PM&R News   •   July 6, 2017

It has been well documented in the literature that particulate steroids carry a significant risk in their use during epidural injections.  In fact, there have been 13 reported cases of spinal cord ischemia or posterior circulation infarction after cervical epidural steroid injections and 19 cases of spinal cord ischemia in lumbar epidural steroid injections when using particulate steroids. Even though this risk exists, particulate steroids (triamcinolone, methylprednisolone, betamethasone) are still used by some providers due to theories of better efficacy.

This systemic review argues that no statistical significance existed for cervical transforaminal epidural steroid injections when using particulate vs non-particulate steroids (dexamethasone). Studies evaluating efficacy of lumbar transforaminal epidural steroid injections resulted with 1 in favor of particulate steroids and 2 in favor of non-particulate steroids. Although non-particulate steroids were favored, the authors thought the results were equivocal. Overall, the general recommendation is for the use of only non-particulate steroids in cervical epidural injections.

So, which steroid should be used for lumbar interlaminar steroid injections? Unfortunately, not enough studies have been performed to make a recommendation on lumbar interlaminar epidural steroid injections.

This review should provide information to the interventionalist when determining the risk/benefit ratio of using particulate vs non-particulate.  We would argue that the risk is too significant compared to the theoretical benefit and that particulate steroids should never be used in epidural injections.

To read more on this topic, check out:

Systematic Review of the Efficacy of Particulate Versus Non-Particulate Corticosteroids in Epidural Injections