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BACKGROUND: The central nervous system contains steroid receptors, particularly in the hypothalamic and limbic systems. These systems are responsible for driving certain emotions in humans, especially stress, anxiety, motivation, energy levels, and mood. Thus, corticosteroids may precipitate patients to experience these emotions. Most existing studies report neuropsychiatric side effects after oral or intravenous corticosteroids rather than epidural. OBJECTIVES: This study examines the neuropsychiatric side effects after epidural steroid injections (ESIs), with a focus on whether certain factors in patients’ histories further exacerbate symptomatology. STUDY DESIGN: Prospective observational cohort study. SETTING: Fluoroscopy suite at an urban academic teaching hospital. METHODS: Patients were called 24 hours and one week after their ESIs and asked if they experienced certain neuropsychiatric symptoms more than usual compared to baseline. PATIENTS: Seventy-four patients undergoing a lumbosacral ESI (interlaminar (ILESI), caudal or transforaminal (TFESI)) were invited to take part in the study the day of his or her procedure. INTERVENTION/MEASUREMENT: Assessed whether psychiatric history, gender, race, type of ESI, or the number of levels injected affected frequency and duration of neuropsychiatric symptoms at one day and one week after an ESI. RESULTS: Significantly (P < 0.05) more patients with a psychiatric history experienced restlessness and irritability at day one than those without a psychiatric history. At week one, male gender (IRR 2.29, 95% CI 1.37, 3.83, P = 0.002), ILESI (IRR 7.75, 95% CI 1.03, 58.6, P = 0.047), and 2-level injections (IRR 2.14, 95% CI 1.13, 4.06, P = 0.019) were significantly associated to more total symptoms. LIMITATIONS: Single center study, reliance on subjective responses from patients, lack of follow-up after one week post-ESI. CONCLUSION(s): This study demonstrates that neuropsychiatric symptoms are rare overall after an ESI, though certain factors may influence patients experiencing these symptoms. Restlessness and irritability were more likely to occur one day after an ESI in those with a psychiatric history. Those who had a 2-level injection were more likely to keep experiencing most symptoms by week one, suggesting a possible correlation between corticosteroid dose and neuropsychiatric symptoms. KEY WORDS: Epidural steroid injections, transforaminal epidural steroid injections, interlaminar epidural steroid injections, caudal epidural steroid injections, neuropsychiatric symptoms, restlessness, irritability, psychiatric history, anxiety, depression, dexamethasone, men, women, race, one-level epidural steroid injection, 2-level epidural steroid injection

Spine injections are commonly performed in the treatment of back pain. The purpose of this article is to review the current literature surrounding image guided spine injections focusing on scenarios where fluoroscopic guidance can be advantageous in addition to discussing similarities among the different modalities.

Epidural steroid injections (ESI) are frequently used to treat lumbosacral radicular pain, but the solute spread in the epidural space needs further investigation. This semi-blind, randomized study assessed clinical outcomes and contrast spread patterns between the parasagittal interlaminar (PIL) and transforaminal (TF) approaches in 79 adults with low back pain. Participants were randomly assigned to receive either TF-ESI (3 ml) or high-volume PIL-ESI (10 ml). All procedures were performed under fluoroscopic guidance. Contrast spread was evaluated by a blinded pain specialist, and clinical outcomes, including analgesia, patient satisfaction, and quality of life, were measured at two weeks, one month, two months, and six months post-treatment. Results showed no differences in baseline characteristics between groups. There were no statistically significant differences between the two groups in mean pain intensity at baseline and six months after treatment ( p  = 0.590 and 0.484, respectively). Pain relief, satisfaction, quality of life, and contrast spread to the anterior epidural space did not differ over six months. However, the TF group required significantly more fluoroscopic images ( p  < 0.001). High-volume PIL-ESI provides clinical efficacy and anterior contrast distribution equivalent to TF-ESI, with fewer fluoroscopic images needed.

