Risks And Patient Selection For Epidural Steroid Injections

In the 10 years between 1997 and 2006, interventional pain treatments went up by 235% in the Medicare demographic. There is building evidence that early imaging and injection treatments result in better outcomes. The results have been very promising.

When looking at neck and back pain causes, there are really 3 main categories: 1) Disc Degeneration 2) Disc bulges/herniations and 3) Facet Degeneration

When imaging studies are obtained, one of the main reasons is to exclude non-degenerative pain problems such as tumors, compression fractures, or neural disorders.

Safety of lumbar and cervical epidural injections and nerve blocks has been shown in many studies, with a complication rate of <1% requiring additional treatment.

Transforaminal injections into the cervical spine entail risk higher than lumbar due to 1)Tortuosity of the vertebral artery 2) Direct injection possibility into the spinal cord and 3) Injection potential into the microvasculature surrounding the spinal cord.

It's unclear whether these injections in the cervical spine are that much better and with the increased risk, it may be better just to stick to regular cervical epidural injections. The contrast used to elucidate correct placement may end up in one of these vessels, causing potentially serious complications.

The most common complications seen in back and neck procedures are 1) Pain and 2) Needle misplacement. As mentioned, transforaminal cervical epidural injections are questionable with their safety profile. It's debated where some studies show them to be safe, while others display an unfavorable safety profile.

Patient Selection for ESI

Injections are of value to patients with both spinal stenosis and painful disc herniations. With spinal stenosis, one may see a situation where the stenosis is chronic and the patient is functional, however, an acute exacerbation makes it intolerable. ESI's may put the situation back to baseline.

Injections are not a permanent cure, and surgery is an option for stenosis or herniations. One injection may not do the trick, it may take a series of injections with a repeat of the series every few months.

If a series works and then wears off it does not mean it was a failure, simply it ran its course.

ESI's can achieve pain relief, lower operative rates, and less medical cost, especially in those over age 65. Acute problems and leg/arm radicular pain respond the best. Disc herniations have an overall efficacy response (61%) better than stenosis (38%). Interestingly, though, with stenosis the degree of the problem is independent of the patient response to the injection. For patients with multilevel spinal stenosis, injections may be a godsend as it can prevent a multi-level surgery with increased risk.