title: Human Serum Modifies Aggregation Properties of Commonly Used Epidural Steroids.
abstract: BACKGROUND
  Case reports of catastrophic neurological sequelae during ESIs have questioned the safety of this procedure. A proposed mechanism is particulate steroid embolization resulting in neuralischemia. Previous reports have described steroid clumping in common epidural injection mixtures. We demonstrate that physiologic medium can also modify aggregation.
  
  
  OBJECTIVE
  To inspect and compare aggregative properties of steroid preparations with and without human serum.
  
  
  METHODS
  Academic tertiary care center.
  
  
  OBJECTIVE
  Particulate steroids display different aggregation characteristics in serum compared to non-physiologic solutions.
  
  
  METHODS
  Solutions were inspected under light microscopy: betamethasone sodium phosphate/betamethasone acetate, methylprednisolone, and dexamethasone were each mixed in lidocaine 1%, bupivacaine 0.5%, or sterile water in a 1:1 ratio. All preparations were inspected under light microscopy with 100x and 400x magnifications by a pathologist blinded to our expectations and hypothesis. Five random viewing fields were selected within each slide and the number of aggregates per field and the number of particles per aggregate was evaluated.
  
  
  RESULTS
  The addition of serum had a significant effect on steroid particle aggregation and number of particles per aggregate.
  
  
  CONCLUSIONS
  This study was limited by sample size as only 2 sets of human serum samples were tested with each preparation against one non-serum control. Additionally, as steroid preparations were evaluated under light microscopy, the ex vivo setting must be considered in the interpretation of results. Finally, mixing preparations with human serum as opposed to whole blood was necessary to allow for improved visibility on light microscopy despite the fact that whole blood may be necessary to more closely emulate in vivo coagulation setting.
  
  
  CONCLUSIONS
  Overall, the presence of serum resulted in fewer large steroid particle aggregates when compared to non-serum control samples. Amongst particulate steroids, betamethasone with bupivacaine 0.5% demonstrated the fewest and smallest particle aggregates, suggesting that preparation may reduce the risk of embolic infarction. Methylprednisolone formed significantly larger particles in bupivicaine 0.5% with serum compared to non-serum controls.
authors.forename: Sayed E
authors.initials: SE
authors.lastname: Wahezi
authors.affiliation: Montefiore Medical Center, Bronx, NY.
authors.forename: Andrew
authors.initials: A
authors.lastname: Lederman
authors.affiliation: Montefiore Medical Center, Bronx, NY.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Algra
authors.affiliation: Montefiore Medical Center, Bronx, NY.
authors.forename: Soo Yeon
authors.initials: SY
authors.lastname: Kim
authors.affiliation: Montefiore Medical Center, Bronx, NY.
authors.forename: Rani
authors.initials: R
authors.lastname: Sellars
mesh_terms: D001623:Betamethasone / Q000737:chemistry; D002045:Bupivacaine / Q000737:chemistry; D003907:Dexamethasone / Q000737:chemistry; D004617:Embolism / Q000209:etiology; D006801:Humans; D007268:Injections, Epidural; D008012:Lidocaine / Q000737:chemistry; D008775:Methylprednisolone / Q000737:chemistry; D010316:Particle Size; D044967:Serum / Q000737:chemistry*; D013256:Steroids / Q000008:administration & dosage / Q000737:chemistry*
chemical_list: D013256:Steroids; D003907:Dexamethasone; D001623:Betamethasone; D008012:Lidocaine; D008775:Methylprednisolone; D002045:Bupivacaine