SpU: How do physicians know if a spinal epidural corticosteroid injection is right for a particular patient?
Dr. Kamhi:
Now, the single most important factor that influences the success of an epidural corticosteroid injection in treating a painful spinal condition is the accuracy of the physician's diagnosis. My own clinical observations and evidence-based findings published in spine journals support this fact. Critical to an accurate diagnosis is the following:

1) The physician should him/herself obtain a detailed medical history from the patient, perform a physical and neurological examination, and procedure interview before performing any procedure. From these findings, the physician will come to his own diagnostic impression.

2) The physician who will perform the spinal epidural injection must read all supporting plain x-rays, CT or MRI films, and electrodiagnostic studies. He must take all the available information into consideration when making the final diagnosis.

Pinpointing the cause of back and neck pain can be difficult. The causes of back and neck pain are many and may not always be as obvious as a herniated disc or spinal stenosis. Sometimes radiating back pain from the spine is caused by diseased facet joints. Sometimes low back pain is due to disease of nearby sacroiliac joints.

The importance of making an accurate diagnosis cannot be overstated. As a professor of mine once pointed out to me, "There is no point, doctor, in performing the wrong procedure very well!"

SpU: How are corticosteroids administered?
Dr. Kamhi:
Corticosteroids can be administered orally, intravenously and by spinal injection.

Methylprednisolone (trade name Medrol®) is a common oral corticosteroid taken in a one- or two-week taper. This means the patient takes seven pills day one, six pills on day two, and decreases the dose by one pill a day until at the end of a week no more medication is taken. The severity of the condition dictates whether the patient takes the medication for one or two weeks.

Prednisone is another oral corticosteroid medication. The results are similar to methylprednisolone, but oral corticosteroids take longer to exert their effect. This is because certain necessary blood levels of medication must reach the spinal nerves.

Before taking oral corticosteroids, patients should discuss this with their physicians. Patients should never attempt to self-prescribe corticosteroid medication or alter a prescribed dosing regimen without first talking to their treating physician. Very large doses of corticosteroids - overdoses - can cause problems including acute psychosis (steroid psychosis is a well-described entity), is associated with osteoporosis and aseptic necrosis of the head of the femur.

Corticosteroids are usually not administered intravenously for spine pain. The intravenous administration of corticosteroids is usually reserved for more urgent indications. Urgent indications include: treatment of cerebral edema from head trauma or a stroke or when a steroid-dependent asthmatic undergoes the stress of general anesthesia and major surgery. Then IV steroids are often administered.