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Shah RV. Paraplegia following thoracic and lumbar transforaminal epidural steroid injections: how relevant are particulate steroids? Pain Pract 2013; 14:297-300. [PMID: 24152137 DOI: 10.1111/papr.12110] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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El-Yahchouchi C, Geske JR, Carter RE, Diehn FE, Wald JT, Murthy NS, Kaufmann TJ, Thielen KR, Morris JM, Amrami KK, Maus TP. The noninferiority of the nonparticulate steroid dexamethasone vs the particulate steroids betamethasone and triamcinolone in lumbar transforaminal epidural steroid injections. PAIN MEDICINE 2013; 14:1650-7. [PMID: 23899304 DOI: 10.1111/pme.12214] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess whether a nonparticulate steroid (dexamethasone, 10 mg) is less clinically effective than the particulate steroids (triamcinolone, 80 mg; betamethasone, 12 mg) in lumbar transforaminal epidural steroid injections (TFESIs) in subjects with radicular pain with or without radiculopathy. DESIGN Retrospective observational study with noninferiority analysis of dexamethasone relative to particulate steroids. SETTING Single academic radiology pain management practice. SUBJECTS Three thousand six hundred forty-five lumbar TFESIs at the L4-5, L5-S1, or S1 neural foramina, performed on 2,634 subjects. METHODS/OUTCOME MEASURES Subjects were assessed with a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M) prior to TFESI, and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score. Noninferiority analysis was performed with δ = -10% as the limit of noninferiority. Continuous outcomes (mean NRS, R-M scores) were analyzed for noninferiority with difference bounds of 0.3 for NRS scores and 1.0 for R-M scores. RESULTS With categorical outcomes, dexamethasone was demonstrated to be noninferior to the particulate steroids in pain relief and functional improvement at 2 months. Using continuous outcomes, dexamethasone was demonstrated to be superior to the particulate steroids in both pain relief and functional improvement at 2 months. CONCLUSION This retrospective observational study reveals no evidence that dexamethasone is less effective than particulate steroids in lumbar TFESIs performed for radicular pain with or without radiculopathy.
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Berthelot JM, Le Goff B, Maugars Y. Side effects of corticosteroid injections: What's new? Joint Bone Spine 2013; 80:363-7. [DOI: 10.1016/j.jbspin.2012.12.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2012] [Indexed: 12/13/2022]
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Cervical epidural steroid injections for the treatment of cervical spinal (neck) pain. Curr Pain Headache Rep 2013; 17:314. [PMID: 23315021 DOI: 10.1007/s11916-012-0314-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cervical epidural steroid injections (CESI) are an accepted treatment for neck pain with a radicular component, and may be accomplished by using either transforaminal (CTFESI) or interlaminar (CILESI) approaches. CESIs are routinely performed using real-time fluoroscopic-guidance in conjunction with the injection of water soluble, iodine-based contrast media to enhance visualization of intravascular injections. Digital subtraction angiography (DSA) imaging is an adjuvant to fluoroscopic methods for visualizing blood vessels while performing spinal injections. However, as with any neuraxial procedure, various complications associated with CESIs have been reported. Complications are directly associated with the technical procedures of CESIs. Particulate steroids may have a prolonged duration of action but non-particulate steroids are safer for CESIs. Blunt-beveled needles are less likely than sharp-beveled needles to penetrate blood vessels to cause bleeding complications during CTFESI procedures. Small doses of local anesthetics appear to be safe and assist in identifying intravascular injections previously overlooked by conventional techniques.
