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Flushing After Lumbar Epidural Steroid Injection with Dexamethasone

  • Chronic Pain Management (O Viswanath, Section Editor)
  • Published:
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Abstract

Purpose of Review

Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing—1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%).

Recent Findings

There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone.

Summary

Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.

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References

  1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–858.

    Article  Google Scholar 

  2. Henschke N, Kamper SJ, Maher CG. The epidemiology and economic consequences of pain. Mayo Clin Proc. 2015;90(1):139–47.

    Article  PubMed  Google Scholar 

  3. Patel K, Chopra P, Upadhyayula S. Epidural steroid injections. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.

  4. Goppelt-Struebe M. Molecular mechanisms involved in the regulation of prostaglandin biosynthesis by glucocorticoids. Biochem Pharmacol. 1997;53(10):1389–95.

    Article  CAS  PubMed  Google Scholar 

  5. Devor M, Govrin-Lippmann R, Raber P. Corticosteroids suppress ectopic neural discharge originating in experimental neuromas. Pain. 1985;22(2):127–37.

    Article  PubMed  Google Scholar 

  6. Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998;14(2):148–51.

    Article  CAS  PubMed  Google Scholar 

  7. Johansson A, Hao J, Sjolund B. Local corticosteroid application blocks transmission in normal nociceptive C-fibers. Acta Anaesthesiology Scand. 1990;34:335–8.

    Article  CAS  Google Scholar 

  8. Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain. Spine J. 2009;9(6):509–17.

    Article  PubMed  Google Scholar 

  9. Bicket MC, Gupta A, Brown CH 4th, Cohen SP. Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. Anesthesiology. 2013;119(4):907–31.

    Article  PubMed  Google Scholar 

  10. Kennedy DJ, Zheng PZ, Smuck M, McCormick ZL, Huynh L, Schneider BJ. A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. Spine J. 2018;18(1):29–35. https://doi.org/10.1016/j.spinee.2017.08.264.

    Article  PubMed  Google Scholar 

  11. Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: a comprehensive review of the published data. Pain Med. 2020;21(3):472–87.

    Article  PubMed  Google Scholar 

  12. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699–802.

    Article  PubMed  Google Scholar 

  13. Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WESET study. Rheumatology. 2005;44:1399–406.

    Article  CAS  PubMed  Google Scholar 

  14. Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, et al. Death during transforaminal epidural steroid nerve root block (C7) due to per-foration of the left vertebral artery. Am J Forensic Med Pathol. 2003;24:351–5.

    Article  PubMed  Google Scholar 

  15. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequel-ae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4:468–74.

    Article  PubMed  Google Scholar 

  16. Huntoon MA, Martin DP. Paralysis after transforaminal epidural injection and previous spinal surgery. Reg Anesth Pain Med. 2004;29:494–5.

    Article  PubMed  Google Scholar 

  17. Hammam El Abd O. Immediate and acute adverse effects following transforaminal epidural steroid injections with dexamethasone. Pain Physician. 2015;18(3;5):277–86. https://doi.org/10.36076/ppj.2015/18/277.

  18. Kang WY, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Systemic effects of fluoroscopically guided epidural steroid injection with dexamethasone. Korean J Pain. 2019;32(3):178–86. https://doi.org/10.3344/kjp.2019.32.3.178.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Everett CR, Baskin MN, Speech D, Novoseletsky D, Patel R. Flushing as a side effect following lumbar transforaminal epidural steroid injection. Pain Physician. 2004;7:427–9.

    Article  PubMed  Google Scholar 

  20. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Hanna A, Rittenberg J, et al. Complications of fluoroscopically guided caudal epidural injections. Am J Phys Med Rehabil. 2001;80(6):416–24. https://doi.org/10.1097/00002060-200106000-00005.

    Article  CAS  PubMed  Google Scholar 

  21. Kim CH. Flushing following interlaminar lumbarepidural steroid injection with dexamethasone. Pain Physician. 2010;13(5;9):481–4. https://doi.org/10.36076/ppj.2010/13/481.

  22. DeSio JM, Kahn CH, Warfield CA. Facial flushing and/or generalized erythema after epidural steroid injection. Anesth Analg. 1995;80(3):617–9. https://doi.org/10.1097/00000539-199503000-00034.

    Article  CAS  PubMed  Google Scholar 

  23. Cicala RS, Westbrook L, Angel JJ. Side effects and complications of cervical epidural steroid injections. J Pain Symptom Manage. 1999;4(2):64–6. https://doi.org/10.1016/0885-3924(89)90024-9.

    Article  Google Scholar 

  24. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974–84.

    Article  CAS  PubMed  Google Scholar 

  25. Duszynski B. Spine Intervention Society Position Statement on best practices for epidural steroid injections in the setting of a preservative-free dexamethasone shortage. Pain Med. 2019;20:1277–80.

    Article  PubMed  Google Scholar 

  26. Popescu A, McCormick ZL, Smith CC, Spine Intervention Society’s Patient Safety Committee. Strategies to minimize risk in lumbar transforaminal injections: imaging and injectate. Pain Med. 2019;20(7):1449–50.

    Article  PubMed  Google Scholar 

  27. Neal JM, Barrington MJ, Brull R, Hadzic A, Hebl JR, Horlocker TT, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine. Reg Anesth Pain Med. 2015;40(5):401–30. https://doi.org/10.1097/aap.0000000000000286.

