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Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians
  1. Nathan Clements1,
  2. Darrell Vydra2,
  3. Daniel M. Cushman3,
  4. Ameet Nagpal4,
  5. Jonathan Julia4,
  6. Patricia Zheng5 and
  7. Zachary L. McCormick6
  1. 1Physical Medicine and Rehabilitation, UT Health San Antonio, San Antonio, Texas, USA
  2. 2Physical Medicine and Rehabilitation, University of Texas Health Science Center at San Antonio Texas - Research Park Campus, San Antonio, Texas, USA
  3. 3Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
  4. 4Anesthesiology, University of Texas Health Science Center at San Antonio Texas - Research Park Campus, San Antonio, Texas, USA
  5. 5Orthopaedic Surgery, University of California San Francisco Department of Otolaryngology Head and Neck Surgery, San Francisco, California, USA
  6. 6Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
  1. Correspondence to Dr Nathan Clements,Physical Medicine and Rehabilitation, UT Health San Antonio, San Antonio, Texas, USA; ClementsN4{at}


Background Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown.

Objective Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures.

Methods Cross-sectional survey study of 314 physician members of the Spine Interventional Society.

Results 41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs.

Conclusion Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.

  • spinal/epidural injection
  • chronic pain: back pain
  • chronic pain: head and neck
  • interventional pain management

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  • Contributors All authors made substantial contributions to the study design, acquisition, analysis and interpretation of data, revised critically important intellectual content, contributed to final approval of the version submitted for publishing and agreed to be accountable for all aspects of the work and that questions related to the accuracy or integrity of the work were appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests ZM on the board of directors of the Spine Intervention Society. None of the other authors declare conflicts of interests.

  • Patient consent for publication Not required.

  • Ethics approval Institutional Review Board (IRB) approval for the study was acquired through the University of Utah School of Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available upon reasonable request.