Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study

Background: Epidural injections have been used for pain relief since the 1880s. Corticosteroids are antiinflammatory medications that can alleviate pain, but also have harmful systemic adverse effects. Literature regarding methylprednisolone dosage efficacy is limited. Objectives: To determine the lowest effective dose of methylprednisolone in a lumbar epidural steroid injection (LESI) for maximal pain relief without exposing patients to adverse events caused by steroid use. Study Design: Retrospective chart review. Setting: Outpatient interventional pain clinic at an academic center. Methods: Adults (n = 133), aged 18 to 85 years, with low-back pain and radicular symptoms treated with LESI from August 2011 to November 2015. Patients who received prior cervical epidural steroid injections were excluded. Interventions were LESI with methylprednisolone 40 mg, 80 mg, or 120 mg. Main outcome measures showed change in pain score using a numeric pain scale (NPS; 0 = no pain, 10 = excruciating pain), and patient’s self-reported reduction in pain (percentage), pre- and postprocedure. The primary endpoint measurement was 2 weeks postinjection. Adverse effects were recorded. Results: The number of patients who received each dose varied: n = 88 received 120 mg, n = 30 received 80 mg, and n = 13 received 40 mg. The NPS pain scores pre- and postprocedure for 120 mg were 8.89 ± 1.32 and 4.08 ± 3.74, (mean ± standard deviation), respectively; for 80 mg: 9.06 ± 1.00 and 3.75 ± 4.00; and for 40 mg: 9.00 ± 1.00 and 4.00 ± 0.00. Percentage of pain relief for 120 mg, 80 mg, and 40 mg was 57.26%, 50.74%, and 57.26, respectively (P = 0.3347). n = 4 experienced adverse effects, all received 120 mg. Conclusions: All 3 dosage groups had similar efficacy in pain relief, but only patients who received 120 mg experienced adverse effects. This demonstrates that lower dosages can be used for pain relief with less potential harm to the patient. Key words: Methylprednisolone, interlaminar epidural, radiculopathy

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Do Information Leaflets Effect Pre-Procedural Anxiety Level and Immediate Pain Level After Transforaminal Epidural Steroid Injections? A Prospective Randomized Controlled Study

Ağrı - The Journal of The Turkish Society of Algology ◽

10.14744/agri.2020.27048 ◽

2020 ◽

Author(s):

Savas Sencan

Keyword(s):

Anxiety Level ◽

Randomized Controlled Study ◽

Controlled Study ◽

Pain Level ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Randomized Controlled ◽

Information Leaflets ◽

Epidural Steroid

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Digital Subtraction Angiography Does Not Reliably Prevent Paraplegia Associated with Lumbar Transforaminal Epidural Steroid Injection

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/515 ◽

2012 ◽

Vol 6;15 (6;12) ◽

pp. 515-523

Author(s):

Kenneth D. Candido

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Lower Extremity ◽

Digital Subtraction Angiography ◽

Test Dose ◽

Spinal Cord Infarction ◽

Digital Subtraction ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Epidural Steroid

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epidural steroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately following the completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids. Key words: Digital subtraction angiography, transforaminal epidural steroid injections, paraplegia, chronic low back pain.

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The Value of Short-Term Pain Relief in Predicting the One-Month Outcome of Lumbar Transforaminal Epidural Steroid Injections

World Neurosurgery ◽

10.1016/j.wneu.2016.09.016 ◽

2016 ◽

Vol 96 ◽

pp. 323-333 ◽

Cited By ~ 5

Author(s):

Holger Joswig ◽

Armin Neff ◽

Christina Ruppert ◽

Gerhard Hildebrandt ◽

Martin Nikolaus Stienen

Keyword(s):

Pain Relief ◽

Short Term ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

The One ◽

Epidural Steroid

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The retroneural approach: an alternative technique for lumbar transforaminal epidural steroid injections

Acta Radiologica ◽

10.1177/0284185118762248 ◽

2018 ◽

Vol 59 (12) ◽

pp. 1508-1516

Author(s):

Stefan Ignjatovic ◽

Reza Omidi ◽

Rahel A Kubik-Huch ◽

Suzanne Anderson ◽

Frank J Ahlhelm

Keyword(s):

Pain Relief ◽

Nerve Root ◽

Spinal Cord Infarction ◽

Short Term ◽

Neural Foramen ◽

Ct Guided ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Tip Position ◽

Epidural Steroid

Background Compared with other available injection techniques for lumbar transforaminal epidural steroid injections (LTFESIs), the traditionally performed subpedicular approach is associated with a higher risk of spinal cord infarction, a rare but catastrophic complication. Purpose To assess the short-term efficacy of the retroneural approach for computed tomography (CT)-guided LTFESIs with respect to different needle-tip positions. Material and Methods This retrospective analysis included 238 patients receiving 286 CT-guided LTFESIs from January 2013 to January 2016. Short-term outcomes in terms of pain relief were assessed using the visual analogue scale (VAS) at baseline and 30 min after. The needle-tip location was categorized as extraforaminal, junctional, or foraminal relative to the neural foramen. Additionally, the distance from the needle tip to the nerve root was measured. Results A mean pain reduction of 3.22 points (±2.17 points) on the VAS was achieved. The needle-tip location was extraforaminal in 48% (136/286), junctional in 42% (120/286), and foraminal in 10% (28/286) of the cases. The mean distance from the needle tip to the nerve root was 3.83 mm (±3.37 mm). There was no significant correlation between pain relief and needle-tip position in relation to the neural foramen. Therapy success was not dependent on the distance between the needle tip and the nerve root. No major complications were observed. Conclusion In our population treated with LTFESIs, the retroneural approach was shown to be an effective technique, with no significant differences in pain relief following different needle-tip positions.

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