Steroid Blocks continued

Robert Blanchard

Attorney
(866) 735-1102 Ext 545

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Clients with back injuries may want to know more about steroid blocks being recommended for back pain.

Recent studies have demonstrated positive efficacy of lumbar ESIs when proper placement is confirmed by using fluoroscopic guidance and radiographic confirmation through the use of contrast. Approximately 60-75% of patients receive some relief after ESIs. Benefits include relief of radicular pain and LBP (generally relieving leg pain more than back pain), improvement of quality of life, reduction of analgesic consumption, improved maintenance of work status, and obviating the need for hospitalization and surgery in many patients.
Aside from the technical considerations (eg, C-arm/fluoroscope, various approaches of ESIs), response to the injection is related to several other factors such as the type and quantity of steroid preparation used, volume of injectate, underlying pathophysiology, and the duration of symptoms.

Most patients take several days to respond to ESIs. This is generally due to the delayed effects of the corticosteroid. The commonly used compounds with prominent glucocorticoid action include betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan), methylprednisolone acetate (Depo-Medrol), and triamcinolone hexacetonide (Aristospan). The multidose vials of Depo-Medrol contain benzyl alcohol, which is potentially toxic when administered locally to neural tissue and may increase the risk of arachnoiditis or meningitis. Thus, for epidural injections, many physicians prefer to use only steroid preparations without such preservatives.

The response of ESIs is also related to the underlying pathophysiology. In general, acute radicular pain from lumbar disk herniation responds more favorably to the radicular pain from lumbar spinal stenosis. The patients with radicular pain after lumbar spine surgery frequently received less benefit from ESIs unless the radicular pain is from a recurrent herniated nucleus pulposus. In general, patients who have had symptoms fewer than 3 months have response rates of 90%. When patients have radiculopathy symptoms for fewer than 6 months, response decreases to approximately 70%. Response decreases to 50% in patients who have had symptoms for over 1 year. Patients with shorter duration of symptoms also have more sustained relief than those with chronic pain. Patients with chronic back pain have better response if they develop an acute radiculopathy.

Complications

When performed by a skilled experienced clinician within an appropriate setting and with carefully selected patients, the chance of significant complication from ESIs is small and remote. Theoretical risks of ESIs include inducing bleeding and infection. Common risks of epidural injection are backache, postural puncture headache (0.5-1% for lumbar interlaminar and 0.6% for caudal epidural injections), nausea, vomiting, dizziness, and vasovagal reaction. Epidural hematoma occurs in 0.02-0.01% of performed procedures. Nerve root injury and meningitis also have been reported. Risks of injected steroids in at-risk patients (eg, those with ulcers or diabetes, history of tuberculosis, acquired immunodeficiency syndrome, bacterial infections, psychiatric disorders) are not known at the present time. Mild hypothalamic-pituitary-adrenal axis suppression has been reported from 1-3 months after receiving a total of 3 epidural injections (once weekly) with 80 mg of Aristocort in 7 mL of 1% lidocaine.