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Spine Pain Care pp 281–290Cite as

Epidural Steroid Injections

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Abstract

The incidence of lower back or neck pain and related radicular pain has become increasingly common throughout the industrialized and developing world. Epidural injections for management of back pain and radicular pain have been performed for decades. It is the most commonly utilized intervention for managing chronic and acute lower back pain. Improvement in anatomic knowledge, coupled by major advances in medical equipment and imaging devices, has led to rapid growth in use of epidural steroid injections beyond the lower back pain treatment. Cervical, thoracic, and sacral anatomic sites are becoming more utilized to target spine pain by interventional clinicians. This chapter describes patient selection; indications and contraindications; techniques and anatomic considerations for interlaminar, transforaminal, and caudal approaches; complications; and the scientific evidence behind these procedures.

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References

  1. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353–71.

    Google Scholar 

  2. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783–92.

    CAS  PubMed  Google Scholar 

  3. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR, North Carolina Back Pain Project. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med. 1995;333(14):913–7.

    CAS  PubMed  Google Scholar 

  4. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:1462–9: annrheumdis-2013.

    PubMed  Google Scholar 

  5. Nyman T, Grooten WJ, Wiktorin C, Liwing J, Norrman L. Sickness absence and concurrent low back and neck–shoulder pain: results from the MUSIC-Norrtälje study. Eur Spine J. 2007;16(5):631–8.

    PubMed  Google Scholar 

  6. Montgomery W, Sato M, Nagasaka Y, Vietri J. The economic and humanistic costs of chronic lower back pain in Japan. Clinicoecon Outcomes Res: CEOR. 2017;9:361.

    Google Scholar 

  7. Deyo RA. Back Pain Patient Outcomes Assessment Team (BOAT). US Department of Health & Human Services-Agency of Healthcare Research; 1994.

    Google Scholar 

  8. Sinnott PL, Dally SK, Trafton J, Goulet JL, Wagner TH. Trends in diagnosis of painful neck and back conditions, 2002 to 2011. Medicine. 2017;96(20):e6691.

    PubMed  PubMed Central  Google Scholar 

  9. Sicard A. Les injections medicamenteuses extra-durales par voie sacrococcygienne. Compt Rend Soc De Biol. 1901;53:396–8.

    Google Scholar 

  10. Hollander JL. The local effects of compound F (hydrocortisone) injected into joints. Bull Rheum Dis. 1951;2(2):3.

    CAS  PubMed  Google Scholar 

  11. Robecchi A. L’idrocortisone (composto F). Prime experienze cliniche in campo reumatologico. Minerva Med. 1952;98:1259–63.

    Google Scholar 

  12. Gharibo C, Koo C, Chung J, Moroz A. Epidural steroid injections: an update on mechanisms of injury and safety. Techn Reg Anesth Pain Manag. 2009;13(4):266–71.

    Google Scholar 

  13. Vidyasagar KY. Assessment of the growth of epidural injections in the Medicare population from 2000 to 2011. Pain Physician. 2013;16:E349–64.

    Google Scholar 

  14. Benditz A, Brunner M, Zeman F, Greimel F, Florian V, Boluki D, et al. Effectiveness of a multimodal pain management concept for patients with cervical radiculopathy with focus on cervical epidural injections. Sci Rep. 2017;7(1):7866.

    PubMed  PubMed Central  Google Scholar 

  15. Center P, Director MP, Manchikanti L. Thoracic interlaminar epidural injections in managing chronic thoracic pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Pain Physician. 2014;17:E327–38.

    Google Scholar 

  16. Costandi SJ, Azer G, Eshraghi Y, Zeyed Y, Atalla JE, Looka ME, et al. Cervical transforaminal epidural steroid injections: diagnostic and therapeutic value. Reg Anesth Pain Med. 2015;40(6):674–80.

    Google Scholar 

  17. Leung SM, Chau WW, Law SW, Fung KY. Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy. Hong Kong Med J. 2015;21(5):394–400.

    CAS  PubMed  Google Scholar 

  18. Narouze S, Benzon H, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2015;40(3):182–212.

    CAS  PubMed  Google Scholar 

  19. Shulman M. Treatment of neck pain with cervical epidural steroid injection. Reg Anesth. 1986;11:92–4.

    Google Scholar 

  20. Purkis IE. Cervical epidural steroids. Pain Clin. 1986;1:3–7.

    Google Scholar 

  21. Rowlingson JC, Kirschenbaum LP. Epidural analgesic techniques in the management of cervical pain. Anesth Analg. 1986;65:938–42.

