Comparison of the Particle Sizes of Different Steroids and the Effect of Dilution

2007 ◽  
Vol 106 (2) ◽  
pp. 331-338 ◽  
Author(s):  
Honorio T. Benzon ◽  
Teng-Leong Chew ◽  
Robert J. McCarthy ◽  
Hubert A. Benzon ◽  
David R. Walega
Keyword(s):  
Sodium Phosphate ◽  
Laser Scanning ◽  
Pure Liquid ◽  
Particle Sizes ◽  
Bonferroni Correction ◽  
Chi Square ◽  
Laser Scanning Confocal Microscope ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Betamethasone Sodium Phosphate

Background Central nervous system injuries after transforaminal epidural steroid injections have been ascribed to occlusion of the blood vessels supplying the spinal cord and brain by the particulate steroid. Methods The authors compared the sizes of the particles of the steroids methylprednisolone acetate, triamcinolone acetonide, dexamethasone sodium phosphate, betamethasone sodium phosphate/betamethasone acetate (both Celestone Soluspan; Schering-Plough, Kenilworth, NJ, the commercial betamethasone; and betamethasone repository, a betamethasone preparation that can be ordered from a compounding company), and betamethasone sodium phosphate. Both undiluted and diluted samples were examined. The samples were examined with a laser scanning confocal microscope, and images were analyzed and measured. The particles were categorized (or tabulated) into groups: 0-20, 21-50, 51-1000, and greater than 1000 mu. Chi-square analyses, with Bonferroni correction, were used to compare the proportion of particles among the undiluted and diluted drug formulations. Results Dexamethasone and betamethasone sodium phosphate were pure liquid. The proportion of larger particles was significantly greater in the methylprednisolone and the compounded betamethasone preparations compared with the commercial betamethasone. There was no statistical difference between the commercial betamethasone and triamcinolone, although betamethasone had a smaller percentage of the larger particles. Increased dilution of the compounded betamethasone with lidocaine decreased the percentage of the larger particles, whereas increased dilution of methylprednisolone 80 mg/ml with saline increased the proportion of larger particles. Conclusion Commercial betamethasone is the recommended preparation if a nonsoluble steroid is preferred. Dexamethasone is a nonparticulate steroid, but its routine use awaits further studies on its safety and efficacy.

scholarly journals Determination of the Particulate Size and Aggregation of Clonidine and Corticosteroids for Epidural Steroid Injection

2012 ◽  
Vol 1;15 (1;1) ◽  
pp. 87-93 ◽  
Author(s):  
Halena M. Gazelka
Keyword(s):  
Particle Size ◽  
Light Microscopy ◽  
Triamcinolone Acetonide ◽  
Sodium Phosphate ◽  
Steroid Injection ◽  
Epidural Injection ◽  
Radicular Pain ◽  
Phosphate Injection ◽  
Epidural Steroid ◽  
Betamethasone Sodium Phosphate

Background: Epidural injection of corticosteroids is a commonly used treatment for radicular pain. However, the benefits are often short lived, and repeated injections are often limited secondary to concerns of side effects from cumulative steroid doses. In addition, rare, catastrophic complications, including brain and spinal cord embolic infarcts have been attributed to particulate steroid injections. A previous study has shown that dexamethasone has less particulate than other corticosteroids, possibly reducing embolic risk. Furthermore, a recent study indicated that clonidine may be useful in the treatment of radicular pain when administered via epidural steroid injection. The combination of corticosteroid and clonidine is an intriguing, yet unstudied, alternative to traditional treatment. Objective: Our study examines whether mixing clonidine and various corticosteroids results in increased particle size or aggregation. Methods: Evaluations under light microscopy for particle size were made of samples of clonidine alone and clonidine mixed with equal parts of 3 corticosteroids solutions: dexamethasone sodium phosphate injection, triamcinolone acetonide injectable suspension, and betamethasone sodium phosphate and betamethasone acetate injectable suspension. Four mL each of clonidine (100 μcg/ mL), clonidine (100 μcg/mL) + dexamethasone sodium phosphate injection (4 mg/mL), clonidine (100 μcg/mL) + triamcinolone acetonide injectable suspension (40 mg/mL), and clonidine (100 μcg/mL) + betamethasone sodium phosphate and betamethasone acetate injectable suspension (6 mg/mL) were examined Their particle sizes were compared to measurements taken when each steroid solution was examined alone. Results: Clonidine was determined to be nonparticulate when examined by light microscopy. Clonidine mixed with equal parts of each of the 3 corticosteroids mentioned above did not result in increased clumping or increased particle size over each of the corticosteroids measured alone. Conclusion: Mixing clonidine with corticosteroids did not increase particulation compared to corticosteroids alone. Combining clonidine and corticosteroids for epidural injection may prove to be a useful treatment for radicular pain. The combination of these is unlikely to result in a solution that is more likely to cause embolic infarcts than the use of corticosteroids alone. Key words: steroid, epidural, clonidine, injection, particulate, aggregation

Interpreting Reviews and Guidelines: The Case of Lumbar Epidural Steroid Injections

PM&R ◽  
2009 ◽  
Vol 1 (6) ◽  
pp. 576-579 ◽  
Author(s):  
Venu Akuthota ◽  
Charles Argoff ◽  
William C. Watters
Keyword(s):  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

A video rate laser scanning confocal microscope

2008 ◽  
Author(s):  
Hongzhou Ma ◽  
James Jiang ◽  
Hongwu Ren ◽  
Alex E. Cable
Keyword(s):  
Laser Scanning ◽  
Confocal Microscope ◽  
Laser Scanning Confocal Microscope

Transforaminal Lumbar and Thoracic Interventions and Ischemic Spinal Cord Injury

2016 ◽  
Author(s):  
Scott E. Glaser ◽  
Rinoo Shah
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Spinal Cord Infarction ◽  
Supporting Evidence ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Root Cause ◽  
Cord Injury ◽  
Epidural Steroid ◽  
Ischemic Spinal Cord Injury

Transforaminal epidural steroid injections have been shown to be associated with catastrophic neurologic complications secondary to spinal cord infarction. The reflexive, ad hoc response of practitioners to these injuries has been to recommend risk minimization strategies to prevent embolism of the injected particulate steroids and to use nonparticulate steroids. This focus on distal embolism as the sole or primary cause of catastrophic outcomes lacks conclusive supporting evidence and does not suffice to protect the patient from paraplegia as it fails to address the root cause of the complications. A root cause analysis of the procedure provides evidence that the injection technique itself—the “safe triangle”—creates a risk of arterial damage and sequelae leading to ischemia of the spinal cord. The evidence is strong that the only way to mitigate or eliminate the risk of paraplegia is to use a different technique to perform transforaminal injections: the Kambin triangle approach. This change in technique is the only definitive solution that addresses the root cause of these catastrophic sequelae associated with transforaminal epidural steroid injections. Key Words: Artery of Adamkiewicz, ischemic spinal cord injury, Kambin triangle, safe triangle, transforaminal epidural injection

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