Manuscript title	Authors	Study	Results
Systemic effects of fluoroscopically guided epidural steroid injection with dexamethasone	Kang et al. (2019) 17	A retrospective review of the systemic effects after a single dexamethasone injection at the cervical or lumbosacral levels	Facial flushing was the most common systemic effect, with only 0.4% reporting elevated blood sugar and 0.5% reporting systemic edema. The systematic effects were higher in patients receiving cervical injections than lumbar ones, likely because the size of the dorsal venous plexus is larger at the cervical level
Systemic effects of epidural steroid injections for spinal stenosis	Friedly et al. (2018) 16	A multicenter randomized controlled trial that described the effect of either a single epidural steroid injection or local anesthetic only epidural injection on cortisol levels in 400 patients with spinal stenosis	Twenty percent of patients in the steroid group had cortisol reductions at 3 weeks, compared to 6.7% of patients in the lidocaine only group. The use of insoluble steroids, such as methylprednisolone or triamcinolone, had an average of a 3‐week cortisol reduction of 41% from baseline. Those injected with betamethasone or dexamethasone did not have significant reductions in cortisol levels compared to the lidocaine injection group.
Hypothalamic pituitary adrenocortical axis suppression following a single epidural injection of methylprednisolone acetate	Abdul et al. (2017) 15	Prospective study	A single epidural injection of 80 mg methylprednisolone reduces ACTH levels, with a nadir at 7 days but lasting until 14 days, returning to normal by day 28
IA glucocorticoid injections and their effect on HPA‐axis function	Johnston et al. (2015) 14	Review	A single IA steroid injection can cause a sharp decline in cortisol levels, and the subsequent HPA axis suppression can last up to 4 weeks. The steroid itself can be retained in the joint for 2–3 weeks, but screening urine can show the presence of synthetic glucocorticoids up to 9 months after a single IA injection. TA and TH in particular have the lowest solubility profiles, followed by prednisolone and then hydrocortisone. TA and TH have peak levels 8 h after IA injections and are completely cleared from the injection site by 3 weeks. Methylprednisolone has peak levels between 2 and 12 h and complete clearance after 5 days.
Diagnosing the unrecognized systemic absorption of IA and epidural steroid injections	Lansang et al. (2009) 13	Case series of 3 patients misdiagnosed with endocrine disorders	The patients developed iatrogenic Cushing syndrome after receiving epidural or joint injections with 40–60 mg of triamcinolone at a time
Epidural triamcinolone suppresses the pituitary‐adrenal axis in human subjects	Kay et al. (1994) 24	Prospective study that measured cortisol and ACTH levels in 14 patients receiving 3 non‐image‐guided epidural steroid injections of 80 mg triamcinolone at weekly intervals	Both cortisol and ACTH levels were reduced at one month after the last epidural steroid injection

Abbreviations: HPA, hypothalamic‐pituitary‐adrenal; IA, intra‐articular; TA, triamcinolone acetonide; TH, triamcinolone hexacetonide.