Incidence of intravascular penetration in transforaminal cervical epidural steroid injections

STUDY DESIGN A prospective, observational, human, study was conducted. OBJECTIVES To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced transforaminal cervical epidural steroid injections, and to determine whether the observation of blood in the needle hub can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA Incorrectly placed intravascular cervical spinal injections result in medication flow systemically and not to the desired target. A recently published study demonstrates a high incidence of intravascular injections in transforaminal lumbosacral epidural injections. No studies so far have evaluated the incidence of vascular injections in transforaminal cervical epidural steroid injections, nor have they calculated the ability of observed blood in the needle hub to predict a vascular injection in the cervical spine.METHODS The incidence of fluoroscopically confirmed intravascular uptake of contrast was prospectively observed in 337 patients treated with cervical transforaminal epidural steroid injections. The ability of observed blood in the needle hub to predict intravascular injection was also investigated. For each subject, the injection level was chosen on the basis of the clinical scenario including history, physical examination, and review of imaging studies. Some patients had multilevel injections. Using fluoroscopic guidance, the authors placed a 25-gauge needle into the epidural space using a transforaminal approach according to accepted standard technique. Needle tip location was confirmed with biplanar imaging. The presence or absence of blood in the needle hub spontaneously ("flash") and after attempted aspiration by pulling back on the syringe's plunger was documented. Contrast then was injected under real-time fluoroscopy to determine whether the location of the needle tip was intravascular. The results were recorded in a prospective manner indicating the presence or absence of blood in the needle hub and whether a vascular pattern was noted with contrast injection, and these were correlated. Relevant epidemiologic data also were recorded. RESULTS The study included 504 transforaminal epidural steroid injections. The overall rate of fluoroscopically confirmed intravascular contrast injections was 19.4%. Use of observed blood in the needle hub to predict intravascular injections was 97% specific, but only 45.9% sensitive. There was no significant difference in intravascular rates related to age or gender. CONCLUSIONS As compared with a previous study of lumbosacral epidural steroid injections, there is an overall higher incidence of intravascular injections with cervical transforaminal epidural steroid injections. Use of observed blood in the needle hub to predict an intravascular injection is not sensitive, and therefore the absence of blood in the needle hub despite aspiration is not reliable. The reported sensitivity and specificity rates are similar to lumbar data. Fluoroscopically guided procedures without contrast confirmation instill medications intravascularly, and therefore not in the desired epidural location. This study confirms that there is a need not only for fluoroscopic guidance, but also for contrast instillation in cervical transforaminal epidural steroid injections.     

Quadriparesis following cervical epidural steroid injections: case report and review of the literature.

BACKGROUND CONTEXT: Cervical epidural steroid injections are frequently used in the conservative management of neck pain, cervical radiculitis, and cervical radiculopathy. Between 64-76% of patients who receive injections report subjective pain improvement. Injections are usually well-tolerated with only mild, transient side effects, although a few case reports of patients with adverse effects do appear in the literature. Some clinicians have expressed concerns about epidural injections above the C7-T1 level, and in the use of methylprednisolone epidurally; as yet, neither is a consensus viewpoint. PURPOSE: This case report describes severe adverse effects (quadriplegia and respiratory arrest) associated with an epidural injection into the C6-C7 space. Although the patient's symptoms improved somewhat with supportive care, quadriparesis appears irreversible. No reports of quadriparesis after cervical epidural injection were found in the literature, although other adverse effects have been reported. STUDY DESIGN/SETTING: The patient was injected by a fellowship-trained pain management specialist in an outpatient surgicenter using C-arm fluoroscopic guidance. Immediately he experienced respiratory arrest with quadriplegia. He was intubated and transferred to the hospital, then transferred again to Christiana Health Care Services. METHODS: The patient was hospitalized, treated with steroid protocol within 8 hours, and followed clinically for 6 months. RESULTS: Magnetic resonance imaging within 6 hours of the injury and 6 months later showed no significant findings aside from lordosis (40 degrees angle) of the cervical spine at the C6-C7 level. CONCLUSION: Although evidence is not conclusive, this patient may have suffered a vascular event from a cervical epidural injection.     

