Five pain management physicians discuss epidural steroid injections for pain treatment.
Ask Pain Physicians is a weekly series of questions posed to pain physicians around the country about clinical, business and policy issues affecting pain management care. We invite all pain physician and specialist responses. Next week's question is: Are you doing anything different in your practice in response to the opioid abuse epidemic?
Please send responses to Taryn Tawoda at taryn@beckershealthcare.com by Monday, March 5 at 5pm CST.
Marc E. Lynch, DO, medical director, Casa Colina Surgery Center (Chino, Calif.): There have been a lot of changes in the way we deliver epidural steroid injections over the past 10 to 15 years. For the first 100 years they were delivered 'blind,' without imaging. Then in the late 1990s, fluoroscopy became more prominent. Using fluoroscopy then allowed us a view to the different structures of the body, and a number of new and potentially dangerous procedures. The addition of transforaminal ESIs were one of the benefits of using fluoroscopy, but with that change came the access to areas that can lead to catastrophic injury if not performed with diligence and understanding.
There has also been a number of new studies related to the steroids that we use. Particulate steroids, with few exceptions, should be avoided in the epidural space, most specifically in the cervical region where intra-arterial injection is more likely to occur, accidentally, than in other places in the spine. Most, if not all, serious side effects can be avoided by using non-particulate steroids, and avoiding deep sedation during these procedures, especially when performed in the cervical region.
Ronald DeMeo, MD, MBA, board-certified anesthesiologist and pain-management specialist, Meridian Spine & Interventional Pain Medicine (Coral Gables, Fla.): I think when Medicare and other carriers have made an effort to take procedures outside the ASC and hospital setting to the setting of the office, they remove the quality control and peer-to-peer review and credentialing. What happens is you open the door to a lot of untrained physicians doing these procedures. When you start seeing large numbers of untrained physicians doing things in an office, you're going to see a surge in complications as well. If you separated that to see what procedures were done in an ASC or hospital and the office, I think you would see a huge disparity in the complication rate.
Timothy Spencer, DO, Saginaw (Mich.) Valley Neurosurgery: Epidural steroids have been offered to patients for many years and like any procedure can have serious side effects. This has been well known for many years.
Sudhir Vaidya, MD, director of sports medicine and pain management, Burke Rehabilitation Hospital (White Plains, N.Y.): Epidural Steroid is not without risks and the benefits are only for the short term.
Uzma Parvez, MD, Elite Pain Management (Union, N.J.): Epidural steroid injections are an option when performed by a trained physician for the appropriate patients with the indicated presenting symptoms and signs that are supported by objective finding on MRI and EMG/NCV studies. The chances of side effects and complications can increase with imprudent patient selection and due to lack of experience and training of the physician performing them.
Related Articles on Pain Management:
Dr. Scott Gottlieb: 3 Proven Ways to Grow a Pain Practice's Referral Base
6 Points for Physicians on Identifying and Preventing Chronic Pain Medication Abuse
The Future of Evidence-Based Medicine in Pain Management: Q&A With Dr. Laxmaiah Manchikanti of ASIPP
Please send responses to Taryn Tawoda at taryn@beckershealthcare.com by Monday, March 5 at 5pm CST.
Question: A recent report cited growing and serious side effects for epidural steroid injections to treat pain. What is your reaction?
Marc E. Lynch, DO, medical director, Casa Colina Surgery Center (Chino, Calif.): There have been a lot of changes in the way we deliver epidural steroid injections over the past 10 to 15 years. For the first 100 years they were delivered 'blind,' without imaging. Then in the late 1990s, fluoroscopy became more prominent. Using fluoroscopy then allowed us a view to the different structures of the body, and a number of new and potentially dangerous procedures. The addition of transforaminal ESIs were one of the benefits of using fluoroscopy, but with that change came the access to areas that can lead to catastrophic injury if not performed with diligence and understanding.
There has also been a number of new studies related to the steroids that we use. Particulate steroids, with few exceptions, should be avoided in the epidural space, most specifically in the cervical region where intra-arterial injection is more likely to occur, accidentally, than in other places in the spine. Most, if not all, serious side effects can be avoided by using non-particulate steroids, and avoiding deep sedation during these procedures, especially when performed in the cervical region.
Ronald DeMeo, MD, MBA, board-certified anesthesiologist and pain-management specialist, Meridian Spine & Interventional Pain Medicine (Coral Gables, Fla.): I think when Medicare and other carriers have made an effort to take procedures outside the ASC and hospital setting to the setting of the office, they remove the quality control and peer-to-peer review and credentialing. What happens is you open the door to a lot of untrained physicians doing these procedures. When you start seeing large numbers of untrained physicians doing things in an office, you're going to see a surge in complications as well. If you separated that to see what procedures were done in an ASC or hospital and the office, I think you would see a huge disparity in the complication rate.
Timothy Spencer, DO, Saginaw (Mich.) Valley Neurosurgery: Epidural steroids have been offered to patients for many years and like any procedure can have serious side effects. This has been well known for many years.
Sudhir Vaidya, MD, director of sports medicine and pain management, Burke Rehabilitation Hospital (White Plains, N.Y.): Epidural Steroid is not without risks and the benefits are only for the short term.
Uzma Parvez, MD, Elite Pain Management (Union, N.J.): Epidural steroid injections are an option when performed by a trained physician for the appropriate patients with the indicated presenting symptoms and signs that are supported by objective finding on MRI and EMG/NCV studies. The chances of side effects and complications can increase with imprudent patient selection and due to lack of experience and training of the physician performing them.
Related Articles on Pain Management:
Dr. Scott Gottlieb: 3 Proven Ways to Grow a Pain Practice's Referral Base
6 Points for Physicians on Identifying and Preventing Chronic Pain Medication Abuse
The Future of Evidence-Based Medicine in Pain Management: Q&A With Dr. Laxmaiah Manchikanti of ASIPP