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DePalma MJ, Stout A, Kennedy DJ. Corticosteroid Choice for Epidural Injections. PM R 2013; 5:524-32. [DOI: 10.1016/j.pmrj.2013.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 05/29/2013] [Indexed: 11/28/2022]
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Ryan TM, Kavanagh EC, MacMahon PJ. Is there a need for contrast administration prior to CT-guided cervical nerve root block? AJNR Am J Neuroradiol 2013; 34:E45. [PMID: 23493897 DOI: 10.3174/ajnr.a3544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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107
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Cervical Foraminal Versus Interlaminar Epidurals: Risks, Benefits, and Alternatives. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0013-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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108
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MacVicar J, King W, Landers MH, Bogduk N. The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systematic Analysis of the Published Data. PAIN MEDICINE 2013; 14:14-28. [DOI: 10.1111/j.1526-4637.2012.01508.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study. Skeletal Radiol 2013; 42:69-78. [PMID: 22609989 DOI: 10.1007/s00256-012-1434-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 04/23/2012] [Accepted: 04/24/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the short-term effects and advantages of ultrasound-guided selective nerve root block with fluoroscopy-guided transforaminal epidural block for radicular pain in the lower cervical spine through assessment of pain relief, functional improvement, and safety. METHODS A total of 120 patients with radicular pain from cervical spinal stenosis or cervical herniated disc were enrolled. All procedures were performed using a fluoroscopy or ultrasound apparatus. The subjects were randomly assigned to either the fluoroscopy (FL) or ultrasound (US) group. The complication frequencies during the procedures, treatment effects, and functional improvement of the nerve root block were compared at 2 and 12 weeks after the procedures. RESULTS Verbal Numeric Pain Scale (VNS) improved 2 weeks and 12 weeks after the injections in both groups. Statistical differences were not observed in VNS, Neck Disability Index (NDI), and effectiveness between the groups. In 21 patients at US, vessels were identified at the anterior aspect of the foramen. Eleven patients had a critical vessel at the posterior aspect of the foramen and five patients had on artery continue medially into the foramen, forming, or joining a segmental feeder artery. In both cases, the vessels might well have been in the pathway of the needle correctly positioned under fluoroscopic guidance. Five cases of intravascular injections were observed only in FL without significant difference between the groups. CONCLUSIONS The US-guided method may facilitate identifying critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical transforaminal injections. On treatment effect, using either method of epidural injections to deliver steroids for cervical radicular pain, secondary to herniated intervertebral disc or foraminal stenosis, significant improvements in function and pain relief were observed in both groups after the intervention. However, significant difference was not observed between the groups. Therefore, the ultrasound-guided method was shown to be as effective as the fluoroscopy-guided method in pain relief and functional improvement, in addition to the absence of radiation and avoiding vessel injury at real-time imaging.
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Affiliation(s)
- Haemi Jee
- Department of Medical Science, University of Ulsan College of Medicine, Seoul, Korea
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A case series of thoracic paravertebral blocks using a combination of ropivacaine, clonidine, epinephrine, and dexamethasone. J Clin Anesth 2012; 24:664-7. [DOI: 10.1016/j.jclinane.2012.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 05/02/2012] [Accepted: 05/16/2012] [Indexed: 11/21/2022]
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Abstract
Epidural steroid injection (ESI) is the most commonly performed intervention in pain clinics across the United States. This article provides an evidence-based review of ESI, including data on efficacy, patient selection, comparison of types, and complications. The data strongly suggest that ESI can provide short-term relief for radicular symptoms but are less compelling for long-term effects or relief of back pain. Although it has been asserted that transforaminal ESIs are more efficacious than interlaminar injections, the evidence supporting this is limited.
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Samimi DB, Alabiad CR, Tse DT. An anatomically based approach to intralesional corticosteroid injection for eyelid capillary hemangiomas. Ophthalmic Surg Lasers Imaging Retina 2012; 43:190-5. [PMID: 22432604 DOI: 10.3928/15428877-20120315-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 02/21/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To describe a corticosteroid injection technique for eyelid capillary hemangiomas that minimizes the risk of a central retinal artery occlusion and is based on anatomic, physiologic, and pharmacologic rationales. PATIENTS AND METHODS In this retrospective, non-comparative, interventional case series, the medical records of 50 eyes of 50 patients over a 10-year period were reviewed for retinal complications associated with the described injection technique. RESULTS Ophthalmoscopy showed no retinal complications in the 50 eyes treated with this injection technique. CONCLUSION The risk of central retinal artery occlusion from retrograde embolization can be minimized by using an anatomically based injection technique that prevents canalization of an artery and avoids injection pressures exceeding the mean systemic arterial pressure.
