epidural steroid injection
{{Short description|Medical treatment}}
{{Use dmy dates|date=September 2017}}
{{Use American English|date=September 2017}}
{{Infobox medical intervention
| name = Epidural steroid injection
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| image = Blausen 0354 EpiduralSteroidInjection.png
| caption = Steroids are injected into the cerebrospinal fluid in the canal surrounding the spine. Nerves branch out from the spine. The nerve roots, which may be compressed, are at the base of the nerves.
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| specialty = Pain Medicine
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Epidural steroid injection (ESI) is a technique in which corticosteroids and a local anesthetic are injected into the epidural space around the spinal cord in an effort to improve spinal stenosis, spinal disc herniation, or both. It is of benefit with a rare rate of major side effects. The Food and Drug Administration (FDA) has not approved ESI for pain management, and has raised concerns about rare, but serious, side effects.{{cite web | title = FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain | publisher = Food and Drug Administration | url = https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-label-changes-warn-rare-serious-neurologic-problems-after | accessdate = 2025-03-04 }}
Medical uses
Epidural steroid injection for sciatica and spinal stenosis is of unclear effect.{{cite journal |last1 = Shaughnessy |first1 = AF |title = Epidural Steroid Not Better Than Placebo Injection for Sciatica and Spinal Stenosis Pain and Function. |journal = American Family Physician |date = 15 February 2016 |volume = 93 |issue = 4 |pages = 315–6 |pmid = 26926820 }} The evidence to support use in the cervical spine is not very good.{{cite journal |last1 = Cohen |first1 = SP |last2 = Hooten |first2 = WM |title = Advances in the diagnosis and management of neck pain |journal = BMJ (Clinical Research Ed.) |date = 14 August 2017 |volume = 358 |pages = j3221 |pmid = 28807894 |doi = 10.1136/bmj.j3221 |s2cid = 29500924 }} When medical imaging is not used to determine the proper spot for injection, ESI benefits appear to be of short-term benefit when used in sciatica.{{cite journal |last1 = Vorobeychik |first1 = Y |last2 = Sharma |first2 = A |last3 = Smith |first3 = CC |last4 = Miller |first4 = DC |last5 = Stojanovic |first5 = MP |last6 = Lobel |first6 = SM |last7 = Valley |first7 = MA |last8 = Duszynski |first8 = B |last9 = Kennedy |first9 = DJ|last10=Standards Division of the Spine Intervention|first10=Society |title = The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. |journal = Pain Medicine (Malden, Mass.) |date = December 2016 |volume = 17 |issue = 12 |pages = 2185–2202 |doi = 10.1093/pm/pnw091 |pmid = 28025354 |doi-access = free }} It is unclear if ESI is useful for chronic pain after spinal surgery.{{cite journal |last1 = Wylde |first1 = V |last2 = Dennis |first2 = J |last3 = Beswick |first3 = AD |last4 = Bruce |first4 = J |last5 = Eccleston |first5 = C |last6 = Howells |first6 = N |last7 = Peters |first7 = TJ |last8 = Gooberman-Hill |first8 = R |title = Systematic review of management of chronic pain after surgery. |journal = The British Journal of Surgery |date = September 2017 |volume = 104 |issue = 10 |pages = 1293–1306 |doi = 10.1002/bjs.10601 |pmid = 28681962 |pmc=5599964}}
Steroid effectiveness
Steroids are included in ESI based on the belief that steroids reduce inflammation, but clinical practice has indicated that steroids plus lidocaine (anesthetic) produces no greater reduction in pain than lidocaine alone.{{cite journal | vauthors = Manchikanti L, Knezevic NN, Hirsch JA | title = Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis | journal = Pain Physician | volume = 19 | issue = 3 | pages = E365-410 | date = 2016 | url=https://physicaltherapyresearch.net/wp-content/uploads/2023/05/Epidural-Injections-for-Lumbar-Radiculopathy-and-Spinal-Stenosis2016.pdf | pmid = 27008296 }} The fact that there is no association between quantity of steroid and reported pain reduction has caused speculation of a placebo effect for steroids.{{cite journal | vauthors = Whynes DK, McCahon RA, Hardman J | title = Cost effectiveness of epidural steroid injections to manage chronic lower back pain | journal = BMC Anesthesiology | volume = 12 | pages = 26 | date = 2012 | doi = 10.1186/1471-2253-12-26 | pmc=3468401 | pmid = 23016755 | doi-access = free }}
