thanks
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i settled on 4 a year. but... patients get steroid injections from other providers. difficult to keep track of total number. ortho might be doing knee or shoulder etc. in addition to my spine injections. patients have no idea how many mg of steroid they are getting, or even what steroid. there are patients who get oral steroids for all sorts of things, from poison oak to bronchospasm. there are inhaled steroids and intranasal steroids. i even met what i think was a steroid addict once. so it can be a tough thing to keep track of. all of this becomes very interesting when a patient develops AVN.
 
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I have radically decreased my steroid dose per injection over the years without noticing a difference in number of patients I refer out to surgeons.

This is mainly because I eventually end up treating my low back patient’s neck as well their hips, knees, shoulders etc... The number of injections can add up fast.

Thank goodness for rfa. I have a lot of patients who start off with several pain generators requiring steroids who eventually “graduate” to seeing me once a year for rfa and maybe an single SI or ESI mixed in if they don’t keep up with their HEP or tweak their back for whatever reason

To the OP -read a very old study that cortisol levels take about 2ish weeks to rebound after esi. Don’t have the citation.
 
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I don’t think the number of injections matter as much as dose and type of steroid. I use dex for most everything and with its negligible HPA suppression and temporal effects I think > 4/y is very safe.
 
pmrmd said:
I don’t think the number of injections matter as much as dose and type of steroid. I use dex for most everything and with its negligible HPA suppression and temporal effects I think > 4/y is very safe.
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You use dex is your joints? What kind of results do you get? Never used anything other than Kenalog in a joint
 
There are patients receiving at least 20 steroid injections a year by different types of specialists. Of course some blow up like balloons, have chronic adrenal suppression, may suffer severe depression or psychosis, severe out of control sugar or BP spikes, develop electrolyte abnormalities, AVN, etc. They do not link all these other symptoms with steroids. Steroids suppress the adrenal axis from 1-4 weeks depending on the steroid. More is not better, and it has been shown 40mg methylprednisolone is for all purposes equivalent to 80mg with respect to effectiveness. Perhaps 20 injections a year at 10-20mg would be well tolerated? For equivalency purposes, remember systemic availability after oral absorption of prednisone is 70%, therefore a person taking 5mg a day prednisone (for e.g. asthma) has an effective methylprednisolone dosage of around 1000mg a year taking into account absorption and potency. It is unlikely most patients will receive 1000mg a year methylprednisolone injections per year, but could based on the above data.
 
Depo 40 in joint and bursas and dex 10 epidural for me.

I had a pt 6 or so months ago that had 38 epidurals over like 5 yrs or so. Around 2005 to 2010 or something. Surgery x 5 or something. I can't verify her numbers but that is what she told me.
 
SommeRiver said:
Depo 40 in joint and bursas and dex 10 epidural for me.

I had a pt 6 or so months ago that had 38 epidurals over like 5 yrs or so. Around 2005 to 2010 or something. Surgery x 5 or something. I can't verify her numbers but that is what she told me.
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I'm intrigued by this Dex 10 for epidurals. I've been taught that dex is useless ... guess it isnt. Nice.
 
Blitz2006 said:
I'm intrigued by this Dex 10 for epidurals. I've been taught that dex is useless ... guess it isnt. Nice.
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I use 4mg in my ESI. Try pubmed. It has useful peer reviewed literature on the subject. And whoever taught you needs a whooping. Or a library card.
 
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Blitz2006 said:
I'm intrigued by this Dex 10 for epidurals. I've been taught that dex is useless ... guess it isnt. Nice.
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What?

I do dex 10mg on a single level TFESI or an ILESI. If a two level TFESI I do half of the injectate at each level.
 
There is a pretty good study lurking on the forum that 4mg dex works as well as higher diesel for tfesi
 
I was chatting with random older docs at SIS last year, and couldn’t believe how many people use depo and kenalog in their tfesi still.
 
max 6/year for me, TF = 8 single, 6 for 2-level (4mg vials), depo or celestone for everything else
 
Two spine surgeons I know use Depo 80 and 2cc of bupi in 100% of their TFESI. One of them had a cord infarct I kid you not...and he hasn't changed his practice.
 
smarterchild said:
hey everyone. i was wondering if you could point me towards any articles regarding how many steroid injections is safe in a 12 month time period?

if no formal articles, what are your thoughts about how many injection is safe? and i mean, total steroid (epidurals, joints, bursa...)

thanks
Click to expand...
Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections. Anesthesiology. 2015. doi:10.1097/ALN.0000000000000614
 
lobelsteve said:
Send to medical board for review. A serial killer in the making.
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I've spoken to them. Response was, "I've done 10k of these and had one problem. It works better than dex and has less risk than surgery."
 
SommeRiver said:
I've spoken to them. Response was, "I've done 10k of these and had one problem. It works better than dex and has less risk than surgery."
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Tell them at 1/10000 makes them 100x more likely than the odds suggest to get the complication. But if he does not mind paralyzing people for money for no recognized benefit per the literature, you cannot fix that. Call in Dexter.
 
lobelsteve said:
Tell them at 1/10000 makes them 100x more likely than the odds suggest to get the complication. But if he does not mind paralyzing people for money for no recognized benefit per the literature, you cannot fix that. Call in Dexter.
Click to expand...

I agree with you completely.

Here's my problem though - Whenever I get pts from outside providers with a history of injxns, I always look at the procedure notes (if available). I see Depo TFESI notes all the time, and not from 2003...Like 2018...

I recently did a repeat RFA on a guy who had an RFA by someone last year and that doctor moved so he came to me. I read the previous RFA note and after the lesion at L3-4, L4-5, and L5-S1 each needle got 3cc of a mixture containing 80 Depo and 0.5% bupi. That is 12cc total just after the injxn! Of course that pt got propofol for the RFA. Each MBB on that pt was same mixture, so of course the MBB worked. Only reason I repeated the RFA without another MBB is bc the RFA was so helpful (he got like 8 months or so of really good relief).
 
SommeRiver said:
I agree with you completely.

Here's my problem though - Whenever I get pts from outside providers with a history of injxns, I always look at the procedure notes (if available). I see Depo TFESI notes all the time, and not from 2003...Like 2018...

I recently did a repeat RFA on a guy who had an RFA by someone last year and that doctor moved so he came to me. I read the previous RFA note and after the lesion at L3-4, L4-5, and L5-S1 each needle got 3cc of a mixture containing 80 Depo and 0.5% bupi. That is 12cc total just after the injxn! Of course that pt got propofol for the RFA. Each MBB on that pt was same mixture, so of course the MBB worked. Only reason I repeated the RFA without another MBB is bc the RFA was so helpful (he got like 8 months or so of really good relief).
Click to expand...

Saw a guy who moved from SC to GA. Prior failed RF was done in the joints. pics scanned to prove it.
 
lobelsteve said:
Saw a guy who moved from SC to GA. Prior failed RF was done in the joints. pics scanned to prove it.
Click to expand...

I just don't understand how that can happen. That has to be intentional.
 
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