Objective: Epidural steroid injections (ESI) are used extensively to treat radicular back pain. This study is designed to evaluate the types and dosages of steroids commonly used and understand prescribing habits of the Texas Pain Society pain management physicians. Method: From April to May 2014, we sent all 270 Texas Pain Society members a questionnaire to complete online. We collected 45 responses. Result: Type of steroid commonly used in injectate: Eighteen (41.9%) phy-sicians reported using methylprednisolone most. Fifteen (34.9%) physicians use triamcinolone, 9 (20.9%) physicians use dexamethasone, 1 (2.3%) uses betamethasone, and 2 skipped this question. Important factors influencing the type of steroid use in injectate: Half of the physicians reported that the location of the ESI was most important (19 responses, 48.7%). Ten (25.6%) reported that the approach of the ESI was most important. Another ten (25.6%) agreed that the potency of the steroid was most important. Dosage of steroid used in injectate: About half of the physicians use a fixed dose of steroid (22, 51.2%) while 21 (48.8%) use a variable dose of steroid. Of those who use a fixed dose of steroid, many use methylprednisolone 80 mg (9, 39.1%). Of those who use a variable dosage of steroid, the most important factor in their determination of the dosage is the patient’s comorbidities (20 responses, 58.8%). The use of depo-steroid in injectate: Thirty-two out of 43 (74.4%) use depo-steroid while 11 out of 43 (25.6%) wouldn’t use depo-steroid. Of those who use depo-steroid, the duration and availability in the epidural space is the most common reason for its use (23, 76.7%). Conclusion: By using a simple questionnaire detailing what types and dosages of steroids are used, compiling a list of best practices can help Texas Pain Society physicians tremendously in the treatment of radicular back pain.
Chronic radicular back pain is a common health problem that debilitated millions of people in the United States annually [
Currently, the most commonly used preparations of steroid for neuraxial blockage are betamethasone acetate, dexamethasone, triamcinolone acetonide and diacetate, and methylprednisolone acetate [
This study did not require approval from our internal review board. With the approval of the Texas Pain Society, 270 contacts were released to the principle investigator. At the beginning of April 2014, an email was sent to all Texas Pain Society members detailing the purpose of the study and inviting each member to complete a questionnaire through an interactive link (Appendix). Every two weeks since April 2014, an email was sent out to remind members to complete the online survey until the end of May 2014. The names and responses of the physicians were kept confidential and no incentives were given for their participation in the survey.
After the two-month survey period, we collected 45 out of 270 surveys (16.6 %). Of the 45 surveys received, 34 responses were from anesthesia trained pain physicians (79.1%), 8 responses were from PMNR (physical medicine and rehab) trained physicians (18.6%), 1 response (2.3%) was from a neurology trained pain physician, 1 response (2.3%) was from a family medicine trained pain physician, and 1 response was from a physician who chose not to answer this question.
Of the 45 surveys received, 18 (41.9%) physicians reported that they use methylprednisolone most in their injectate. Fifteen (34.9%) physicians use triamcinolone, 9 (20.9%) use dexamethasone, 1 (2.3%) uses betamethasone, and 2 physicians did not comment on the most common type of steroid used in their injectate, stating that the type of steroid used depends on the location of the epidural steroid injection (
Almost half of the physicians in the survey reported that the most important factor guiding their selection of steroid in their injectate is the location of the epidural steroid injection (19 responses, 48.7%). Ten (25.6%) physicians stated that the most important factors in determining the type of steroid used is the approach of the epidural steroid injection (interlaminar vs. caudal vs. transforaminal). Another ten (25.6%) physicians agreed that the most important factor is the potency of the steroid (
menting on reasons such as formulary, absorption, and non-particulate preparations of the steroid as being the most important factor in their selection of the steroid used in their practice.
About half of the physicians in the survey use a fixed dose of steroid (22 responses, 51.2 %) while 21 physicians (48.8%) use a variable dose of steroid in their practice. Of those who use a fixed dose of steroid, many use methylprednisolone 80 mg in their injectate (9 responses, 39.1%). The second most common type and dosage of steroid used is dexamethasone 10 mg (4 responses, 17.4%) (
Of the 45 surveys collected, 2 physicians did not comment on the use of depo-steroid in their practice. Thirty-two out of 43 physicians (74.4%) stated that they use depo-steroid while 11 out of 43 (25.6%) would not use depo-steroid. Of those who use depo-steroid, the duration and availability of the depo-steroid is the most common reason for its use (23 physicians, 76.7%). Ten percent of physicians use depo-steroid because of its potency and another 10 percent use depo-steroid due to its safety. On the other hand, only one physician stated that the cost and market availability of depo-steroid is the reason for its use in his/her clinical practice.
One out of 45 physicians did not comment on the use of compound steroid. However, of the 44 physicians, 38 (86.36%) stated that they would not use compound steroid in their practice. Of the six physicians who use compound steroid, 4 (66.67%) stated that the cost and availability of this steroid preparation is the main reason for
its use. One physician noted that the reason for its use is its duration and availability in the epidural space while another stated that the safety profile is the reason for its use in the clinic. Interestingly, one physician stated that she/he used compound steroid in the past but stopped after the outbreak of fungal meningitis among patients who received contaminated steroid injections manufactured from the New England Compounding Center in Framingham, Massachusetts in 2012.
