Steroid Question - page 3

by sewnew

26,333 Views | 26 Comments

I was wondering... What is the rationale for using one steroid over another in an epidural steroid injection? How does the CRNA decide which steroid to use? I am particularly interested in the differences between Kenalog... Read More


  1. 0
    Quote from sleepy26
    Of course it can be incorrectly placed, you have to know what you're looking at. That's why you look at the flow patterns of contrast.

    Any addition of fluid into the epidural space can place pressure on the nerve. The ability to recreate "their pain" during the injection is actually a good sign that you're in the right spot since that is where the medication is going. Of course if you're hitting the nerve with the needle that will hurt too - it's why you use contrast!
    So let me get this straight...I am not quite understanding what you are saying.

    Are you saying that pain radiating down the leg can be both a good thing AND a bad thing? Good because it indicates that the medication is being delivered to the affected nerve and that is what's causing the pain during the procedure. And bad because there is pressure that is being exerted on the nerve by the needle?

    Also, would the pain during the procedure be a good indicator of how effective the ESI will be and how long the patient would experience pain relief post-procedure?

    Looking forward to some clarification...
  2. 1
    Radiating pain down both legs during interlaminar epidural injections can be a sign the needle is misplaced (subarachnoid even without aspirate of CSF, subdural-supraarachnoid), that there is significant scar tissue in the epidural space, that the CSF cross-sectional area is very small (ala spinal stenosis due to disc compression, zygapophyseal hypertrophy, interspinous ligament thickening and calcification, PLL thickening, congenitally short pedicles), that the patient has a chronic pain hypersensitization (NMDA receptor activation, WDR neuron activation), that there is a psychological overlay espeically anxiety, or that the contrast/injectate compression of the dura may result in transmitted pain down the exiting nerve roots. Radiating pain down one leg usually is due to eccentric (errant) needle tip placement. Only if the needle tip is far lateral under the border of the lamina can one actually touch a nerve with the needle tip in the epidural space. Otherwise, it is not possible for the needle tip to ever touch a nerve since the traversing nerve roots lie in the anterior sheeths in the anterior epidural space. The exiting nerve is the only one that could be dinged by a needle in the lateral recess before entering into the neuroforamen.
    So pain referring down the legs is not necessarily a good thing or a bad thing. It can signify one of the pathologies above or may occur without pathology.
    sewnew likes this.
  3. 0
    Your question leads me to question your motives. If I was a betting person, I would put money on the fact that you are either a patient who is contemplating a lawsuit related to an epidural pain block or an attorney trying to get information for a suit.

    If so, this is an inappropriate use of this forum. I would caution those answering to consider the motives of this poster.

    If I am wrong, I apologize. Let us know your background, are you a nurse and what is going on?
  4. 0
    Quote from alterego33
    Your question leads me to question your motives. If I was a betting person, I would put money on the fact that you are either a patient who is contemplating a lawsuit related to an epidural pain block or an attorney trying to get information for a suit.

    If so, this is an inappropriate use of this forum. I would caution those answering to consider the motives of this poster.

    If I am wrong, I apologize. Let us know your background, are you a nurse and what is going on?
    I am neither. I am just a nursing student who is just fascinated with anesthesia and who is an aspiring CRNA.

    I have been fortunate to observe some procedures and that's where all the curiosity and questions came from. Absolutely nothing to do with a lawsuit. I guess you bet wrong...
  5. 0
    Quote from sewnew
    I am neither. I am just a nursing student who is just fascinated with anesthesia and who is an aspiring CRNA.

    I have been fortunate to observe some procedures and that's where all the curiosity and questions came from. Absolutely nothing to do with a lawsuit. I guess you bet wrong...
    Thanks for the clarification. Unfortunately, I have seen the internet, especially medical related sites, used by patients who are searching for answers, attorneys who are looking for clients or experts to defend certain practices. This is frequently seen on areas related to chronic pain. So, forgive the paranoia, but I have sat in courtroom and have seen a plaintiff state that she got her information from the internet. It was quite scary, because although, she had real pain, her allegations about substandard care leading to the pain were way, way, way off.
  6. 0
    For the physicians on this thread, I would appreciate any information you might have on the matter of truly preservative-free depot-medrol or kenalog.

    I remember well the 2000 paper in the New England Journal of Medicine which specified preservative-free depot-medrol (methylprednisolone) for intrathecal injection for postherpetic neuralgia; said specified preservative-free steroid in order to avoid arachnoiditis.

    I would also mention that a mistake I see all the time is misdiagnosing lumbar pain and radiculopathy as coming from the spine/vertebrae/foraminal stenosis/disk ruptures, etc., when in fact the pain and the radiculopathy is coming from the Iliolumbar ligaments, in particular those that insert onto L4 and L5 and originate from the posterior, superior, anterior-surface, Iliac crests. Since, by very carefully placing small amounts of lidocaine at the origins on the Iliac crests, far, far away from the spine, I have often been able to identify damage to the origins of the ligaments as the true cause of particular patients' pain, it appears to me that there is a significant percentage of patients that are being needlessly placed at risk from epidural injections near the spine when that is not where the problem actually is. Just food for thought. Referred pain, as well as radiculopathy, can be very misleading; the brain does not map these areas well at all, and there appears to me to be significant variation in mapping from individual to individual, to a more frequent extent, even, than variations in physical anatomy.

    In the meantime, I continue to be puzzled, as was the student nurse, over the relative merits of depot-medrol versus kenalog. I must say, however, that depot-medrol, with preservatives, does seem to present the higher risk, if used intrathecally or epidurally, but if depot-medrol is being used distally to the spine, such as, for example, into shoulder structures, I have found experientially that depot-medrol is more effective.

    Best Regards To All
  7. 0
    With regards to joint injections (knee, shoulder, hips and hands), which is better to give to the patient, kenalog + lidocaine or depo-medrol + lidocaine? Which one lasts longer and works faster?


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