16
8/24/2011 1 Epidural Steroid Injections: A Review of the Recent Literature Janette (Jan) Elliott, RN-BC, MS, AOCN September 9, 2011 What is an Epidural Steroid Injection? An injection of a steroid medication into the epidural space with the intent to alleviate pain Epidural anatomy Spinal meninges Pia mater Arachnoid Dura Epidural “outside the dura”

Epidural Steroid Injections: A Review of the Recent · PDF fileEpidural Steroid Injections: A Review of the Recent Literature Janette (Jan) Elliott, RN-BC, MS, AOCN September 9, 2011

  • Upload
    lyngoc

  • View
    215

  • Download
    0

Embed Size (px)

Citation preview

8/24/2011

1

Epidural Steroid Injections:A Review of the Recent Literature

Janette (Jan) Elliott, RN-BC, MS, AOCN

September 9, 2011

What is an Epidural Steroid Injection?

An injection of a steroid medication into the epidural space with the intent to alleviate pain

Epidural anatomy

Spinal meninges

Pia mater

Arachnoid

Dura

Epidural

“outside the dura”

8/24/2011

2

How is it administered?Translaminar: lumbar or cervical

Needle inserted via the midline through the spinal ligament

Patel, V.B. (2009) Techniques for Epidural Injections. Techniques in Regional AnesthesiaAnd Pain Management, 13:217-228.

How is it administered?Transforaminal: lumbar

Transforaminal –lumbar Needle inserted via

a lateral approach to the neuroforamin

Cervical transforaminal steroids no longer recommended

8/24/2011

3

How is it administered?Caudal

Needle inserted thru sacral hiatus

8/24/2011

4

How do steroids work?

Reduce inflammation by blocking transmission of C fiber input.

Steroids decrease inflammation by inhibiting phospholipase A2 action.

Epidural steroid injection places the medication at the site of inflammation

Indications for Epidural Steroid Injection

Herniated nucleus pulposus with nerve root irritation

Herniated nucleus pulposus with nerve root compression

Annulus tear—hasten recovery

Spinal stenosis—transient relief

Post laminectomy syndrome

Contraindications of ESI

Uncontrolled diabetes +/- epidural lipomatosis Bleeding concerns

Anticoagulation Bleeding disorders

Bleeding factor deficiencies Von Willebrand’s disease Idiopathic thrombocytopenic purpura (ITP) Low platelet count Severe liver dysfunction Hemophilia

Infection

8/24/2011

5

Anticoagulants and ESIs

Warfarin (Coumadin) Stop 5 days in advance of procedure

Clopidogrel (Plavix)• Stop 7 days in advance of procedure

Low Molecular weight heparin (Enoxaparin)• Last dose 24 hours prior

Ticlopidine (Ticlid)• Stop 14 days prior

Anticoagulants and ESIs (cont)

Platelet GP IIb/IIIa receptor antagonists abciximab (Reopro) iptifibatide (Integrilin) tirofiban (Aggrastat)

Stop 5 days in advance of procedure Resume on postop day Enoxiparin bridge

Horlocker, T. et al, (2010) Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Regional Anesthesia and Pain Medicine. Volume 35(1), January/February 2010, pp 64-101, DOI: 10.1097/AAP.0b013e3181c15c70

Newer Anticoagulants

Dabigatran (Pradaxa)

Rivaroxaban (Xarelto)

Apixaban (Eliquis)--investigational

Dabigatran and Rivaroxaban approved in post-op total hip and knee patients

Research in other settings

Liau, J.V. and Ferrandis, R. (2009) New Anticoagulatns and Regional Anesthesia. Current Opinion in Anaesthesiology, 22:661-666.

8/24/2011

6

How is the procedure performed? Lumbar

Prone—Preferred Sitting—if person too heavy for procedure table, blind stick Side lying—more likely used with inpatients, blind stick Caudal – through sacral hiatus Loss of resistance technique +/- contrast

Cervical Prone—Preferred, may use fluoro Sitting Loss of resistance or hanging drop technique +/- contrast

Fluoroscopic guidance—current standard of care Ultrasound guidance—help determine depth

Potential complications

Dural puncture—”wet tap”

Hematoma Spinal injury

Direct nerve injury

Infection

Direct nerve injury from needle or pressure of injectate

Vertebral artery dissection

Stroke

Death

Potential side effects of the steroid medication

Localized increase in pain Non-positional headaches resolving within 24 hours Facial flushing Anxiety Sleeplessness Fever the night of injection High blood sugar A transient decrease in immunity because of the

suppressive effect of the steroid Stomach ulcers Severe arthritis of the hips (avascular necrosis) Cataracts

