They also kept a blood glucose diary. Employment status and clinical outcome were evaluated at 8 weeks after the procedure. The numeric rating scale for pain reported by the patients decreased for 2 weeks after treatment with no difference between groups. Employment status and clinical outcome was not different between groups.
Limitations: The patients who chose to participate in this study may be a cohort of well-controlled patients with diabetes mellitus. The type of procedure performed was determined by a clinical decision and not randomized. The different routes of administration and diagnosis of failed back surgery syndrome can result in different levels of systemic absorption, thereby influencing the degree and duration of hyperglycemia. In patients with FBSS, the epidural space may be destructed by surgery and adhesive changes in epidural space could be extensive.
Therefore, we thought that the absorption of epidural space in these patients would be incomplete or slow compared with those without FBSS. Conclusion: Epidural steroid injections were associated with statistically significant elevations in PBG in patients with diabetes for up to 4 days after the procedure. The higher dose of triamcinolone increased FBG and PBG greater than a lower dose did without affecting pain control, employment status, or clinical outcome.
Thus, with respect to glucose and pain control, 20 mg of triamcinolone appears to be recommended rather than 40 mg in patients with diabetes. Plain X-ray film Fig. One week following the second trigger point injection, a pain management specialist administered 40 mg of triamcinolone and 2 mL of 0. The patient presented to the emergency department 1 week after receiving the fluoroscopy-guided epidural injection, complaining of a 3-day history of xerostomia, polydipsia, polyuria, generalized weakness and diarrhea.
Chemistry studies showed a calculated anion gap of The patient was started on an insulin drip with fluid resuscitation and admitted to the intensive care unit with a diagnosis of DKA. Our case describes a patient who was a documented non-diabetic who went into DKA following cervical epidural steroid injection. At the time of the epidural injection, the patient showed no signs of acute infection, concomitant drug use or any documented diabetes, all potential causes of DKA [ 6 ].
The patient had been seen regularly for chronic degenerative changes and had recent workup confirming her non-diabetic status. Three days after the fluoroscopy-guided epidural injection, the patient complained of increased urination, dry mouth, generalized weakness and diarrhea.
Studies have shown epidural steroid injections can transiently raise blood glucose levels in diagnosed diabetics [ 7 ]. Following epidural steroid injections, elevations in postprandial glucose levels have also been shown in non-diabetics, but the elevations lasted longer in diabetic than non-diabetic patients [ 8 ]. Although the mechanism of hyperglycemia following epidural steroid injection is clear, it remains difficult to distinguish how long these effects will last.
Injection location cervical, thoracic, lumbar , route of injection epidural, intra-articular , dose and type of corticosteroid triamcicolone, methylprednisolone are all important prognostic variables. The duration of hyperglycemia and insulin resistance depends on the type of corticosteroid administered: triamcicolone duration of action 7 - 84 days, half-life 5 - 8 days versus methylprednisolone duration of action 14 days, half-life 3.
Our patient was administered a high-dose 40 mg triamcinolone injection and did not complain of any symptoms until 3 days after the injection. Because of the physiologic properties of this particular steroid involving the duration of action and half-life, it makes sense the patient did not have any symptoms until 3 days after the fluoroscopy-guided injection. Both increased glucose levels and epidural steroid injections have each been shown to increase the risk of subsequent infection [ 7 ].
Though uncommon, DKA can arise following either oral or epidural steroid treatments in diagnosed diabetics [ 6 , 8 ]. The literature does describe some cases of DKA arising in non-diabetics following steroid treatment, but many of these patients have a concurrent infection exacerbating the metabolic disorder by activating endogenous stress hormones [ 8 , 11 ].
There are also cases of non-diabetic pregnant women administered glucocorticoids and subsequently presenting with DKA [ 12 ]. However, in this case, acute steroid-induced insulin resistance, superimposed on a pregnancy-related fasting insulinopenic state, may have served as the trigger [ 12 ]. Current literature lacks sufficient data on epidural steroid injections in non-diabetics and the occurrence of DKA.
In addition, there is a dearth of case reports pertaining to this complication in this specific patient population. Our case is unique because our patient was a documented non-diabetic with no concomitant infection or any evidence of previous adverse effects to any prior epidural steroid injections.
