How Safe Is Epidural Steroid Injection? Examining Drug-Related Factors
While the frequency of serious complications due to ESI is undefined, certain pharmaceutical characteristics of corticosteroids (ie, particulate vs nonparticulate) are thought to contribute to overall risk.
Epidural steroid injection (ESI) … involves administration of corticosteroids into the epidural space around the spinal cord and nerves.
The beneficial effects of ESI are proposed to include decreased production of inflammatory mediators, depressed nerve conduction, and dilution of local concentrations of endogenous inflammatory cytokines.
Although the majority of controlled studies of ESI for LBP and neck pain document a moderate and transient benefit from ESI,1 there is controversy over whether these benefits are long-term.
Examples of serious adverse events include inadvertent injection of drug into a vein or artery, which can result in debilitating or fatal infarction of the brainstem or spinal cord.
Available review articles highlight the infrequent nature and difficulty of quantifying the risk of severe adverse events, despite large sample sizes. For example, one 7-year retrospective review in which 4,265 ESIs were administered to 1,857 patients reported no major complications.7 The majority of data describing disastrous complications from ESI come from case reports.
It seems it would be very difficult to get a doctor to admit anything but the most obvious and serious adverse events. Anything else can be blamed on the patient’s condition getting worse.
Of 1,340 surveyed physicians, 21.4% responded, revealing 78 total ESI complications in patients receiving cervical transforaminal ESI. Serious complications included 16 brain infarcts, 12 spinal cord infarcts, and 2 combined brain/spinal cord infarcts; death occurred in 13 cases. Corticosteroids were used in 70 of the cases with reported complications. The reported corticosteroids included triamcinolone, betamethasone, and methylprednisolone, which were associated with 10%, 11%, and 79% of complications, respectively
While the frequency of serious complications due to ESI is undefined, certain pharmaceutical characteristics of corticosteroids are thought to contribute to overall risk.1,24 For example, the size of aggregated drug molecules may affect the likelihood of embolization following inadvertent injection into vertebral or foraminal arteries.
Other pharmaceutical characteristics presumed to increase risk of injury include the presence of the neurotoxic preservatives polyethylene glycol (PEG) and benzyl alcohol.1 However, controversy exists regarding which is the offending agent