Particulate and non-particulate steroids in spinal epidurals: a systematic review and meta-analysis

Lumbar transforaminal epidural steroid injections with particulate vs. nonparticulate steroid: an evidence-informed review on shifting gear to a personalized medicine paradigm

PURPOSE OF REVIEW

To provide an evidence-informed review weighing the pros and cons of particulate vs. nonparticulate steroids for lumbar transforaminal epidural steroid injections (TFESI).

RECENT FINDINGS

The relative use of nonparticulate vs. particulate steroids for lumbar TFESI has risen recently in light of catastrophic consequences reported for the latter during cervical TFESI. Among various causes of spinal cord infarct, an exceedingly rare event in the lower lumbar spine, embolization of particulate steroid is among the least likely. Case reports have documented cases of spinal cord infarct during lower lumbar TFESI with both particulate and nonparticulate steroids, with database reviews finding no difference in complication rates. There is some evidence for superiority of particulate over nonparticulate steroids in well-designed studies, which could lead to increase steroid exposure (i.e. more injections) and treatment failure resulting in surgical and/or opioid management when nonparticulate steroids are utilized.

SUMMARY

Similar to a paradigm shift in medicine, a personalized approach based on a shared decision model and the consequences of treatment failure, should be utilized in deciding which steroid to utilize. Alternatives to ESI include high-volume injections with nonsteroid solutions, and the use of hypertonic saline, which possesses anti-inflammatory properties and has been shown to be superior to isotonic saline in preliminary clinical studies.

Long-term effectiveness of transforaminal anterolateral approach CT-guided cervical epidural steroid injections for cervical radiculopathy treatment

AIM

To evaluate the long-term clinical effectiveness of computed tomography (CT)-guided transforaminal cervical epidural steroid injection using an anterolateral approach for the treatment of cervical radiculopathy (CR) using well-established robust clinical scoring systems for neck pain and neck disability. Despite its widespread use, evidence to support the long-term benefit of routine cervical epidural steroid injection is currently very limited.

MATERIALS AND METHODS

This study included 113 patients with magnetic resonance imaging (MRI)-confirmed CR who underwent a steroid injection at a single cervical level via a unilateral transforaminal anterolateral approach. Pain was assessed quantitatively at pre-injection, 15 minutes post-injection, 1 month, 3 months, and at 1 year. Neck disability was assessed using the Oswestry Neck Disability Index (NDI) at pre-injection, 1 month, 3 months, and 1 year time points.

RESULTS

Eighty patients completed the study. Sixty per cent reported reduced neck pain (mean pain reduction, 55%), which was clinically significant in 45% cases. Furthermore, 66% reported an improvement in neck disability (mean improvement, 51%), which was clinically significant for 56% patients. Clinically significant good outcomes in both neck pain and neck disability were evident from as early as 1-month, and importantly, were independent both of pre-treatment CR characteristics (including severity of pre-injection neck pain or disability) and of findings on pre-injection MRI imaging.

CONCLUSION

Transforaminal anterolateral approach CT-guided epidural steroid injection resulted in a clinically significant long-term improvement in both neck pain and disability for half of the present cohort of patients with unilateral single-level CR. This improvement was independent of the severity of the initial symptoms and pre-injection MRI findings.

An update on epidural steroid injections: is there still a role for particulate corticosteroids?

Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.

2. Cervical radicular pain

INTRODUCTION

Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both.

METHODS

The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized.

RESULTS

The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered.

CONCLUSIONS

There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].

Image-Guided Spine Interventions for Pain: Ongoing Controversies

An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.

Complications of injections in conservative treatment of degenerative spine disease: a prospective unicentric study

BACKGROUND

Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction.

METHODS

Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated.

RESULTS

Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4-73.5%), radiating pain (9.4-34.7%), and nerve root irritation (2-18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up.

CONCLUSIONS

Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient.

A rabbit model for embolic infarct potentials of injectables using ultrasound-guided carotid artery puncture

In order to evaluate the in vivo thrombogenicity of injectable agents, a suitable animal model is needed. We introduce an ultrasound-guided non-selective cerebral artery occlusion model via the common carotid arteries of rabbits. A total of 30 rabbits were assigned to an experimental group (n = 20) and a control group (n = 10). Each group received 2 mL suspension of embolic agent or 2 mL of normal saline, respectively, under ultrasound guidance. The animals were observed for immediate reaction and underwent magnetic resonance imaging (MRI) scan. Follow-up neurologic examination was conducted 24 h following the procedure. In 7 of the 30 rabbits, 2 in the control group and 5 in the experimental group, the administration of either normal saline or the embolic agent failed. Among the successfully injected 15 experimental animals, 14 showed neurologic impairment or deceased, whereas 1 animal did not show significant neurologic deficit. The MRI of 4 experimental animals showed detectable cerebral infarction on diffusion-weighted imaging. None of the 8 control animals showed neurologic abnormality and their brain MRI was normal. Our minimally invasive model is technically feasible and competent to show thrombogenecity of an injectable agent and consequent in vivo neurologic outcome.