Side effects
Major side effects are rare. These include loss of vision, stroke, paralysis, or death when the corticosteroids are infected, as in a 2012 meningitis outbreak.{{cite journal |last1 = Schneider |first1 = B |last2 = Zheng |first2 = P |last3 = Mattie |first3 = R |last4 = Kennedy |first4 = DJ |title = Safety of epidural steroid injections. |journal = Expert Opinion on Drug Safety |date = August 2016 |volume = 15 |issue = 8 |pages = 1031–9 |doi = 10.1080/14740338.2016.1184246 |pmid = 27148630 |s2cid = 27053083 }}{{cite journal |last1 = Kauffman |first1 = CA |last2 = Malani |first2 = AN |s2cid = 42550449 |title = Fungal Infections Associated with Contaminated Steroid Injections |journal = Microbiology Spectrum |date = April 2016 |volume = 4 |issue = 2 |pages = 359–374 |doi = 10.1128/microbiolspec.EI10-0005-2015 |pmid = 27227303 |isbn = 978-1-55581-944-6 }} Another study found an increased odds of developing epidural lipomatosis, independent of body mass index (BMI) or other factors.{{cite journal |last1 = Jaimes |first1 = Rafael |last2 = Rocco |first2 = Angelo |title = Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a case series |journal = BMC Anesthesiology |date = August 2014 |volume = 14 |issue = 70 |pages = 70 |doi =10.1186/1471-2253-14-70 |pmid =25183952 |pmc=4145583 |doi-access = free }}
Locally injected glucocorticoids can have systemic effects, including loss of bone mineral density, suppression of the immune system as well as effects on the central nervous system and cardiovascular system.{{cite journal | vauthors = Stout A, Friedly J, Standaert CJ | title = Systemic Absorption and Side Effects of Locally Injected Glucocorticoids | journal = PM&R | volume = 11 | issue=4 | pages = 409-419 | date = 2019 | doi = 10.1002/pmrj.12042 | pmid = 30925034 }}
Technique
Elective spinal injections should be performed with imaging guidance, such as fluoroscopy or the use of a radiocontrast agent, unless that guidance is contraindicated.{{Citation |author1 = North American Spine Society |author1-link = North American Spine Society |date = February 2013 |title = Five Things Physicians and Patients Should Question |publisher = North American Spine Society |work = Choosing Wisely: an initiative of the ABIM Foundation |url = http://www.choosingwisely.org/doctor-patient-lists/north-american-spine-society/ |access-date = 25 March 2013 }} Imaging guidance ensures the correct placement of the needle and maximizes the physician's ability to make an accurate diagnosis and administer effective therapy. Without imaging, the risk increases for the injection to be incorrectly placed, and this would in turn lower the therapy's efficacy and increase subsequent risk of need for more treatment.
Epidural steroid injections can be given in different areas of the spine, which include the lower back (lumbar), neck (cervical), or mid-back (thoracic).{{Cite web |last=Ketan Patel; Pooja Chopra; Seth Martinez; Sekhar Upadhyayula |date=June 8, 2024 |title=Epidural Steroid Injections |url=https://www.ncbi.nlm.nih.gov/books/NBK470189/ |website=National Library of Medicine}}
The way the needle is inserted can vary. It can be interlaminar, which means it's placed between the lamina (the protective layers of the spine). It can be transforaminal, meaning it's inserted across the foramen (the openings on the sides of your vertebrae where the nerves exit). Or it can be caudal, which means it's inserted through the sacrum (the large, triangular bone at the base of the spine).