Staehler, R. (2007) Epidural Steroid Injections: Risks and Side Effects. Downloaded 8/10/11 from http://www.spine-health.com/treatment/injections/epidural-steroid-injections-risks-and-side-effects

8/24/2011

7

Epidural Space Identification

?? Liquid or air as medium for loss of resistance

5 publications included in a meta analysis

Hypothesis: LOR technique with liquid medium associated with fewer epidural-related complications

Results Not statistically different in obstetric population

Small statistically difference (1.5%) in chronic pain population for post dural puncture headache with fluid

Schier, R. et al, (2009) Epidural Space Identification: A Meta-Analysis of Complications After Air Versus Liquid as the Medium for Loss of Resistance. Anesthesia & Analgesia, 109:2012-2021.

Identification of Cervical Spinous Level

Control group—palpate for C7 with patient in anatomical position, N=48

Flex/Ex group—palpate for C& for flexing and extending patients neck, N=48

Used fluoro to confirm accuracy

Control—37.5% accurate

Flex/Ex—77.1% accurate

Shin, S., Yoon, D, and Yoon, K.B. (2011) Identification of the Correct Cervical Level by Palpation of Spinous Processes. Anesthesia-Analgesia, 112(5): 1232-1235

Ultrasound Guidance

Advantages Portability, cost, ability to see soft tissues, lack of

radiation

Help identify needle depth 100% lumbar L4/5, less at higher levels

Helpful in pediatric/infant populations

8/24/2011

8

Ultrasound Guidance (cont)

Limitations Lack of contrast medium for visualization of

vascular structures

Small window for visualization of needle, injectate and dura mater.

Requires 2 people

Shankar, H and Zainer, C. (2009) Ultrasound guidance for Epidural Steroid Injections. Techniques is Regional Anesthesia and Pain Management, 13:229-235.

Quality of Evidence Developed by U.S. Preventive Services Task Force

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

11-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence

III: Opinions of respected authorities, based on clinical experience descriptive studies and case reports or reports of expert committees

Adapted from Berg, A.O. and Allan, J.D. (2001) Introducing the Third U.S. Preventive Services Task Force. American Journal of Preventive Medicine, 20:21-35.

Outcome measures

Short term relief--< 6 months

Long term relief--> 6 months

Improvement in function or psychological status This wasn’t always commented on in the reviews

Return to work Not commented on in the reviews

Reduction in opioid intake Not commented on in the reviews

All of these reviews done by the same clinical group

8/24/2011

9

Buenaventura--Lumbar Transforaminal

Systematic Review—4 randomized studied included

Results Short term– level II-1

Long term—level II-2

Pain reduction—64-81%

Disability reduction—60-63%

Reduce depression—56%

Buenaventura, R.M., Datta, S., Abdi, S. and Smith, H.W. (2009) Systematic Review of Therapeutic Lumbar Transforaminal Epidural Steroid Injections. Pain Physician, 12:233-251.

Benyamin-Cervical Interlaminar

Systematic Review—1,994 reviewed--3 systematic reviews, 3 randomized studies and 5 observational studies included

Studies included multiple injections

Some used local anesthetic alone instead of steroid

Results—Level II-1 Pain reduction—68-79% at 6 months

Disability reduction—not reported

Reduce depression—not reported

Limitation—paucity of available research

Benyamin, R. et al (2009) Systematic Review of The Effectiveness of Cervical Epidurals in the Management of Chronic Neck Pain. Pain Physician, 12:137-157.

Parr—Lumbar InterLaminar

Systematic Review—1,647 reviewed—8 systematic reviews, 20 randomized studies and 30 observational studies included

Studies included multiple injections

Some used local anesthetic alone instead of steroid

Results— Level II-2 for short term and level III for long term--disc

herniation or radiculitis

Level III for short and long term—spinal stenosis and discogenic pain without radiculitis or hernation

8/24/2011

10

Parr—Lumbar InterLaminar (cont)

Pain reduction—at 3, 6 and 12 months no significant difference for disc herniation or

radiculitis Significant difference in 1 study at 3 months,

no significant difference at 6 or 12 months Disability reduction—not reported Reduce depression—not reported

Parr, A.T., Diwan, S., and Abdi, S. (2009) Lumbar Interlaminar Epidural Injections in Managing Chronic Low back and Lower Extremity Piana; A Systematic Review . Pain Physician, 12:163-188.

