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      Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

      , MD, FIPP, PhD , 1 , , MD, PhD 2 , , MD, PhD 3 , 4 , , MD 5 , , MD, FIPP 6 , , MD, FIPP, PhD 7 , , MD, FIPP, PhD 8 , , MD, FIPP 9 , 10 , , MD, FIPP, PhD 1 , 8

      Pain Practice

      John Wiley and Sons Inc.

      epidural, corticosteroid, complications, dexamethasone, safe use

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          Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.


          A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.


          Twenty‐six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.


          Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

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          Most cited references 211

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          Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial.

          To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up. Randomised controlled trial. Nine Dutch hospitals. 283 patients with 6-12 weeks of sciatica. Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed. Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery. Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between "areas under the curves" over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome. Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year. ISRCT No 26872154.
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            Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review

            The effectiveness of surgery in patients with sciatica due to lumbar disc herniations is not without dispute. The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation. A comprehensive search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to October 2009. Randomised controlled trials of adults with lumbar radicular pain, which evaluated at least one clinically relevant outcome measure (pain, functional status, perceived recovery, lost days of work) were included. Two authors assessed risk of bias according to Cochrane criteria and extracted the data. In total, five studies were identified, two of which with a low risk of bias. One study compared early surgery with prolonged conservative care followed by surgery if needed; three studies compared surgery with usual conservative care, and one study compared surgery with epidural injections. Data were not pooled because of clinical heterogeneity and poor reporting of data. One large low-risk-of-bias trial demonstrated that early surgery in patients with 6–12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years. Another large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care.
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              A randomized trial of epidural glucocorticoid injections for spinal stenosis.

              Epidural glucocorticoid injections are widely used to treat symptoms of lumbar spinal stenosis, a common cause of pain and disability in older adults. However, rigorous data are lacking regarding the effectiveness and safety of these injections.

                Author and article information

                Pain Pract
                Pain Pract
                Pain Practice
                John Wiley and Sons Inc. (Hoboken )
                02 July 2018
                January 2019
                : 19
                : 1 ( doiID: 10.1111/papr.2019.19.issue-1 )
                : 61-92
                [ 1 ] Department of Anesthesiology Critical Care and Multidisciplinary Pain Center Ziekenhuis Oost‐Limburg Genk/Lanaken Belgium
                [ 2 ] Pain Clinic Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
                [ 3 ] Multidisciplinary Pain Center Antwerp University Hospital Edegem Belgium
                [ 4 ] Laboratory for Pain Research University of Antwerp Wilrijk Belgium
                [ 5 ] Department of Pain Management Westfriesgasthuis Hoorn The Netherlands
                [ 6 ] Department of Anesthesiology and Pain Management Rijnstate Ziekenhuis Arnhem The Netherlands
                [ 7 ] Department of Anesthesiology, Pain and Palliative Medicine Radboud University Nijmegen Medical Center Nijmegen The Netherlands
                [ 8 ] Department of Anesthesiology and Pain Management University Medical Centre Maastricht Maastricht The Netherlands
                [ 9 ] Department of Anesthesia and Critical Care Massachusetts General Hospital Boston Massachusetts U.S.A.
                [ 10 ] Department of Anesthesiology Perioperative, and Pain Medicine Brigham and Women’s Hospital Boston Massachusetts U.S.A.
                Author notes
                [* ]Address correspondence and reprint requests to: Koen Van Boxem, MD, FIPP, PhD, Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost‐Limburg, Bessemerstraat 478, 3620 Lanaken, Belgium. E‐mail: koen.vb@ 123456telenet.be .
                © 2018 The Authors. Pain Practice published by Wiley Periodicals, Inc. on behalf of World Institute of Pain

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                Page count
                Figures: 5, Tables: 4, Pages: 32, Words: 21772
                Review Article
                Review Articles
                Custom metadata
                January 2019
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.5 mode:remove_FC converted:24.07.2020


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