Steroid Question

Happy Halothane · Sep 22, 2008

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.

paindoc · Sep 22, 2008

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 · Sep 23, 2008

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!

paindoc · Sep 25, 2008

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....

Happy Halothane · Sep 25, 2008

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.

paindoc · Sep 25, 2008

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 · Sep 26, 2008

Thanks again for your answers.

BTW, paindoc, are you an interventional pain management specialist??? (I am just assuming this from your screen name.)

paindoc · Sep 26, 2008

I am a comprehensive pain physician...interventional is one part of what I do....

sewnew · Sep 26, 2008

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?

paindoc · Sep 27, 2008

The manufacturers never applied to the FDA for that usage. The common usage administered epidurally is so prevalent that the manufacturers elected not to spend the tens to hundreds of millions of dollars to have the FDA approve an already commonly employed practice.

Happy Halothane · Sep 28, 2008

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.
___
Fluoroscopy or not, intrathecal injection is still a very real risk when administering epidural treatments. I'm sure you inform every one of your patients of the slight risk of a wet tap, right?
There is no need to "fundamentally change the way we practice pain medicine." That seems a just a little perponderant, don't you think? Epidural injection can inadvertantly become intravascular or intrathecal. "It seems fluoroscopy guidance may not prevent intrathecal perforation or spinal cord penetration"(Tripathi. Anesth Analg 2005;101:1209-1211).

Injecting an alcohol into the CSF would be deleterious, would you not agree?

So what makes it acceptable to administer a drug via a route not approved by the FDA? Because its common practice...because everyone does it?

Is that how you would respond to an attorney during a trial?
Nelson DA. Arch Neurol. 1988 Jul;45(7):804-6.
"Dangers from methylprednisolone acetate therapy by intraspinal injection."
Section of Neurology in Medicine, Medical Center of Delaware, Wilmington.
"Clinical trials first began in 1960 with methylprednisolone acetate (Depo-Medrol) administered intrathecally, in an attempt to treat both disk disease and multiple sclerosis. After a few reports of salubrious results, there began an outpouring of contradictory data, which continues in 1988. During this time span, researchers who cautiously tested the different theses of improvement began to publish serious warnings of many complications. For ten years prior to the intraspinal use of methylprednisolone acetate, basic scientists in anesthesiology and neurochemistry had published the following facts:
(1) Methylprednisolone acetate's content of polyethylene glycol raises the risks of using it near the central nervous system.
(2) Deleterious effects follow the use of glycols when they are placed into or near the neuraxis.
(3) Methylprednisolone acetate contains approximately 30 mg of polyethylene glycol per milliliter.
(4) When that glycol, which is both alcohol and detergent, is injected intraspinally, sterile meningitis, arachnoiditis, or pachymeningitis will occur.
It has also been recognized since the 1960s that the epidural space is not wholly separate from the subdural and/or subarachnoid space. Many thousands of arachnoid villi subtend all the membranes from the intrathecal space, and many of these end in the large epidural veins. Therefore, the various spaces and membranes are not only contiguous, but continuous.
It follows that an injection of methylprednisolone acetate into the epidural space does not guarantee that it will remain isolated there.
Finally, the inadvertency of injections by the epidural route occurs with the following frequency: 40% of injections can be inadvertently made into interspinous ligaments, and 2.5% into the subarachnoid space.
PMID: 3291836"