Efficacy of Particulate Versus Non-particulate Transforaminal Epidural Steroid Injections in Relation to their Complication Risk
Adam Rupp1* and Usman Latif2
1Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA
2Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
*Corresponding Author: Adam Rupp, Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA.
December 22, 2021; Published: March 02, 2022
Background: The FDA released guidelines in 2014 addressing multiple reported neurological complications associated with epidural steroid injections. FDA findings were generalized and did not specify type of steroid. Various cohort studies and systematic reviews have compared particulate versus non-particulate corticosteroids, showing minimal differences in outcomes. Case series and systematic reviews revealed multiple cases of neurological compromise with particulate steroid injections, but none with non-particulate steroid injections. Despite these two premises, practitioners have strongly skewed towards utilizing particulate steroids for transforaminal epidural steroid injections. The Spine Intervention Society (SIS) published guidelines in 2019 taking a stronger stance in favor of the use of non-particulate steroids. This review aims to explore the literature on this controversial subject.
Objectives: This study aims to review the current literature on efficacy for particulate versus non-particulate corticosteroid transforaminal epidural steroid injections in relation to the potential for neurological complications.
Design: Narrative review.
Methods: Literature review of all available evidence was conducted via Google Scholar and PubMed databases. Search terms included: transforaminal epidural steroid injection complications and effectiveness of particulate versus non-particulates in transforaminal epidural steroid injections. Studies of exclusively interlaminar epidural steroid injections were excluded.
Results: There are various studies and case reports citing neurological complications associated with particulate transforaminal steroid injections, ranging from spinal infarct and blindness to death. This is contrasted with no reported cases for dexamethasone. Multiple cohort studies and systematic reviews have been completed comparing the efficacy of particulate steroids to non-particulates. There appears to be a minimal but greater short-term benefit of particulates over non-particulates. This benefit disappears after 2 months in studies that include long-term follow up.
Limitations: This is a limited narrative literature review comparing data ranging from case reports to randomized controlled trials. There was no standardization or secondary statistical data analysis. Further meta-analyses could focus on pooling data to draw broader conclusions.
Conclusions: Numerous studies have shown minimal greater short-term benefit of particulates over non-particulates; however, after factoring in possible neurological risk with particulates, scales have heavily tipped in favor of use of non-particulate steroids. These findings support the use of non-particulate steroids in the context of documented safety concerns with particulate steroids.
Keywords [8-12]: Spine Interventional Society; Transforaminal Epidural Steroid Injection; Non-particulate Corticosteroids; Particulate Corticosteroids; Neurological Complications; Dexamethasone; Triamcinolone; Methylprednisolone; Betamethasone
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