Role of neuraxial steroids in interventional pain management

The clinical introduction of cortisone in 1949 revolutionized medical care of patients with a host of diseases. Soon after that, the first use of steroids in epidural injections was described in 1952 and 1953. A variety of corticosteroid agents (hydrocortisone, methylprednisolone, triamcinolone, betamethasone) have been applied neuraxially to treat spinal pain and other types of painful conditions. The utilization of neuraxial steroids had its empirical beginning in the 1950s and 60's. When steroid administration seemingly was effective for management of low back pain and sciatica, the concept was adapted for other types of neural blockade, including facet joint injections. It is postulated that corticosteroids reduce inflammation by inhibiting either the synthesis or release of a number of pro-inflammatory substances and by causing a reversible local anesthetic effect. Multiple complications of corticosteroid administration are two-fold: those resulting from withdrawal of steroids and those resulting from continued use of large doses. These include neural toxicity, separation of pituitary-adrenal axis, weight gain, osteoporosis, as well as many other complications. However, a review of the literature on epidural steroids or other types of neuraxial blockade mentions very few complications that can be directly attributed either to the chemistry or the pharmacology of the steroids, except for reports of adrenal suppression. This review describes various aspects of neuraxial steroids including historical concepts, mechanism of action, pharmacological aspects, side effects, complications and their role in treatment.