Practice of epidural steroid injections outside of the United States

2009 ◽  
Vol 13 (4) ◽  
pp. 258-265
Author(s):  
Preeti P. Doshi ◽  
Jalpa D. Makwana
Keyword(s):  
United States ◽  
The United States ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Variations of Technique in Transforaminal Epidural Steroid Injections and Periprocedural Practices by Interventional Pain Medicine Physicians in the United States

2019 ◽  
Vol 5 (22;5) ◽  
pp. E435-E440
Author(s):  
Lisa Doan
Keyword(s):  
United States ◽  
Image Guidance ◽  
Steroid Injection ◽  
The United States ◽  
Epidural Steroid Injection ◽  
Pain Medicine ◽  
Needle Size ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Background: Interlaminar and transforaminal epidural steroid injections (ILESI and TFESI) are commonly performed procedures. However, the United States Food and Drug Administration has required the addition of drug warning labels for injectable corticosteroids. Updated evidence and scrutiny from regulatory agencies may affect practice patterns. Objective: To characterize TFESI practices as well as to provide an update on periprocedural practices for any type of epidural steroid injection (ESI), we surveyed pain medicine physicians in the United States. Study Design and Setting: This was a cross-sectional survey of pain medicine physicians in the United States. Methods: A web-based survey was distributed to pain medicine physicians in the United States selected from the Accreditation Council for Graduate Medical Education accredited pain medicine fellowship program list as well as the American Society of Interventional Pain Physicians membership database. Physicians were queried about TFESI practices, including needle size, use of image guidance, methods to detect vascular uptake, and preference for injectate. Results: A total of 249 responses were analyzed. Only a minority of respondents reported performing cervical TFESI. There were variations in needle size, methods to detect vascular uptake, and choice of injectate. There were also variations in monitoring practices. Limitations: The response rate is a limitation. Thus the results may not be representative of all US pain medicine physicians. Conclusions: Though all respondents used image guidance for TFESI, variations in other TFESI practices exist. There are also differences in periprocedural practices. Since the closure of this survey, a multisociety pain workgroup published recommendations regarding ESI practices. Our survey findings support the need for more evidence-based guidelines regarding ESI. Key words: Epidural steroid injections, transforaminal epidural steroid injection, steroids, local anesthetic, survey, interventional pain

scholarly journals Improving the Safety of Transforaminal Epidural Steroid Injections in the Treatment of Cervical Radiculopathy

2011 ◽  
Vol 3;14 (3;5) ◽  
pp. 285-293
Author(s):  
Jon E. Block
Keyword(s):  
Cervical Radiculopathy ◽  
The United States ◽  
Injection System ◽  
Study Endpoint ◽  
Primary Study ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Spinal Injection ◽  
Epidural Steroid ◽  
Versus Test

Background: Unplanned vascular trespass occurs in 20% of cervical transforaminal epidural steroid injections (CTFESI) and rarely results in devastating neurologic complications. The Trucath Spinal Injection System is a novel integrated catheter and needle device that is specifically designed to minimize vascular trespass risk. Objective: To compare the vascular trespass incidence with the Trucath Spinal Injection System versus standard spinal needles during CTFESI treatment in patients with cervical radiculopathy. Study Design: Prospective, multicenter, nonrandomized safety trial. Setting: Six tertiary spinal pain management centers in the United States. Methods: We treated 290 patients (411 levels) with recalcitrant cervical radiculopathy using CTFESI; 129 patients (180 levels) were treated with the Trucath Spinal Injection System (Test group) and 161 patients (231 levels) were treated with standard spinal needles (Control group). All injections were administered via a transforaminal approach. Each site attained IRB approval for this study before any research was performed. The primary study endpoint was vascular trespass per treated level. Secondary endpoints included nerve pain or paresthesia, injection accuracy, device performance measures, and procedural adverse events. Results: Vascular trespass occurred more often (odds ratio (OR): 3.1, 95% Confidence Interval (CI): 1.8-5.4, P < 0.001) in Controls (26.8%, 62/231 levels) versus Test patients (10.6%, 19/180 levels). Radicular pain or paresthesia from device positioning was more frequent (OR: 21.1, 95% CI: 6.9-64.5, P < 0.001) in Controls (26.4%, 61/231) versus Test participants (1.7%, 3/179). Inadequate epiradicular flow was observed in 3.0% (7/231) of Controls and 5.6% (10/179) of Test participants (OR: 0.5, 95% CI: 0.2-1.4, P = 0.22). Based on subjective physician judgment (scale: 1-10), there were no differences between the Test and Control groups, respectively, for ease of use (mean 8.9 vs. 9.0), visualization under fluoroscopy (mean 9.2 vs. 9.0), and overall performance (mean 9.0 vs. 8.6). No additional adverse effects were reported in either treatment group in this clinical study. Limitations: The study did not randomly allocate the type of injection procedure to participants and no clinical outcomes beyond the initial treatment were collected. Conclusions: The Trucath Spinal Injection System demonstrated a statistically significant reduction in the rate of intravenous and intra-arterial trespass, procedural pain, and paresthesia, and has similar accuracy and performance versus standard spinal needles for CTFESI treatment of cervical radiculopathy. Key words: cervical, epidural, radiculopathy, steroid, transforaminal, Trucath, vascular trespass

Interpreting Reviews and Guidelines: The Case of Lumbar Epidural Steroid Injections

PM&R ◽  
2009 ◽  
Vol 1 (6) ◽  
pp. 576-579 ◽  
Author(s):  
Venu Akuthota ◽  
Charles Argoff ◽  
William C. Watters
Keyword(s):  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Transforaminal Lumbar and Thoracic Interventions and Ischemic Spinal Cord Injury

2016 ◽  
Author(s):  
Scott E. Glaser ◽  
Rinoo Shah
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Spinal Cord Infarction ◽  
Supporting Evidence ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Root Cause ◽  
Cord Injury ◽  
Epidural Steroid ◽  
Ischemic Spinal Cord Injury

Transforaminal epidural steroid injections have been shown to be associated with catastrophic neurologic complications secondary to spinal cord infarction. The reflexive, ad hoc response of practitioners to these injuries has been to recommend risk minimization strategies to prevent embolism of the injected particulate steroids and to use nonparticulate steroids. This focus on distal embolism as the sole or primary cause of catastrophic outcomes lacks conclusive supporting evidence and does not suffice to protect the patient from paraplegia as it fails to address the root cause of the complications. A root cause analysis of the procedure provides evidence that the injection technique itself—the “safe triangle”—creates a risk of arterial damage and sequelae leading to ischemia of the spinal cord. The evidence is strong that the only way to mitigate or eliminate the risk of paraplegia is to use a different technique to perform transforaminal injections: the Kambin triangle approach. This change in technique is the only definitive solution that addresses the root cause of these catastrophic sequelae associated with transforaminal epidural steroid injections. Key Words: Artery of Adamkiewicz, ischemic spinal cord injury, Kambin triangle, safe triangle, transforaminal epidural injection

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