covers common causes of low back pain, indications and techniques of epidural steroid injections- interlaminar, caudal, transforaminal approaches, both surface landmark and guided methods.

1. Epidural steroid injection in
low back pain
DR. DARENDRAJIT MD (PMR)
Department of Physical Medicine and Rehabilitation
AIIMS, Bhubaneswar
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2. INTRODUCTION
 Most common and important clinical, social,
economic, and public health problem
 Life time prevalence - as high as 84%
(Ref.: Interv Neuroradiol 2009)
 Disc prolapse - common cause
 Highest prevalence of disc prolapse: 30-50
years
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3. INTRODUCTION
• Most episodes of acute back pain resolve on their
own in 4 to 6 weeks
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5. Mechanisms Governing Pain in Radiculalgias
• Chemical phenomena
• Edematous phenomena
• Vascular phenomena
• Local inflammation
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6. Chemical phenomena:
• Toxic spill of inflammatory mediators
• phospholipase A-2 (PLA-2), interleukins, and
proteoglycans.
• Action of PLA-2: to release arachidonic acid from cell membranes,
so inhibiting this (which requires steroids) would help decrease the
elaboration of inflammatory mediators
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7. Edematous phenomena:
• Compression of the nerve causes increased permeability of the
intraneural vessels, leading to intraneural edema, and
consequently a nervous dysfunction causing pain
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8. Vascular phenomena
• Compression of the venous plexuses leads to dilatation and then
foraminal venous congestion, disturbing the local circulation
and producing ischemia, edema and demyelinating lesions
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9. Local inflammation
• An autoimmune reaction with respect to discal material causes
an inflammatory reaction with secondary development of
perineural fibrosis
• Spinal ganglion: vulnerable part of the spinal complex and its
mechanical compression can produce neuronal hyperactivity in
the nociceptive transmission system
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10. Epidural corticosteroids in the lumbar spine
• Specific indications
• lumbosacral radiculopathy
• lower back pain syndrome
• spinal stenosis
• post laminectomy syndrome
• phantom limb pain
• vertebral compression fractures
• diabetic polyneuropathy
• chemotherapy related peripheral
neuropathy
• post herpetic neuralgia
• complex regional pain syndrome, or
orchalgia, proctalgia
• pelvic pain syndrome
• Indicated acute pain, chronic benign pain, and cancer related pain
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11. Contraindications
Absolute contraindications:
• Unwilling to consent to the procedure
• Pregnancy (under fluoroscopy)
• Known true anaphylactic reaction and/or allergy
to any constituents of the injectate
• Cauda equina syndrome
• Anticoagulation
• Coagulopathy
• Suspected local or systemic infection.
Relative contraindications
• Hypovolemia
• Diabetes mellitus
• Glaucoma
• severe chronic respiratory
insufficiency (for the posterior
approach)
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12. Mechanism of Action of Steroids
• Anti-inflammatory, direct neuro-membrane stabilization effects, and
modulation of peripheral nociceptor input
• Blocking nociceptor C-fiber conduction and inhibiting prostaglandin
synthesis
• Inhibition of nerve root edema with resultant improved micro-
circulation
• Reduce ischemia and decrease sensitivity of the prostaglandin-
sensitized dorsal horn neurons by inhibiting inflammatory mediators
such as phospholipase A2
• Direct inhibition of C-fiber neuro-membrane excitation 4/27/2019 12

