Corticosteroid Choice In Epidural Injection

Executive Summary

  • Major decision branch point is particulate (DepoMedrol, Kenalog, Celestone) versus non-particulate (Decadron).
  • Serious complications have been documented with particulate steroids AND nonparticulate steroids.
  • Studies have not demonstrated the superiority of particulate or non-particulate steroid in terms of efficacy (specifically in Cervical TFESI).
  • Lumbar TFESI studies lacked statistical significance between groups using particulate and non-particulate steroids.
  • Digital subtraction should be used in transforaminal injections if available to maximize identification of aberrant or variant arterial anatomy.
  • Source Paper

Adverse Effects

There is, however, an increasing burden of evidence of a wide array of adverse events following cervical and lumbar ESIs including but not limited to spinal cord infarction with subsequent paralysis [4–7], cerebellar and brainstem infarction with and without herniation [8, 9], cortical blindness [10], and death [11, 12].

Dose Ranges

Generally, dexamethasone is used in dosages from 10 – 15 mg in volumes of 1-3 mL. Particulate steroid ranges are around 80 mg for DepoMedrol and 60 mg for Kenalog.

Interlaminar Caudal ESI

While interlaminar and even caudal injections have case reports of paralysis in the literature [68], these procedural routes clearly have a lower risk of this particular complication due to the known vascular anatomy of the spinal column. Therefore, the main consideration with these approaches is the efficacy of the corticosteroid. There are currently insufficient data to give a clear recommendation on which corticosteroid should be utilized for these procedures.

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