    CAS  PubMed  Google Scholar 

  22. Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012;15:E363–404.

    PubMed  Google Scholar 

  23. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001;91:397–9.

    CAS  PubMed  Google Scholar 

  24. Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol. 2003;24:351–5.

    PubMed  Google Scholar 

  25. Costandi S, Eshraghi Y, Mekhail N, Azer G, Zeyed Y, Looka M, et al. Cervical transforaminal epidural steroid injections diagnostic and therapeutic value. Reg Anesth Pain Med [serial on the Internet]. n.d. [cited February 16, 2018];40(6):674–680.

    PubMed  Google Scholar 

  26. Lee JW, Park KW, Chung SK, Yeom JS, Kim KJ, Kim HJ, et al. Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy: a comparative study of particulate versus non-particulate steroids. Skelet Radiol. 2009;38:1077–82.

    Google Scholar 

  27. Lee SH, Kim KT, Kim DH, Lee BJ, Son ES, Kwack YH. Clinical outcomes of cervical radiculopathy following epidural steroid injection: a prospective study with follow-up for more than 2 years. Spine (Phila Pa 1976). 2012;37:1041–7.

    Google Scholar 

  28. Razzaq AA, O’Brien D, Mathew B, Bartlett R, Taylor D. Efficacy and durability of fluoroscopically guided cervical nerve root block. Br J Neurosurg. 2007;21:365–9.

    CAS  PubMed  Google Scholar 

  29. Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir. 2005;147:1065–70.

    CAS  PubMed  Google Scholar 

  30. Cohen SP, Hayek S, Semenov Y, Pasquina PF, White RL, Veizi E, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121(5):1045–55.

    PubMed  Google Scholar 

  31. Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine. 2002;27:509–14.

    PubMed  Google Scholar 

  32. Landa J. Outcomes of interlaminar and transforaminal spinal injections. Bull NYU Hosp Joint Dis. 2012;70:6–10.

    Google Scholar 

  33. Okmen K. The efficacy of interlaminar epidural steroid administration in multilevel intervertebral disc disease with chronic low back pain: a randomized, blinded, prospective study. Spine J. 2017;17:168–74.

    PubMed  Google Scholar 

  34. Sharm AK. The effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections: a systematic review with comprehensive analysis of the published data. Pain Med. 2017;18:239–51.

    Google Scholar 

  35. DePalma MJ. Evidence-informed management of chronic low back pain with epidural steroid injections. Spine J. 2008;8:45–55.

    PubMed  Google Scholar 

  36. Roberts ST. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PMR. 2015;1:756–68.

    Google Scholar 

  37. MacVicar J, King W, Landers MH, Bogduk N. The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of published data. Pain Med. 2013;14:14–28.

    Google Scholar 

  38. Bhatia A, Flamer D, Shah PS, Cohen SP. Transforaminal epidural steroid injections for treating lumbosacral radicular pain from herniated intervertebral discs: a systematic review and meta-analysis. Anesth Analg. 2016;122(3):867–70.

    Google Scholar 

  39. Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: a comprehensive literature review. J Back Musculoskelet Rehabil. 2011;24(2):67–76.

    PubMed  Google Scholar 

  40. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, Christo PJ, Ward SP. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199–245.

    PubMed  Google Scholar 

  41. Fish DE, Lee PC, Marcus DB. The S1 “Scotty Dog”: report of a technique for S1 transforaminal epidural steroid injection. Arch Phys Med Rehabil. 2007;88(12):1730–3.

    PubMed  Google Scholar 

  42. Kim D-H, Yoon DM, Yoon KB. Incidence of intravascular injection and the spread of contrast media during S1 transforaminal epidural steroid injection by two approaches: anteroposterior vs oblique. Anaesthesia. 2015;70(8):975–84.

    CAS  PubMed  Google Scholar 

  43. Park SJ, Kim SH, Kim SJ, Yoon DM, Yoon KB. Comparison of incidences of intravascular injection between medial and lateral side approaches during traditional S1 transforaminal epidural steroid injection. Pain Res Manag. 2017;2017:6426802.

    PubMed  PubMed Central  Google Scholar 

  44. Ferris HA, Kahn CR. New mechanisms of glucocorticoid-induced insulin resistance: make no bones about it. J Clin Invest. 2012;122(11):3854–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  45. Lansang M, Farmer T, Kennedy L. Diagnosing the unrecognized systemic absorption of intra-articular and epidural steroid injections. Endocr Pract. 2009;15(3):225–8.