Evaluation of the efficacy and safety of epidural steroid injection using a nonparticulate steroid, dexamethasone or betamethasone: a double-blind, randomized, crossover, clinical trial

Background

The U.S. Food and Drug Administration has prohibited epidural steroid injection (ESI) with particulate steroids. Thus, this study aimed to compare the efficacy and safety of ESI with two nonparticulate steroids, dexamethasone and betamethasone.

Methods

The eligible patients (n = 600) who received ESI (0 week) with dexamethasone (ESI-dexa) or betamethasone (ESI-beta) had follow-up visits at 2, 4, and 8 weeks with a phone interview at 12 weeks. The primary endpoint was the proportion of effective responders without pain or who were much improved at 2 weeks. The secondary endpoints were the proportion of crossover injections at 2 weeks; changes in the visual analog scale (VAS) and disability index scores at 2, 4, and 8 weeks; the number of additional ESIs in 12 weeks; the number of participants having spinal surgery, as well as the incidence of adverse events over the 12 weeks.

Results

The proportion of effective responders at 2 weeks was not different between ESI-beta (72/216, 33.3%) and ESI-dexa (63/200, 31.5%; P = 0.670). Adverse events were more common with ESI-dexa (40/200, 20.0%) than with ESI-beta (24/216, 11.1%; P = 0.012). VAS scores decreased more with ESI-beta than with ESI-dexa at 2 weeks (difference, 0.35; P = 0.023) and 4 weeks (difference, 0.42; P = 0.011). The disability score improved significantly more with ESI-beta compared with ESI-dexa at 2 weeks (difference, 3.37; P = 0.009), 4 weeks (difference, 4.01; P = 0.002), and 8 weeks (difference, 3.54; P = 0.007).

Conclusions

Betamethasone would be more appropriate for ESI.

Safety and Efficacy of Minimally Invasive Transforaminal Lumbar Interbody Fusion Combined with Gelatin Sponge Impregnated with Dexamethasone and No Drainage Tube after Surgery in the Treatment of Lumbar Degenerative Disease

Objective

The aim of the present study was to use a gelatin sponge impregnated with dexamethasone, combined with minimally invasive transforaminal lumbar interbody fusion (MIS‐TLIF) and no drainage tube after the operation for early postoperative recurrence of root pain caused by edema.

Methods

A prospective case series study was designed. From September 2015 to January 2018, eligible patients diagnosed with lumbar degenerative disease underwent MIS‐TLIF combined with a gelatin sponge impregnated with dexamethasone and no drainage tube after surgery. The short‐term clinical data were collected, such as visual analog scale (VAS) scores for low back pain and leg pain preoperatively and on postoperative days (POD) 1–10, time bedridden postoperatively, and length of hospital stay postoperatively. Long‐term indicators include the Japanese Orthopaedic Association (JOA) score, the Oswestry Disability Index (ODI) score, and the 36‐Item Short‐Form Health Survey (SF‐36) score, evaluated preoperatively and 1 week, 3 months, and more than 1 year postoperatively.

Results

Complete clinical data was obtained for 139 patients. All patients were followed up for more than 12 months (13.7 ± 3.3 months). The average bedridden period was 1.5 ± 0.4 days and hospital stays were 2.7 ± 0.9 days. The VAS score of leg and back pain on POD 1–10 were all decreased compared with preoperation (all P < 0.0001). At the last follow up, the VAS scores for back pain and leg pain (0.69 ± 0.47; 1.02 ± 0.55) and the ODI score (11.1 ± 3.5) decreased (all P < 0.0001), and the JOA score (27.1 ± 3.2) and the SF‐36 (physical component summary, 50.5 ± 7.3; mental component summary, 49.4 ± 8.9) increased (all P < 0.0001) compared with preoperative values. Patients' early and long‐term levels of satisfaction postoperatively were 92.8% and 97.8%, respectively. At POD 7 and the last follow‐up, the improvement rate of the JOA score, respectively, was 41.8% ± 10.6% and 87.7% ± 8.2%, and clinical effects assessed as significantly effective according to the improvement rate of the JOA score was 16.5% and 66.9%, respectively. There were 2 (1.4%) cases with complications, including 1 (0.7%) case of wound infection and 1 (0.7%) case of deep vein thrombosis. There were no device‐related complications or neurological injuries.