Conn—Caudal

Systematic Review—3,387 reviewed—18 randomized studies and 20 observational studies included

Studies included multiple injections

Some used local anesthetic alone instead of steroid

Conn—Caudal (cont)

Results— Level I for short and long term for disc herniation and/ and/or

radiculitis and discogenic pain

Level II1 or II-2 for Post-laminectomy syndrome and spinal stenosis

Pain reduction

56-81% for disc herniation or radiculitis

65-77% post-laminectomy syndrome

Disability reduction—not consistently stated in the review

One study showed > 40% decrease in 55-70% of patients

Conn, A., Buenaventura, R.M., Datta, S., Abdi, S and Diwan, S. (2009) Systematic Review of Caudal Epdiural Injections in the Management of Chronic Low Back Pain. Pain Physician, 12:109-135.

8/24/2011

11

Abdi--Epidural Steroids

Combines all types of ESIs < 6 weeks short term and > 6 weeks long term Concludes:

Moderate evidence for interlaminar cervical and lumbar for long term relief

Moderate for cervical and lumbar transforaminals for long term relief in nerve root pain

Moderate evidence for caudal for long term relief in nerve root pain and chronic LBP

Adbi, et al. (2007) Epidural Steroids in the Management of Chronic Spinals Pain: A Systematic Review. Pain Physician, 10:185-212

Boswell-Practice Guidelines-2007

Includes all spinal procedures but puts into separate procedures

Caudal--states the reviews come to different conclusions from the same studies

Concludes Chronic LBP and radicular pain

Short term benefit--strong Long term--moderate

Post laminectomy syndrome and spinal stenosis Limited evidence

Boswell-Practice Guidelines

Concludes Interlaminar in lumbar radiculopathy

Short term--strong Long term--limited

Interlaminar in postlaminectomy syndrome Limited

Interlaminar in cervical radiculopathy Short term & long term--moderate

Transforaminal lumbar Short-term--strong Long term--moderate

8/24/2011

12

Boswell-Practice Guidelines (cont)

Transforaminal cervical Short and long term--moderate

Evidence is indeterminate in managing axial LBP, axial neck pain, and lumbar disc extrusions

Boswell et al, (2007) Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician: 10:7-111.

ASIPP IPM Guidelines-2009

Chronic Spinal Pain Interventional Techniques

Comprehensive review

Manchikanti, L. et al (2009) Comprehensive Evidence-Based Guidelines for interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician: 12:699-802.

ASIPP--Caudal

Level 1—caudal for disc herniation or radiculitis and discogenic pain

Level II-1 or II-2 for post-laminectomy and spinal stenosis

8/24/2011

13

ASIPP—Cervical, Lumbar & Thoracic Interlaminar

Level II-1 or II-2

ASIPP Common Indications for ESIs

Chronic pain poorly responsive to non-interventional or non-surgical therapy Disc herniation or radiculitis

Spinal Stenosis

Post spinal surgery syndrome

Epidural fibrosis

DDD/discogenic pain

Absence of facet pain

Pain causing functional disability

Average pain level > 6

“Other causes”

Transforaminal Cervical ESIs Fallen into disfavor Catastrophes

Cerebellar and cerebral infarcts Spinal cord injury and infarction Massive cerebral edema Visual defects r/t vascular occlusion Persistent neurological deficits Transient quadriplegia Subdural hematoma

Unknown incidence, but “rare”

Adbi, et al. (2007) Epidural Steroids in the Management of Chronic Spinals Pain: A Systematic Review. Pain Physician, 10:185-212

8/24/2011

14

Frequency of ESIs

One week apart if in diagnostic phase, 2 weeks preferred in cancer pain

2 months or longer in therapeutic phase provided > 50% pain relief ofr 6-8 weeks

Repeated only as necessary according to medical necessity criteria

Limit to a max of 4-6 per year Manchikanti, L. et al (2009) Comprehensive Evidence-Based Guidelines for interventional

Techniques in the Management of Chronic Spinal Pain. Pain Physician: 12:699-802.

What steroid does one use?

Depends on the type of ESI to be performed

Cerebral/cerebellar complications occur mainly through intravascular embolization of the particulate steroid in transforaminal ESIs

No CNS events reported with interlaminar ESIs

No CNS events reported with non-particulate steroid

Medications

Methylprednisolone (Depo-medrol)

Triamcinolone (Kenalog)

Dexamethasone (Decadron)

Betamethasone (Celestone) Betamethadone sodium phosphate/betamethasone acetate

Betamethasone repository (compounded drug) Betamethadone sodium phosphate/betamethasone acetate