The standard of care for managing DKA remains the same regardless of the cause: administration of insulin and correction of electrolyte abnormalities including hyperglycemia, hypovolemia, metabolic acidosis and potassium depletion. Though rare, DKA arising after an epidural steroid injection should warrant halting of any further epidural steroid injections until a fasting glucose assay 3 - 4 weeks following the initial injection confirms non-diabetic status [ 8 ].
If the patient turns out to be a previously undiagnosed diabetic, future epidural steroid injections should be met with caution as the possibility of a cumulative effect on insulin sensitivity arises because of frequent injections [ 13 ]. Patients with risk factors for diabetes must be screened according to guidelines prior to undertaking steroid injections. Additionally, they may need to be advised to seek earlier treatment for potential signs of infection as, just like those with systemic steroids, they are at higher risk for a non-specific time course following the injection.
If no infection is found, the signs may be related to another complication, such as DKA, of the steroid injections. Clinicians should counsel diabetic patients about the importance of glucose control pre-injection and for at least the week following injection.
ORLANDO — Glucocorticosteroids that are epidurally administered produce a transient increase in fasting blood glucose levels in patients with diabetes, according to data presented at the annual meeting of the American Academy of Pain Medicine. Stoller said in an interview. He and his associates at Beth Israel Deaconess were prompted to study the effect of epidural steroid injections on blood sugar after a diabetic patient went into a ketoacidosis coma following the procedure.
The patients were randomized to receive epidural administration of 40 mg or 80 mg of methylprednisolone acetate Depo-Medrol. Hemoglobin A 1c HbA 1c levels were drawn on the day of the epidural, and baseline blood sugars were obtained from the patients' glucose log, or from a glucose monitoring device. Fasting blood sugars were monitored for 2 weeks after the epidural.
Fasting blood glucose levels were elevated for an average of 7 days in the patients who received the mg dose of Depo- Medrol and for an average of 2 days in those on the mg dose. The magnitude of the rise in blood sugar was correlated with HbA 1c levels at the time of the injection, Dr.
Selective transforaminal epidural block with triamcinolone 20 mg. Other Names: selective transforaminal block Triamcinolone epidural steroid injection. Selective transforaminal epidural block with triamcinolone 40 mg. Outcome Measures. Primary Outcome Measures : fasting blood glucose level [ Time Frame: at am of postprocedure day 1 ] before breakfast fasting state.
Secondary Outcome Measures : post-prandial glucose level [ Time Frame: 2 hour after dinner at postprandial day 1, 2, 3, 4, 5, 6, 7, 14 ] 2 hour after dinner. Eligibility Criteria. Information from the National Library of Medicine Choosing to participate in a study is an important personal decision.
Inclusion Criteria: subjects who undergo epidural steroid injection caudal epidural injection or selective transforaminal block in the pain medicine outpatient clinic subjects older than 20 yrs. Exclusion Criteria: ASA American society of Anesthesiologists class III or more severe cardiopulmonary disease or brain disorder Subjects diagnosed uncontrolled diabetes with complications subjects undergoing hormone therapy subjects with active infection subjects with pregnancy subjects with recent stress condition such as surgery or trauma subjects with active neurologic disorder those with anticoagulation therapy.
Contacts and Locations. Information from the National Library of Medicine To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor. Please refer to this study by its ClinicalTrials.
More Information. Publications automatically indexed to this study by ClinicalTrials. Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus. Pain Physician. National Library of Medicine U. National Institutes of Health U. Department of Health and Human Services.
The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Low Back Pain. Other: epidural steroid injection with Triamcinolone 40mg Other: Selective transforaminal epidural block with triamcinolone 20 mg Other: caudal epidural steroid injection with Triamcinolone 20mg Other: Selective transforaminal epidural block with triamcinolone 40 mg.
Not Applicable. Study Type :. Interventional Clinical Trial. Actual Enrollment :. Study Start Date :. Actual Primary Completion Date :. Actual Study Completion Date :. Experimental: Caudal 40 group subjects who undergo caudal epidural block with triamcinolone 40 mg.
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