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.     

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.     

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.     

Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections.

BACKGROUND CONTEXT: The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. PURPOSE: To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. STUDY DESIGN/SETTING: A prospective, observational, in vivo, study. PATIENT SAMPLE: Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. OUTCOME MEASURES: Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. METHODS: One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. RESULTS: The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis. CONCLUSIONS: Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.     

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.     

Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study

Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections.     

Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections

STUDY DESIGN: A prospective, observational, human, in vivo study. OBJECTIVES: To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced, transforaminal lumbar epidural steroid injections (ESIs) and determine whether a "flash" (blood in the needle hub) or aspiration of blood can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA: Incorrectly placed, intravascular lumbosacral spinal injections result in systemic medication flow that misses the desired target. No previous studies evaluate the incidence of vascular injections in transforaminal ESIs, nor the ability of flash to predict a vascular injection. METHODS: The incidence of flash or positive blood aspiration and the incidence of fluoroscopically confirmed vascular spread were prospectively observed in 670 patients treated with lumbosacral fluoroscopically guided transforaminal ESIs. Presence of a flash or positive aspiration was documented. Contrast was injected to determine whether the needle tip was intravascular. RESULTS: Seven hundred sixty-one transforaminal ESIs were included. The overall rate of intravascular injections was 11.2%. There was a statistically significant higher rate of intravascular injections (21.3%) noted with transforaminal ESIs performed at S1 (n = 178), compared with those at the lumbar levels (8.1%, n = 583). Using flash or positive blood aspirate to predict intravascular injections was 97.9% specific, but only 44.7% sensitive. CONCLUSIONS: There is a high incidence of intravascular injections in transforaminal ESIs that is significantly increased at S1. Using a flash or blood aspiration to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in lumbosacral transforaminal ESIs.     

Prospective,double-blind,randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us

Background contextThe prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective.PurposeThis article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials.Study designReview article.MethodsExtensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature.ResultsFluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effiective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervial medial branch neurotomy are both effective. Intraarticular sacrociliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections.ConclusionsThe prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.     

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.     

Distribution patterns of transforaminal injections in the cervical spine evaluated by multi-slice computed tomography

Transforaminal injections are sometimes used for the diagnosis and treatment of painful conditions in the lumbar and to a lesser degree in the cervical spine. The technique is most often used when investigating/treating radiculopathy caused by degenerative disease. But how selective are the nerve root blocks? What possible structures other than the intended nerve root are affected from such injections? This study was undertaken in order to try to answer these questions, as no study focusing on the possible spread from the transforaminal selective nerve root blocks in the cervical spine has been performed earlier. In three groups of patients, each group including three patients, we injected three different volumes (0.6, 1.1 and 1.7 ml) with a transforaminal technique in the cervical spine. In all the injections, a small amount of contrast media was added. The spread of the injections were then investigated using multi-slice computed tomography with reconstructions. The imaging revealed a possible effect on other nerve roots than the intended ones when a larger volume was used for the root blocks. The spread was related to the injected volume as well as to local anatomy (size of foraminal area). In this study, only 0.6-ml injections could be accepted for being selective enough for diagnostic investigations.     

Steroid injections: effect on pain of spinal origin

Pain originating from the spine is a common clinical problem that is often difficult to manage. This chapter considers the evidence supporting the use of corticosteroid injections for pain of spinal origin. Clinical problems considered in this review are radicular pain, zygapophyseal joint pain, discogenic pain and non-specific pain from the cervical, lumbar and thoracic spine. Issues of efficacy and adverse events are considered.No useful data were found concerning the treatment of any type of thoracic pain with corticosteroid injections. In the lumbar spine, there is evidence to support the use of transforaminal injections for radicular pain. Intradiscal and intra-articular injections in both lumbar and cervical spines have not been shown to be effective. Sacroiliitis responds well to intra-articular corticosteroids. There is insufficient evidence to support the use of atlanto-axial or atlanto-occipital joint injections.     

Reversible posterior leukoencephalopathy syndrome after cervical transforaminal epidural steroid injection presenting as transient blindness

Transforaminal epidural steroid injections have been introduced as a nonsurgical treatment for cervical pain syndromes; however, they have also raised safety concerns. We present a patient who developed a headache and bilateral visual disturbance after cervical transforaminal epidural steroid injections. Brain magnetic resonance imaging showed a high signal intensity in the posterior region on T2-weighted and fluid-attenuated inversion recovery images, and the findings of diffusion-weighted imaging and the apparent diffusion coefficient map suggested vasogenic edema. The symptoms and abnormal imaging findings disappeared during follow-up. The clinical and imaging characteristics and their complete reversibility corresponded to reversible posterior leukoencephalopathy syndrome.     

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.     

