Influence of Epidural Steroid Injection on Adrenal Function

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.

[1]  P. Heagerty,et al.  Systemic effects of epidural steroid injections for spinal stenosis , 2018, Pain.

[2]  A. Bhansali,et al.  Hypothalamic Pituitary Adrenocortical Axis Suppression following a Single Epidural Injection of Methylprednisolone Acetate. , 2017, Pain physician.

[3]  G. Habib,et al.  The effect of epidural methylprednisolone acetate injection on the hypothalamic-pituitary-adrenal axis. , 2013, Journal of clinical anesthesia.

[4]  L. Manchikanti,et al.  Growth of Spinal Interventional Pain Management Techniques: Analysis of Utilization Trends and Medicare Expenditures 2000 to 2008 , 2013, Spine.

[5]  D. Whynes,et al.  Cost effectiveness of epidural steroid injections to manage chronic lower back pain , 2012, BMC Anesthesiology.

[6]  L. Manchikanti,et al.  The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. , 2012, Pain physician.

[7]  Howard S. Smith,et al.  Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. , 2012, Pain Physician.

[8]  Reza Nazari,et al.  Cardiopulmonary arrest following cervical epidural injection. , 2012, Pain physician.

[9]  M. McGirt,et al.  Effects of Epidural Steroid Injections on Blood Glucose Levels in Patients With Diabetes Mellitus , 2012, Spine.

[10]  Rahul Gupta,et al.  Steroid induced spinal epidural lipomatosis--case report and review of the literature. , 2011, The West Virginia medical journal.

[11]  M. Schaefer,et al.  Incidence and characteristics of complications from epidural steroid injections. , 2011, Pain medicine.

[12]  Monica E. Rho,et al.  Efficacy of Lumbosacral Transforaminal Epidural Steroid Injections: A Systematic Review , 2009, PM & R : the journal of injury, function, and rehabilitation.

[13]  M. Rhee,et al.  Complications of Transforaminal Cervical Epidural Steroid Injections , 2009, Spine.

[14]  R. Derby,et al.  Size and aggregation of corticosteroids used for epidural injections. , 2008, Pain medicine.

[15]  S. Novak,et al.  The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. , 2008, Archives of physical medicine and rehabilitation.

[16]  T. Chew,et al.  Comparison of the Particle Sizes of Different Steroids and the Effect of Dilution: A Review of the Relative Neurotoxicities of the Steroids , 2007, Anesthesiology.

[17]  A. Silverberg,et al.  Secondary Cushing's syndrome after a single epidural injection of a corticosteroid. , 2005, Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists.

[18]  D. Browning.  Acute retinal necrosis following epidural steroid injections. , 2003, American journal of ophthalmology.

[19]  S. Weinstein,et al.  Lumbar epidural steroid injections. , 2003, The spine journal : official journal of the North American Spine Society.

[20]  C. Slipman,et al.  Dysphonia associated with epidural steroid injection: a case report. , 2002, Archives of physical medicine and rehabilitation.

[21]  C. Warfield,et al.  Facial flushing and/or generalized erythema after epidural steroid injection. , 1995, Anesthesia and analgesia.

[22]  S. Tuel,et al.  Cushing's syndrome from epidural methylprednisolone , 1990, Pain.

[23]  R. Rothman,et al.  Transient hypercorticism after epidural steroid injection. A case report. , 1984, The Journal of bone and joint surgery. American volume.

[24]  G. Shenfield,et al.  Adrenal suppression following extradural steroids , 1983, Anaesthesia.

[25]  G. Lee,et al.  Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre , 2017, European Radiology.