Steroid Epidurals – Why Some Work And Some Not So Well

Recent findings demonstrate lying patient with bad side down for 15 minutes can almost double its effectiveness.
Spine 2010 Jun 8. [in press]
Is the Outcome of Caudal Epidural Injections Affected by Patient Positioning?
Makki D, Nawabi DH, Francis R, Hamed AR, Hussein AA.  abstract here

• Radicular low back pain with leg pain the predominant finding. Some had evidence of spinal stenosis.
• While prone, 10 mL of normal saline, 10 mL of 0.5% Bupivacaine, and 40 mg of methylprednisolone injected epidurally
• Test subjects were lay with bad side down for 15 minutes (range 12-19 minutes) before sitting up. Control subjects did not lay on side.

Results:

I would like to thank Dr.

D Makki for supplying the information to complete this graph. The results are 6 week post injection: Y axis is pain scale.

There are so many studies that have decreed steroid epidurals worthless and now it is becoming clearer that there are some necessary factors required to make it work.
The results are astounding. Those that did not lay on side were 20% better 6 weeks later. Those who had lay on side were 46% better. They contended because the injection solution is hyperdense, it would gravitate to affected side and make a difference.

This would add credibility to the finding of an inflammatory membrane seen foraminally by the affected nerve root.:

Surg Technol Int. 2006;15:243-56.
In-vivo endoscopic visualization of patho-anatomy in painful degenerative conditions of the lumbar spine.
Yeung AT, Yeung CA. abstract here

“Neo-angiogenesis and neurogenesis in the inflammatory membrane present in the foraminal triangle was a new finding not reported in traditional clinical studies.” – the steroid must land on this membrane and help neutralize it.
Comment – I was taught to do steroid epidurals sidelying with the bad side down and to leave them there for a period after. This now makes very good sense. Some thoughts I have:

1) There have always been concerns that the preservatives in injectable steroids are toxic and can induce scarring in their own right  – causing adhesive arachnoiditis  – see Dr. Burton’s site re this here:
EPIDURAL INJECTIONS and the LUMBAR SPINE

I have talked to a spokesman from the Kenalog company and confirmed at least for their agent – the active ingredient is the the precipitated powder – and hence allowing the powder to settle and sucking off the supernatent does not affect its potency.  PLEASE take off at least half the settled volume and just double the potency figures.

2) Specific gravity is an issue; the steroid with preservative has sg of 1.025; you can achieve that same specific gravity by adding 7.5% dextrose – used in spinal anesthesia at that strength so safe.

3) Just how long would be best kept on the side remains to be seen. They referred to one study that suggested it took 20 minutes for full anesthetic effect side lying. Perhaps 20-30 minutes would be optimal or minimal?

I am hopeful the news spreads fast on this study and will talk to those I can.