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Background: Epidural steroid injections (ESI) are commonly used to treat refractory radicular spinal pain. Although evidence suggests that an increasing cumulative dose of exogenous corticosteroid may be harmful, knowledge of current practice patterns is limited regarding the choice of dose and frequency of epidural steroid injections (ESIs).Objective: Describe current practice trends in the dose selection and frequency of administration of transforaminal ESIs (TFESIs) and interlaminar ESIs (ILESIs).Design: Cross-sectional survey study.Setting: Not applicable.Participants: Three hundred fourteen physician members of the Spine Intervention Society (SIS). From May to June 2018, an online survey was distributed to 5907 physician members of the SIS.Interventions: Not applicable.Main Outcome Measures: Corticosteroid dose used by practitioners and the number of annual ESIs administered per patient.Results: Three hundred fourteen physicians responded to the survey. For single cervical or lumbar injections of dexamethasone, most physicians (56.0%) reported using 10 mg; 17% of physicians reported use of doses greater than 10 mg, with 6% using a dose of 20 mg per injection level. The most common particulate corticosteroid dose used during both cervical and lumbar ILESIs was 80 mg (cervical = 55.4%, lumbar = 54.7%). During cervical and lumbar ILESIs, 17% and 12.7% of physicians reported using doses greater than 80 mg, respectively. Almost 10% of physicians reported performing cervical TFESIs with particulate steroids. Forty percent of physicians reported allowing four ESIs at a given spinal segmental level per year (cervical/thoracic/lumbosacral). A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%).Conclusions: There is considerable variability among this large cohort of interventionists with regard to corticosteroid dose selection and epidural steroid injection frequency. A small proportion of respondents reported Mulitsociety Pain Workgroup guideline-discordant use of particulate steroids during cervical TFESIs. These findings demonstrate a need for additional research regarding both the reasons for such variation in care and the reasons for guideline-discordant practice in a subset of physicians.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

The article focuses on sedation that has been used commonly during interventional pain procedures. It mentions that deep sedation caries risk of cardiorespiratory depression and potentially death; and also mentions the American Society of Anesthesiologists (ASA) and the Spine Intervention Society (SIS) have developed practice advisories and position statements recommending the judicious use of moderate sedation and warning against the use of deep sedation during interventional pain procedures.

The article offers information on Serious Complications Associated with Interventional Spine Procedures. Topics include large number of injections during cumulative lifetime practice experience; and information regarding complications associated with transformational epidural steroid injection (TFESI) without the use of particulate steroid.

Background: Numerous combination intrathecal drug therapy (CIDT) strategies exist and are utilized for varying pain syndromes, typically when monotherapy dose escalation or medication alternation is deemed untenable or unfeasible. Unfortunately, the supportive evidence basis for the use of these strategies and specific drug combinations is generally lacking and unclear, with many medications being used for off-label indications., Objective: In this manuscript, we provide a robust exploration and analysis of the literature to provide an evidence-based narrative for the use of CIDT strategies in regard to clinical indications, pharmacologic parameters, specific drug combinations, safety profiles, and future directions., Study Design: Narrative review., Methods: This was an evidence based narrative performed after extensive review of the literature., Results: Variances in intrathecal pharmacokinetics and pharmacodynamics are utilized advantageously with CIDT strategies to achieve improved analgesic benefit; however, appropriate use may be limited by increased or compounded risk of adverse effects. The supportive evidence for CIDT use for chronic pain conditions is largely lacking and limited to small, uncontrolled, observational studies, with many having various confounding factors, including a lack of standardized dosing. The most evidenced CIDT strategies include polyanalgesia with morphine-ziconotide, opioid-clonidine, and morphine-bupivacaine. Notably, in addition to pain relief, morphine-bupivacaine has been shown to decrease early opioid escalation requirements., Limitations: The supportive evidence for CIDT use for chronic pain conditions is largely lacking and limited to small, uncontrolled, observational studies, with many having various confounding factors including a lack of standardized dosing., Conclusions: CIDT strategies and polyanalgesia combinations can be effective for treating various patient populations with chronic pain. The appropriate use of these strategies may be limited by increased or compounded risk of adverse effects, both of which are highly patient and scenario dependent. Therefore, practitioners should maintain a particularly low threshold of suspicion for adverse effects in patients with CIDT such that safety profiles associated with this therapy can be favorably maintained.

Background: Epidural steroid injections (ESI) are commonly used to treat refractory radicular spinal pain. Although evidence suggests that an increasing cumulative dose of exogenous corticosteroid may be harmful, knowledge of current practice patterns is limited regarding the choice of dose and frequency of epidural steroid injections (ESIs)., Objective: Describe current practice trends in the dose selection and frequency of administration of transforaminal ESIs (TFESIs) and interlaminar ESIs (ILESIs)., Design: Cross-sectional survey study., Setting: Not applicable., Participants: Three hundred fourteen physician members of the Spine Intervention Society (SIS). From May to June 2018, an online survey was distributed to 5907 physician members of the SIS., Interventions: Not applicable., Main Outcome Measures: Corticosteroid dose used by practitioners and the number of annual ESIs administered per patient., Results: Three hundred fourteen physicians responded to the survey. For single cervical or lumbar injections of dexamethasone, most physicians (56.0%) reported using 10 mg; 17% of physicians reported use of doses greater than 10 mg, with 6% using a dose of 20 mg per injection level. The most common particulate corticosteroid dose used during both cervical and lumbar ILESIs was 80 mg (cervical = 55.4%, lumbar = 54.7%). During cervical and lumbar ILESIs, 17% and 12.7% of physicians reported using doses greater than 80 mg, respectively. Almost 10% of physicians reported performing cervical TFESIs with particulate steroids. Forty percent of physicians reported allowing four ESIs at a given spinal segmental level per year (cervical/thoracic/lumbosacral). A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%)., Conclusions: There is considerable variability among this large cohort of interventionists with regard to corticosteroid dose selection and epidural steroid injection frequency. A small proportion of respondents reported Mulitsociety Pain Workgroup guideline-discordant use of particulate steroids during cervical TFESIs. These findings demonstrate a need for additional research regarding both the reasons for such variation in care and the reasons for guideline-discordant practice in a subset of physicians., Level of Evidence: IV., (© 2019 American Academy of Physical Medicine and Rehabilitation.)