Abstract
Epidural steroid injections are well accepted as a treatment for radicular back pain in appropriate candidates. While overall incidence of systemic side effects has not been well established, at least five biochemically proven cases of iatrogenic Cushing's Syndrome have been reported as complications of epidural steroid treatment. We present an additional case of iatrogenic Cushing's Syndrome and adrenal suppression in a middle-aged woman who received three epidural steroid injections over a four-month period. We review this case in the context of previous cases and discuss diagnostic and management issues.
Highlights
Epidural injections of corticosteroids are an accepted and widely used treatment for radicular low back pain
Jacobs et al assert that the lack of a detectable plasma methylprednisolone level after epidural injection in 12 patients indicated that systemic absorption does not occur, and patients are unlikely to have systemic side effects [6]
Epidural steroid injections should be held in the setting of HPA suppression even if overt Cushing’s is not present
Summary
Epidural injections of corticosteroids are an accepted and widely used treatment for radicular low back pain. The American Society of Interventional Pain Physicians-Interventional Pain Management comments in their 2009 guidelines that there is no “basis for reported assumptions and limitations” on epidural steroid injection doses or frequency and that “administration must be based solely on patients’ response, safety profile of the drug, experience of the patient, and pharmacologic and chemical properties such as duration of action and suppression of adrenals [5].”. At one and two months after our initial visit (2-3 months after her last epidural injection), the prednisone was held for 24 hours, and repeat morning cortisol levels remained low at 80.0 and 63.5 nmol/L (2.9 and 2.3 mcg/dL), respectively (Table 1).
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