Outcomes of interlaminar and transforminal spinal injections

Epidural spinal injections can be administered via a translaminar or transforaminal route, depending on the clinical scenario. When it is more desirable to target a specific nerve root, a transforaminal approach is typically used, and when the target is more diffuse, a translaminar method is chosen. Both are commonly used and can be utilized similarly in the lumbar or cervical spine. However, it is essential that the clinician understand the risks and benefits of these injections. In the lumbar spine, both translaminar epidural steroid injections (TLESI) and transforaminal epidural steroid injections (TFESI) have been shown to provide up to 6 months of pain relief, though long-term benefits are less reliable. In the cervical spine, translaminar injections may provide longer relief and have a lower complication rate than cervical transforaminal injections. Proper technique is essential to minimize the rate of these rare but occasionally severe complications.     

Cervical epidural steroid injections for symptomatic disc herniations

OBJECTIVES: Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs. METHODS: Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention. RESULTS: Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series. CONCLUSIONS: Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.     

Epidural lipomatosis complicating lumbar steroid injections

Corticosteroid injections into the spinal epidural space are frequently used to effect a relief of back pain and associated radicular extremity symptoms. Spinal epidural lipomatosis has been documented after the use of systemic corticosteroid therapy. This case report documents the development of epidural lipomatosis after the administration of multiple epidural steroid injections. The development and subsequent resolution after discontinuation of the steroid injections are demonstrated with serial magnetic resonance imaging.     

Cerebellar herniation after cervical transforaminal epidural injection

OBJECTIVE: The purpose of this study is to inform readers of potential catastrophic complications associated with performing cervical transforaminal epidural steroid injections. CASE REPORT: A 31-year-old man presented to the pain clinic with a history of cervical radicular pain and right upper-extremity radicular symptoms. He was referred from the orthopedic spine clinic for evaluation for epidural steroid injection, having failed conservative treatment consisting of nonsteroidal anti-inflammatory drugs, muscle relaxants, oral steroids, and physical therapy. After undergoing a transforaminal epidural steroid injection at the right C8 nerve root, he developed a cerebellar infarct and brainstem herniation. He survived but has residual deficits of persistent diplopia on right lateral gaze and difficulties with short-term memory loss and concentration. CONCLUSIONS: Although transforaminal epidural steroid injections are an efficacious treatment for radicular syndromes, there can be catastrophic complications. In light of the growing body of similar case reports, further investigation is warranted to establish a safe protocol for the use of this modality.     

Lumbar epidural perineural injection: a new technique

Two controlled studies for a new epidural, perineural, singleshot, selective nerve root injection with a double-needle approach to the anterior epidural space of the lumbar spinal canal are presented. The results were analysed to determine the effectiveness of the new epidural perineural injection technique. The trial comprised two controlled studies on 182 patients. One study compared prospectively randomized results of patients with lumbar radicular syndromes who received epidural perineural injections (n = 47), conventional posterior epidural injections (n = 40) and, as a control group, paravertebral local anaesthetic (n = 46). A second, prospective, double-blind study compared the effect of epidural perineural injections with triamcinolone (n = 24) and pure saline (n = 25). Epidural perineural injections were more effective than conventional posterior epidural injections. Both epidural groups had better results than the paravertebral local injection group. Epidural perineural injections with steroids (10 mg triamcinolone) were more effective than saline alone. A systemic steroid effect was excluded by additional intramuscular steroid injections in the saline group. There were no severe complications or side effects in any of the three groups. The studies concluded that single-shot epidural perineural injection is effective in the treatment of lumbar radicular pain. It is a one drop only therapy to the source of pain.     