13.  Epidural steroid injection:
 Level 1a evidence
 83% of patients reported relief on day one
(Ref.: Kathmandu Univ Med J, 2005)
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14. PREPROCEDURE STUDIES
• Coagulation studies
• PT, INR
• h/o prolonged bleeding or easy bruising, or is currently taking
medications that interfere with blood coagulation
• Reason for taking the medicines
• Medications known to interfere with clotting are stopped at an
appropriate time prior to the procedure
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15. INFORMED CONSENT
• Risks of nerve damage from direct needle trauma, perforation
of the dura, infection, and bleeding
• Unrecognized, unintentional arterial injection with particulate
corticosteroids can have catastrophic sequelae and is the
possible mechanism for ischemia of the spinal cord with
paraplegia
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16. Approaches available to access the lumbar epidural space
1. Interlaminar: Surface landmark/ “blind” method
Fluoroscopic guided
2. Transforaminal: Fluoroscopic guided
3. Caudal: Surface landmark/ ‘blind’ method
Fluoroscopic guided
Ultrasound guided
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17. ANATOMY
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22. Epidural steroid injection
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23. Materials required
• 5 ml glass syringe/ three-ringed syringe
• 20G spinal needle/ Touhy needle
• 1% lidocaine
• Disposables: syringes
• Strictly aseptic conditions: sterile drapes, clothing, and gloves, and
scrupulous disinfection of the surface of the skin
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24. Materials required
Injectate:
• Particulate: Methylprednisolone acetate 80-120 mg (Depomedrol),
Triamcinolone acetonide (40-80 mg)
• Non-particulate: Dexamethasone acetate (8-12mg),
Betamethasone acetate(6-12mg)
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25. Surface landmark or ‘blind’ method
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26. Surface landmark or ‘blind’ method
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27. Surface landmark or ‘blind’ method
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28. Surface landmark or ‘blind’ method
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29. Surface landmark or ‘blind’ method
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30. Surface landmark or ‘blind’ method
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31. Surface landmark or ‘blind’ method
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32. Surface landmark or ‘blind’ method
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33. Surface landmark or ‘blind’ method
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34. Surface landmark or ‘blind’ method
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35. Surface landmark or ‘blind’ method
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36. Surface landmark or ‘blind’ method
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37. Surface landmark or ‘blind’ method
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38. Surface landmark or ‘blind’ method
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39. Look for
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40. Surface landmark or ‘blind’ method
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41. Surface landmark or ‘blind’ method
Post-procedure:
• Placed in the lateral recumbent position with the head
slightly elevated and the knees flexed for approx. ½ hrs
• May be allowed to leave in a wheelchair but must rest on the
bed for at least 2 hrs
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42. Complications
• Inadvertant injection of the LA either into the
subarachnoid space or into a blood vessel
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43. Fluoroscopic guided inter-laminar ESI
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44. Fluoroscopic guided inter-laminar ESI
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45. Fluoroscopic guided inter-laminar ESI
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46. Fluoroscopic guided inter-laminar ESI
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47. Fluoroscopic guided inter-laminar ESI
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48. Fluoroscopic guided inter-laminar ESI
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54. Complications of IL ESI
• Infections:
• Epidural abscess
• Meningitis
• Osteomyelitis/discitis
• Neurologic:
• Nerve injury
• Paraesthesias
• Paralysis
• • Seizures
• • Increased sciatic pain
• • Headaches
• Ophthalmologic:
• Retinal hemorrhage
• Acute retinal necrosis
• Dural Puncture
• Epidural Hematoma
• Pain at injection site
• Anaphylaxis
• Dysphonia
• Cerebrospinal fluid—cutaneous fistula
• Corticosteroid side effects
• Local anesthetic effects
• Adverse effects of contrast media
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55. Table 1. Results of published reports of lumbar interlaminar ESI
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56. Transforaminal epidural injection
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57. Transforaminal epidural injection
• Purpose and Objectives
• To deliver corticosteroid close to the site of pathology,
presumably onto an inflamed nerve root
• Caudal and interlaminar lumbar epidural injections are
affected by the presence or absence of epidural ligaments or
scarring
• Prevent migration of the posteriorly administered injected
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58. “safe zone”
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59. Transforaminal epidural injection
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60. Transforaminal epidural injection
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61. Transforaminal epidural injection
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62. Transforaminal epidural injection
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63. Transforaminal epidural injection
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64. Complications Transforaminal ESI
• Neural trauma
• Vascular trauma
• Intravascular injection
• Infection
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65. Table 2. Results of published reports on lumbar transforaminal ESI
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66. Caudal ESI
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67. Indications: Caudal ESI
• Disk herniations, or spinal stenosis
• Sacral nerve root scarring
• Coccygodynia
• Rectal pain
• Pudendal neuralgia
• Sacral fracture
• Post radiation sacral radiculopathy
• Sacral metastasis
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69. Caudal ESI
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70. Caudal ESI
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75. Ultrasound guided caudal epidural
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77. Table 3. Results of published reports on caudal ESI
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78. Disadvantages of caudal, lumbar, interlaminar
and transforaminal epidural injections
Caudal
• Requirement of substantial volume of fluid
• Dilution of the injectate
• Extraepidural placement of the needle
• Intravascular placement of the needle
• Atypical anatomy
• Dural puncture
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79. Disadvantages of caudal, lumbar, interlaminar
and transforaminal epidural injections
Interlaminar
• Dilution of the injectate
• Extraepidural placement of the needle
• Intravascular placement of the needle
• Preferential cranial flow of the
solution
• Preferential posterior flow of the
solution
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• Difficult placement in postsurgical
patients
• Difficult placement below L4/5
interspace
• Deviation of needle to nondependent
side
• Dural puncture
• Trauma to spinal cord

80. Disadvantages of caudal, lumbar, interlaminar
and transforaminal epidural injections
Transforaminal
• Intraneural injection
• Neural trauma
• Technical difficulty in presence of fusion and/or hardware
• Intravascular injection
• Spinal cord trauma
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81. 1. Corticosteroid mechanisms of action: direct anti-inflammatory,
neuro-membrane stabilization, and inhibition of nociceptor C-fiber
conduction
2. Specific indications for lumbar IL ESI include radiculopathy, spinal
stenosis, post laminectomy syndrome, and low back pain syndrome
3. Absolute contraindications: coagulopathy, anticoagulant medications,
sepsis, pregnancy, and local infection
4. Fluoroscopic guidance ensures proper placement, and therefore,
delivery of medications
5. Tuohy needles may decrease the risk of dural puncture because of
their blunt tips
Key points
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82. 6. Two different techniques: loss of resistance technique with air, saline,
or the hanging drop technique
7. Basis of transforaminal ESI: To deliver corticosteroid close to the site of
pathology, presumably onto an inflamed nerve root
8. Studies have demonstrated short-term benefits from interlaminar ESI,
especially in patients with radicular pain
9. Evidence for therapeutic lumbar transforaminal ESI: strong for short-
term and moderate for long-term in managing lumbar nerve root pain,
limited in managing pain secondary to lumbar post laminectomy
syndrome and spinal stenosis
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83. 10. Evidence of effectiveness of caudal epidural steroid injections was
strong for short-term relief and moderate for long-term relief
11. Complications related to needle placement: infection, hematoma
formation, abscess formation, subdural injection, intracranial air injection,
nerve damage, intravascular injection, vascular injury, and cerebral vascular
or pulmonary embolus
12. Complications of corticosteroid administration include suppression of
pituitary adrenal axis, Cushing’s syndrome, osteoporosis, avascular necrosis
of the bone, steroid myopathy, epidural lipomatosis, weight gain, fluid
retention, and hyperglycemia.
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