Human serum modifies aggregation properties of commonly used epidural steroids

Sayed E. Wahezi, Andrew Lederman, Jeffrey Algra, Soo Yeon Kim, Rani Sellers

Research output: Contribution to journalArticle

1 Citation (Scopus)

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. Setting: Academic tertiary care center. Hypothesis: Particulate steroids display different aggregation characteristics in serum compared to non-physiologic solutions. Design: 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. Limitations: 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.

Original languageEnglish (US)
Pages (from-to)E1131-E1138
JournalPain Physician
Volume18
Issue number6
StatePublished - Sep 1 2015

Fingerprint

Steroids
Serum
Microscopy
Light
Bupivacaine
Methylprednisolone
Epidural Injections
Betamethasone
Lidocaine
Tertiary Care Centers
Sample Size
Infarction
Dexamethasone
Safety
Water

Keywords

  • Corticosteroid
  • Embolic infarction
  • Epidural injection
  • Particulate aggregate
  • Serum

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Human serum modifies aggregation properties of commonly used epidural steroids. / Wahezi, Sayed E.; Lederman, Andrew; Algra, Jeffrey; Kim, Soo Yeon; Sellers, Rani.

In: Pain Physician, Vol. 18, No. 6, 01.09.2015, p. E1131-E1138.

Research output: Contribution to journalArticle

Wahezi, SE, Lederman, A, Algra, J, Kim, SY & Sellers, R 2015, 'Human serum modifies aggregation properties of commonly used epidural steroids', Pain Physician, vol. 18, no. 6, pp. E1131-E1138.
Wahezi, Sayed E. ; Lederman, Andrew ; Algra, Jeffrey ; Kim, Soo Yeon ; Sellers, Rani. / Human serum modifies aggregation properties of commonly used epidural steroids. In: Pain Physician. 2015 ; Vol. 18, No. 6. pp. E1131-E1138.
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AB - 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. Setting: Academic tertiary care center. Hypothesis: Particulate steroids display different aggregation characteristics in serum compared to non-physiologic solutions. Design: 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. Limitations: 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.

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