Conclusion

Use of a gelatin sponge impregnated with dexamethasone combined with MIS‐TLIF and no drainage tube after the operation, compared with previous studies, appears to be safe and feasible to reduce recurrent back pain and leg pain after decompression in the treatment of lumbar degenerative disease.

A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results

Objectives

Compare the effectiveness of catheter-directed cervical interlaminar epidural steroid injection (C-CIESI) with triamcinolone to cervical transforaminal steroid injection (CTFESI) with dexamethasone for the treatment of refractory unilateral radicular pain.

Design

Prospective, randomized, comparative trial.

Methods

Primary outcome: proportion of participants with ≥50% numeric rating scale pain score reduction from baseline “dominant pain” (the greater of arm vs neck) at one month postinjection. Secondary outcomes: ≥30% Neck Disability Index (NDI-5) reduction and Patient Global Impression of Change (PGIC) response indicating “much improved” or “very much improved.”

Results

One hundred twenty participants (55.6% females, 52.3 ± 12.5 years of age, BMI 28.2 ± 6.5 kg/m2), were enrolled. The proportions of participants who experienced ≥50% pain reduction at one, three, and six months were 68.5% (95% CI = 54.9–79.5%), 59.3% (95% CI = 45.7–71.6%), and 60.8% (95% CI = 46.7–73.2%), respectively, in the C-CIESI group compared with 49.1% (95% CI = 36.4–62.0%), 46.4% (95% CI = 33.8–59.6%), and 51.9% (95% CI = 38.4–65.2%), respectively, in the CTFESI group. The between-group difference at one month was significant (P = 0.038). The proportions of participants who experienced a ≥30% NDI-5 score improvement were 64.0% (95% CI = 49.8–76.1%) and 54.9% (95% CI = 41.1–68.0%) in the C-CIESI and CTFESI groups (P = 0.352). Participants reported similar PGIC improvement in both groups: At six months, 53.2% (95% CI 38.9–67.1%) and 54.5% (95% CI = 39.7–68.7%) of the C-CIESI and CTFESI groups reported being “much improved” or “very much improved,” respectively (P = 0.897).

Conclusions

Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.

Particulate steroids in axial spinal blockade and the increasing role of patient consent: Les grains de sable dans l'engrenage

The complexity of modern medical practice is such that it is very unlikely that on any single issue we can give a definitive answer in any circumstance, and in our view the medical debate as to the use of particulate corticosteroid medicines in axial spinal blockade is one such argument. The medical discussion of the use of particulate corticosteroids has to be set against the uncertain risk and benefits of axial spinal procedures in which the drugs are utilised, and in which the most likely catastrophic complication may occur with their use, and then, as the law now demands, involve the patient in the relevant consenting issues.

Comparison of Transforaminal Triamcinolone and Dexmedetomidine in Radicular Low-Back Pain: A Randomized Double-Blind Clinical Trial

Background

Administration of steroids in the lumbar transforaminal block for lumbar radicular pain is considered one of the preferred treatment methods though it is associated with some complications.

Objectives

The effects and side effects of triamcinolone and dexmedetomidine in the lumbar transforaminal block were investigated in the present study.

Methods

In this study, 30 patients, aged 40 - 70 years, suffering from lumbar radicular pain arising from the lumbar disc protrusion were equally divided into two groups of triamcinolone (T) and dexmedetomidine (D). They all underwent lumbar transforaminal blocks. An injection solution of triamcinolone (20 mg) plus ropivacaine (0.2%) and another one containing dexmedetomidine (50 μg) plus ropivacaine (0.2%) were administered in the triamcinolone and dexmedetomidine groups, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Straight Leg Raise (SLR or lasègue’s test), and Fasting Blood Sugar (FBS) were measured at 0, 2 weeks, 1, 3, and 6 months post-procedure. The levels of calcium, magnesium, and vitamin D, as well as potential complications, were also evaluated.

Results

Significant differences were found in the VAS and ODI during the measurement times within each group. The VAS and ODI were remarkably different between the dexmedetomidine group and the triamcinolone group. In addition, there were considerable differences in the increased FBS and reduced calcium and vitamin D levels in the triamcinolone group from changes in the dexmedetomidine group.