Lumbar disc herniation regression after successful epidural steroid injection

In some lumbar disc herniation patients, noninvasive measures fail, necessitating more aggressive treatment, such as epidural steroid injections or surgery. This study sought to determine whether improvement in patients who receive epidural steroid injections is related to regression of herniated nucleus pulposus or whether such patients' symptoms decrease because of the steroid effect in the presence of continued herniated nucleus pulposus. Two nonoperatively treated patient cohorts were followed who had follow-up MRI. Specifically, 38 other patients who improved without invasive treatment within 6 weeks after the onset of their symptoms were compared with 20 patients who improved with epidural steroid injections. Results found that both groups had similar initial and follow-up herniated nucleus pulposus size and outcomes. The epidural steroid injection group had fewer sequestered or extruded herniations that resorbed, and most were of lower hydration. In conclusion, epidural steroid injections do not alter ultimate herniated nucleus pulposus regression. Patients in whom the disc herniation has less hydration may have prolonged symptoms, but many improve with epidural steroid injections.     

Bacterial meningitis and cauda equina syndrome after epidural steroid injections

Purpose

To describe a rare adverse outcome resulting from lumbar epidural steroid injections for the treatment of chronic lower back pain.

Clinical features

We report a case of staphylococcus aureus meningitis and cauda equina syndrome following a series of epidural steroid injections for chronic back pain. Although rare, bacterial meningitis following epidural analgesia has been reported, but epidural steroid injections have not been associated with either bacterial meningitis or cauda equina syndrome. The causal relationship between epidural steroid injections, bacterial meningitis, and cauda equina syndrome is discussed.

Conclusion

A thorough pre-procedure assessment with attention to the neurologic examination and signs/symptoms of infection is essential.     

The use of lumbar epidural/transforaminal steroids for managing spinal disease

Lumbar epidural steroid injections are used to manage low back and leg pain (ie, sciatica). Utilization of the procedure is increasing, with Medicare spending for lumbar epidural procedures topping $175 million annually. Few prospective randomized controlled trials have clearly demonstrated the efficacy of epidural steroid injections; many have shown conflicting results. Several studies show favorable short-term outcomes with epidural steroid injection for radicular pain, but less conclusive results are achieved >6 months. Methodologic flaws limit interpretation of results from most scientific studies. As a tool for predicting surgical outcome, epidural spinal injection has been found to have a sensitivity between 65% and 100%, a specificity between 71% and 95%, and a positive predictive value as high as 95% for 1-year surgical outcome. Despite inconclusive evidence, when weighing the surgical alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable nonsurgical option in select patients.     

Cervical epidural steroid injection for cervicobrachialgia

Fifty patients with chronic resistant cervicobrachialgia were randomly divided into two groups. Twenty-five patients (group A) were treated with cervical epidural steroid/lidocaine injections and 17 patients (group B) were treated with steroid/lidocaine injections into the posterior neck muscles. Another eight patients from group B were excluded from the study because they had started the process of litigation of insurance claims and their subjective analysis of pain relief might therefore not be trustworthy. One to three injections were administered at 2-week intervals according to the clinical response. All patients continued their various pre-study treatments: non-steroidal anti-inflammatory drugs, non-opioid analgesics and physiotherapy. Pain relief was evaluated by the visual analogue scale 1 week after the last injection and then 1 year later. One week after the last injection we rated pain relief as very good and good in 76% of the patients in group A, as compared to 35.5% of the patients in group B. One year after the treatment 68% of the group A patients still had very good and good pain relief, whereas only 11.8% of group B patients reported this degree of pain relief. These differences were statistically significant. We failed to achieve significant improvement of tendon reflexes or of sensory loss in both groups, but the increase in the range of motion, the fraction of patients who were able to decrease their daily dose of analgesics, and recovery of the capacity for work were significantly better in group A. We encountered no complications in either group of patients. We conclude that cervical epidural steroid/local anaesthetic injection is an effective method for achieving immediate and long-standing pain relief and improvement in motion and performance in chronic resistant cervicobrachialgia.     

Inadvertent subdural spread complicating cervical epidural steroid injection with local anaesthetic agent

Although cervical epidural steroid injection with local anaesthetic is considered a safe technique and widely practiced, complications may occur. We report a patient experiencing unexpected delayed high block, moderate hypotension and unconsciousness eight to ten minutes after an apparently normal cervical epidural steroid injection. The most probable diagnosis was a subdural block. Anatomical peculiarities of the epidural and subdural space in the cervical region increase the risk of subdural spread during cervical epidural injection. Fluoroscopic guidance is important during cervical epidural injection to increase certainty of correct needle placement, thus minimizing the risk of complications.     

Concomitant sacroiliac joint pain in patients with lumbar disc herniation: case series

Recent studies have shown that not all lumbar disc herniations are symptomatic and that when followed longitudinally, these patients develop back pain independent of the previous imaging study. This is a case report of two patients with radicular symptoms and lumbar disc herniations that underwent diagnostic injections to locate their pain generator. Both patients failed to respond to transforaminal epidural steroid injections. Transforaminal injections can be diagnostically sensitive for radicular pain but not specific. This is a direct result of the spread of medication to other levels in the epidural space, thus affecting multiple levels of innervation. Follow-up with two sacroiliac injections gave significant relief of their pain. They were both treated conservatively for sacroiliac joint pain and did well. One remained pain free after several months and the second remained with minimal pain until she presented again in her 3rd month of pregnancy with return of her pain. The differential diagnosis of lumbar radicular pain is discussed as well as the authors' experience in using diagnostic injections.     

Epidural hematoma after epidural block: implications for its use in pain management

BACKGROUND: Spinal epidural hematoma after spinal puncture such as for injection of steroids for pain management may result in a rare complication of a spinal epidural hematoma causing acute myelopathy. Although this complication is well known with epidural anesthesia, where it is usually seen with impaired hemostasis, there are surprisingly few case reports of epidural hematoma after an epidural steroid block. CASE DESCRIPTION: A healthy 34-year-old man with no evidence of coagulopathy and not taking antiplatelet medication suddenly had onset of acute cervical myelopathy from a large cervical epidural hematoma 8 days after a cervical epidural steroid block. Following prompt surgical evacuation of the clot, the patient made a near complete recovery. CONCLUSION: Spinal epidural hematoma after spinal puncture is usually associated with impaired hemostasis. This case illustrates that it may occur in the absence of known risk factors. The delayed onset and the absence of risk factors have implications for the use of this procedure in chronic pain management.     

Incidence of intravascular injection and the spread of contrast media during S1 transforaminal epidural steroid injection by two approaches: anteroposterior vs oblique

The aim of this randomised study was to compare the incidence of intravascular injections during S1 transforaminal epidural steroid injection performed in the anteroposterior and oblique views. We also compared epidural spread patterns of contrast media, which included 201 injections at the S1 level. The overall incidence of intravascular injection during S1 transforaminal epidural steroid injection in the anteroposterior view was 29% (29/99), significantly higher than in the oblique view (11%, 11/102, p = 0.001). There were no significant differences between the two groups for epidural spread of contrast media in cases where intravascular injections did not occur (p = 0.77). Performing S1 transforaminal epidural steroid injection in the oblique view rather than the anteroposterior view reduces the risk of intravascular injections.     

Effects of epidural steroids on lumbar dura material properties.

