Anesth Analg 2003;96:907-908
© 2003 International Anesthesia Research Society
LETTERS TO THE EDITOR
Epidural Steroid Injections
Douglas G. Merrill, MD,
James P. Rathmell, MD, and
John C. Rowlingson, MD
The Virginia Mason Clinic, Seattle, WA
Department of Anesthesiology, University of Vermont College of Medicine
Dept. of Anesthesiology, University of Virginia Health System, Charlottesville, VA
To the Editor: The recent survey regarding epidural steroid injections (ESIs) does not give an accurate depiction of the use of fluoroscopy (1). We applaud the intent, but the design was flawed and the results do not support the article’s conclusions.
Anesthesiologists perform most ESIs. They routinely place epidurals for surgical and obstetric anesthesia as well as ESIs without fluoroscopy. The majority are not members of the International Spinal Injection Society (ISIS). ISIS members typically have this technology available and choose it readily. Surveying ISIS members to represent "private practice" insured an inaccurate bias toward use of fluoroscopy.
The authors state "further outcome studies are needed to examine the value of fluoroscopy for ESI," yet conclude that fluoroscopy "seems to be underused in academic pain programs." The use of fluoroscopy to guide precise placement of ESIs is intellectually appealing, but its value in improving outcomes is not proven. Anesthesia residents (thus, pain fellows) are not routinely taught to use fluoroscopy for all ESIs because its advantage remains unproven and is not available to most once in practice.
We agree that the current literature is of little value in directing a search for the optimal way to perform ESIs. Conclusions should be based on randomized controlled studies with meaningful outcome measures rather than on poorly designed surveys.
Reference
- Cluff R, Mehio A-K, Cohen SP, et al. The technical aspects of epidural steroid injections: a national survey. Anesth Analg 2002; 95: 403–8.[Abstract/Free Full Text]
Response
Milan P. Stojanovic, MD,
Christine N. Sang, MD MPH, and
Steven P. Cohen, MD
MGH Pain Center, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School
Inpatient Pain Service, NYU School of Medicine
In Response: We are grateful to Merrill et al for their constructive criticism, and agree with the authors that surveys are of limited value. Our main aim for conducting the survey was to determine how epidural steroid injections (ESIs) are performed among selected pain practitioners.
By labeling our study design flawed, we feel Drs. Merrill, Rathmell and Rowlingson have missed the main point of our survey. In contrast to the ideal situation in which all clinicians perform ESIs based on scientific evidence, the purpose of our survey was to outline the present state of practice in selected academic and private institutions. In the discussion section, we felt it was appropriate to compare our survey results to previously published studies on this topic.
We had several reasons for choosing ISIS as our source for selected private practitioners-anesthesiologists (we polled only ISIS members who are board certified or board eligible in anesthesiology):
- 1) Other listings (ASRA, ASA, APS, IASP, AAPM) may include practitioners whose main focus is not pain management or who do not perform ESIs;
- 2) ISIS focuses on spinal injection techniques for pain management, and its members are authors of many respectable publications and guidelines in this field.
The possibility that ISIS clinicians may tend to be more academically oriented than average pain physicians in private practice does not detract from the utility of the survey to establish a consensus.
The letter by Merill et al states that "anesthesia residents (thus, pain fellows) are not routinely taught to use fluoroscopy for all ESIs because its advantage remains unproven and is not available to most once in practice". There are no studies (surveys) looking at the percentage of residents and fellows "routinely taught" to perform ESIs under fluoroscopic guidance. Our survey results indicated that 69% of polled anesthesia pain fellowships use fluoroscopy on some occasions when conducting ESIs. Thus, it is logical to assume that a similar percentage of anesthesia residents and pain fellows are exposed to fluoroscopically-guided ESIs at some point during their training. In addition to fluroscopically guided ESIs the anesthesia residents and pain fellows are routinely taught to perform many other procedures of "unproven value."
We are surprised by the comment that fluoroscopy is not available to most anesthesia residents/fellows once in practice. Since many other pain management procedures are performed only under fluoroscopy (including medial branch blocks, lumbar sympathetic block, celiac plexus block, radiofrequency neurolysis, spinal cord stimulation, and provocative discography), fluoroscopy remains a critical resource.
In fact, there are several well conducted studies indicating that, at least in certain patients, the injectate in "blind" ESIs does not reach the area of pathology (1–3). Since this should never be the case with properly performed fluoroscopically-guided ESIs, one must conclude a priori that fluoroscopy is of proven value when performing ESIs in these patients. As stated in our survey and in the letter by Merrill et al, future outcome studies are needed to determine just when and in whom it is necessary.
References
- White A, Derby R, Wynne G. Epidural injections for the diagnosis and treatment of low-back pain. Spine 1980; 5: 78–83.[Web of Science][Medline]
- Stojanovic MP, Vu T, Caneris O et al. The Role of Fluoroscopy in Cervical Epidural Steroid Injections: An Analysis of Epidurograms. Spine, 2002; 27: 509–514.[Web of Science][Medline]
- Fredman B, Nun MB, Zohar E et al. Epidural steroids for treating "failed back surgery syndrome:" is fluoroscopy really necessary? Anesth Analg 1999; 88: 367–72.[Abstract/Free Full Text]
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