The efficacy and safety of corticosteroids in the treatment of acute and chronic pain

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.