Epidural steroid injections are commonly used in the treatment of low back pain and radiculopathy based on their antiinflammatory and analgesic benefits. However, steroids are known to affect collagen synthesis, material strength, and tissue healing. The purpose of this study was to assess the effects of serial epidural steroid injections on the material properties of the lumbar dura mater. Serial epidural steroid injections of saline or methylprednisolone at 2-week intervals were performed in three paired groups of canines; a separate noninjected group was used as controls. Postmortem, dural sample testing to failure and histologic analysis was performed. Mechanical failure testing revealed no clinically significant change in the transverse dorsal dura tensile strength between all saline-injected, steroid-injected, or noninjected controls. Histologic analysis demonstrated no overt disruption of collagen matrix organization; however, electron microscopy demonstrated a significant decrease in the number of intracytoplasmic mitochondria of dural fibroblasts in steroid-injected animals, suggesting a metabolic inhibitory effect within steroid-injected dura mater. In the clinical time frame of this study, serial epidural steroid injections appeared to produce no significant material or matrix changes in the lumbar dura.     

Epidural injections for the treatment of symptomatic lumbar herniated discs

Epidural steroid injections are widely used as part of the conservative care for symptomatic herniated lumbar discs. There are studies showing their effectiveness, and some studies demonstrating no clinical benefits. The purpose of this study was to evaluate the effectiveness of epidural steroid injections for patients with symptomatic lumbar disc herniations who were surgical candidates. Sixty-nine patients were diagnosed with a herniated disc in the lumbar spine and remained symptomatic despite conservative care, and were treated with an epidural injection in an attempt to avoid surgical discectomy. Of the total group of 69 patients (average age = 44.8 years, range 19-77 years, average follow-up = 1.5 years), 53 (77%) had successful resolution or significant decrease of their symptoms and were able to avoid surgery. Only 16 (23%) patients failed to have significant relief of their symptoms and required surgical treatment of their herniated disc. Epidural steroid injections have a reasonable success rate for the alleviation of radicular symptoms from lumbar herniated discs for up to twelve to twenty-seven months. Patients treated with injections may be able to avoid surgical treatment up to this period and perhaps even longer.     

Use of intraoperative sodium tetradecyl sulfate for the treatment of a spinal epidural hemangioma. Technical note

Spinal hemangiomas can be categorized into three different groups based on location. Vertebral body (VB) hemangiomas are frequent incidental findings on magnetic resonance (MR) imaging. There is a subdivision of these with spinal epidural extension that have been reported in the literature. Spinal hemangiomas can also be epidural without VB involvement; these are extremely rare with few reported cases in the thoracic epidural spinal column. The diagnosis and imaging characteristics as well as the surgical tools used in gross-total resection of spinal epidural hemangioma are not well understood. The authors present a detailed characterization of a spinal epidural hemangioma in a 30-year-old woman who presented with complaints of gradual onset of low-back pain that worsened over 1 year. The MR imaging findings indicated a large L2-S1 epidural spinal mass causing thecal sac compression. The patient underwent an L2-S1 laminectomy, and a vascular extradural mass was noted on the posterior aspect of the dura mater. Preoperative spinal angiography as well as intraoperative angiography was performed. Total resection of the tumor was achieved using intraoperative embolization with sodium tetradecyl sulfate and microscopic dissection. The postoperative MR imaging findings and clinical outcome were excellent. The findings and use of sodium tetradecyl sulfate in gross-total resection are discussed. The authors also review treatment modalities and demonstrate the utility and effectiveness of intraoperative sodium tetradecyl sulfate in grosstotal resection of large difficult spinal epidural hemangiomas.     

Hirayama disease: Three cases

Hirayama disease is a rare, lower cervical myelopathy affecting young adults. It is responsible for pure distal motor impairment of the upper limbs, with slow progressive development in the metameric territories of C7 to T1. It is thought to be caused by movements involved in flexing the neck. Neutral position magnetic resonance imaging (MRI) looks for abnormal cervical curvature, atrophy with flattening of the cervical spine, anterior cord hyperintensity and especially a lack of posterior apposition of the dural sac. If the condition is suspected, an MRI in flexion should be performed to show anterior displacement of the cord and dural sac, enlargement of the posterior epidural space, an increase in flattening of the cord and congestion of the epidural veins. These dynamic abnormalities tend to disappear after evolving for 10 years. We report two confirmed cases and a probable case of Hirayama disease and discuss its physiopathology.