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Incidence of Adrenal Insufficiency and Cushing’s Syndrome After Long-Term Epidural Steroid Injections Over Six Months or Longer: A Preliminary Study

Authors Park J, Kwak J, Chung S, Hong HJ, Chon JY, Moon HS

Received 17 March 2020

Accepted for publication 27 May 2020

Published 24 June 2020 Volume 2020:13 Pages 1505—1514


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Dr Robert B. Raffa

JungHyun Park, Jueun Kwak, Sukyung Chung, Hyo Ju Hong, Jin Young Chon, Ho Sik Moon

Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

Correspondence: Ho Sik Moon
Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul 03312, Republic of Korea
Tel +822-2030-3864
Fax +822-2030-3861

Purpose: Endocrinological complications of an epidural steroid injection (ESI) are rare but dangerous. Nevertheless, despite the associated risks, repeated long-term ESIs are indispensable in some clinical situations. However, only a few reports to date have assessed the safety of this procedure. In this study, we evaluate the incidence of adrenal insufficiency (AI) and Cushing’s syndrome after long-term ESIs.
Methods: This clinical observational study enrolled herniated nucleus pulposus or spinal stenosis patients who had received ESIs over a period of six months or longer. The adrenocorticotropic hormone (ACTH) stimulation test was performed to confirm AI and the late-night salivary cortisol (LNSC) test was performed to diagnose Cushing’s syndrome. To evaluate the hypothalamus pituitary adrenal axis suppression, salivary cortisol (SC) levels were measured on days 0, 1, 7, 21, 28, 35, and 42.
Results: This study included 17 patients. Among these, two patients (11.8%) developed AI, but no cases of Cushing’s syndrome were reported. There was no predictor for the development of AI. The SC levels tended to increase with time after an ESI (β = 0.003). The slope of the mixed effect model between the AI and non-AI groups showed a significant difference (p value = 0.015). However, the differences in mean SC levels at each time point between the two groups were not significant (adjusted p value = 0.053).
Conclusion: Long-term ESI use may be associated with AI development. An unexpected adrenal crisis due to AI could be life threatening. Therefore, regular monitoring of adrenal function in patients who have received long-term ESIs may be prudent.

Keywords: epidural, glucocorticoid, salivary cortisol, adrenal insufficiency, long-term

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