    PubMed  Google Scholar 

  46. Moon HJ, Choi KH, Lee SI, Lee OJ, Shin JW, Kim TW. Changes in blood glucose and cortisol levels after epidural or shoulder intra-articular glucocorticoid injections in diabetic or nondiabetic patients. Am J Phys Med Rehabil. 2014;93(5):372–8.

    PubMed  Google Scholar 

  47. Younes M, Neffati F, Touzi M, Hassen-Zrour S, Fendri Y, Béjia I, Amor AB, Bergaoui N, Najjar MF. Systemic effects of epidural and intra-articular glucocorticoid injections in diabetic and non-diabetic patients. Joint Bone Spine. 2007;74(5):472–6.

    CAS  PubMed  Google Scholar 

  48. Kim S, Hwang B. Relationship between bone mineral density and the frequent administration of epidural steroid injections in postmenopausal women with low back pain. Pain Res Manag. 2014;19(1):30–4.

    PubMed  PubMed Central  Google Scholar 

  49. Windsor RE, Storm S, Sugar R. Prevention and management of complications resulting from common spinal injections. Pain Physician. 2003;6(4):473–84.

    PubMed  Google Scholar 

  50. Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. 2004;79(5):682–6. Elsevier.

    PubMed  Google Scholar 

  51. Zhang JH, Wang ZL, Wan L. Cervical epidural analgesia complicated by epidural abscess: a case report and literature review. Medicine. 2017;96(40):e7789.

    PubMed  PubMed Central  Google Scholar 

  52. Simopoulos TT, Kraemer JJ, Glazer P, Bajwa ZH. Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar epidural steroid injection. Pain Physician. 2008;11(5):693–7.

    PubMed  Google Scholar 

  53. Martin RJ, Yuan HA. Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis. Orthop Clin N Am. 1996;27(1):125–36.

    CAS  Google Scholar 

  54. Kabbara A, Rosenberg SK, Untal C. Methicillin-resistant Staphylococcus aureus epidural abscess after transforaminal epidural steroid injection. Pain Physician. 2004;7(2):269–72.

    PubMed  Google Scholar 

  55. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726–31.

    Google Scholar 

  56. Goodman BS, Bayazitoglu M, Mallempati S, Noble BR, Geffen JF. Dural puncture and subdural injection: a complication of lumbar transforaminal epidural injections. Pain Physician. 2007;10(5):697.

    PubMed  Google Scholar 

  57. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, Riew KD, et al. Safeguards to prevent neurologic complications after epidural steroid injections consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974–84.

    CAS  PubMed  Google Scholar 

  58. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage: two case reports. Spine. 1998;23(19):2137–40.

    CAS  PubMed  Google Scholar 

  59. Tripathi M, Nath SS, Gupta RK. Paraplegia after intracord injection during attempted epidural steroid injection in an awake-patient. Anesth Analg. 2005;101(4):1209–11.

    PubMed  Google Scholar 

  60. Windsor RE, Storm S, Sugar R, Nagula D. Cervical transforaminal injection: review of the literature, complications, and a suggested technique. Pain Physician. 2003;6(4):457–66.

    PubMed  Google Scholar 

  61. Ludwig MA, Burns SP. Spinal cord infarction following cervical transforaminal epidural injection: a case report. Spine. 2005;30(10):E266–8.

    PubMed  Google Scholar 

  62. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10(8):1389–94.

    PubMed  Google Scholar 

  63. Suresh S, Berman J, Connell DA. Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block. Skelet Radiol. 2007;36(5):449–52.

    CAS  Google Scholar 

  64. Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections. Expert Opin Drug Saf. 2016;15(8):1031–9.

    CAS  PubMed  Google Scholar 

  65. Pountos I, Panteli M, Walters G, Bush D, Giannoudis PV. Safety of epidural corticosteroid injections. Drugs R&D. 2016;16(1):19–34.

    CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Pain Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA

    Thomas Suchy & Jack Diep

  2. Department of Pain Management and Neurosciences, Cleveland Clinic, Cleveland, OH, USA

    Jianguo Cheng

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  1. Thomas Suchy
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  2. Jack Diep
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  3. Jianguo Cheng
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Correspondence to Jianguo Cheng .

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Editors and Affiliations

  1. Richard J. Kitz Professor of Anesthesia Research Harvard Medical School, Harvard University, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA

    Jianren Mao

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Suchy, T., Diep, J., Cheng, J. (2020). Epidural Steroid Injections. In: Mao, J. (eds) Spine Pain Care. Springer, Cham. https://doi.org/10.1007/978-3-030-27447-4_22

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  • DOI: https://doi.org/10.1007/978-3-030-27447-4_22

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  • Publisher Name: Springer, Cham

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