What are the risks of an epidural steroid injection (ESI)?

From the Guidelines

Epidural steroid injections are generally considered safe when performed by a trained medical professional, but they do carry some risks, including infection, bleeding, nerve damage, and temporary worsening of pain, as well as potential long-term complications such as chronic headache, backache, and depression 1. The procedure involves injecting a corticosteroid medication and a local anesthetic into the epidural space around the spinal cord.

Potential Risks and Complications

• Infection
• Bleeding
• Nerve damage
• Temporary worsening of pain
• Serious complications like paralysis or spinal cord injury are extremely rare
• Side effects from the steroid may include temporary weight gain, increased blood sugar, mood changes, and weakening of nearby bones or tissues with repeated injections

Procedure and Effects

• The procedure is typically done on an outpatient basis and takes about 15-30 minutes
• Patients usually resume normal activities the next day
• Effects can last from a few weeks to several months
• It's most commonly used to treat back pain and sciatica caused by conditions like herniated discs or spinal stenosis

Recommendations and Guidelines

• Epidural steroid injections should be used judiciously, usually recommended only after more conservative treatments have failed 1
• The number of injections per year is typically limited to minimize potential side effects from repeated steroid use
• Clinicians should follow appropriate guidelines regarding neuraxial injection in patients receiving antithrombotics or patients with low platelet counts 1
• Caution should be exercised when considering an EBP in febrile patients or patients presenting with other systemic signs of infection 1

From the FDA Drug Label

The following adverse reactions may be associated with corticosteroid therapy: Allergic reactions: Anaphylactoid reaction, anaphylaxis, angioedema Cardiovascular: Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, fat embolism, hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis Dermatologic: Acne, allergic dermatitis, cutaneous and subcutaneous atrophy, dry scaly skin, ecchymoses and petechiae, edema, erythema, hyperpigmentation, hypopigmentation, impaired wound healing, increased sweating, lupus erythematosus-like lesions, purpura, rash, sterile abscess, striae, suppressed reactions to skin tests, thin fragile skin, thinning scalp hair, urticaria Endocrine: Decreased carbohydrate and glucose tolerance, development of cushingoid state, glycosuria, hirsutism, hypertrichosis, increased requirements for insulin or oral hypoglycemic agents in diabetes, manifestations of latent diabetes mellitus, menstrual irregularities, secondary adrenocortical and pituitary unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness), suppression of growth in pediatric patients. Arachnoiditis, meningitis, paraparesis/paraplegia, and sensory disturbances have occurred after intrathecal administration

The risks of an epidural steroid injection (ESI) include:

• Allergic reactions: anaphylactoid reaction, anaphylaxis, angioedema
• Cardiovascular events: bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, fat embolism, hypertension, myocardial rupture
• Dermatologic effects: acne, allergic dermatitis, cutaneous and subcutaneous atrophy, impaired wound healing
• Endocrine effects: decreased carbohydrate and glucose tolerance, development of cushingoid state, glycosuria, hirsutism, hypertrichosis, increased requirements for insulin or oral hypoglycemic agents in diabetes
• Neurologic effects: arachnoiditis, meningitis, paraparesis/paraplegia, sensory disturbances 2, 2, 2

From the Research

Risks of Epidural Steroid Injections

• Complications from epidural steroid injections are rare but can be catastrophic, including permanent disability and death 3
• The primary risks associated with epidural steroid injections are related to the technique and selection of specific corticosteroids used for epidural injection 3
• Although epidural steroid injections are considered safe and effective, there is a risk of adverse events, including intravascular spread and radiation exposure 4

Minimizing Risks

• The use of a parasagittal interlaminar (PIL) approach has been shown to be a more reliable, safe, and suitable approach to minimize complications related to midline interlaminar (MIL) and transforaminal (TF) approaches 4
• Fluoroscopic guidance can help reduce the risk of adverse events, including intravascular spread and radiation exposure 4, 5
• Careful patient selection and technique are crucial to minimizing the risks associated with epidural steroid injections 3, 6

Specific Risks

• Intravascular spread is a potential risk of epidural steroid injections, particularly with the TF approach 4
• Radiation exposure is a potential risk of epidural steroid injections, particularly with the use of fluoroscopic guidance 4
• Adverse events, including permanent disability and death, are rare but can occur with epidural steroid injections 3