title: Safety of Epidural Corticosteroid Injections.
abstract: OBJECTIVE
  Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports.
  
  
  METHODS
  Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis.
  
  
  RESULTS
  Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating.
  
  
  CONCLUSIONS
  The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.
authors.affiliation: Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing Level A, Great George Street, Leeds, LS1 3EX, UK. pountos@doctors.org.uk.
authors.forename: Ippokratis
authors.initials: I
authors.lastname: Pountos
authors.affiliation: Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing Level A, Great George Street, Leeds, LS1 3EX, UK.
authors.forename: Michalis
authors.initials: M
authors.lastname: Panteli
authors.affiliation: University of Leeds, Leeds, UK.
authors.forename: Gavin
authors.initials: G
authors.lastname: Walters
authors.affiliation: Anaesthetic Department, Leeds Teaching Hospitals, NHS Trust, Leeds, UK.
authors.forename: Dudley
authors.initials: D
authors.lastname: Bush
authors.affiliation: Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing Level A, Great George Street, Leeds, LS1 3EX, UK.
authors.forename: Peter V
authors.initials: PV
authors.lastname: Giannoudis
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000009:adverse effects*; D064420:Drug-Related Side Effects and Adverse Reactions / Q000209:etiology*; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects*; D011446:Prospective Studies; D012189:Retrospective Studies; D012449:Safety
chemical_list: D000305:Adrenal Cortex Hormones