Utilization o on of Epidur dural Steroid I d Injec ections ns - - PowerPoint PPT Presentation

Utilization o

• n of Epidur

dural Steroid I d Injec ections ns

Di Cui MD Emory Spine Center

Utilization and trends

• Primary Purpose is to decrease pain and

improve function

• Complements other conservative options
• May help some patients avoid surgery
• Buying patient time for preparation for

surgery

• Alternative for patient who are not

surgical candidates

• Utilization decreasing since 2009  More

selective?

Pain Physician 2017; 20:551-567

The Indications

• Pain from nerve compression
• Spinal stenosis
• Disc herniation
• Pain with likely inflammatory

basis

• Favorable natural history for

disc herniation

• Not so much for spinal

stenosis….

I II III IV

Favorable Response (at least 50% pain relief) - Pain Med 2011; 12:871-879

75% 25%

The Mechanism

• Local Anesthetics
• Sympathetic blockade  Vasodilation  Improved blood flow to nerves
• Nociceptive C-fiber Blockade  Decrease Central sensitization
• Steroids
• Inhibition of phospholipid arachidonic acid and reduce inflammation
• Decrease Inflammation locally of injured nerves
• No inferiority of non-particular steroids vs particular steroids
• Epidural injection shown to be superior than oral or IM steroids
• Spine. 2007; 32(16): 1754-60. Can J Anesth. 2010l 67: 694-703.

The Techniques

• Interlaminar
• Midline
• Paramidline
• Transforaminal

Interlaminar Transforaminal

Epidural in Spinal stenosis

• Epidural Injection For Spinal Stenosis
• 16 site multicenter RCT, 400 patient randomized
• Central lumbar canal stenosis with pain worse in buttock/leg than low back
• Interlaminar vs transforaminal
• Could repeat at 3 weeks, May cross-over at 6 weeks.
• Primary outcome
• RMDQ at 6 weeks
• 1 week pain Average Pain at 6 weeks
• Secondary outcome
• > 30% relief at 6 weeks
• > 50% relief at 6 weeks

NEJM 2014: 371(1): 11-21

Epidural in Spinal Stenosis

• Both lidocaine only injection and steroid injection showed good relief
• Approx. 50 % of patients received at least 30% relief at 6 weeks
• Approx. 40% of patient received at least 50% relief at 6 weeks
• Average pain level went from 7 to 5
• Patient who received steroids reports to be more satisfied with their

relief.

• 67% vs 54%
• Patient with lidocaine only had a higher cross-over rate compared to

group receiving steroid

• 45% vs 30%

NEJM 2014: 371(1): 11-21

Epidural injection and Disc Herniation

• TFESI for radicular pain due to disc herniation at L4-5, L5-S1 or S1 NF
• 2024 subjects
• Follow up at 2 months
• 70% of patients achieved 50% relief at 2 months
• Up to 40% of patients had relief that lasted 12 months

Pain Medicine 2013, 13: 1126-1133

Long term effect of Epidural injection

RCT suggests surgical sparing effect of TFESIs

• RCT of 55 patients that were operative candidates for nerve root

decompression.

• Transforaminal epidural injections done with bupivicaine vs. bupivicaine

w/betamethasone

• 28 received bupivicaine w/betamethasone; 21/28 did not proceed with
• perative tx at 28 months out
• 27 received bupivicaine only; 9/27 opted not to proceed with operative tx at

28 months

• 5 year f/u study after this showed that majority still had not undergone

surgery

Journal of Bone and Joint Surgery, 2000, 82-A(11): 1589-93.

The Risks

• 16638 consecutive epidural injection (Pain Med. 2014; 15, 1436-1446)
• Mayo Clinic, Northwestern and University of Pennsylvania
• No permanent neurologic injuries reported
• Compared to
• >100,000 NSAIDS related hospitalization/year (AmJ Ther 2000; 7: 115-121)
• 14800 opioid related death in US in a year (CDC, MMWR 2011; 60: 1-6)
• Fungal Meningitis Outbreak in 2012
• Isolated care reports of spinal and brain infarcts
• Most involve particulate steroids
• At least 1 involving non-particulate steroids

The limitations

• Criticism over long term efficacy of epidural injection
• Concern about safety
• Timing of injections and number of injections
• Better evidence for radicular pain from disc herniation compared to

central canal stenosis

Where does Epidural injection stand?

Low High

Safety

Low High

Cost

Low High

Efficacy

Low High

Ease of Admin

Low High

Availability

Thank you