Transforaminal injection of autologous platelet-rich plasma for lumbar disc herniation: A single-center prospective study in Vietnam

ObjectiveLumbar radiculopathy is a major health problem, which often treated by neurosurgery or guided lumbar epidural steroids for pain relief. We used autologous Platelet Rich Plasma (PRP) as a novel pharmaceutical agent that has strongly emerged in recent years to treat patients of lumbar disc herniation. From that, we evaluated the efficacy of PRP via transforaminal route in treatment of radicular pain in patients with lumbar disc herniation.MethodsTwenty-five patients were enrolled and injected with 4 ml of autologous platelet rich plasma under fluoroscopic guidance via transforaminal epidural injection into area of affected nerve root. They were followed using Visual Analogue Scale (VAS), Modified Oswestry Disability Index (ODI) and Straight Leg Raising Test (SLRT) for clinical assessment.ResultsPatients who received transforaminal injections with autologous PRP showed statistically significant improvements on all three evaluation tools (VAS, ODI, SLRT). The improvements were sustained over twelve-month follow-up and there were no associated complications.ConclusionTransforaminal injection with autologous PRP helps patients relieve chronic pains and be able return to work. Besides, autologous PRP can be considered as a good alternative to epidural steroids in management of lumbar disc herniation.     

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

Background

As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.

Questions/purposes

In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.

Methods

We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.

Results

Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.

Conclusions

The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3490-4) contains supplementary material, which is available to authorized users.     

A novel technique for delivery of epidural steroids and diagnosing the level of nerve root pathology

Transforaminal epidural steroids are a commonly used technique for diagnosis and treatment of nerve root irritation secondary to herniated disc material. The recent reported occurrences of severe complications using the transforaminal technique have led to the search for a novel alternative that is both a safe and accurate method of steroid delivery. The technique described offers improved safety and diagnostic accuracy over traditional transforaminal steroid injections.     

Approaches in injections for radicular pain: The transforaminal, epidural and transfacet approaches

Spinal injections must be carried out adhering to very strict conditions. However, these procedures have almost come to be seen as everyday and may be practised under quite questionable conditions. The recent reports of new and extremely serious neurological complications have changed the attitudes of those making referrals as well as the attitudes of the interventional radiologists carrying out these procedures. The range of indications for transforaminal injections has shrunk in favour of epidural injections. Where the transforaminal approach is still used, the needle must be positioned extremely accurately. A prior radioopaque contrast medium injection is essential from a safety perspective. The transforaminal epidural injection via the transfacet approach looks to be a promising alternative that is strictly avascular.     

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.     

Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids.

BACKGROUND CONTEXT: Selective transforaminal epidural injections are frequently employed in the treatment of pain emanating from the spine. Complication rates are typically low and include paresthesia, hematoma, epidural abscess, meningitis, arachnoiditis and inadvertent subdural or subarachnoid injection. Persistent paraplegia after lumbar transforaminal block has been recently reported. Undetected intra-arterial injection has been implicated as a possible cause. PURPOSE: We present a case of massive cerebellar infarction after uneventful selective cervical transforaminal block. Intra-arterial injection of corticosteroid is implicated with focus on particulate size of compound versus blood vessel dimension. Light microscopic data are presented to confirm the potential for embolic vascular occlusion. STUDY DESIGN/SETTING: Case report; light microscopic data. PATIENT SAMPLE: A patient underwent selective transforaminal block on the right at the C5-C6 level. There was C5-C6 disc herniation documented by magnetic resonance imaging and C6 radiculopathy by electromyographic studies. OUTCOME MEASURES: Patient follow-up from medical office records. METHODS: Needle placement at the C5-C6 foramen on the right was confirmed by biplanar fluoroscopy and injection of contrast medium. Frequent heme-negative aspirations were documented. RESULTS: In this patient, quadriparesis ensued shortly after injection of corticosteroid solution. The patient was admitted to the neurosurgical intensive care unit and ultimately underwent brainstem decompressive surgery when focal neurologic deficits became evident. Working diagnosis was massive cerebellar infarct. Light microscopic data are presented to illustrate particulate size in corticosteroid solutions and potential for embolic microvascular occlusion. Corticosteroid suspensions (and to a lesser extent solutions) contain large particles capable of occluding metarterioles and arterioles. CONCLUSIONS: We present a case of quadriparesis and brainstem herniation after selective cervical transforaminal block. We propose a potential role for corticosteroid particulate embolus during unintended intra-arterial injection as a potential mechanism.     

Epidural morphine for control of pain after spinal surgery: a preliminary report

Epidural opiates have been used successfully for the control of postoperative pain after obstetrical, abdominal, and orthopedic procedures. The use of these agents for the control of pain after operation on the thoracic and lumbar spine is reported. A catheter is inserted under direct vision into the epidural space after semihemilaminectomy and disc excision, posterior decompressive lumbar laminectomy, and anterolateral thoracolumbar decompression and just before wound closure. Excellent postoperative pain relief is achieved for 8 to 20 hours after single epidural injections of between 2 and 6 mg of morphine. Catheters are left in situ for 2 to 5 days. To date, no complications requiring treatment have been encountered with this approach.