An update on technical and safety practice patterns of interlaminar epidural steroid injections

Abstract

Introduction: Interlaminar epidural steroid injections (ILESIs) are mainstay in the management of low back, neck and radicular pain and are a commonly performed pain management procedure in the United States. Our survey aims to provide an update in practice patterns of ILESIs among interventional pain physicians.

Methods: We distributed a 91-item survey nationwide to private and academic interventional pain physicians who perform epidural steroid injections (ESIs). The survey was distributed via REDCap with a series of questions inquiring about current practices in epidural steroid injections from March 2021 to March 2022. Cross sectional data from survey responses specific to ILESI-related practices were captured and synthesized.

Results: Of 103 complete survey responses, 96 physicians perform ILESIs (cervical, 87.5 %; thoracic, 82.3 %; lumbar 99 %). Nearly all surveyed physicians utilize fluoroscopy (98.1 %) over other modalities like MRI and ultrasound. For CIESIs, dexamethasone was the preferred steroid (52.4 %) over methylprednisolone (23.7 %); the converse was true for LIESIs in which methylprednisolone (44.2 %) was preferred over dexamethasone (32.6 %). The majority of providers performing ILESI's (91.7 %) preferred a Tuohy/Weiss needle while only a small fraction preferred the Quincke needle (7.2 %). Sedation practices were more varied with only about half of providers (47.6 %) offering medications. Furthermore, a great fraction of providers continue to use contrast for LIESIs (97.9 %) and CIESIs (89.6 %).

Discussion: Our survey suggests that despite updated consensus recommendations, variability continues to exist in procedural practice patterns. Highlighting areas of variable adherence to current safety guidelines can assist with what is emphasized in the generation of future evidence-based guidelines. Though our survey was conducted in the context of the COVID-19 pandemic with resultant supply chain shortages, more research is needed to elucidate what variables may factor into why proceduralists may stray from guideline concordant care.

Keywords: Back pain; Epidural steroid injections; Interlaminar epidural steroid injections; Interventional pain procedures; Pain medicine.

Fig. 1

Dexamethasone was the steroid of choice for 52.4 % of providers who perform CIESIs, followed by methylprednisolone (27.4 %), triamcinolone (13.1 %) then betamethasone (7.1 %). For LIESIs, the preferred steroid was methylprednisolone (44.2 %), while 32.6 %, 16.8 % and 6.3 % chose dexamethasone, triamcinolone and betamethasone respectively. n = 84 (CIESIs), n = 96 (LIESIs). Abbreviations: CIESI, cervical interlaminar epidural steroid injection, LIESI, lumbar interlaminar epidural steroid injection.

Fig. 2

2a and 2b: 80 mg is the selected dose of methylprednisolone (68.2 %, 70.0 %) and triamcinolone (70.0 %, 73.3 %) for both CIESIs and LIESIs respectively. Fig. 2c: 10 mg of Dexamethasone is the preferred dose for CIESIs (70.5 %) and LESIs (71.0 %). Fig. 2d: Respondents who use Betamethasone prefer 6 mg for CESIs (66.7 %), while 83.3 % use 12 mg for LIESIs. Abbreviations: CIESIs, cervical interlaminar epidural steroid injection, LIESI, lumbar interlaminar epidural steroid injection.

Fig. 3

For a typical CIESI and LIESI, the most commonly used total injectate used was 3 ml at 36.9 % and 29.5 % respectively. Total injectate volume includes steroid, saline and local anesthetic, if used. Abbreviations: CIESIs, cervical interlaminar epidural steroid injection, LIESI, lumbar interlaminar epidural steroid injection.