Browse the corpus

Epidural steroid injections have been used for pain relief since 1952. When indicated, they are an invaluable nonsurgical treatment for low back pain radiating to the lower extremities and, less commonly, for neck pain radiating to the arms. Performing an effective epidural steroid injection requires the steroids to reach the epidural space. Successful epidural steroid injections provide pain relief, restoring function and return to a physical therapy regimen when indicated. The 3 primary routes for epidural steroid delivery include the transforaminal, interlaminar, and caudal approach. The standard of care involves using fluoroscopy or, less commonly, computed tomography guidance to ensure proper needle placement with the aid of contrast flow. This activity reviews the indications and techniques for performing an effective epidural steroid injection, equipping clinicians with procedural knowledge. Epidural steroid injections are crucial for chronic pain management, requiring a multidisciplinary team for patient-centered care. Nurses handle pre- and post-procedural care, physical therapists support rehabilitation, and primary care clinicians educate on lifestyle changes, ensuring informed consent, ethical practices, and effective interprofessional communication. Objectives: Identify appropriate indications for epidural steroid injections based on patient history and severity of symptoms. Evaluate the preparation required for epidural steroid injections involving necessary personnel. Interpret the potential complications of epidural steroid injections post-procedure. Implement interprofessional team strategies to advance the appropriate and safe use of epidural steroids for low back pain. Access free multiple choice questions on this topic.

Epidural steroid injections have been used to treat pain caused by lumbar disc injuries since the 1950s.[1][2][3] These injections are often used in treating radicular pain, a neuropathic pain syndrome that radiates down a dermatome of 1 or more spinal nerves. Typically, the pain is due to nerve root irritation from mechanical compression by an intervertebral herniated disc, leading to inflammation. Additional etiologies leading to mechanical spinal nerve compression include spondylosis, spondylolisthesis, and ligamentum flavum hypertrophy, resulting in neuroforaminal stenosis. In patients with lumbosacral radiculopathy, more than half of the patients report interference in their activities of daily living, and a quarter continue to have severe pain that does not respond well to oral pharmacological treatments.[4][5][6] Approximately 14% of patients with lumbosacral radiculopathy eventually require surgery for severe pain that may or may not be associated with a neurological deficit.[7] However, in many cases, radicular pain secondary to intervertebral disc herniation improves with medical and rehabilitative treatment. Steroid injection into the epidural space is used to achieve inflammation reduction and pain relief and limit medications or surgery. The 3 primary routes for epidural steroid delivery include the transforaminal, interlaminar, and caudal approach. The standard of care involves using fluoroscopy or, less commonly, computed tomography guidance to ensure proper needle placement with the aid of contrast flow.[8] The efficacy of epidural steroid injections in lumbosacral radiculopathy has been widely studied, and based on a recent systematic review including 8 randomized controlled trials, a strong recommendation on moderate-quality evidence demonstrates that transforaminal epidural steroid injections can be used to reduce pain at 3 months. However, a clear improvement in physical disability and reduction in surgery was not consistently observed in the literature.[9]

The 3 primary routes for epidural steroid delivery include the transforaminal, interlaminar, and caudal approach. The standard of care involves using fluoroscopy or, less commonly, computed tomography guidance to ensure proper needle placement with the aid of contrast flow.[8] The efficacy of epidural steroid injections in lumbosacral radiculopathy has been widely studied, and based on a recent systematic review including 8 randomized controlled trials, a strong recommendation on moderate-quality evidence demonstrates that transforaminal epidural steroid injections can be used to reduce pain at 3 months. However, a clear improvement in physical disability and reduction in surgery was not consistently observed in the literature.[9] Cervical epidural steroid injections have similarly been shown to provide short-term relief for radicular cervical pain, but long-term outcomes have not been well studied. Limited high-quality evidence suggests that cervical epidural steroid injections can be beneficial for radiculitis secondary to disc herniation and discogenic pain.[10] Most studies focus on interlaminar cervical epidural steroid injections instead of transforaminal cervical epidural steroid injections.[11] Although rare, the morbidity associated with these injections can be catastrophic.

Although rare, possible complications include: Bleeding Infection Allergic reaction Nerve injury Transient lower or upper extremity numbness and tingling Dural puncture causing positional headache Epidural abscess Epidural hematoma Transient back or lower extremity pain Side effects of steroids, such as transient flushing or hot flashes, fluid retention, weight gain, elevated blood sugars, and mood swings Adrenal suppression Spinal cord infarction (cervical transforaminal epidural steroid injections with particulate steroids) Cerebral infarction (cervical transforaminal epidural steroid injections with particulate steroids) [43][44][45]

Epidural steroid injections are crucial for managing chronic pain, necessitating care coordination from a multidisciplinary team to ensure patient-centered care, optimal outcomes, and safety. Successful administration of epidural steroid injections hinges on the specialized skills and strategic planning of clinicians trained in pain management techniques, underscored by ongoing education in evidence-based practices. Nurses are integral to the process and responsible for pre- and post-procedural care, including monitoring for complications and ensuring patient comfort. Including physical therapists in the care plan underscores the holistic approach to chronic pain management and rehabilitation. Primary care clinicians should educate patients on lifestyle changes such as regular exercise, discontinuing smoking, maintaining a healthy weight, and avoiding a sedentary lifestyle. Adherence to ethical principles, including informed consent and confidentiality, alongside a commitment to managing patient expectations through clear communication about the benefits and risks of epidural steroid injections, is essential. Interprofessional communication involves informed decision-making and care coordination, ensuring comprehensive discussions about patient selection, risks, and expected outcomes are shared across disciplines.