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Reading time: 4 minutes | Original blog: July 2, 2020

Yes. While chiropractors cannot administer epidural steroid injections (ESI), we cannot turn a blind eye to a commonly used therapy. Sometimes our patients have already had an injection, while other times, we need to consider an ESI during our treatment plan for a patient that may benefit from its effects. Regardless of the timeline, valuable lessons from a patient’s response to this therapy may alter your care plan. 

Watch Dr. Steele explain how to foster a relationship with an interventional pain management physician that benefits the patient first.

Here are five things to consider when discussing cervical epidural steroid injections (ESI) with your patients.

1. ESI AS A DIAGNOSTIC TEST

A selective injection may help guide further treatment based on the patient’s response.  Disc herniations and age-related cervical spondylosis frequently cause cervical radiculopathy.  The C7, C6, and C8 nerve roots are the most common nerves affected in descending order of frequency. (1) ESIs may confirm a differential diagnosis, possibly leading to a specific treatment method or location.

Off-label prescriptions of gabapentin and pregabalin are common even though a recent systematic review found no evidence to support their use for neuropathic pain in the lower back or leg. (2)

2. PAIN RELIEF

Cervical steroid injections can provide temporary relief when there is inflammation or damage to a nerve.  Pain relief allows a patient to re-engage in normal activities of daily living. ESI therapy only provides short-term relief, often between 2-3 weeks. (3) Many evidence-based chiropractors understand the importance of co-managing these cases with a local pain management physician for CHEMICAL pain symptoms during painful episodes.  Utilizing ESI’s will provide chemical relief of the affected nerve root allowing patients to engage in exercise therapy and tolerate your in-office MECHANICAL treatments.

Chemical Pain:
  • Constant pain
  • Recent onset (traumatic or possibly insidious)
  • Cardinal signs may be present – swelling, redness, heat, tenderness
  • Lasting aggravation of pain by all movements
  • No movement found which abolishes pain
Mechanical Pain:
  • More commonly intermittent, but may be constant
  • Specific repeated movements cause a lasting reduction or abolition of pain
  • Movements in one direction may worsen symptoms, whereas movements in the other direction will improve them

3. REDUCE DISABILITY

Epidural steroid injections may also help with secondary conditions or symptoms.  In a study by Persson et al., 48% of patients reported ≥50% VAS reduction in arm pain after cervical ESIs. More interesting is that 91% of patients had improved neck disability indices (NDI). Neck disability scores measuring pain intensity, sleep, and headache had improved by the most significant magnitude. (4)

Steroid injections are commonly performed procedures in patients with degenerative spinal conditions. However, there is an overall increased odds of surgery after any injection. (5)

4. PATIENT EDUCATION

Pain relief from ESIs is quick and can sometimes last for days to months. Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after cervical epidural injections. (1) This procedure provides a window of opportunity to educate your patients on possible changes to their postures and activities, ultimately leading to dysfunction.  Remember, pain is a good thing! It is a warning sign indicating damage to the body.  Pain relief is not the end goal; instead, use this episode of care to educate your patients on the factors that need to be changed to prevent reinjury. 

5. SIDE EFFECTS

Some patients may experience side effects. Approximately 4.8% of the patients who underwent spinal injections experienced minor and transient systemic effects. These effects were more common in patients who had undergone previous spine surgery or received a prior cervical ESI. (4) Other possible systemic effects include; facial flushing, headache, vasovagal reaction, mood change, gastrointestinal problems, and cardiovascular symptoms (5)

Keep In Mind: Most cases of radiculopathy eventually resolve, but severe pain often prompts physician-directed interventions. (1) Recovery from a disc herniation may take up to 4-6 months, and complete recovery (83% of patients) within 24–36 months. (6) Many patients are not going to wait that long for healing to occur.  Chiropractors are uniquely positioned to recommend what we think is best for the patient without external pressures.  Sometimes best practice management may include services not performed in your office. 

Download our Clinical Evidence Synopsis here for more information! 

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References
  1. Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, McCormick ZL. The effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Medicine. 2020 Jan 1;21(1):41-54.
  2. Giménez-Campos MS, Pimenta-Fermisson-Ramos P, Díaz-Cambronero JI, Carbonell-Sanchís R, López-Briz E, Ruíz-García V. A systematic review and meta-analysis of the effectiveness and adverse events of gabapentin and pregabalin for sciatica pain. Atencion primaria. 2022 Jan 1;54(1):102144.
  3. Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Annals of internal medicine. 2012 Dec 18;157(12):865-77.
  4. Persson L, Anderberg L. Repetitive transforaminal steroid injections in cervical radiculopathy: A prospective outcome study including 140 patients. Evid Based Spine Care J 2012;3(3):13–20.
  5. Manzur MK, Samuel AM, Vaishnav A, Gang CH, Sheha ED, Qureshi SA. Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy. Global Spine Journal. 2021 Jul 5:21925682211024573. Link
  6. Kang WY, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Systemic effects of fluoroscopically guided epidural steroid injection with dexamethasone. The Korean journal of pain. 2019 Jul;32(3):178.
  7. Plasters C, McCormick ZL, Garvan C, Macron D, Joshi A, Chimes G, et al. Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. Spine J. 2015;15:2157–65. doi: 10.1016/j.spinee.2015.05.034.
  8. Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: A systematic review of the literature. Spine J 2014;14(8):1781–9.

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