Epidural steroid injection an alternate pain management option

LAS VEGAS — CDC guidelines issued in response to the opioid crisis have led to many health care providers reducing or eliminating pain control with opioids, Paul J. Christo, MD, MBA, said at PAINWeek 2022.

“The guidelines suggested nonpharmacological therapies and nonopioid therapies,” Christo, associate professor of anesthesiology and critical care medicine at Johns Hopkins Medicine, said. “We’ve seen an interest in procedural interventions and the number of procedural interventions being performed.”

The CDC’s suggestions of nonpharmacological procedures include exercise, weight loss, psychological and sleep interventions, and procedures, he said.

“Injections can be helpful,” Christo said. “We do them for the therapeutic value, diagnostic value, prognostic value and expectations.”

Christo suggested epidural steroid injection (ESI) as one alternative pain management option.

ESI is indicated for neck, back, leg and shooting arm or thoracic pain, he said. The source is nerve root irritation, compression or spinal narrowing from herniated discs or spinal stenosis.

Candidates for ESI include, “patients with radicular pain caused by herniated nucleus pulposus, patients with shorter duration of pain, more leg pain than back pain, intermittent pain, younger [age], no psychological overlay,” Christo said.

Those with pain duration longer than 6 months, degenerative disc disease or spinal stenosis, back pain more than leg pain, poor imaging correlation, failed interventions, constant pain, unemployment due to pain and psychological overlay have unfavorable prognoses.

“Guidelines on when to offer an ESI would say to use conservative therapies first,” Christo said, “such as acetaminophen and exercise.”

Acute pain is considered to be pain that lasts 4 to 6 weeks; after 12 weeks it is chronic, he said.

Sixty percent of more than 40 clinical trials indicate that ESI has short-term benefits, Christo said.

“For acute pain, engage in conservative therapies,” he said, “but, personally, if I had radicular pain, I’d like to have these earlier. It’s not easy to function with shooting leg pain that lasts a month.”

Side effects tend to be minimal and include post-injection headache and some nausea.

“The risk of postdural puncture is pretty low,” he said. “Patients with diabetes may see an escalation of blood glucose levels. Based on retrospective studies, there’s a slight increase vertebral fracture risk.”

Christo said he is unaware of any consistent guidelines or randomized clinical trials addressing frequency.

“Some will say no more than three injections in the same location in a 12-month period,” he said. “The reason is due to the risk of hypothalamic-pituitary-adrenal axis suppression, which can lead to complications. There is no consensus. I’d keep it to four per year if you can.

“Also with ESI, we don’t have guidelines on the dose of steroids and which one,” he continued. “It’s a mixture. We don’t have randomized clinical trials on how to perform these and the ideal dose.”

Christo also discussed facet blocks, radiofrequency denervation, sacroiliac joint injection, neuromodulation, spinal cord stimulation, dorsal root ganglion stimulation, peripheral nerve stimulation and intrathecal drug delivery as other alternatives to opioids.