What is the role of epidural corticosteroids in pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

Epidural corticosteroids should be used with caution or avoided in some cases of congenital anomaly or prior surgery that has altered the normal anatomy of the epidural space, when corticosteroids may unmask an infection, in patients with coagulopathy, and in patients susceptible to fluid retention and congestive heart failure. Epidural corticosteroids are absorbed systemically, which may cause suppression of adrenal function for up to 2-3 weeks.

Other "red flags" that should warn practitioners considering use of corticosteroids include patients with significant contributing operant and psychosocial factors, clinical presentation suggestive of somatization, nonmechanical back pain, disability related to the lumbosacral syndrome under treatment, normal straight leg raising, and pain that is not decreased by medication of any type. Factors that seem to have no bearing on the decision to use corticosteroids include age, pattern and frequency of pain intensity, results of physical examination, and presence or absence of structural pathology.

Corticosteroids have been advocated using the same techniques and operational procedures as described previously in this article for somatic, transforaminal, and epidural neural blockade. The issues associated with the use of epidural corticosteroids include those attributed to injection technique and local anesthetics. Infection is possible following any injection but is an exceedingly rare complication of epidural corticosteroids and has been documented only in several case reports.

Arterial hypotension has been reported as a complication of epidural steroids unrelated to LA toxicity. Other adverse effects ascribed to corticosteroids have included nausea, vomiting, respiratory insufficiency, insomnia, and facial flushing.

The technical risks of epidural steroid injection include bloody tap, nerve root injury, and dural puncture. Dural puncture usually is associated with postural or low-pressure headaches, which are increased in intensity when the patient is vertical and improve in deliberate fashion when the patient moves to a horizontal position. Bed rest, fluid intake, and caffeinated beverages usually resolve such headaches; however, in some cases, placement of a blood patch is necessary over the presumed site of dural puncture.


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