Steroid Question

sewnew · Sep 28, 2008

Sorry, I did not intend for this to turn into a heated discussion. These questions are only coming from a nursing student who is an aspiring CRNA...

Nevertheless, Happy Halothane, you raise a very good point...

It seems to me that this study implies that the risks outweigh the benefits in using the aforementioned steroids in ESIs (and of course this process has to be done on an individualized basis depending on the condition of each patient). If this is the case, why have there not been any more recent studies to test this theory? The study you mentioned dates back to 1988. If this is such common practice, don't you think that health care providers who practice pain medicine would want more substantiated evidence about the efficacy of ESIs?

I guess what I am trying to say is, doesn't the modern medical model (and nursing model for that matter) follow the approach of utilizing evidence-based medicine? It seems that the practice of using ESIs does not have well documented evidence that they are effective.

Please correct me if I am wrong...

Happy Halothane · Sep 29, 2008

In all fairness, I selected the article to prove a point...for a discussion that can't be won. There have been countless studies on ESI since then, and the practice of ESI is commonplace--because of evidenced based medicine.

I helped evolve the original question into a non sequitur discussion.

Still, isn't it interesting....administering a medication in a way not intended by the manufacturer, nor approved by the FDA??

I hope our first 2 responses were helpful to you. Happy

Happy Halothane · Sep 29, 2008

I responded earlier....but the post hasn't appeared (hours ago?)

In all fairness, I selected that article to help prove a point...for a discussion that cannot be won. There have been numerous studies regarding ESI since then: ESI is commonly practiced, as a result of evidenced-based medicine.

This discussion has circumlocuted away from your original question, but that's part of what makes forums interesting.

Still, isn't it interesting that medications are being administered in a way not intended by the manufacturer, nor approved by the FDA for that use?

I hope our initial responses were able to answer your question.

Happy

paindoc · Sep 29, 2008

There is no proof of the assertions in the Nelson paper. It is all conjecture based on supposition...he did NO STUDIES. Now if you have any PROOF as I asked for, by all means present it here. It is an insult to the intelligence of this forum to present an opinion paper as science. Surely have have heard of EBM and that OPINION holds virtually no weight at all, unless you are an anesthesiologist. Read the ASA website policy statements....they are based on primarily OPINION and totally disregard scientific process in establishing their dictums. Don't fall into the same trap as the anesthesiologists....if they say it, it must be true.... NOT!!!! Proof goes far beyond quoting 20 year old conjecture papers. There has never been published a scientific paper demonstrating the transferrance of PEG across the dura. It is all conjecture my friend.

As far as common usage, this is a legal defense. I serve as both an expert witness and on state medical review panels and am well versed in what is acceptable from a legal standpoint. I am sure you are also a nationally recognized expert in the field of pain medicine and understand the FDA process, common usage, off label usage, and the requirements for all of these....

Inadvertent subarachnoid injection of steroids, when done by stupid people that do not incorporate fluoroscopy with contrast, can cause arachnoiditis. However, if one knows what they are doing, can interpret in real time epidurograms, myelograms, and subdural injections using the STANDARD OF CARE WHICH IS FLUOROSCOPY (ISIS) with contrast confirmation for all spinal injections, then one would not even broach the subject. Alcohol, such as in Kenalog, can indeed cause problems when injected subarachnoid.

sewnew · Sep 29, 2008

Many thanks to you both for taking the time to answer my numerous questions.

There are just some days when it feels like I will never make it all the way to becoming a CRNA, but it is discussions like these that give me renewed strength to keep pursuing my goals.

Take care!

sleepy26 · Oct 8, 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!

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!

sleepy26 · Oct 8, 2008

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!

In addition to the properties of the steroids, the practitioner may consider the particulate content in relation to where the injection will be. For example, methylprednisolone and triamcinolone are suspensions with particles. If the injection was inadvertently given in an artery, the small particles could embolize the artery and infarct the cord. Dexamethasone is commonly used in high risk cases such as cervical and high-lumbar ESIs.

paindoc · Oct 10, 2008

Agree with the caveat that some patients respond with radiating leg pain with the epidural needle in the multifidus musculature far outside the spine. The safest place for interlaminar injections are with the needle tip ending up dead midline. There are no exiting or traversing nerves that can be injured in the posterior epidural space midline. Particulate steroids (Celestone, Kenalog, Aristospan, Depomedrol) work longer than non-particulates. The epidural space is relatively vascular as can be seen when one injects contrast, then re-examines the patient under fluoroscopy 20 min later. The contrast is essentially all gone from the epidural space in many patients due to vascular uptake. Non-particulates are similarly rapidly removed from the epidural space and therefore do not work as well or as long as the particulates. However in highly vascular fields such as transforaminal injections or near the radicularis magnus, I agree the non-particulates are safer, albeit less effective.

sewnew · Oct 10, 2008

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. :confused:

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...

paindoc · Oct 11, 2008

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.

alterego33 · Nov 7, 2008

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?

sewnew · Nov 7, 2008

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...