What are clinical findings of corticosteroids used in epidural steroid injections (ESIs)?

Updated: Aug 06, 2018
  • Author: Boqing Chen, MD, PhD; Chief Editor: Stephen Kishner, MD, MHA  more...
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The fact that corticosteroids differ significantly in microscopic size has become an important consideration because of an awareness that the larger a particle is, the greater are its chances of occluding a blood vessel should the compound be inadvertently injected intravascularly. A study that analyzed the microscopic size of the aforementioned corticosteroids found the following:

  • Dexamethasone - Particles were 5-10 times smaller than red blood cells, contained few particles, and showed no aggregation.

  • Triamcinolone - Particles varied greatly in size, were densely packed, and formed extensive aggregations.

  • Betamethasone - Particles varied greatly in size, were densely packed, and formed extensive aggregations.

  • Methylprednisolone - Particles were relatively uniform in size, smaller than red blood cells, and densely packed and did not form very many aggregations.

A study that compared dexamethasone and methylprednisone in the treatment of lumbar radiculopathy by lumbar epidural injection found the corticosteroids equivalent in efficacy and adverse effects. [31]

In a randomized, controlled, double-blind trial, caudal epidural injection with local anesthetic with or without steroids was found to be effective in 120 patients with disk herniation or radiculitis, although relief with first and second procedures was significantly higher in the steroid group at 1-year follow-up. [32]  Meta-analysis data indicate that either bupivicaine or sodium chloride with corticosteroids is not effective in the treatment of spinal stenosis or lumbar radiculopathy. However, lidocaine with or without corticosteroids is effective. [33]

Most patients take several days to respond to ESIs. Celestone Soluspan provides an extended anti-inflammatory effect, whereas Depo-Medrol and Kenalog provide a more rapid anti-inflammatory effect that is of shorter total duration.

Multidose vials of Depo-Medrol contain benzyl alcohol, which is potentially toxic when administered locally to neural tissue and may increase the risk of arachnoiditis or meningitis. Thus, for epidural injections, many physicians prefer to use steroid preparations without such preservatives. One option is to use only single-dose vials of the corticosteroids, because these generally do not contain benzyl alcohol. However, for some steroid products, even the single-dose vials may contain at least some preservatives or antimicrobial additives, so physicians should be aware of all of these factors when deciding on the steroid to be used for the injection.

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