Study shows no standardized approach to epidural steroid injections for back pain

Today at the American Academy of Pain Medicine's 25th Annual Meeting, researchers from University of California at San Diego report that no standardized practices exist for administering an epidural steroid injection for back pain. Researchers looked at many factors including: which steroids were given, the amount of steroid used, and whether or not a local anesthetic was mixed with the steroid.

Epidural steroid injections (ESI) are minimally invasive procedures used to treat pain in the neck, arms, back and legs caused by inflamed nerves. While injections in the lumbar (low back) region are low risk, injections in the thoracic (mid back) and cervical (neck) region have the risk of injury to the spinal cord and brain. It usually consists of a steroid diluted with sterile saline, and sometimes also addition of local anesthesia. Controversy exists on the long-term efficacy of this procedure to treat spine associated pain.

To compare currently taught techniques, Yogesh Patel, MD, and his colleagues at UCSD, identified and surveyed attending pain physicians at interventional pain programs in the United States about their protocols regarding ESI. Results showed that no standard protocols with regard to type of steroid, dose or use of local anesthesia exist. In fact, the data showed that while most physicians use a moderate volume and dose of steroid, some physicians are giving very high volumes (up to 10 cc) of steroids in areas such as the cervical epidural space. In limited enclosed areas like the cervical region that volume of medicine could lead to increased pressures which could potentially be painful for patients.

"Epidural steroid injections are an important and common option for the treatment of back pain. However, we found that a great variety of techniques are being used. There is no gold standard," said Dr. Patel, lead author of the study and resident at the University of California at San Diego. "Guidelines may need to be explored with regard to this procedure to increase the effectiveness and decrease risk when using this approach to treat pain."

Dr. Patel's study found there were differences from institution to institution regarding which steroid was preferred for these injections. The most common steroids identified for this procedure and respective dose ranges were: depomedrol (dose range 40-120 mg), celestone (dose range 6-15 mg), decadron (dose range 4-12 mg), and kenalog (dose range 10-80 mg).

"These variations in technique might affect why some patients get better results from ESI than others and may also explain good and poor outcomes. This needs to be explored further," Patel concluded.