Steroid Question

  1. 0
    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 and Depo-Medrol. What are the pros and cons of using each?

    Thanks in advance!
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  4. 26 Comments so far...

  5. 1
    Steroid anti-inflammatory drugs/adrenocorticosteroids generally fall into 3 main categories: glucocorticoids, mineralcorticoids, and corticosteroids.

    Both Depo-medrol and Kenalog are glucocorticoids. Depo-medrol is better known as methylprednisolone/Solu-Medrol. Kenalog is better known as triamcinolone. Both have very similar anti-inflammatory strengths (5x as strong as cortisone, 1/6 as strong as dexamethasone).

    Kenalog is intermediate-acting, while Depo-medrol is more short acting. Both have no salt-retaining properties.

    Keep in mind that neither are FDA approved for epidural injection, even with substantial evidence-based research. So it would be considered an "off-label" route. An important consideration would be the depot preparation; preservative-free is a must for intrathecal/epidural injections. Kenalog-40 is made without the traditional polyethylene glycol (can be neurotoxic).

    The goal of an epidural steroid injection is not to cure, but to limit pain so that the patient can progress in rehabilitation...to live a more normal life.

    Hope this helps.
    sewnew likes this.
  6. 1
    The subject is much more complex than a simple pro or con list, and I would suggest anyone considering injecting epidural steroids be fully versed in the information contained in the package insert (including their composition, preservatives, etc), are completely aware of all potential side effects that may occur, recognize that 40% of the time the procedure is being performed as a scamming of patients (sitting epidurals without fluoroscopic confirmation are not even in the target area 40+% of the time), that you have a thorough understanding of the pathophysiology, diagnostic criteria, various routes and techniques of steroid injections, are familiar with the effectiveness data for epidural steroids, and have done a complete neurological workup and history to assure epidural steroids with all their side effects are even appropriate. After conquering these absolutely minimal prerequisites for performance of epidural steroid injections, then one should consider using them.
    sewnew likes this.
  7. 0
    Thank you both for your answers. They have been very informative.

    One last question if you don't mind. If the ESI is performed under fluoroscopic guidance, does the possibility still exist that the needle can be placed in the wrong position? Would pain radiating down the patient's leg during the procedure (after the administration of the local anesthetic) indicate an incorrect needle position?

    Thanks again!
  8. 1
    Particulate corticosteroids all contain preservatives. Kenalog 40 contains the neurotoxin benzyl alcohol and polysorbate 80, a preservative. Depomedrol single dose also has a preservative MPC, which you have probably never heard of. Both have adrenalcorticoid activity and cause salt retention and peripheral edema. Depomedrol and Kenalog clinically have the same duration of action.

    Fluoroscopy helps protect patients from people blindly sticking needles into the spine and into neural structures. But a feral practitioner using blind techniques will still be a feral practitioner using fluoro techniques. Fluoro cannot prevent the practitioner from injuring the patient, but can help the careful practitioner from injuring a patient. Of course fluoroscopy has its own degree of ionizing radiation that can cause injury, and anyone using fluoroscopy should be well versed in dosage curves, ALARA principles, effect of kV and ma on scatter and direct radiation and be familiar with a multitude of techniques to reduce these....
    sewnew likes this.
  9. 1
    Quote from paindoc
    Particulate corticosteroids all contain preservatives. Kenalog 40 contains the neurotoxin benzyl alcohol and polysorbate 80, a preservative. Depomedrol single dose also has a preservative MPC, which you have probably never heard of. Both have adrenalcorticoid activity and cause salt retention and peripheral edema. Depomedrol and Kenalog clinically have the same duration of action.
    I suppose my wording created misnomer. Your absolutely right that Kenalog-40 does contain BnOH. Any alcohol is considered neuro-toxic..but I would consider it to be an improvement over the issue on polyethylene glycol-causing adhesive arachnoiditis.

    I would consider Polysorbate 80 to be more of an emulsifier...it's commonly utilized in "preservative-free" eye gtts.

    Both Kenalog and Depomedrol have insignificant mineracorticoid properties.
    sewnew likes this.
  10. 1
    Actually, there is no evidence polyethylene or polypropylene glycol cause adhesive arachnoiditis, but there is speculation by those that have no proof of such. If you have proof, please present it here as it would fundamentally change the way we practice pain medicine. There is no absolute method of assuring some medication administered epidural or partially transdural would not cross over into the CSF, therefore all epidural injections containing any PEG would be contraindicated according to such thinking.
    Depomedrol and kenalog both cause significant edema in many patients on a dose related nature, therefore definitely have mineralocorticoid activity, as is indicated in the package insert.
    sewnew likes this.
  11. 0
    Thanks again for your answers.

    BTW, paindoc, are you an interventional pain management specialist??? (I am just assuming this from your screen name.)
  12. 0
    I am a comprehensive pain physician...interventional is one part of what I do....
  13. 0
    Quote from paindoc
    Actually, there is no evidence polyethylene or polypropylene glycol cause adhesive arachnoiditis, but there is speculation by those that have no proof of such. If you have proof, please present it here as it would fundamentally change the way we practice pain medicine. There is no absolute method of assuring some medication administered epidural or partially transdural would not cross over into the CSF, therefore all epidural injections containing any PEG would be contraindicated according to such thinking.
    Is this the basis for the reason that both Kenalog and Depo-Medrol are not approved by the FDA for use in ESIs?


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