Indications, Risks, and Contraindications: Epidural Corticosteroid Injections

Indications

Epidural steroid injections (ESIs) are an acceptable treatment method for discogenic and radicular pain emanating from the cervical, thoracic, and lumbar spine (2, 3, 9, 11, 12, 16, 17, 18,19). ESIs are also utilized in the treatment of spondylosis, nonspecific radiculitis, and spinal stenosis. Other uses reported in the literature and in clinical settings include the treatment of pain from post-laminectomy syndrome, post-herpetic or post-traumatic (including intercostal) neuralgia, muscle contraction headaches, or from a subacute inflammatory spine pain syndrome unresponsive to more conservative treatment (3, 5). Epidurals have also been used to treat pain from malignant syndromes, from viral brachial plexitis, or from reflex sympathetic dystrophy. Support for lumbar epidural steroid injections comes mainly from uncontrolled case studies or trials in which 33% to 77% of injected patients reported pain reduction. The success of the injections, as with all therapeutic interventions, depends on patient selection and technique. Unfortunately, even the controlled studies available on epidural steroids are limited methodologically by mixed or nonspecific diagnoses, by lack of functional outcome data, by insufficient patient numbers in control or treatment groups, and by failure to confirm delivery to the epidural space through use of fluoroscopy (4, 8).

Risks and Contraindications

Risks associated with needle placement or with the injection of diagnostic/therapeutic substances, including the local anesthetic and steroid suspension, include, infection, bleeding, nerve injury, transient numbness or weakness, paralysis, contrast reaction (allergy), adrenal suppression, and fluid retention with systemic manifestations which may include peripheral swelling. Pneumothorax may occur if undergoing a thoracic procedure. Total spinal blockade is possible with cervical procedures. There is also a potential for minor subcutaneous infection, vasovagal episode, as well as failure to obtain a definitive diagnosis or positive therapeutic injection with persistence of chronic pain. Dural puncture with subsequent spinal (positional) headache has been reported to occur us high as 5% of the time in translaminar injections. However it is accepted that medical procedures, by their very nature, contain a certain risk-to-benefit ratio that needs to be taken into consideration when deciding upon a responsible treatment modality, and/or prior to initiating interventional therapies. Procedures that are used primarily as a means of temporary chronic-pain control are certainly no exception and currently there are no official safety or procedural guidelines enjoying widespread acceptance in existence, for physicians who routinely perform epidural injection procedures. Such guidelines could potentially be utilized to help reduce or alleviate many of the potential inherent procedural risks. (See Appendix 1 for a list of proposed guidelines for the performance of cervical epidural injections.)

Absolute contraindications to performing epidural injections include known hypersensitivity to agents, local or systemic infection, local malignancy, bleeding diathesis, congestive heart failure, and uncontrolled diabetes mellitus. Insulin dependent diabetics can obtain substantial elevations in their blood sugars following epidural steroid injections.