Objective Epidural steroid injections are frequently performed to manage radicular symptoms. Most research investigating the effectiveness of different routes of epidural injections were conducted with non-homogeneous groups. In this study our aim was to investigate the efficacy of caudal versus transforaminal approaches in patients with unilateral S1 radiculopathy secondary to a paracentral L5–S1 disc herniation. Study design Prospective, randomized clinical trial. Setting A university hospital pain management center. Methods The study was conducted between January 2022 and February 2023. Patients with unilateral S1 radiculopathy were randomly divided into two groups: the caudal epidural steroid injection (CESI) and the transforaminal epidural steroid injection (TFESI) group. Severity of pain and disability were assessed with Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) at baseline, 3 weeks, and 3 months after treatment. Fifty percent or more improvement in NRS-11 was defined as treatment success. Fluoroscopy time and doses of exposed radiation were also recorded. Results A total of 60 patients were included in the final analysis (n = 30 for each group). Significant improvement in pain and disability scores was observed at 3rd week and 3rd month compared to baseline (P < .001). Treatment success rate at 3rd month was 77% for the CESI group and 73% for the TFESI group without any significant difference between the groups (P = .766). Conclusions CESI is equally effective as TFESI in the management of S1 radiculopathy due to a paracentral L5–S1 disc herniation. Both approaches can reduce pain and disability, while CESI requires shorter fluoroscopy time and less radiation exposure.

Background: For decades, epidural steroid injections have been an effective tool in the management of many pain related conditions, including lumbar radiculopathy. Transforaminal epidural steroid injections in particular have been reported to potentially result in central nervous system infarctions which have not been reported with interlaminar epidural steroid injections, while providing comparable efficacy. This rare, catastrophic complication has been attributed by some authors to be due to vascular injury secondary to vasospasm, thrombus formation, dissection, as well as concerns with placing the needle at the so-called “safe triangle.” Others, however, have proposed it to be secondary to embolization of the vessel by particulate steroids. This has led to the recommendation of the use of soluble steroids such as dexamethasone when performing TFESI’s, despite concerns over its efficacy and potential for neurotoxicity in the literature. Furthermore, there have also been multiple studies which have revealed that IV dexamethasone is analgesic and that peri-neural dexamethasone is no more effective than IV dexamethasone. Case History: The present case involves a 60-year-old patient with right back and radicular leg pain for 3 years. Two right L4 TFESI’s had been performed with betamethasone several years prior with satisfactory results, until the patient presented to the physician with a pain recurrence of 6 weeks of duration. The patient again underwent a right L4 TFESI with dexamethasone, which provided good relief after 2 weeks. The patient underwent a repeat right L4 TFESI with dexamethasone which was followed by a prompt onset of lower extremity numbness, weakness, and incontinence that was discovered to be related to a conus infarction. While this is the first publicly reported case of a conus medullaris infarction following a lumbar transforaminal injection utilizing dexamethasone, the incidence of these reports may rise as the prevalence of dexamethasone use increases in clinical practice. Conclusion: The spinal cord infarction with TFESI’s may occur related to various mechanisms, regardless of the type of particulate or non-particulate steroid used during these procedures. Key words: Dexamethasone, particulate steroids, non-particulate steroids, conus medullaris infarction, cauda equina syndrome, transforaminal epidural steroid injection, epidural steroid injection, safe triangle, methylprednisolone, paralysis

Background De Quervain’s disease is tenosynovitis of the first dorsal compartment causing severely painful radial-side wrist pain and impaired function. Steroids are effective in treating this condition due to their anti-inflammatory properties. However, this drug causes problems such as hypopigmentation, and is contradicted in diabetes mellitus patients. Non-steroidal anti-inflammatory drug (NSAID) which are efficacious in shoulder pathology and not contraindicated in diabetics and can be used to avoid the local effects of steroids could be beneficial for some patients. The present study was a randomized controlled trial to examine the differences in pain scores and functional response to local injections of a corticosteroid and the NSAID ketorolac. Methods Sixty-four patients with radial styloid tenosynovitis were randomized using a computer-generated random number table into two groups receiving either a ketorolac injection or a triamcinolone injection. We evaluated post-injection pain intensity using a verbal numerical rating scale (VNRS), functional outcomes using the Thai Disabilities of the Arm, Shoulder and Hand (DASH) scale, and evaluated grip and pinch strengths, recorded at baseline and 6 weeks after the injection. Results Thirty-one participants in the ketorolac group and 29 participants in the triamcinolone group completed the study and were included in the analysis. There were no significant differences in the assessments at baseline. At the 6-week conclusion of the study, patients in the triamcinolone group had a statistically lower average pain score than in the ketorolac group (0.7 ± 2.0 vs 5.3 ± 3.2, P  < 0.001), higher DASH functional score (4.4 ± 6.5 vs 34.1 ± 20.2, P  < 0.001), higher right grip strength (60.8 ± 16.8 vs 49.2 ± 18.6, P  < 0.015), and higher left grip strength (59.8 ± 18.1 vs 50.3 ± 18.0, P  < 0.04). However, there was no difference in pinch strength. Conclusions Our study found that ketorolac injections resulted in inferior pain reduction, functional score and grip improvement than triamcinolone injection in patients with radial styloid tenosynovitis. Future studies are required to examine the effects of ketorolac in larger group and with longer follow-up periods to further elucidate the findings of this study. Trial registration The study was registered at Clinicaltrials.in.th (TCTR20200909006).

BackgroundIntralesional steroid injection has recently evolved as a novel treatment modality for localized idiopathic granulomatous mastitis (= IGM). We aimed to explore the therapeutic efficacy of local steroid injections (LSI) in patients with severe IGM.MethodsFifty-one patients diagnosed with severe IGM were included in the study and treated with either local steroid injection (LSI) alone ( n = 25) or combined LSI with systemic oral steroid treatment (OST) ( n = 26). The local steroid injection protocol included an intralesional triamcinolone acetonide injection into the palpable granulomas every 4-week, and topical administration of steroid-containing pomades twice a day on the affected surface of the breast. Patients with a combined LSI and OST received low-dose oral methylprednisolone (<16 mg).ResultsPatients with LSI alone required more LSI applications than those in the combined LSI with OST group (LSI: 5 ± 2.9; vs. LSI/OST: 3.5 ± 2.5; p = 0.080) to obtain an effective optimum therapeutic response. At a median of 12 months (range, 4–42), no difference was found in complete response rates between patients in the LSI group and the combined LSI group with OST (52 vs. 53.9%, p = 0.999). However, steroid-related systemic side effects were lower in the LSI alone group ( p < 0.008).ConclusionLocal steroid injection could be considered as the first-line treatment in patients with severe IGM until a therapeutic response has been obtained either as the sole treatment modality or combined with oral steroids. Compared with systemic oral steroid therapy, local steroid administration can be considered a new treatment modality with fewer side effects.

Chronic discogenic low back pain (DLBP) with active discopathy (Modic type 1 changes) is a specific and debilitating phenotype. Transforaminal epidural steroid injection (TESI) and transforaminal intradiscal steroid injection (TISI) are commonly used treatments, yet their comparative efficacy remains uncertain due to a lack of high-quality, direct comparative studies. To compare the clinical efficacy and safety of TISI versus TESI and to investigate whether the anatomical target of corticosteroid delivery (intradiscal vs. epidural) influences clinical and radiological outcomes in patients with chronic DLBP with active discopathy. This is a single-center, prospective, parallel-group, assessor- and patient-blinded, randomized, controlled trial. A total of 118 eligible participants will be randomly allocated in a 1:1 ratio to receive either TISI or TESI. The primary outcome is the change in low back pain intensity from baseline to 1-month post-intervention, measured by the Numerical Rating Scale (NRS). Secondary outcomes, assessed at multiple time points up to 12 months, include longitudinal pain intensity (NRS), functional status (Oswestry Disability Index, Japanese Orthopaedic Association score), health-related quality of life (12-item Short Form Health Survey), psychological status (Hospital Anxiety and Depression Scale), radiological changes (Modic classification, intervertebral disc heigh and Pfirrmann grade), and the incidence of procedure-related adverse events. The primary analysis will follow the modified intention-to-treat principle, with longitudinal data analyzed using a linear mixed model. This trial addresses a critical evidence gap by conducting a direct head-to-head comparison of two mechanistically distinct injection therapies. The findings are anticipated to significantly inform clinical practice and guide the development of evidence-based treatment algorithms for managing chronic low back pain with active discopathy. The study protocol has been approved by the Ethics Committee of Beijing Shijitan Hospital, Capital Medical University (IIT2024-032-003). Written informed consent will be obtained from all participants. The results of this trial will be submitted for publication in peer-reviewed journals and presented at scientific conferences, regardless of the outcome. ChiCTR2500096006, https://www.chictr.org.cn/showproj.html?proj=249912.

Objective: To compare the efficacy of Transforaminal Epidural Steroid Injection with local anesthetic versus Transforaminal Epidural Steroid Injection with local anesthetic and Ozone in patients with lumbar spine radiculopathy. Study Design: Quasi-experimental study. Place and Duration of Study: Pain Management Centre, Department of Anesthesia, Combined Military Hospital Rawalpindi, Pakistan from Oct 2022- Mar 2023. Methodology: A total of 412 patients who underwent interventional procedures for radiculopathy were included in the study. These patients were divided into two equal groups, group-A (n=206) received Transforaminal Epidural Steroid Injection (40mg Triamcinolone) with local anesthetic (20mg Lignocaine) and Ozone (30 µg/ml) and group-B (n=206) received Transforaminal Epidural Steroid Injection (40mg Triamcinolone) with local anesthetic (20mg Lignocaine). The effects of both the regimens to treat pain in lower back were observed in the groups. Patients were assessed for pain using the visual analogue scale (VAS), for disability ... Results: VAS at pre-procedure was 7.96 ± 0.587 and 8.15 ± 0.615 for group-A and B respectively (p= 0.005) and then at six months was 3.06 ± 0.898 for group-A and 3.45 ± 1.075 for group-B (p=0.001). Similarly, ODI at pre-procedure was 29.95 ± 4.032 and 30.06±3.761 for group-A and B respectively (p< 0.001) and then at six months was 13.83 ± 2.345 for group-A and 14.65± 2.336 for ... Conclusion: Lumbar Radiculopathy treated with Transforaminal Epidural Steroid Injection with local anesthetic and Ozone has more patient satisfac...  

Purpose of Review Cervical transforaminal epidural steroid injections (CTFESIs) are widely used for the treatment of radicular pain caused by cervical spine pathology, including disc herniations and foraminal stenosis. This review aims to analyze the risks and benefits of CTFESIs, address their efficacy and safety profile, improve clinical decision-making, and educate interventional pain medicine physicians. Recent Findings CTFESIs have demonstrated benefits such as pain relief, functional improvement, and the potential to avoid surgical interventions. However, their use is limited by safety concerns due to the proximity of vascular structures in the cervical spine. Complications, including neurological injuries, infections, and vascular injuries, though rare, can be severe. Recent studies emphasize the importance of using advanced procedural techniques, such as fluoroscopic guidance and non-particulate corticosteroids, to minimize risks. Summary CTFESIs remain a valuable tool for managing cervical radiculopathy in selected patients. While they provide substantial therapeutic and diagnostic benefits, careful patient selection and adherence to safety protocols are crucial to minimizing serious complications. This review compiles current evidence to assist clinicians in evaluating the risks and benefits of CTFESIs in clinical practice.