Clin Orthop Surg.  2019 Jun;11(2):183-186. 10.4055/cios.2019.11.2.183.

Influence of Epidural Steroid Injection on Adrenal Function

• Shin WS
• Ahn DK
• Kim MJ
• Cho KJ
• Go YR

• KMID: 2445053
• DOI: http://doi.org/10.4055/cios.2019.11.2.183

Abstract

BACKGROUND
Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients.
METHODS
This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7-28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test.
RESULTS
There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015).
CONCLUSIONS
Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.

Keyword

Serum cortisol level; Epidural steroid injection; Adrenal function

Reference

1. Benyamin RM, Manchikanti L, Parr AT, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012; 15(4):E363–E404.

2. Rivera CE. Lumbar epidural steroid injections. Phys Med Rehabil Clin N Am. 2018; 29(1):73–92.

3. Manchikanti L, Buenaventura RM, Manchikanti KN, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012; 15(3):E199–E245.

4. Whynes DK, McCahon RA, Ravenscroft A, Hardman J. Cost effectiveness of epidural steroid injections to manage chronic lower back pain. BMC Anesthesiol. 2012; 12:26.

5. Lee JW, Lee E, Lee GY, Kang Y, Ahn JM, Kang HS. Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre. Eur Radiol. 2018; 28(1):418–427.

6. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011; 12(5):726–731.

7. Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine (Phila Pa 1976). 2009; 34(7):731–739.

8. Abdul AJ, Ghai B, Bansal D, Sachdeva N, Bhansali A, Dhatt SS. Hypothalamic pituitary adrenocortical axis suppression following a single epidural injection of methylprednisolone acetate. Pain Physician. 2017; 20(7):E991–E1001.

9. Browning DJ. Acute retinal necrosis following epidural steroid injections. Am J Ophthalmol. 2003; 136(1):192–194.

10. Horani MH, Silverberg AB. Secondary Cushing's syndrome after a single epidural injection of a corticosteroid. Endocr Pract. 2005; 11(6):408–410.

11. Jacobs S, Pullan PT, Potter JM, Shenfield GM. Adrenal suppression following extradural steroids. Anaesthesia. 1983; 38(10):953–956.

12. Manchikanti L, Pampati V, Falco FJ, Hirsch JA. Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine (Phila Pa 1976). 2013; 38(2):157–168.

13. Even JL, Crosby CG, Song Y, McGirt MJ, Devin CJ. Effects of epidural steroid injections on blood glucose levels in patients with diabetes mellitus. Spine (Phila Pa 1976). 2012; 37(1):E46–E50.

14. DeSio JM, Kahn CH, Warfield CA. Facial flushing and/or generalized erythema after epidural steroid injection. Anesth Analg. 1995; 80(3):617–619.

15. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical epidural injection. Pain Physician. 2012; 15(2):147–152.

16. Gupta R, Shah M, Reese CM. Steroid induced spinal epidural lipomatosis: case report and review of the literature. W V Med J. 2011; 107(4):20–22.

17. Slipman CW, Chow DW, Lenrow DA, Blaugrund JE, Chou LH. Dysphonia associated with epidural steroid injection: a case report. Arch Phys Med Rehabil. 2002; 83(9):1309–1310.

18. Stambough JL, Booth RE Jr, Rothman RH. Transient hypercorticism after epidural steroid injection: a case report. J Bone Joint Surg Am. 1984; 66(7):1115–1116.

19. Tuel SM, Meythaler JM, Cross LL. Cushing's syndrome from epidural methylprednisolone. Pain. 1990; 40(1):81–84.

20. Habib G, Jabbour A, Salman J, Hakim G, Haddad H. The effect of epidural methylprednisolone acetate injection on the hypothalamic-pituitary-adrenal axis. J Clin Anesth. 2013; 25(8):629–633.

21. Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. Arch Phys Med Rehabil. 2008; 89(3):543–552.

22. Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008; 9(2):227–234.

23. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology. 2007; 106(2):331–338.

24. Friedly JL, Comstock BA, Heagerty PJ, et al. Systemic effects of epidural steroid injections for spinal stenosis. Pain. 2018; 159(5):876–883.

25. Roberts ST, Willick SE, Rho ME, Rittenberg JD. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R. 2009; 1(7):657–668.