Epidural steroid injections a review of the recent literature

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Epidural Steroid Injections: A Review of the Recent Literature

Janette (Jan) Elliott, RN-BC, MS, AOCN September 9, 2011

What is an Epidural Steroid Injection?

An injection of a steroid medication into the epidural space with the intent to alleviate pain

Epidural anatomy

Spinal meninges Pia mater Arachnoid Dura

Epidural "outside the dura"

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How is it administered? Translaminar: lumbar or cervical

Needle inserted via the midline through the spinal ligament

Patel, V.B. (2009) Techniques for Epidural Injections. Techniques in Regional Anesthesia And Pain Management, 13:217-228.

How is it administered?

Transforaminal: lumbar

Transforaminal ? lumbar

Needle inserted via a lateral approach to the neuroforamin

Cervical transforaminal steroids no longer recommended



How is it administered?


Needle inserted thru sacral hiatus



How do steroids work?

Reduce inflammation by blocking transmission of C fiber input.

Steroids decrease inflammation by inhibiting phospholipase A2 action.

Epidural steroid injection places the medication at the site of inflammation

Indications for Epidural Steroid Injection

Herniated nucleus pulposus with nerve root irritation

Herniated nucleus pulposus with nerve root compression

Annulus tear--hasten recovery Spinal stenosis--transient relief Post laminectomy syndrome

Contraindications of ESI

Uncontrolled diabetes +/- epidural lipomatosis Bleeding concerns

Anticoagulation Bleeding disorders

Bleeding factor deficiencies Von Willebrand's disease Idiopathic thrombocytopenic purpura (ITP) Low platelet count Severe liver dysfunction Hemophilia


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Anticoagulants and ESIs

Warfarin (Coumadin)

Stop 5 days in advance of procedure

Clopidogrel (Plavix)

? Stop 7 days in advance of procedure

Low Molecular weight heparin (Enoxaparin)

? Last dose 24 hours prior

Ticlopidine (Ticlid)

? Stop 14 days prior

Anticoagulants and ESIs (cont)

Platelet GP IIb/IIIa receptor antagonists

abciximab (Reopro) iptifibatide (Integrilin) tirofiban (Aggrastat)

Stop 5 days in advance of procedure Resume on postop day Enoxiparin bridge

Horlocker, T. et al, (2010) Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine EvidenceBased Guidelines (Third Edition). Regional Anesthesia and Pain Medicine. Volume 35(1), January/February 2010, pp 64-101, DOI: 10.1097/AAP.0b013e3181c15c70

Newer Anticoagulants

Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis)--investigational

Dabigatran and Rivaroxaban approved in post-op total hip and knee patients

Research in other settings

Liau, J.V. and Ferrandis, R. (2009) New Anticoagulatns and Regional Anesthesia. Current Opinion in Anaesthesiology, 22:661-666.

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