Steroid Distancing in Interventional Pain
Management During COVID-19 and Beyond:
Safe, Effective and Practical Approach
Authors: Manchikanti Laxmaiah 
Published: February 2021

Background: Since the late 1940s, corticosteroids have been a mainstay class of agents in
multiple interventional techniques and intra-articular injections. Exogenous glucocorticoids are
structurally and pharmacologically similar to the endogenous hormones. As such, multiple actions
of corticosteroids are exhibited, including those of anti-inflammatory and immunosuppressive
effects. Epidural injections, with or without steroids, have been extensively used throughout the
world. There are reports of epidural injections starting in 1901, with steroids being added to the
local anesthetic since 1952, when steroids were administered into the sacral foramen.
Purpose: Due to the extensive side effects of steroids in various injections, some have proposed
limiting their use in epidurals and intraarticular injections. With the COVID-19 pandemic, the
multiple side effects of the steroids have elevated the level of concern and recommendations
have been made to utilize local anesthetic alone or the lowest dose of steroids. Fashioned from
common expressions of the day, the term “steroid distancing” began to be used and proposed
for intraarticular injections of the knee. Consequently, we sought to evaluate the evidence and
feasibility of steroid distancing in interventional pain management.
Methods: This focused review of local anesthetics and steroids utilized in interventional pain
management for epidural injections, peripheral nerve blocks, and intraarticular injections
by multiple database searches. This is a focused narrative review and not a systematic review.
Consequently, evidence synthesis was not performed traditionally, but was based on an overview
of the available evidence.
Results: No significant difference was identified based on whether steroids are added to local
anesthetic or not for epidural as well as facet joint injections. However, there was not enough
evidence to compare these 2 groups for peripheral intraarticular injections.
Limitations: The present review is limited by the paucity of literature with bupivacaine alone or
bupivacaine with steroids local anesthetic alone or with steroids of intraarticular injections of knee,
hip, shoulder and other joints, and intraarticular facet joint injections.
Conclusion: This review shows an overall lack of significant difference between lidocaine
alone and lidocaine with steroids in epidural injections. However, available evidence is limited
for bupivacaine alone or with steroids. Evidence is also not available comparing local anesthetic
alone with steroids for facet joint or peripheral joint intraarticular injections. Thus, it is concluded
that local anesthetic with lidocaine may be utilized for epidural injections, with appropriate
patient selection and steroids reserved for non-responsive patients with local anesthetic and with
significant radiculitis.
Key words: Steroid distancing, chronic pain, steroids, epidural injections, local anesthetic alone,
local anesthetic with steroid, steroid distancing, physical distancing