October 2017 Edition. Volume XVII

Physicians who perform “special procedures” (injections and blocks) relating to spine care are referred to as “Procedurists.”  The various physician groups engaged in this endeavor are listed below:

Procedural Radiologists
Procedural Neuroradiologists
Procedural Neurologists
Procedural Physiatrists
Procedural Anesthesiologists
Pain Management Specialists
Other Procedural Physicians

When epidural steroid injection (ESI) is compared to diagnosis-specific procedures such as facet injections,  radio-frequency blocks, intradiscal thermocoagulation (IDET), neucleolectomy, etc. it consistently comes up on the short side in regard to the physician having established a specific diagnosis prior to performing the procedure.  Because of the risk of potential patient harm in performing ESI it is important to explore the difference in steroids being injected and those measures being taken to assure accurate placement of steroid into the epidural (rather than subarachnoid) space.

It is in the patient’s best interest, as well as an issue of common sense, to have only potentially safe (i.e. not containing toxic substance) drugs injected into the epidural space when ESI is prescribed. The Burton Experience clearly indicates that most epidural steroid injections are performed as an excuse for not actually determining the etiology of the patient’s pain combined with physician ignorance regarding other more effective non-invasive therapies available to the patient.  A patient is not likely to experience having informed consent when the ordering physician is ignorant of the actual diagnosis or the actual risks of the treatment being prescribed.  It is not uncommon for patients to present themselves for epidural steroid injection and to be unaware that it requires a needle being placed in their lumbar spine.

As familiarity increases with the potential liabilities of injecting steroids containing substances such as polyethylene glycol (i.e. Depo Medrol) becomes more widespread there will be an increased demand for safer steroids.  Celestone Soluspan has become the most popular substitute for potentially toxic alternatives such as Depo-Medrol.  Unfortunately for the public, because of increased demand and decreased  profit for manufacturers a nationwide shortages have occurred.  While Dexamethasone Sodium Phosphate has been the safest alternative this also has become back ordered leaving knowledgeable physicians with difficult choices. The American System of Health Care Pharmacists (as shown below) has offered patients no real alternatives.

  • Epidural injection for low back pain or sciatica**
  • 1-3 mL (6-18 mg) injected into the epidural space. Ideally, the procedure would be performed under fluoroscopy to confirm needle positioning.No suitable alternative for epidural use.
  • Methylprednisolone acetate (e.g., Depo-Medrol [Pharmacia]): multiple-dose vials contain benzyl alcohol and polyethylene glycol, single-dose vials contain polyethylene glycol
  • Triamcinolone acetonide (e.g., Kenalog-40 [Squibb]): contains benzyl alcohol
  • Triamcinolone hexacetonide (e.g., Aristospan [Fujisawa]): product is on back-order nationwide

What is a procedurist to do if the only steroid preparations available for use contain potentially dangerous substances and ESI is a reasonable therapy for the appropriate patient?  When this actually occurred in Minneapolis, Minnesota one group of procedural neuroradiologists stopped doing ESI until the safer steroids became available again.  Another group of neuroradiologists, with extensive experience in the precision placement of steroids in the epidural space under image-intensification fluoroscopy (see below) had the patients sign an informed consent sheet outlining the known risks (including that of adhesive arachnoiditis). Both of these were acceptable courses to follow.

EpiSterSchellhas

Timely and accurate information regarding the potential complications of epidural steroid injection have been published in the medical literature since 1993.  The above article, published by neuroradiologists from the Center for Diagnostic Imaging in Minneapolis,  surveyed 5,334 cases performed under fluoroscopy with epidurography to assure accurate needle placement, and prominently identified adhesive arachnoiditis as a “well described” potential complication.  The authors also pointed out that:

“The blind interlaminar technique introduces the potential for erroneous needle placement and subsequent injection of substances into undesired locations, such as the subarachnoid space.”  Blind needle injection, even by “skilled and experienced procedurists” has been found to be inaccurate in 25-30% of cases.

The Burton Experience has shown that it is not infrequent for physicians to prescribe blind lumbar interlaminar “epidural” steroid injections in patients who have undergone previous surgery and do not, in fact, continue to have an epidural space present.  In such a circumstance attempted blind interlaminar injection would be, in fact, a direct injection into the subarachnoid space.  Even ESI under fluoroscopy, but  without epidurography, can have potential liabilities as demonstrated here:

Shown below is part of the description of a ESI procedure report relating to a 45 year old patient who developed clinically significant adhesive arachnoiditis following injection with Aristocort® suspension, another steroid preparation containing neurotoxic glycols.

HESProc200GIF

As a means of attempting to avoiding the complications inherent in interlaminar injections some practitioners have begun to advocate trans-foraminal steroid injections as an alternative (in association with fluoroscopic image intensification and epidurography).  This approach also has its limitations, some of which are anatomic.

Epiduroscopy200GIF

The limitations inherent in all needle directed placements have led to the search for better methods of drug delivery.  Shown on the left is an endoscope by which drugs can be reliably directed into the epidural space (under direct vision).

On the bright side more procedurists (particularly those in the radiologic fields) are now using x-ray imaging control, epidurography, and continued advances in endoscopy.  On the other hand there are some procedurists who know little about spine care or the use of radiologic monitoring and continue to perform dangerous blind injections into what they think is the epidural space using toxic drugs.

Although professional organizations such as the International Spine Injection Society now exist there are no organizations who provide quality control in the important area of ESI where many of the procedures are performed outside of the view of Credentialing Committees in hospitals.

The best answer to this dilemma is for the physician to make better use of non-invasive therapies (i.e. spine health maintenance programs).  If epidural steroids containing toxic substances are still felt to be important to the patient’s welfare by a knowledgeable spine care physician it is essential that the technique be the safest possible (performed under image-intensification fluoroscopic imaging with associated epidurography) and that the patient be provided with all pertinent risk information so as to allow for informed consent.

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