What is the history of epidural corticosteroid injections for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Epidural corticosteroid injections reportedly were used first in 1952 by Robecchi and Capra, who claimed to provide relief of lumbar and sciatic pain in a woman after periradicular injection of hydrocortisone into the first sacral root. Sacral epidural injection of steroid by the transforaminal route was largely popularized in Italy and involved passing a needle through the first dorsal sacral foramen to gain access to the first sacral nerve roots.

Caudally administered solutions require a substantial volume so that the injectate reaches the lumbar nerve roots, which lie approximately 10 cm or more cephalad to the site of injection. Frequently, a threaded catheter inserted under fluoroscopic guidance provides more precise anatomical application, thereby avoiding the complications associated with injection of a large volume of fluid. Traditionally, clinicians and investigators have used methylprednisolone or triamcinolone, mixed with variable, often large, volumes of LA and isotonic saline or sterile water, for spinal injections.

Corticosteroids may be administered into the lumbar epidural space through either a caudal or lumbar approach, with the latter approach advocated as more target specific and requiring smaller volumes of injectate. For the same reason, many spine specialists advocate transforaminal steroids because this route of administration is placed more precisely at or near the presumed painful nerve root. Once the drug is injected into the epidural space, the operator has no control over dispersal, which is governed by injection volume and pressure and the anatomy of the epidural space.

Normal epidural ligaments or epidural scarring may obstruct passage of injectate to the desired site. To overcome these perceived difficulties, some operators advocate delivering the drugs into the epidural space immediately surrounding the nerve root. Therefore, the target nerve root is approached with the needle under radiographic guidance along an oblique paravertebral approach. Targeting the root, and not the epidural space, is more likely to deliver the corticosteroid solution to the affected nerve root.

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