1. 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)
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2. Epidural Steroid Injections: Indications.
Johnathan Goree, MD
Director of Chronic Pain Division
Assistant Professor
Department of Anesthesiology
University of Arkansas for Medical Sciences

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4. 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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7. Spine.

9. Ligaments of the Spine.

10. 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

11. 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.

12. Examination Positive Straight Leg Raise Severe Spasms
Pain down L5 dermatome

13. MRI Sagittal / Axial view of a Disc Herniation

14. 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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16. 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

17. 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

18. Model
Interlaminar
Transforaminal

19. 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

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

21. 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)

22. Epidural Steroid Injection (Interlaminar/Translaminar)

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

24. 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

25. 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

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

27. 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

28. SPORT Trial, JAMA, 2006

29. 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.

30. Interlaminar or Transforaminal?

31. Interlaminar v. Transforaminal

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

33. 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.

34. Do epidurals work?
Depends on who you ask?

35. 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.

36. 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

37. 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:
Event ID: