Skip to main content
SpringerLink
Log in

Epidural Administration of Biologics

  • Chapter
  • First Online:
Essentials of Regenerative Medicine in Interventional Pain Management

Abstract

Epidural injections have been utilized in managing chronic low back pain since 1901 with descriptions of caudal epidural injections. Since then, numerous developments have occurred. Epidural injections are performed for various disorders, specifically resulting in radicular pain. Epidural injections have been shown to be effective in radicular pain secondary to disc herniation, post-surgery syndrome, and spinal stenosis. However, they also have been shown to be effective in discogenic pain with similar evidence as in those conditions with radicular pain.

Epidural administration of local anesthetic and steroids have been extensively discussed in randomized controlled trials (RCTs), systematic reviews, meta-analysis, and guidelines. However, epidural injections are only one of the invasive procedures in managing chronic spinal pain, apart from numerous conservative therapies including extensive drug therapy and, finally, a multitude of surgical interventions. In a significant proportion of patients, none of these modalities may provide satisfactory or long-term relief. Consequently, with emergence of advances in regenerative medicine with injection of biologics into various structures in the spine, epidural injection of biologics have been reported.

This chapter describes the role of epidural administration of PRP and bone marrow aspirate.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. US Burden of Disease Collaborators. The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states. JAMA. 2018;319:1444–72.

    Google Scholar 

  2. Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996-2013. JAMA. 2016;316:2627–46.

    PubMed  PubMed Central  Google Scholar 

  3. Dieleman JL, Cao J, Chapin A, et al. US health care spending by payer and health condition, 1996-2016. JAMA. 2020;323:863–84.

    PubMed  PubMed Central  Google Scholar 

  4. Navani A, Manchikanti L, Albers SL, et al. Responsible, safe, and effective use of biologics in the management of low back pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2019;22:S1–S74.

    PubMed  Google Scholar 

  5. Manchikanti L, Centeno CJ, Atluri S, et al. Bone marrow concentrate (BMC) therapy in musculoskeletal disorders: evidence-based policy position statement of American Society of Interventional Pain Physicians (ASIPP). Pain Physician. 2020;23:E85–E131.

    PubMed  Google Scholar 

  6. Manchikanti L, Atluri A, Albers SL, Latchaw RE. Epidural administration of platelet rich plasma and stem cells. In: Manchikanti L, Navani A, Atluri S, editors. Essentials of regenerative medicine in interventional pain management. Paducah, KY: ASIPP Publishing; 2019. p. 421–58.

    Google Scholar 

  7. Manchikanti L, Knezevic NN, Navani A, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) comprehensive evidence-based guidelines. Pain Physician. 2021;24:S27–S208.

    PubMed  Google Scholar 

  8. Knezevic N, Manchikanti L, Urits I, et al. Lack of superiority of epidural injections with lidocaine with steroids compared to without steroids in spinal pain: a systematic review and meta-analysis. Pain Physician. 2020;23:S239–70.

    PubMed  Google Scholar 

  9. Manchikanti L, Kosanovic R, Vanaparthy R, et al. Steroid distancing in interventional pain management during COVID-19 and beyond: safe, effective and practical approach. Pain Physician. 2020;23:S319–52.

    PubMed  Google Scholar 

  10. Manchikanti L, Schultz DM, Glaser SE, Falco FJE. Thoracic epidural injections. In: Manchikanti L, Singh V, Falco FJE, Kaye AD, Soin A, Hirsch JA, editors. Manchikanti’s essentials of interventional techniques in managing chronic pain. 2nd ed. New York, NY: Springer; 2023.

    Google Scholar 

  11. Manchikanti L, Schultz DM, Atluri S, et al. Lumbar epidural injections. In: Manchikanti L, Kaye AD, Falco FJE, Hirsch JA, editors. Essentials of interventional techniques in managing chronic spinal pain. New York, NY: Springer; 2018. p. 141–86.

    Google Scholar 

  12. Manchikanti L, Schultz DM, Falco FJE. Cervical epidural injections. In: Manchikanti L, Kaye AD, Falco FJE, Hirsch JA, editors. Essentials of interventional techniques in managing chronic spinal pain. New York, NY: Springer; 2018. p. 209–40.

    Google Scholar 

  13. Manchikanti L, Heavner JE, Racz GB. Percutaneous adhesiolysis. In: Manchikanti L, Kaye AD, Falco FJE, Hirsch JA, editors. Essentials of interventional techniques in managing chronic spinal pain. New York, NY: Springer; 2018. p. 241–72.

    Google Scholar 

  14. Sanapati J, Manchikanti L, Atluri S, et al. Do regenerative medicine therapies provide long-term relief in chronic low back pain: a systematic review and metaanalysis. Pain Physician. 2018;21:515–40.

    PubMed  Google Scholar 

  15. Basso M, Cavagnaro L, Zanirato A, et al. What is the clinical evidence on regenerative medicine in intervertebral disc degeneration? Musculoskelet Surg. 2017;101:93–104.

    CAS  PubMed  Google Scholar 

  16. Wu T, Song HX, Dong Y, et al. Cell-based therapies for lumbar discogenic low back pain: systematic review and single-arm meta-analysis. Spine (Phila Pa 1976). 2018;43:49–57.

    CAS  PubMed  Google Scholar 

  17. Khan S, Mafi P, Mafi R, et al. A systematic review of mesenchymal stem cells in spinal cord injury, intervertebral disc repair and spinal fusion. Curr Stem Cell Res Ther. 2018;13:316–23.

    CAS  PubMed  Google Scholar 

  18. Goni VG, Singh Jhala S, Gopinathan NR, et al. Efficacy of epidural perineural injection of autologous conditioned serum in unilateral cervical radiculopathy: a pilot study. Spine (Phila Pa 1976). 2015;40:E915–21.

    PubMed  Google Scholar 

  19. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operation on the lumbar spine using local anesthesia. Orthop Clin North Am. 1991;22:181–7.

    CAS  PubMed  Google Scholar 

  20. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med. 1934;211:210–5.

    Google Scholar 

  21. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Pain Physician. 2009;12:E71–E120.

    PubMed  Google Scholar 

  22. Mixter WJ, Ayers JB. Herniation or rupture of the intervertebral disc into the spinal canal. N Engl J Med. 1935;213:385–95.

    Google Scholar 

  23. Manchikanti L, Falco FJE, Singh V, et al. Discography. In: Manchikanti L, Kaye AD, Falco FJE, Hirsch JA, editors. Essentials of interventional techniques in managing chronic spinal pain. New York, NY: Springer; 2018. p. 273–300.

    Google Scholar 

  24. Manchikanti L, Knezevic E, Knezevic NN, et al. The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis. Korean J Pain. 2021;34:346–68.

    PubMed  PubMed Central  Google Scholar 

  25. Manchikanti L, Knezevic NN, Knezevic E, et al. Efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain: a systematic review and meta-analysis of randomized controlled trials. Pain Ther. 2023;12:903–37.

    PubMed  PubMed Central  Google Scholar 

  26. Manchikanti L, Hirsch JA. An update on the management of chronic lumbar discogenic pain. Pain Manag. 2015;5:373–86.

    PubMed  Google Scholar 

  27. Manchikanti L, Hirsch JA. Clinical management of radicular pain. Expert Rev Neurother. 2015;17:681–93.

    Google Scholar 

  28. Spangfort EV. The lumbar disc herniation: a computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl. 1972;142:1–95.

    CAS  PubMed  Google Scholar 

  29. Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med. 2013;14:813–36.

    PubMed  Google Scholar 

  30. Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine (Phila Pa 1976). 1996;21:2S–9S.

    CAS  PubMed  Google Scholar 

  31. Wright-Carpenter T, Klein P, Schaferhoff P, Appell HJ, Mir LM, Wehling P. Treatment of muscle injuries by local administration of autologous conditioned serum: a pilot study on sportsmen with muscle strains. Int J Sports Med. 2004;25:588–93.

    CAS  PubMed  Google Scholar 

  32. Manchikanti L, Staats PS, Nampiaparampil DE, Hirsch JA. What is the role of epidural injections in the treatment of lumbar discogenic pain: a systematic review of comparative analysis with fusion and disc arthroplasty. Korean J Pain. 2015;28:75–87.

    PubMed  PubMed Central  Google Scholar 

  33. Bogduk N. Epidural steroids. Spine (Phila Pa 1976). 1995;20:845–8.

    CAS  PubMed  Google Scholar 

  34. Shanthanna H, Busse JW, Thabane L, et al. Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials. Syst Rev. 2016;5:18.

    PubMed  PubMed Central  Google Scholar 

  35. Kumar R, Goni VG, Batra YK. Autologous conditioned serum as a novel alternative option in the treatment of unilateral lumbar radiculopathy: a prospective study. Asian Spine J. 2015;9:916–22.

    Google Scholar 

  36. Becker C, Heidersdorf S, Drewlo S, et al. Efficacy of epidural perineural injections with autologous conditioned serum for lumbar radicular compression: an investigator-initiated, prospective, double-blind, reference-controlled study. Spine (Phila Pa 1976). 2007;32:1803–8.

    PubMed  Google Scholar 

  37. Manchikanti L, Falco FJE, Benyamin RM, Kaye AD, Boswell MV, Hirsch JA. A modified approach to grading of evidence. Pain Physician. 2014;17:E319–25.

    PubMed  Google Scholar 

  38. Bhatia R, Chopra G. Efficacy of platelet rich plasma via lumbar epidural route in chronic prolapsed intervertebral disc patients—a pilot study. J Clin Diagn Res. 2016;10:UC05–7.

    PubMed  PubMed Central  Google Scholar 

  39. Centeno C, Markle J, Dodson E, et al. The use of lumbar epidural injection of platelet lysate for treatment of radicular pain. J Exp Orthop. 2017;4:38.

    PubMed  PubMed Central  Google Scholar 

  40. Kirchner F, Anitua E. Intradiscal and intra-articular facet infiltrations with plasma rich in growth factors reduce pain in patients with chronic low back pain. J Craniovertebr Junction Spine. 2016;7:250–6.

    PubMed  PubMed Central  Google Scholar 

  41. Noriega DC, Ardura F, Hernández-Ramajo R, et al. Intervertebral disc repair by allogeneic mesenchymal bone marrow cells: a randomized controlled trial. Transplantation. 2017;101:1945–51.

    PubMed  Google Scholar 

  42. Tuakli-Wosornu YA, Terry A, Boachie-Adjei K, et al. Lumbar intradiskal platelet-rich plasma (PRP) injections: a prospective, double-blind, randomized controlled study. PM R. 2016;8:1–10.

    PubMed  Google Scholar 

  43. Wu J, Zhou J, Liu C, et al. A prospective study comparing platelet-rich plasma and local anesthetic (LA)/corticosteroid in intra-articular injection for the treatment of lumbar facet joint syndrome. Pain Pract. 2017;17:914–24.

    PubMed  Google Scholar 

  44. Singla V, Batra YK, Bharti N, et al. Steroid vs. platelet-rich plasma in ultrasound-guided sacroiliac joint injection for chronic low back pain. Pain Pract. 2017;17:782–91.

    PubMed  Google Scholar 

  45. Ko GD, Mindra S, Lawson GE, Whitmore S, Arseneau L. Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction. J Back Musculoskelet Rehabil. 2017;30:363–70.

    PubMed  Google Scholar 

  46. Peng B, Wu W, Hou S, Li P, Zhang C, Yang Y. The pathogenesis of discogenic low back pain. J Bone Joint Surg Br. 2005;87:62–7.

    CAS  PubMed  Google Scholar 

  47. Botwin KP. Lumbar interlaminar epidural steroid injections. In: Manchikanti L, Singh V, editors. Interventional techniques in chronic spinal pain. Paducah, KY: ASIPP Publishing; 2007. p. 355–82.

    Google Scholar 

  48. Manchikanti L, Malla Y, Wargo BW, et al. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012;15:131–40.

    PubMed  Google Scholar 

  49. Ajar AH, Rathmell LP, Mukherji SK. The subdural compartment. Reg Anesth Pain Med. 2002;27:72–6.

    PubMed  Google Scholar 

  50. Murthy NS, Maus TP, Behrns CL. Intraforaminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz): a retrospective review. Pain Med. 2010;11:1756–64.

    PubMed  Google Scholar 

  51. Kim WJ, Shin HY, Yoo SH, et al. Comparison of epidural spreading patterns and clinical outcomes of transforaminal epidural steroid injection with high-volume injectate via the subpedicular versus the retrodiscal approach. Pain Physician. 2018;21:269–78.

    PubMed  Google Scholar 

  52. Atluri S, Glaser S, Shah R, et al. Needle position analysis in cases of paralysis from transforaminal epidurals: consider alternative approaches to traditional technique. Pain Physician. 2013;16:321–34.

    PubMed  Google Scholar 

  53. Goodman B, Petalcorin JS, Mallempati S. Optimizing patient positioning and fluoroscopic imaging for the performance of cervical interlaminar epidural steroid injections. PM R. 2010;2:783–6.

    PubMed  Google Scholar 

  54. Yoon SP, Kim HJ, Choi YS. Anatomic variations of cervical and high thoracic ligamentum flavum. Korean J Pain. 2014;27:321–5.

    PubMed  PubMed Central  Google Scholar 

  55. Ho PS, Yu SW, Sether LA, et al. Ligamentum flavum: appearance on sagittal and coronal MR images. Radiology. 1988;168:469–72.

    CAS  PubMed  Google Scholar 

  56. Lirk P, Kolbitsch C, Putz G, et al. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology. 2003;99:1387–90.

    PubMed  Google Scholar 

  57. Dogliotti AM. Segmental peridural anesthesia. Am J Surg. 1933;20:107–18.

    Google Scholar 

  58. Shenouda P, Cunningham B. Assessing the superiority of saline versus air for use in the epidural loss of resistance technique: a literature review. Reg Anesth Pain Med. 2003;28:48–53.

    PubMed  Google Scholar 

  59. Mehta S, Khalil AA, Alshekhlee A. Air myelopathy following a cervical epidural injection. Pain Med. 2010;11:1678–9.

    PubMed  Google Scholar 

  60. Kim TS, Shin SS, Kim JR, et al. Air bubbles mimic disc herniation in MRI after cervical epidural block. Korean J Pain. 2010;23:202–6.

    PubMed  PubMed Central  Google Scholar 

  61. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371:11–21.

    PubMed  Google Scholar 

  62. Manchikanti L, Candido KD, Singh V, et al. Epidural steroid warning controversy still dogging FDA. Pain Physician. 2014;17:E451–74.

    PubMed  Google Scholar 

  63. Manchikanti L, Falco FJE, Benyamin RM, et al. Epidural steroid injections safety recommendations by the Multi-Society Pain Workgroup (MPW): more regulations without evidence or clarification. Pain Physician. 2014;17:E575–88.

    PubMed  Google Scholar 

  64. Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122:974–84.

    CAS  PubMed  Google Scholar 

  65. Manchikanti L, Falco FJE. Safeguards to prevent neurologic complications after epidural steroid injections: analysis of evidence and lack of applicability of controversial policies. Pain Physician. 2015;18:E129–38.

    PubMed  Google Scholar 

  66. Collier CB. Accidental subdural injection during attempted lumbar epidural block may present as a failed or inadequate block: radiographic evidence. Reg Anesth Pain Med. 2004;29:45–51.

    PubMed  Google Scholar 

  67. Wallace MA, Fukui MB, William RL, et al. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. AJR Am J Roentgenol. 2007;188:1218–21.

    PubMed  Google Scholar 

  68. Scanlon GC, Moeller-Bertram T, Romanowsky SM, et al. Cervical transforaminal epidural steroid injections. More dangerous than we think? Spine (Phila Pa 1976). 2007;32:1249–56.

    PubMed  Google Scholar 

  69. Netter FH. Atlas of human anatomy. 4th ed. Philadelphia, PA: Elsevier (Saunders); 2006.

    Google Scholar 

  70. Kaye AD, Manchikanti L, Novitch MB, et al. Responsible, safe, and effective use of antithrombotics and anticoagulants in patients undergoing interventional techniques: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2019;22:S75–S128.

    PubMed  Google Scholar 

  71. Manchikanti L, Sanapati M, Kaye AD, Kaye AM. Antiplatelet and anticoagulant therapy in regenerative medicine. In: Manchikanti L, Navani A, Atluri S, Sanapati M, editors. Manchikanti’s essentials of regenerative medicine in interventional pain management. 2nd ed. New York, NY: Springer; 2023.

    Google Scholar 

Download references

Acknowledgments

This book chapter is modified and updated from a previous book chapter, “Epidural Administration of Platelet Rich Plasma and Stem Cells” by Laxmaiah Manchikanti, MD, Sairam Atluri, MD, Sheri L. Albers, DO, and Richard E. Latchaw, MD, in Essentials of Regenerative Medicine in Interventional Pain Management published by ASIPP Publishing.

Author information

Authors and Affiliations

  1. Pain Management Centers of America, Paducah, KY, USA

    Laxmaiah Manchikanti

  2. Tri-State Spine Care Institute, Cincinnati, OH, USA

    Sairam Atluri

  3. Pain Management Centers of America, Evansville, IN, USA

    Mahendra Sanapati

  4. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Joshua A. Hirsch

Authors
  1. Laxmaiah Manchikanti
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sairam Atluri
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mahendra Sanapati
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Joshua A. Hirsch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Laxmaiah Manchikanti .

Editor information

Editors and Affiliations

  1. Comprehensive Spine & Sports Center, Campbell, CA, USA

    Annu Navani

  2. Tri-State Spine Care Institute, Cincinnati, OH, USA

    Sairam Atluri

  3. Pain Management Centers Of America, Evansville, IN, USA

    Mahendra Sanapati

Rights and permissions

Reprints and permissions

Copyright information

© 2024 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Manchikanti, L., Atluri, S., Sanapati, M., Hirsch, J.A. (2024). Epidural Administration of Biologics. In: Navani, A., Atluri, S., Sanapati, M. (eds) Essentials of Regenerative Medicine in Interventional Pain Management. Springer, Cham. https://doi.org/10.1007/978-3-031-50357-3_24

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-50357-3_24

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-50356-6

  • Online ISBN: 978-3-031-50357-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation