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Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(23)00209-1
10.1016/j.inpm.2023.100377
100377
Editorial
Corticosteroids for radicular pain: Systemic or epidural?
Van Boxem Koen koen.vanboxem@zol.be
∗
Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Lanaken, Belgium
Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
∗ Corresponding author. Synapspark 1, 3600, Genk, Belgium. koen.vanboxem@zol.be
14 12 2023
12 2023
14 12 2023
2 4 10037729 11 2023
29 11 2023
© 2023 Published by Elsevier Inc. on behalf of International Pain & Spine Intervention Society.
2023

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcIn the present issue the use of corticosteroids for radicular pain is studied from different perspectives.

Gall et al. [1] performed a systematic review on systemic steroids for cervical radicular pain. They found 1 RCT with positive effect of oral steroids over placebo in patients with acute cervical radicular pain.

This positive outcome is in sharp contrast with the negative evidence for lumbar radicular pain. A recent Cochrane analysis [2] stated that systemic corticosteroids are slightly effective at improving short-term pain and function in people with radicular low back pain. However, this is based on a mean difference compared to placebo of 0.56 points out of 10. The same institution has also made a systematic review on the use of NSAIDs for sciatica in 2017 [3] They found that the efficacy of NSAIDs for pain reduction is comparable to that of placebo, with a mean difference of 4.56 points out of 100. Why a similar result crystalized in one Cochrane review in a negative result for NSAIDs and another review in “slightly effective” for systemic steroids, is unclear.

In daily practice the use of interlaminar epidural corticosteroids for subacute cervical radicular pain, not responsive to conservative treatment, is still a standard of care. This is why the survey of Gebrekristos et al. [4] on practice patterns of interlaminar epidural steroid injections (ILESI) offers an interesting perspective on daily practice. The authors questioned about imaging, sedation, imaging guidance, accessing epidural space, the use of contrast, type of corticosteroids, …

Dexamethasone (10mg) is increasingly used, especially (52.4 %) for the cervical region, while for the lumbar region methylprednisolone (44.2 %) holds its position as the steroid of choice. It is not not clear why dexamethasone has been given priority for cervical ILESI since there is currently no clear evidence in favor of switching to dexamethasone for cervical ILESI's. Strange enough the majority of providers chooses for methylprednisolone a dose of 80mg, which is higher than the recommended effective dose. Most physicians limit the total volume injected (steroid, saline and/or anesthetic) to 3 ml in the cervical epidural space, although recommendations to limit the volume are only quite recent [5]. Striking is the fact that a small group clearly fails to adopt recommendations and used sedation as a standard of practice >75 % of the time (12.24 % of the respondents) and in 13.1 % advanced imaging was not required prior to a cervical epidural injection. Especially the latter should be mandatory since review of imaging before cervical ESI could prevent severe complications [6].

The same group [7] also held a survey on the topic of transforaminal epidural steroid injections (TFESI), with a clear trend to use dexamethasone both cervical (91,2 %) as lumbar (74,5 %) and with a majority using a 10mg dose. Also here divergent practice to consensus recommendations exist with 11.8 % of the respondents not requiring advanced imaging before TFESI, 5.9 % of respondents using sedation >75 % of the time and 9 % reporting the use of particulate corticosteroids for cervical TFESI.

In summary the use of dexamethasone has been widely implemented but, in both publications, authors conclude that variability in practice continues to exist, despite consensus recommendations. They suggest that further educational efforts and clarification of existing guidelines are needed. Apparently, adaptations to the consensus guidelines may be easier for newer interventions and medications instead of older ones.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Gall N. Gall N. Ghaffari C. Koduri J. Dove C. Levin J. Systemic steroids for cervical radicular pain : a systematic review. Interventional Intervent Pain Med 2 4 2023
2 Chou R. Pinto R.Z. Fu R. Systemic corticosteroids for radicular and non-radicular low back pain Cochrane Database Syst Rev 10 2022 10.1002/14651858.CD012450.pub2 Cd012450
3 Rasmussen-Barr E. Held U. Grooten W.J.A. Nonsteroidal anti-inflammatory drugs for sciatica: an updated Cochrane review Spine 42 2017 586 594 10.1097/brs.0000000000002092 28399072
4 Gebrekristos B. Turcu R. Kotler D. Gureck A.E. Meleger A.L. An update on technical and safety practice patterns of interlaminar epidural steroid injections Intervent Pain Med 2 4 2023 December 2023
5 Van Boxem K. Rijsdijk M. Hans G. Safe use of epidural corticosteroid injections: recommendations of the WIP benelux work group Pain Pract 19 2019 61 92 10.1111/papr.12709 29756333
6 Rathmell J.P. Benzon H.T. Dreyfuss P. Huntoon M. Wallace M. Baker R. Riew K.D. Rosenquist R.W. Aprill C. Rost N.S. Buvanendran A. Kreiner D.S. Bogduk N. Fourney D.R. Fraifeld E. Horn S. Stone J. Vorenkamp K. Lawler G. Summers J. Kloth D. O'Brien D. Jr. Tutton S. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations Anesthesiology 122 5 2015 May 974 984 25668411
7 Gureck A.E. Gebrekristos B. Turcu R. Kotler D. Meleger A.L. An update on technical and safety practice patterns in transforaminal epidural steroid injections Intervent Pain Med 2 4 December 2023 100286