Conclusions

The lumbar transforaminal block with triamcinolone or dexmedetomidine attenuates the lumbar radicular pain. Further, dexmedetomidine exerts a more potent pain relief effect than triamcinolone.

Dilution and microfiltration of particulate corticosteroids for spinal epidural injections: impact on drug concentration and agglomerate formation

Particulate corticosteroids have been described to lead to greater pain improvement compared with their non-particulate counterparts when used in epidural injections. It is hypothesised that filtering may significantly impact their concentration and long-term efficacy. We investigated if passing particulate suspensions through different commonly-used filters affects drug dosage. Two particulate corticosteroid formulations, triamcinolone acetonide and methylprednisolone acetate, were mixed at different concentrations with either bupivacaine hydrochloride or 0.9% sodium chloride. Solutions were passed through a 5-μm and a 0.2-μm filter. Mass spectroscopy results indicated a complete loss of corticosteroid from the solutions using both filters, and light microscopy imaging demonstrated agglomerate formation, suggesting that filtering interferes with drug dosage. The choice of diluents must also be considered to reduce large agglomerate formation. Clinicians should be aware of the consequences of filtering particulate suspensions and carefully consider the selection of diluent when considering treatment plans.

Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis

BACKGROUND CONTEXT

Epidural steroid injection has been used to treat back or radicular pain from lumbar and lumbosacral disc herniation (LDH). However, the superiority of transforaminal injection (TFESI) to caudal injection (CESI) remains controversial.

PURPOSE

This systematic review and meta-analysis aimed to investigate whether TFESI was more useful than CESI for achieving clinical outcomes in patients with LDH.

STUDY DESIGN/SETTING

A systematic review and/or is not appropriate. A systematic review and meta-analysis. Spine hospital and tertiary care hospital.

PATIENT SAMPLE

Articles were chosen that compared the clinical efficacy of TFESI and CESI for treatment of low back and radicular leg pain caused by LDH.

OUTCOMES MEASURES

Visual analogue scale, numeric rating scale, and Oswestry disability index.

METHODS

A literature search was performed using MEDLINE, EMBASE, Cochrane review, and KoreaMed databases for studies published until July 2017. After reviewing titles, abstracts, and full-texts of 6,711 studies after initial database search, six studies were included in a qualitative synthesis. Data including pain score, functional score, and follow-up period were extracted from four studies and were analyzed using a random effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the grading of recommendations assessment, development and evaluation methodology.

RESULTS

Among six studies, four articles supported the superiority of TFESI to CESI, one article showed no significant difference, and one article supported the superiority of CESI to TFESI. To obtain compatible or superior clinical results to TFESI, CESI might need to inject a larger amount of medication than was usually used. A meta-analysis showed short-term and long-term trends toward better clinical efficacy with TFESI than with CESI without statistical significance. The evidence level was low because of inconsistency and imprecision.

CONCLUSIONS

Comprehensive reviews of selected articles revealed better clinical benefits with TFESI than with CESI, possibly because TFESI had the ability to deliver medication directly into the target area. Because of a low level of evidence and no significant results on meta-analysis, TFESI could be weakly recommended over CESI.

Spinal cord infarction caused by sacral canal epidural steroid injection: A case report

RATIONALE

Spinal cord infarction is one of the complications of epidural steroid injections (ESIs), but has only been reported in cervical vertebra by transforaminal injection and lumbar vertebra by transforaminal injection; and up to now, there is no reporting about spinal cord infarction caused by caudal injection. Here, we report a case.

PATIENT CONCERNS

A 52-year-old man was admitted to our hospital. He was diagnosed as lumbar disc herniation in other hospital, and the patient suffered bilateral lower limb motor and sensory disorders after administration of caudal ESI.

DIAGNOSIS

Spinal cord infarction, tethered cord syndrome (TCS), and acute myelitis.

INTERVENTIONS

High doses of hormones, gamma globulin impact therapy, and rehabilitation were performed.

OUTCOMES

The patient's condition was stable when he discharged from the hospital after 20 days of treatment. Discharge status: grade 0 of bilateral lower limbs muscle strength, inability to urinate and defecate by himself, slightly decreased touch, and needling sensation below the umbilical plane.

LESSONS

When patients are diagnosed with lumbar disc herniation and need to receive invasive treatments, magnetic resonance imaging (MRI) should be performed before the invasive procedures.