Epidural Steroid Injections: Section 2

An additional criticism of the Carette study is that the injections were not performed under fluoroscopic guidance. Performing an epidural steroid injection under fluoroscopic guidance ensures that the injected substances are delivered at the appropriate level. Furthermore, it ensures that the steroid reaches the appropriate side. The dorsal median septum of the epidural space confines the spread of substances to the side of the septum where it was delivered. If an injection is not done using fluoroscopy there is no way to ensure that the steroid reaches the symptomatic root, even if it is injected at the appropriate level.

Dreyfuss. Epidural steroid injections: A procedure ideally performed with fluoroscopic control and contrast media. ISIS newsletter.

Renfrew, et al. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR 1991;12:1003-7.

White, et al. Epidural injections for the diagnosis and treatment of low back pain. Spine 1980;5(1):78-6.

Another advantage of fluoroscopy is that the injection can be done using a transforaminal approach, allowing the steroid to be injected directly into the site of pathology. With a blind approach, the steroid is injected dorsally, relying on diffussion into the anterior epidural space for the steroid to reach the area of inflammation. A transforaminal injection is done using the same technique as a selective epidural injection, although since the procedure is being done for therapeutic purposes a larger volume can be injected.

In summary, the balance of evidence suggests that epidural steroid injections have a role in treating radicular pain, although primarily as an adjunct to a comprehensive rehabilitation program.

The role of epidural steroid injections in treating axial pain is uncertain, although at least one pilot study has demonstrated efficacy in patients with axial pain only.

Johnson, et al. Lumbar epidural myelography and steroid injections: correlation of clinical efficacy related to specific pathology and symptoms. Abstract, ISIS annual meeting, 1998.

As serious side effects and/or complications are rare with epidural steroid injections, it seems reasonable to provide patients with axial pain with a trial of an epidural steroid injection, particularly if it is being used as an adjunct to a comprehensive rehabilitation program. Injections should be performed using fluoroscopic guidance and contrast enhancement.

Dreyfuss. Epidural steroid injections: A procedure ideally performed with fluoroscopic control and contrast media. ISIS newsletter.

Renfrew, et al. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR 1991;12:1003-7.

White, et al. Epidural injections for the diagnosis and treatment of low back pain. Spine 1980;5(1):78-6.

Johnson, et al. Lumbar epidural myelography and steroid injections: correlation of clinical efficacy related to specific pathology and symptoms. Abstract, ISIS annual meeting, 1998.

Sutton, et al. The effectiveness of epidural steroids in the treatment of degenerative spondylolisthesis: a prospective analysis. Abstract, NASS 1997.

The transforaminal approach may prove be more efficacious than the caudal and translaminar approaches, particularly with lateral disc herniations.

Lutz, et al. Transforaminal lumbar epidural steroid injections. Abstract, NASS annual meeting, 1996.

Weiner, et al. Foraminal injection for lateral lumbar disc herniation. JBJS (British) 1997;79B(5):804-7.

Certainly, if no benefit ensues from a translaminar or caudal approach a repeat injection using a transforaminal approach should be considered (particularly if the translaminar technique does not demonstrate adequate flow to the area of pathology).

There are no data to support the routine use of a series of three epidural steroid injections in spinal pain syndromes. Unpublished practice audits have found that if there is no response to the first fluoroscopic guided ESI, then a second will be of no benefit. Most practitioners do not routinely order a series of three epidurals. However, if there is partial relief from the first, with enough residual pain to warrant further treatment, a second injection should be considered. For approximately two weeks following and epidural steroid injection there is some suppression of the hypothalamic-pituitary axis. Therefore, repeat injections should not be administered more than once every two to three weeks.