Even though there are a few types of steroid available, it is challenging for physicians to select the most appropriate steroid in their clinical practice. Furthermore, the Food and Drug Administration has not approved the use of some steroids such as triamcinolone and betamethasone for epidural injections [
In 2005, Blankenbaker et al. from the same institution undertook a study to determine if their result would support that of Stanczak and colleagues. One hundred thirty injections were performed with either triamcinolone (49 patients) or betamethasone (81 patients) and patients were instructed to rank their pain using an 11-point scale (0 = no pain, 10 = maximum pain) during initial visit, 1 day after the procedure, 3 days after the procedure, 7 days after the procedure, and 14 days after the procedure. In contrast, they found that there is no statistical difference between the triamcinolone and the betamethasone group [
Similarly, a few comparative studies since 2005 found no difference in efficacy between selected steroids when used in the epidural space. In 2011, a study that compared dexamethasone and methylprednisolone in the treatment of lumbar radiculopathy by lumbar epidural injection found that both are equivalent in efficacy and adverse effects [
Epidural steroid injections carry a few notable risks, with vasovagal reaction as the most common adverse reaction during the procedure. After the procedure, the most common side effects are nausea, facial flushing, fever, insomnia, non-positional headache, and transient increase in pain [
Interestingly, about half of physicians use a fixed dose of steroid (22 responses, 51.2 %) while 21 physicians (48.8%) use a variable dose of steroid. Of those who use a fixed dose of steroid in their injectate, many use methylprednisolone 80 mg (9 responses, 39.1%). Perhaps the reason for the use of this high dose of steroid is the relatively healthy patient population these physicians see in their clinic, and thus side effects are mitigated. Furthermore, if there is a depression of the hypothalamus pituitary adrenal axis, it is expected to return to normal at 35 days after the procedure in high dose as well as low dose corticosteroid [
On the other hand, of the physicians who use a variable dosage of steroids, the most important factor in their selection of the dosage is the patient’s comorbidities such as diabetes, adrenal insufficiency, etc. (20 responses, 58.8%). High dosage of corticosteroids can be accompanied by adverse metabolic systemic side effects, such as hyperglycemia, especially in diabetic patients. In a prospective randomized study in 84 patients with radicular lower back pain, methylprednisolone 80 mg and methylprednisolone 40 mg showed similar analgesic results and a greater tendency toward hyperglycemia in the group with the higher dosage of steroid. Thus, in diabetic patients, lowering the total dose of steroids in the epidural space is recommended [
Of the 45 responses, two did not comment on the use of depo-steroid. Thirty-two out of 43 physicians (74.4%) stated that they use depo-steroid while 11 out of 43 (25.6%) would not use depo-steroid in their practice. Of those who use depo-steroid, the duration and availability of the depo-steroid is the most common reason for its use (23 physicians, 76.7%). Depo-steroid has the ability to form crystalline deposits, which serve as a reservoir for medication, theoretically prolonging their effect [
Finally, 38 out of 44 physicians (86.36%) stated that they would not use compound steroid in their practice. Of the six physicians who use compound steroid, 4 (66.67%) stated that the cost and availability is the main reason for its use. Costs and availability of medications is an important aspect of patient care that pain specialists deal with everyday. It is understandable, from an economic perspective, how the cost and availability of medications can influence the prescribing habits of the physicians. However, 38 out of 44 physicians would not use compound steroids in their practice perhaps due to the historical outbreak of meningitis in the New England area. In September 2012, the Food and Drug Administration investigated 751 cases of fungal meningitis and localized spinal or paraspinal infections in 20 states with 64 deaths associated with compounded steroids. Even though there are only 2 cases reported in Texas, many Texas pain physicians are hesitant about the use of compound steroids and would prefer brand name steroids.
To our knowledge, this survey is the first of its kind to circulate through the Texas Pain Society. This pilot study focuses on the simplicity of the method, and we expect future modification and replication of this questionnaire to circulate through different pain management organizations. Free-text answers are embedded in the surveys so physicians can response openly about their experience when answering each question. The open-ended answers are reported in the results and incorporated in the figures. We should note that we only received 45 responses from 270 surveys. However, it is worth mentioning that not all Texas Pain Society members are physicians and not all physicians participate in epidural steroid injections. In the future, we will revise this survey and only send to physicians who participate in epidural steroid injections. This will give us a better response rate and allow a simple statistical analysis to make the result even more informative.
Even though epidural steroid injections have been used extensively for the treatment of radicular back pain, there is no gold standard for epidural steroid injections. Currently, the protocols for epidural steroid injections vary greatly with regard to the types and dosages of steroids. Future studies need to be undertaken to implement a protocol for the use of steroids in epidural injections. However, a multicenter, randomized, double blind trial is very difficult for interventional therapies. It is more feasible that as the Texas Pain Society membership expands, a statewide registry can easily be instituted. By using a simple questionnaire detailing what types and dosages of steroids are used and what outcomes are achieved, compiling a list of best practices can help Texas pain physicians tremendously in the challenging yet rewarding treatment of radicular back pain.