How is PIVD (Prolapsed Intervertebral Disc) L4-L5 managed with epidural steroid injections?

From the Guidelines

Epidural steroid injections (ESIs) are a recommended non-surgical management option for PIVD (Prolapsed Intervertebral Disc) at L4-L5 level, particularly for patients with radicular pain (sciatica), as they can provide significant pain relief lasting from weeks to months, allowing patients to participate in rehabilitation and potentially avoid surgery, as supported by the most recent and highest quality study 1. The procedure involves injecting a corticosteroid medication, typically methylprednisolone (40-80mg), triamcinolone (40-80mg), or dexamethasone (4-10mg), mixed with a local anesthetic like lidocaine (1-2%) or bupivacaine (0.25-0.5%), directly into the epidural space around the affected L4-L5 disc. Some key points to consider when using ESIs for PIVD L4-L5 management include:

• The injection is administered under fluoroscopic guidance to ensure accurate placement, as recommended by the British Pain Society 1.
• Patients typically receive a series of 1-3 injections spaced 2-4 weeks apart, with the maximum recommended frequency being 3-4 injections per year to minimize potential side effects.
• The steroids work by reducing inflammation around the compressed nerve roots, thereby decreasing pain, while the local anesthetic provides immediate short-term pain relief.
• This treatment is most effective when combined with physical therapy and appropriate activity modification.
• ESIs are particularly beneficial for patients with radicular pain (sciatica) rather than isolated back pain, and they work best when administered within 3-6 months of symptom onset.
• Patients should be aware that potential side effects include temporary increase in pain, infection, bleeding, nerve damage, and rare but serious complications like spinal cord injury or meningitis, as noted in the most recent study 1.

From the FDA Drug Label

The initial dose of Kenalog-40 Injection (triamcinolone acetonide injectable suspension, USP) may vary from 2.5 mg to 100 mg per day depending on the specific disease entity being treated DOSAGE AND ADMINISTRATION General NOTE: CONTAINS BENZYL ALCOHOL (see PRECAUTIONS). For the purpose of comparison, the following is the equivalent milligram dosage of the various glucocorticoids: In certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages

The management of PIVD (Prolapsed Intervertebral Disc) L4-L5 with Inj.Epidural Steroid is not explicitly stated in the provided drug labels. However, the labels provide information on the dosage and administration of triamcinolone acetonide injectable suspension, USP, for various conditions, including inflammatory and arthritic conditions.

• The dosage of triamcinolone acetonide injectable suspension, USP, can vary from 2.5 mg to 100 mg per day, depending on the specific disease entity being treated.
• The labels do not provide specific guidance on the use of epidural steroid injections for the management of PIVD L4-L5.
• The decision to use epidural steroid injections for PIVD L4-L5 should be made on a case-by-case basis, taking into account the individual patient's condition and response to treatment 2.
• It is essential to follow proper technique and precautions when administering epidural steroid injections to minimize the risk of complications 2.

From the Research

Management of PIVD L4-L5 with Epidural Steroid Injections

• Epidural steroid injections are a common treatment for managing low back pain with lumbosacral radicular pain, including PIVD L4-L5 3, 4, 5, 6, 7.
• The effectiveness of epidural steroid injections for PIVD L4-L5 can vary depending on the approach used, with transforaminal and parasagittal interlaminar approaches showing promising results 4, 5, 7.
• A study comparing the therapeutic efficacy of parasagittal interlaminar (PIL) and midline interlaminar (MIL) approaches found that the PIL approach produced better clinical outcomes due to better ventral epidural spread of the drug 4.
• Another study found that fluoroscopic transforaminal epidural steroid injections were effective in reducing radicular pain in patients with recurrent herniated intervertebral disc, with approximately 54% of patients not undergoing reoperation 5.
• Caudal epidural steroid injections have also been shown to be a safe and effective modality of treatment for lumbar disc prolapse, with good results in the short term and possibly long term in some patients 6.
• The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations has been demonstrated, with the transforaminal route showing more effective pain relief compared to caudal and interlaminar routes 7.

Potential Complications and Considerations

• Serious neurological complications can result from inadvertent intradiscal injection of contrast material during lumbar epidural injection, highlighting the importance of recognizing the possibility of dynamic change in the size of an extruded disk fragment 3.
• The risk of complications, such as spinal cord injury and permanent paralysis, is higher with the transforaminal route, emphasizing the need for careful patient selection and technique 4, 5.