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Affiliation(s)
- David B Samimi
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
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113
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Leung D, Greenberg JS, Henning PT, Chiodo AE. Cervical transforaminal epidural injection in the management of a stinger. PM R 2012; 4:73-7. [PMID: 22269456 DOI: 10.1016/j.pmrj.2011.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 08/25/2011] [Accepted: 09/12/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Daniel Leung
- Department of Physical Medicine and Rehabilitation, University of Michigan Health System, 325 E Eisenhower Parkway, Ann Arbor, MI 48108, USA.
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114
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MacMahon PJ, Shelly MJ, Scholz D, Eustace SJ, Kavanagh EC. Injectable corticosteroid preparations: an embolic risk assessment by static and dynamic microscopic analysis. AJNR Am J Neuroradiol 2011; 32:1830-5. [PMID: 21940803 DOI: 10.3174/ajnr.a2656] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Transforaminal CS injections have been associated with severe adverse CNS events, including brain and spinal cord infarction. Our purpose was to describe the static and dynamic microscopic appearances of CS preparations, with an emphasis on their potential to cause adverse central nervous system events by embolic mechanisms during transforaminal injection. MATERIALS AND METHODS Pharmaceutical preparations of nondilute injectable CSs were used after appropriate mixing: MPA (40 mg/mL), TA (40 mg/mL), and DSP (8 mg/2 mL). For dynamic imaging, a novel methodology was devised to replicate the flow of crystals within spinal cord arterioles. In addition, CS preparations were mixed with plasma to assess for changes in crystal size, morphology, and tendency to aggregate. RESULTS The CS preparations MPA and TA are composed of crystals of varying sizes. MPA crystal size range was 0.4-26 μm (mean, 6.94 μm), TA crystal size range 0.5-110 μm (mean, 17.4 μm), and DSP did not contain any significant crystals or particles. There was no change in the crystal morphology or propensity to aggregate after mixing with local anesthetic. After mixing with plasma, the crystals also were unchanged; however, there was a significant reduction in the size of aggregates. On dynamic imaging, these aggregates were proved to maintain their integrity and to act as potential embolization agents. CONCLUSIONS MPA and TA have a substantial risk of causing infarction by embolization if inadvertently injected intra-arterially at the time of TFESI. DSP is completely soluble and microscopically has no potential to obstruct arterioles. When performing cervical TFESI procedures, the administration of insoluble CSs should be avoided.
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Affiliation(s)
- P J MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland.
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Abstract
STUDY DESIGN Case report and review of the literature. OBJECTIVE To report the first case of inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle. SUMMARY OF BACKGROUND DATA Rare complications from cervical transforaminal epidural corticosteroid injection have resulted in infarction of the spinal cord and brain. The most often-hypothesized mechanism is inadvertent intra-arterial injection of particulate corticosteroids with a resulting embolus and infarction. METHODS Retrospective review of a patient's history and fluoroscopic imaging. RESULTS A 30-year-old man with a diagnosed cervical radiculopathy underwent a right C6-C7 transforaminal epidural corticosteroid injection, using a 25-gauge 3.5-inch Whitacre spinal needle. Simultaneous epidural and radicular artery spread were observed under live fluoroscopy. The patient suffered no complications from the procedure. CONCLUSION This case demonstrates that the use of pencil-point (Whitacre) needles does not eliminate the risk of inadvertent arterial injection during cervical transforaminal epidurals. Further investigation is required to determine whether the incidence of inadvertent vascular injection is reduced with pencil-point needles compared with sharp-beveled needles.
