Dr Radcliff and colleagues conclude, "Despite the common treatment practice of incorporating one or more ESI in the initial nonoperative management of patients with spinal stenosis, these results suggest that ESI is associated with worse outcome in the treatment of spinal stenosis," write. They believe the "most likely" reason for the worse outcomes after ESI is that the injection causes worsening of the spinal narrowing or result spinal nerve impingement, although other explanations are possible. The authors call for further research to clarify the "indications and results of this common procedure."
Given the regular use of epidural steroid treatment for chronic lumbar radicular pain, physicians administering the treatment must be aware of the potential for suppression of the HPA axis that could indicate an increased risk for adrenal crisis in the setting of stress. Some have advocated evaluation of the HPA axis via baseline cortisol levels and stimulation testing or empiric stress-dosed steroids for any patient undergoing a surgical procedure within three weeks of an epidural steroid injection [ 14 , 15 ]. The case report evidence shows that some patients have suppression far beyond three weeks, supporting the use of formal testing of HPA status prior to surgery as the safest route. Conversely, it is notable that despite evidence of routine HPA suppression, there are no case reports of adrenal crisis occurring in patients with recent epidural steroid exposure. Perhaps a prudent approach would be to perform routine screening for symptoms of adrenal insufficiency in all patients who have received epidural steroids in the preceding year and to perform preoperative testing in all patients less than three weeks out from an epidural injection, those who have symptoms suspicious of adrenal insufficiency, and in those with a history of multiple injections in the preceding 4–6 months.
STEROIDS is an international research journal devoted to studies on all chemical and biological aspects of steroidal moieties. The journal focuses on both experimental and theoretical studies on the biology, chemistry, biosynthesis, metabolism, molecular biology, physiology and pharmacology of steroids and other molecules that target or regulate steroid receptors. Manuscripts presenting clinical research related to steroids, steroid drug development, comparative endocrinology of steroid hormones, investigations on the mechanism of steroid action and steroid chemistry are all appropriate for submission for peer review. STEROIDS publishes both original research and timely reviews. For details concerning the preparation of manuscripts see Instructions to Authors, which is published in each issue of the journal.