Epidural Steroid Safety Advice Focuses on Imaging

Benzon HT, Huntoon MA, Rathmell JP. Improving the Safety of Epidural Steroid Injections.JAMA. 2015; doi:10.1001/jama.2015.2912. Online March 30, 2015.

New recommendations on epidural steroid injections seek to reduce or eliminate rare but catastrophic central nervous system injuries. Effective imaging guidance is crucial, they say.

A multidisciplinary team reviewed case reports and malpractice claims¹ to develop guidelines for improving the safety of the millions of injections given to US patients. There were 2.3 million procedures among Medicare patients alone in 2011, the authors note.

Two noteworthy issues are the risks of particulate versus nonparticulate steroids, and the need for contrast medium in fluoroscopic guidance.

Injuries following nonparticulate injections are temporary, whereas paraplegias after particulate steroids are permanent, they point out.

Also, cervical injections require more caution than lumbar injections.

The recommendations include specific guidance about when to use contrast medium, what kind of imaging guidance to use for different locations of injections, and when to choose particulate as opposed to nonparticulate steroids.

“Epidural steroid injections will continue to be used for short-term relief of radicular pain,” the authors state. They add that unanswered questions remain regarding the efficacy of nonparticulate steroids and whether using a lower dose would still produce a “meaningful reduction in pain.”

 

References:

1. Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015; doi:10.1097/ALN.0000000000000614. Online February 9, 2015.