Abstract
Over the past three decades, corticosteroids have become part of a multimodal approach in the management of both cervical and lumbar degenerative disc diseases. Pain management specialists from various fields had a front row seat, and actively participated in the evolution from primarily oral steroid therapy to the development of various fluoroscopically-guided epidural steroid injection approaches. In this review we discuss the different forms of oral and injectable corticosteroids that have been used by different physician specialties in treating acute and chronic pain. We delineate differences between longer-acting particulate ('insoluble') (i.e. methylprednisolone and triamcinolone) and shorter-acting non-particulate steroids ('soluble') (i.e. betamethasone and dexamethasone), and their utilization while performing different epidural injections. We also discuss the presence of different preservatives in the injectable corticosteroid preparations, as well as some simple techniques to reduce the preservative concentrations, which might improve the safety of those injections. Furthermore, we want to illustrate the existing debates within the pain management physician community with regards to the current guidelines as they pertain to the type of steroids, techniques and approaches used to manage radicular type spinal pain. We discuss the underutilization and overutilization of selected injection techniques and some concerns that the United States Food and Drug Administration (FDA) raised, regarding the safe use of corticosteroids in pain management. We also elaborate upon the usefulness of some expensive tools such as digital subtraction angiography, which has been promoted by some in the medical community, and the difference in surgery rates for patients that have been treated by different physician specialties who use corticosteroids to manage pain. This review will emphasize that there is always room for improvement with respect to the following of published guidelines, and will accentuate the importance of reviewing the literature prior to making important clinical decisions.
Highlights
Over the past three decades, corticosteroids have become part of a multimodal approach in the management of both cervical and lumbar degenerative disc diseases
The purpose of this review is both to provide a background regarding the evolution of steroid use in pain management as well as to illustrate the current debates that exist within the pain management community in regards to the type of steroids, techniques and approaches used to manage chronic radicular type spinal pain
Due to the lack of efficacy of oral corticosteroids in alleviating low back pain, attention and research has turned to an examination of the use of epidural steroid injections
Summary
The mechanism of action of corticosteroids can largely be explained by cytokine suppression. In 2014, Risbud and Shapiro discussed the role of cytokines in the development of intervertebral disc generation.[1] Their highlighted pathway begins with an insult (i.e. trauma, infection), followed by the release of cytokines including tumor necrosis factor alpha (TNF), interleukin 1-beta (IL-1β) and interleukin-6 (IL-6). These cytokines promote immunocyte activation and migration, which initiates a molecular cascade, resulting in intervertebral disc degeneration and eventual radicular back and/or neck pain. The role of corticosteroids, through the inhibition of phospholipase A2 (PLA-2) and the subsequent arachidonic acid pathway, is to both directly and indirectly minimize the synthesis/ release of these cytokines This proposed cytokine suppression results in mitigation of disc degeneration and pain expression
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