Betamethasone sodium phosphate

No study has directly compared efficacy

8/24/2011

15

Comparison of Drugs

Measured using laser scanning confocal microscope

Compared diluted vs non-diluted drug

Compared to size of blood vessels

Derby measured size of blood vessels

Steroid Medications Methylprednisone 80mg/ml with more particles than

40mg/ml

Compounded betamethasone with more particles than commercial betamethasone

No statistical difference between methylprednisolone and triamcinolone and compounded betamethasone

INCREASED proportion of particles in MORE HIGHLY DILUTED methylpredsinolone 80mg/ml

Otherwise dilution decreased % larger particles

Dexamethasone and betamethasone phospate were pure liquid

Steroid Medications Recommended

Benzon recommends non-particulate steroid betamethasone phospate for transforaminal ESIs

Benzon states dexamethasone should be used with caution until further studies clarify safety and efficacy

Derby states “interventionalists might consider using a nonparticulate steroid when performing cervical transforaminal injections”

Derby states “Dexamethasone is less likely to cause arterial or capillary obstruction…”

Benzon, H.T. et al. (2007) Comparison of the Particle Sizes of Different Steroids and the Effect of Dilution. Anesthesiology, 106:331-8

Derby, R. et al (2008) Size and Aggregation of Corticosteroids Used for Epidural Injections. Pain Medicine, 9(2): 227-234.

8/24/2011

16

Summary ESIs most used interventional technique

Many patients achieve significant benefit

Conflicting results from systematic reviews

None reach Level I evidence

No specific medication recommendations for interlaminar ESIs

Non-particulate medications recommended for transforaminal ESIs

Debate as to whether to do cervical transforaminal injections

ASRA recommendations for anticoagulation

Use of fluoroscopy is standard of care

References: Adbi, et al. (2007) Epidural Steroids in the Management of Chronic Spinals Pain: A

Systematic Review. Pain Physician, 10:185-212

Benyamin, R. et al (2009) Systematic Review of The Effectiveness of Cervical Epidurals in the Management of Chronic Neck Pain. Pain Physician, 12:137-157.

Benzon, H.T. et al. (2007) Comparison of the Particle Sizes of Different Steroids and the Effect of Dilution. Anesthesiology, 106:331-8

Berg, A.O. and Allan, J.D. (2001) Introducing the Third U.S. Preventive Services Task Force. American Journal of Preventive Medicine, 20:21-35.

Boswell et al, (2007) Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician: 10:7-111.

Buenaventura, R.M., Datta, S., Abdi, S. and Smith, H.W. (2009) Systematic Review of Therapeutic Lumbar Transforaminal Epidural Steroid Injections. Pain Physician, 12:233-251.

Conn, A., Buenaventura, R.M., Datta, S., Abdi, S and Diwan, S. (2009) Systematic Review of Caudal Epdiural Injections in the Management of Chronic Low Back Pain. Pain Physician, 12:109-135.

Derby, R. et al (2008) Size and Aggregation of Corticosteroids Used for Epidural Injections. Pain Medicine, 9(2): 227-234.

Horlocker, T. et al, (2010) Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Regional Anesthesia and Pain Medicine. Volume 35(1), January/February 2010, pp 64-101, DOI: 10.1097/AAP.0b013e3181c15c70

References (cont) Liau, J.V. and Ferrandis, R. (2009) New Anticoagulatns and Regional Anesthesia.

Current Opinion in Anaesthesiology, 22:661-666.

Manchikanti, L. et al (2009) Comprehensive Evidence-Based Guidelines for interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician: 12:699-802.

Parr, A.T., Diwan, S., and Abdi, S. (2009) Lumbar Interlaminar Epidural Injections in Managing Chronic Low back and Lower Extremity Piana; A Systematic Review . Pain Physician, 12:163-188.

Patel, V.B. (2009) Techniques for Epidural Injections. Techniques in Regional Anesthesia And Pain Management, 13:217-228.

Schier, R. et al, (2009) Epidural Space Identification: A Meta-Analysis of Complications After Air Versus Liquid as the Medium for Loss of Resistance. Anesthesia & Analgesia, 109:2012-2021 Shankar, H and Zainer, C. (2009) Ultrasound guidance for Epidural Steroid Injections. Techniques is Regional Anesthesia and Pain Management, 13:229-235.

Shin, S., Yoon, D, and Yoon, K.B. (2011) Identification of the Correct Cervical Level by Palpation of Spinous Processes. Anesthesia-Analgesia, 112(5): 1232-1235

Staehler, R. (2007) Epidural Steroid Injections: Risks and Side Effects. Downloaded 8/10/11 from http://www.spine-health.com/treatment/injections/epidural-steroid-injections-risks-and-side-effects