RE: The risks of epidural and transforaminal steroid injections in the spine: Commentary and a comprehensive review of the literature.

Abstract

Dear Editor, We read with interest the comprehensive literature review and commentary by Dr. Epstein of the risks of epidural and transforaminal steroid injections in the spine.[5] While this manuscript appears to be comprehensive, we are concerned with the lack of evidence in the opinions offered. We disagree with Dr. Epstein's understanding of the literature and makes unusual claims discrediting all interventional techniques even though the title says “epidural and transforaminal steroid injections in the spine.” Further, the author appears to not recognize that transforaminal injections and caudal epidural injections are in facet epidural injections.[8,9] Dr. Epstein has selected all the negative studies and provided seemingly erroneous interpretations of other literature leading to what we believe are best termed inappropriate conclusions. It would appear that her focus may have been on the contaminated epidural steroid injections resulting in meningitis. However, she postulated a multitude of other issues based on incidence of infection from contaminated steroids, projecting that epidural injections are typically short-acting and ineffective over the long-term, exposing patients to major risks and complications, with delay in surgery. Even the very unusually high and unimaginable complications she is describing in these manuscripts of adhesive arachnoiditis of 6-16%, intravascular injections, etc., along with other life-threatening complications are not based on the literature she has reviewed. Even with the extraordinary statements re: Complications in interventional pain procedures, they may well be less when compared with the risks of intraspinous fusion devices in which Dr. Epstein described maximal complication rates of 38%, reoperation rates of 85%, poor outcomes in 77%, along with high costs of the device.[7] Additionally, per Dr. Epstein many operations that are recommended are not necessary or are too complex.[6] The author, in the description of complications and outcomes of interlaminar and transforaminal epidural injections, seems to use the manuscript of facet joint nerve blocks by Manchikanti et al.[20] alleging 11.4% intravascular injury and 76.3% bleeding. This would be a gross misinterpretation of that study. There was no intravascular injury described in this manuscript by Manchikanti et al.,[20] which rather described intravascular entry, unrelated to epidural injections. An assessment of outcomes should describe at least all randomized trials. Instead Dr. Epstein appears to have picked only a few studies with negative results. Based on inadequate utilization of literature, she describes that patients are subject to major life-threatening risks, while delaying potential requisite surgery. Per above, prior reports by Dr. Epstein of surgical complications are enormous.[7] Overall this manuscript would be appropriate for describing the infectious complications based on contaminated steroid injection. Multiple manuscripts in literature[8,10,11,12,13,14,15,16,18,19,21,22,23,24,25,26] have shown equal effectiveness of epidural injections on a long-term basis, along with facet joint nerve blocks, even though that was not the subject of this review, and have shown significant improvement with outcomes of at least 50% pain relief with functional status improvement of 50% over a period of 2 years. A recent systematic review also confirmed these findings.[3] Multiple complications related to transforaminal epidural injections are justifiable;[8,9] however, these complications are related to mainly cervical epidural injections and based on the radicular entry and injection of particulate steroids. The author seems to make multiple statements not substantiated by literature. This trend extended to the clinical effectiveness, complications, and also costs and provides misinterpretations. She quotes Manchikanti et al.[20] as providing a multitude of data, which was not related to this manuscript or to other manuscripts.[17] The author has also made multiple statements regarding financial incentives not described in any of the manuscripts. The author also describes two major types of epidural spinal injections, translaminar and transforaminal; however, there is also a caudal epidural injection. In assessment of the efficacy of epidural injections, one would review all the literature; however, this review is lacking focus on selective literature and using the literature related to the complications in the efficacy. She also described one study by Manchikanti;[14] which was a positive study, and made no comments. Parr et al.[27] is cited in reference to short-term pain relief for disc herniation and radiculitis and evidence was lacking for both short- and long-term treatment from an earlier systematic review published in 2009 rather than using the manuscript published by Benyamin et al.[1] In fact, recent guidelines[8] and multiple systematic reviews[1,2,4,9,28] have provided similar evidence for interlaminar epidural injections, caudal epidural injections, and lumbar transforaminal epidural injections performed in interventional pain management settings under fluoroscopy with proper selection of patients. However, there is no evidence for transforaminal cervical epidural injections. Overall, this manuscript is confusing. It is our opinion that it provides multiple elements of misinformation rather than evidence-based opinions.