    Article  CAS  PubMed  Google Scholar 

  28. Mehta P, Syrop I, Singh JR, Kirschner J. Systematic review of the efficacy of particulate versus nonparticulate corticosteroids in epidural injections. PM&R. 2016;9(5):502–12. https://doi.org/10.1016/j.pmrj.2016.11.008.

    Article  Google Scholar 

  29. Cohen SP, Greuber E, Vought K, Lissin D. Safety of epidural steroid injections for lumbosacral radicular pain. Clin J Pain. 2021;37(9):707–17. https://doi.org/10.1097/ajp.0000000000000963.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Derby R, Lee S-H, Date ES, Lee J-H, Lee C-H. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227–34. https://doi.org/10.1111/j.1526-4637.2007.00341.x.

    Article  PubMed  Google Scholar 

  31. Vydra D, McCormick Z, Clements N, Nagpal A, Julia J, Cushman D. Current trends in steroid dose choice and frequency of administration of epidural steroid injections: a survey study. PM&R. 2019;12(1):49–54. https://doi.org/10.1002/pmrj.12192.

    Article  Google Scholar 

  32. Mattie R, Miller DC, Smith C. Annual maximum dose of epidural steroid injection. Pain Med. 2019;20(10):2069–70. https://doi.org/10.1093/pm/pnz191.

    Article  PubMed  Google Scholar 

  33. Food and Drug Administration. Anesthetic and Analgesic Drug Products Advisory Committee Meeting. Epidural steroid injections (ESI) and the risk of serious neurologic adverse reactions; 2014. Available at: https://wayback.archive-it.org/7993/20170405203405/www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndAnalgesicDrugProductsAdvisoryCommittee/UCM422692.pdf. Accessed 2 Feb 2021.

  34. Donohue NK, Tarima SS, Durand MJ, Wu H. Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study. Korean J Pain. 2020 Apr 1;33(2):192–198. https://doi.org/10.3344/kjp.2020.33.2.192. PMID: 32235020; PMCID: PMC7136301.

  35. Manchikanti L, Singh V, Falco F, Cash K, Pampati, V. Evaluation of the effectiveness of lumbarinterlaminar epidural injections in managingchronic pain of lumbar disc herniation orradiculitis: a randomized, double-blind, controlled trial. Pain Physician. 2010;13(4;7):343–55. https://doi.org/10.36076/ppj.2010/13/343.

  36. Collighan N, Gupta S. Epidural steroids. Contin Educ Anaesth Crit Care Pain. 2010;10(1):1–5. https://doi.org/10.1093/bjaceaccp/mkp043.

    Article  Google Scholar 

  37. Bingham N, Dhall R, Montuori M, Padjen K, Gharibo C, Doan L. Variations in epidural steroid injection practice patterns by pain medicine physicians in the United States. Pain Physician. 2022;25(6):E857–62.

    PubMed  Google Scholar 

  38. Lumbosacral transforaminal epidural steroid injections: a self-controlled study. Korean J Pain. 33(2):192–8. https://doi.org/10.3344/kjp.2020.33.2.192.

  39. Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospective, randomized, doubleblind, dose-response trial. Reg Anesth Pain Med. 2011;36:572–8. https://doi.org/10.1097/AAP.0b013e318232e843.

    Article  CAS  PubMed  Google Scholar 

  40. Abram SE. Treatment of lumbosacral radiculopathy with epidural steroids. Anesthesiology. 1999;91:1937–41.

    Article  CAS  PubMed  Google Scholar 

  41. DeSio JM, Kahn CH, Warfield CA. Facial flushing and/or generalized erythema after epidural steroid injection. Anesth Analg. 1995;80:617–9.

    CAS  PubMed  Google Scholar 

  42. Brook EM, Hu CH, Kingston KA, Matzkin EG. Corticosteroid injections: a review of sex-related side effects. Orthopedics. 2017;40(2):211–5. https://doi.org/10.3928/01477447-20161116-07.

    Article  Google Scholar 

  43. Husseini JS, Simeone FJ, Staffa SJ, Palmer WE, Chang CY. Fluoroscopically guided lumbar spine interlaminar and transforaminal epidural injections: inadvertent intravascular injection. Acta Radiol. 2020;61(11):1534–40. https://doi.org/10.1177/0284185120903450.

    Article  PubMed  Google Scholar 

  44. Karaman H, Kavak GÖ, Tüfek A, Yldrm ZB. The complications of transforaminal lumbar epidural steroid injections. Spine. 2011;36(13):819–24. https://doi.org/10.1097/brs.0b013e3181f32bae.

    Article  Google Scholar 

  45. Nahm FS, Lee CJ, Lee SH, Kim TH, Sim WS, Cho HS, et al. Original article: risk of intravascular injection in transforaminal epidural injections. Anaesthesia. 2010;65(9):917–21. https://doi.org/10.1111/j.1365-2044.2010.06447.x.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA

    Suzanne Shermon, Gustaf Van Acker & Chong Kim

  2. Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA

    Vladimir Suric

  3. Department of Anesthesiology, University of Wisconsin, Madison, WI, USA

    Alaa Abd-Elsayed

  4. Physical Medicine and Rehabilitation, All Star Pain Management, Annapolis, MD, USA

    Nicholas Mata

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  1. Suzanne Shermon
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Correspondence to Alaa Abd-Elsayed.

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Shermon, S., Van Acker, G., Suric, V. et al. Flushing After Lumbar Epidural Steroid Injection with Dexamethasone. Curr Pain Headache Rep 27, 143–148 (2023). https://doi.org/10.1007/s11916-023-01117-2

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