Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 30664-24581

Epidural Steroid Injections: Indications. Johnathan Goree, MD Director of Chronic Pain Division Assistant Professor Department of Anesthesiology University of Arkansas for Medical Sciences

Poll Everywhere Phone Computer Text JOHNATHANGOR491 to 37607 to respond Computer Respond at Pollev.com/johnathangor491

Disclosures I have no financial interests to disclose related to this presentation I will present some non-FDA approved uses of medications which include steroids (dexamethasone) for lumbar epidural steroid injections and anti-convulsants/anti-depressants for the treatment of neuroinflammatory chronic pain. Both of these medications have been used for these indications for over 20 years.

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Spine.

Ligaments of the Spine.

Categories of Chronic Back Pain. Axial Pain along the axis of the spine Usually Isolated in Low back Never pain below the knees. Radicular Pain extending to one of more extremity Characterized by pain in legs. Usually burning or electric in character

Case Healthy 23 y/o male presents to the clinic with severe 8/10 back pain with spasms and new onset “Sciatica” after lifting a heavy box of books while helping his girlfriend move into a 3rd story walk up apartment. He knew that carrying this box was a TERRIBLE idea but instead of using a dolly, he wanted to impress her by showing off his brute strength. He has taken 800mg ibuprofen q 8 hours for the past 24 hours without benefit.

Examination Positive Straight Leg Raise Severe Spasms Pain down L5 dermatome

MRI Sagittal / Axial view of a Disc Herniation

Grading of Disc Displacement Bulge (out of round) Protrusion (pointed, but not thru all the fibers) Herniation (thru the fibers, leaks Nucleus Pulposis) Extrusion (travels up or down the canal and starting to pinch off) Free Fragment (a loose piece that can travel in the canal or nerve root) Bulge Protrusion Herniation Extrusion Free Fragment

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Discussion. Continued oral anti-inflammatory +/- muscle relaxant Referral to physical therapy for eval and treatment Evaluation for an epidural steroid injection Referral to chiropractic therapy Short term prescription of opioids

What is an epidural? Epidural Space is a potential space between the ligamentum flavum and the dura. This space can be accessed by two techniques Interlaminar Most common Loss of Resistance Technique is used Transforaminal Can inject saline, blood, opioids, local anesthetics, or steroid

Model Interlaminar Transforaminal

Labor Epidural Most common use of Epidurals Loss of resistance Technique Thick, tough ligamentum flavum Air v. saline Normally a Catheter is Placed Opioids and local anesthetic infusions can be delivered 10:1 conversion of opioid strength when compared to IV

History Break. Who is credited with the first Neuraxial Technique? August Bier (correct)

History August Bier (1861 -1949) German Surgeon Performed the first operation under spinal anesthetic (1898) Segmental resection of the left ankle due to tuberculosis infection History of “Complications from General Anesthesia” Performed “cocainization” of the spinal cord with 15mg of cocaine intrathecally Performed first operation under IV regional anesthesia (1908)

Epidural Steroid Injection (Interlaminar/Translaminar)

Transforaminal Steroid Injection The advantage is that steroids are placed in the anterior epidural space and concentrated mostly to one side.

Epidural Medications Steroid Phospholipase A2 inhibitor Inflammatory mediator Elevated concentration in herniated/degenerated discs Rate limiting factor in production of Arachidonic Acid, principle substrate in formation of prostaglandins, prostacyclins, thromboxanes, and lukotrienes Decrease conduction in unmyelinated C fibers Suppress ectopic discharges from injured nerves

Epidural Medications Local Anesthetics Saline Increase blood flow to ischemic nerve roots Suppresses ectopic discharge from injured neurons Inhibit release of proinflammatory cytokines and prevent leukocyte adhesion Saline Washout of inflammatory cytokines Adhesiolysis of scar tissue

If I have a herniated disc, Why not cut it out!?!?!?

Participating Sites Maine Spine & Rehab Dartmouth-Hitchcock Medical Center Lebanon, NH William Beaumont Hospital Royal Oak, MI HJD NY, NY University of California San Francisco, CA Rush-Presbyterian-St. Luke’s Chicago, IL HSS NY, NY Case-Western Cleveland, OH Kaiser Permanente Oakland, CA Nebraska Foundation for Spinal Research Rothman Institute Philadelphia, PA Washington University St. Louis, MO Emory Spine Center Atlanta, GA

SPORT Trial, JAMA, 2006

SPORT Trial No change in outcomes in patients who failed conservative management first and switched to surgical management when compared to patients who went straight to surgical management.

Interlaminar or Transforaminal?

Interlaminar v. Transforaminal

Interlaminar v. Transforaminal - 64 patients - 2x steroid in IL group

How long do epidurals last? Epidurals provided outstanding temporary relief of lumbar radicular pain Temporary can mean up to 3 months or longer Should be coupled with lifestyle modifications and quality physical therapy. Discs take up to 18 months to heal.

Do epidurals work? Depends on who you ask?

My practice. New Diagnosis of Lumbar Radicular pain Referral to PT. Anti-Inflammatories and Muscle Relaxants Return to Clinic in 6 months If pain is SEVERE or not improving with PT, TFESI with continued PT. If no improvement after THREE TFESI OR onset of weakness or numbness – referral to spine surgeon for decompression.

My practice For lumbar radicular pain or disc herniations Transforaminal > interlaminar Anterior epidural space Diagnostic of nerve root of injury in case patient will need surgical intervention Trends towards faster improvement For spinal stenosis Interlaminar > Transforaminal Trends towards longer lasting improvement

Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 30664-24581