What are the contraindications, typical side effects, monitoring recommendations, and management strategies for corticosteroids administered in a spinal (epidural) block?

Reactions to Spinal Block Steroids

Epidural steroid injections carry a very small risk of catastrophic complications including spinal cord infarction, paraplegia, stroke, and death, alongside more common minor complications such as transient pain increases, hyperglycemia in diabetic patients, and injection site discomfort. 1, 2

Contraindications

Absolute Contraindications

• Active systemic infection or uncontrolled local infection at the injection site, as corticosteroids suppress immune function and can lead to disseminated infections 2
• Known hypersensitivity to methylprednisolone or other corticosteroid components 2
• Cerebral malaria (corticosteroids should be avoided) 2
• Systemic fungal infections unless the steroid is needed to control drug reactions 2

Relative Contraindications Requiring Careful Assessment

• Latent or active tuberculosis - reactivation may occur; chemoprophylaxis should be considered during prolonged therapy 2
• Hepatitis B carriers - viral reactivation can occur; screen patients before immunosuppressive treatment and consider antiviral prophylaxis 2
• Non-immune patients to varicella or measles - these infections can have serious or fatal courses in corticosteroid-treated patients 2
• Known or suspected Strongyloides infestation - corticosteroid-induced immunosuppression may lead to hyperinfection with potentially fatal gram-negative septicemia 2
• Latent amebiasis - should be ruled out before initiating steroids, particularly in patients who have spent time in the tropics or have unexplained diarrhea 2

Anticoagulation Considerations

• NSAIDs and aspirin (≤325 mg/day) do NOT increase the risk of spinal hematoma and are safe to continue during epidural steroid injections 3
• Platelet counts should be assessed if there is a history of bruising or bleeding, though counts <100 × 10⁹/L are rare 3

Common Side Effects and Adverse Reactions

Minor Complications (Overall Rate: 2.4%)

• Increased pain (1.1% of injections) - most common complication, typically self-limited 4
• Pain at injection site (0.33%) 4
• Persistent numbness (0.14%) 4
• Blood noted during needle placement (5.2%) - not associated with NSAID use but increased with larger needle gauge, multiple passes, and accidental dural puncture 3
• Transient neurologic symptoms - new or worsening symptoms persisting >24 hours occurred in 42 patients, with median duration of 3 days (range 1-20 days) 3

Metabolic Effects in Diabetic Patients

• Fasting blood glucose elevation occurs on postprocedure days 1-3 with 40 mg triamcinolone (mean 179 mg/dL on day 1) versus only day 1 with 20 mg dose (mean 146 mg/dL) 5
• Postprandial glucose elevation occurs for up to 4 days, significantly greater with 40 mg (288 mg/dL on day 0) versus 20 mg (242 mg/dL) 5
• 20 mg triamcinolone provides equivalent pain relief with less hyperglycemia compared to 40 mg in diabetic patients 5

Ophthalmic Effects (With Prolonged Use)

• Posterior subcapsular cataracts 2
• Glaucoma with possible optic nerve damage 2
• Enhanced risk of secondary ocular infections (fungal or viral) 2

Rare but Catastrophic Complications

Between 1997-2014, the FDA Adverse Event Reporting System captured 90 serious adverse events occurring within minutes to 48 hours after epidural corticosteroid injections, including: 1

• Death
• Spinal cord infarction
• Paraplegia and quadriplegia
• Cortical blindness
• Stroke
• Seizures
• Brain edema

Other Serious Risks

• Kaposi's sarcoma has been reported in patients receiving chronic corticosteroid therapy 2
• Dural puncture (1.4% incidence) with potential for post-dural puncture headache 3
• Deep infection (0.7% incidence) 1

Monitoring Recommendations

Pre-Procedure Screening

• Screen for hepatitis B infection before initiating immunosuppressive treatment 2
• Rule out latent tuberculosis in patients with tuberculin reactivity 2
• Assess platelet count if history of bruising or bleeding is present 3
• Evaluate for active infections - delay procedure if uncontrolled infection is present 1

Intra-Procedure Monitoring

• Fluoroscopic or CT guidance should be used routinely to ensure proper needle placement 6
• Aspiration before injection to check for blood or CSF return 3
• Monitor for immediate adverse reactions including cardiovascular and neurologic changes 1

Post-Procedure Monitoring

• Observe patients closely for 15-30 minutes after injection for infusion-related reactions 1
• Assess neurologic function before discharge to establish baseline 1
• Blood glucose monitoring in diabetic patients: Measure finger-stick glucose twice daily (fasting and postprandial) for 7 days after injection, with particular attention to days 0-4 when elevations are most pronounced 5
• Contact patients within 10 days to assess for delayed complications 4

Long-Term Monitoring (If Repeated Injections)

• Ophthalmologic examination for cataracts and glaucoma with prolonged corticosteroid use 2
• Monitor for signs of immunosuppression including opportunistic infections 2
• Assess for adrenal suppression if considering discontinuation after prolonged therapy 2

Management Strategies for Complications

Immediate Management of High/Total Spinal Block

If signs of high block develop (agitation, severe hypotension, bradycardia, upper limb weakness, dyspnoea, difficulty speaking): 1

• Support circulation with vasopressors (ephedrine or metaraminol) and intravenous fluids
• Administer supplemental oxygen immediately
• Prepare for tracheal intubation and ventilation if respiratory compromise occurs
• Assess block height every 5 minutes until no further extension is observed

Management of Hyperglycemia in Diabetic Patients

• Use 20 mg triamcinolone instead of 40 mg to reduce glucose excursions while maintaining pain control efficacy 5
• Intensify glucose monitoring for 4-7 days post-procedure 5
• Adjust diabetic medications as needed during the hyperglycemic period
• Consider H2 blockers or proton pump inhibitors in patients at high risk for GI complications (perioperative patients, history of ulcers/GI bleeding, concurrent NSAIDs or anticoagulation) 1

Management of Increased Pain

• Reassure patients that transient pain increases occur in 1.1% of cases and are typically self-limited 4
• Multimodal analgesia with acetaminophen and NSAIDs unless contraindicated 1, 7
• Short-term opioids may be considered if multimodal analgesia is ineffective 1
• Median duration of new neurologic symptoms is 3 days (range 1-20 days); differentiate from complications requiring intervention 3

Management of Infection Risk

• Do not routinely administer corticosteroids as premedication for other procedures in patients receiving epidural steroids 1
• Maintain high index of suspicion for opportunistic infections including fungal, viral, and parasitic pathogens 2
• Consider prophylaxis for Pneumocystis jiroveci in immunosuppressed patients receiving repeated injections 1

Exposure Prophylaxis

• Varicella exposure: Administer varicella zoster immune globulin; if varicella develops, consider antiviral agents 2
• Measles exposure: Administer immunoglobulin prophylaxis 2

Key Clinical Pearls

Transforaminal injections have lower complication rates (2.1%) compared to interlaminar injections (6.0%), though both are generally safe 4

Risk factors for minor hemorrhagic complications include increased age, larger needle gauge, multiple interspace insertions, multiple needle passes, larger injectant volumes, and accidental dural puncture - but NOT NSAID use 3

The lowest effective steroid dose should be used for the shortest time possible, with downward titration attempted whenever feasible 1

Failure to aspirate CSF does not exclude subarachnoid catheter positioning - always use slow, incremental dosing for any top-up 1