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116
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Infiltrations rachidiennes foraminales lombaires : analyse des risques potentiels. ACTA ACUST UNITED AC 2010; 91:1086-92. [DOI: 10.1016/s0221-0363(10)70153-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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117
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Park CH, Lee SH, Kim BI. Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain. PAIN MEDICINE 2010; 11:1654-8. [PMID: 20807343 DOI: 10.1111/j.1526-4637.2010.00941.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Lumbar transforaminal epidural steroid injections are procedures often utilized in the treatment of low back pain associated with radicular pain. Particulate steroids have been known to play a role in embolism. It is, unknown whether nonparticulate steroids are as effective as particulate steroids. To investigate the effect of an epidural steroid injection on back pain, we conducted a randomized, controlled trial comparing nonparticulate steroid with particulate steroid to treat lumbar disc herniation. DESIGN One hundred-six patients were randomized to receive lumbar transforaminal epidural steroid injections (N = 53) with either dexamethasone 7.5 mg, or with triamcinolone acetate 40 mg (N = 53). Measurement were taken before treatment and one month after treatment using a visual analog scale, short McGill pain questionnaire, and revised Oswertry Back Disability Index. RESULTS There was a statistically significant difference in the visual analog score between those treated with dexamethasone and those given triamcinolone. The two groups did not differ significantly on the McGill Pain Questionnaire, or the Oswestry Disability Index before and after treatment. CONCLUSION In this study, dexamethasone and triamcinolone treatments were shown to have different effects on low back pain with sciatica, with triamcinolone being more effective than dexamethsone in lumbar radiculopathy.
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Affiliation(s)
- Chan Hong Park
- Department of Anesthesiology and Pain Medicine, Daegu Wooridul Hospital, Daegu, South Korea.
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118
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Mathis JM, Golovac S, Cho CH. Pharmaceuticals used in image-guided spine interventions. Neuroimaging Clin N Am 2010; 20:215-22. [PMID: 20439017 DOI: 10.1016/j.nic.2010.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
As image-guided (nonvascular) spine interventions have become progressively more common in the interventional radiologic community, there is a growing need for physician expertise regarding the materials and pharmaceuticals that are used for these procedures. This article is intended to provide information to address these needs.
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Affiliation(s)
- John M Mathis
- Centers for Advanced Imaging, Roanoke, VA 24014, USA.
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119
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Friedrich JM, Harrast MA. Lumbar epidural steroid injections: indications, contraindications, risks, and benefits. Curr Sports Med Rep 2010; 9:43-9. [PMID: 20071921 DOI: 10.1249/jsr.0b013e3181caa7fc] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The clinical use of lumbar epidural steroid injections has increased dramatically. Although there are certainly beneficial effects to using epidural steroid injections in a treatment regimen for lumbar radicular pain, there is a lack of well designed, placebo-controlled studies to define conclusively specific indications and techniques for different spinal diagnoses. This article reviews the pathophysiology of lumbar radiculopathy and the use of epidural steroid injections as one treatment option, as well as describes their risks and benefits. Based on current literature, we offer an evidence-based perspective regarding rational use of lumbar epidural steroid injections for certain indications and treatment goals.
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Affiliation(s)
- Jason M Friedrich
- University of Washington, Department of Rehabilitation Medicine, Seattle, WA98104, USA.
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120
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Colimon FJ, Villalobos FJ. Epidural steroid injections: Evidence and technical aspects. ACTA ACUST UNITED AC 2010. [DOI: 10.1053/j.trap.2010.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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121
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122
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Rosas HG, Gilula LA. Performing Thoracic Transforaminal Injections: A New Technique. Radiology 2010; 254:595-600. [DOI: 10.1148/radiol.09082085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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123
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Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. PAIN MEDICINE 2009; 10:1389-94. [PMID: 19863744 DOI: 10.1111/j.1526-4637.2009.00728.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases. BACKGROUND Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe. CASE REPORTS An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma. CONCLUSION These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.
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Affiliation(s)
- David J Kennedy
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL 32607, USA.
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125
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MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology 2009; 252:647-61. [PMID: 19717750 DOI: 10.1148/radiol.2523081929] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Corticosteroids and local anesthetics are some of the most commonly administered medications in radiology departments. These medications have marked variability in their formulations, which may increase their adverse event profile for specific procedures. In particular, certain corticosteroid preparations are associated with adverse central nervous system (CNS) sequelae. This is most likely due to distal embolization by particulate formulations. Nonparticulate steroid formulations are not associated with such events. Local anesthetics have severe CNS and cardiac adverse effects if injected intravascularly and have recently been associated with intraarticular chondrolysis if used in large doses. This review discusses these medications with particular emphasis on their established and postulated adverse effects. The administering radiologist should be aware of these potential effects and how best to reduce their occurrence.
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Affiliation(s)
- Peter J MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
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Abstract
STUDY DESIGN A comprehensive literature review. OBJECTIVES To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with transforaminal cervical epidural steroid injection (TFCESI) and techniques employed to avoid them. The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications and measures that may be undertaken to increase safety. SUMMARY OF BACKGROUND DATA TFCESI is a component in the diagnosis and management of cervical radicular syndromes in patients who have failed conservative management. There has been much discussion and also controversy in the recent literature. Considerable attention has been paid to reports of catastrophic complications and proposed measures to avoid them. METHODS Medical databases were searched for studies of TFCESI. The bibliographies of these articles were then searched as well. Thoracic and lumbar articles were discarded as were any non-transforaminal cervical procedures or those that did not involve injection into the epidural space. Particular attention was paid to serious neurologic sequelae after TFCESI and its mechanism, as well as techniques being employed to avoid complications. RESULTS There are a limited number of studies looking at complications of TFCESI. One retrospective study reported an overall rate of complications of 1.64%. There are reports of serious neurologic sequelae in the literature including brain and spinal cord infarction due to embolic phenomenon of particulate steroids. Cadaveric dissection revealed ascending and deep cervical arterial branches entering the external opening of the posterior intervertebral foramen, the classic target site for TFCESI. Measures to avoid complications mentioned in the literature include the use of nonparticulate steroids, test dose of local anesthetic before injection of steroids, live fluoroscopy, digital subtraction, no to light sedation, use of true lateral view to supplement frontal and oblique views in fluoroscopy, use of blunt needles, and computed tomography guidance. CONCLUSION The literature reveals a number of rare, potentially catastrophic neurologic sequelae including brain and spinal cord infarction. Most of these are thought to be due to intravascular uptake of particulate steroids. The true overall incidence remains obscure due to the lack of blinded controlled studies. Injectionists, referring physicians, and patients should be aware of the nature and potential consequences of these complications. Additionally, it is imperative for injectionists to standardize techniques to minimize complications, especially by using a test dose of local anesthetic before injection of preferably nonparticulate corticosteroid.
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Derby R, Wolfer LR. Response to Letter by Dr. Bainbridge. PAIN MEDICINE 2009. [DOI: 10.1111/j.1526-4637.2009.00575.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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128
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Eckel TS, Bartynski WS. Epidural Steroid Injections and Selective Nerve Root Blocks. Tech Vasc Interv Radiol 2009; 12:11-21. [DOI: 10.1053/j.tvir.2009.06.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bainbridge JS. Betamethasone: Friend (Soluble), Foe (Particulate), or Either? PAIN MEDICINE 2009; 10:420; author reply 421. [DOI: 10.1111/j.1526-4637.2009.00574.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Goodman BS, Posecion LWF, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008; 1:212-22. [PMID: 19468908 PMCID: PMC2682416 DOI: 10.1007/s12178-008-9035-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 07/23/2008] [Indexed: 12/13/2022]
Abstract
Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging.
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Affiliation(s)
- Bradly S Goodman
- Department of Physical Medicine and Rehabilitation, University of Missouri- Columbia, USA.
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131
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Cyteval C. [Periradicular injections: should we make it earlier or stop it?]. JOURNAL DE RADIOLOGIE 2008; 89:743-744. [PMID: 18641560 DOI: 10.1016/s0221-0363(08)73779-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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