Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre

Post-Discectomy Infection: A Critical Review and Suggestion of a Management Algorithm

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.

The Anatomy, Technique, Safety, and Efficacy of Image-Guided Epidural Access

Epidural steroid injections have demonstrable efficacy and safety in treatment of radicular pain syndromes; transforaminal access has greater evidence of efficacy than interlaminar approaches. The interventionalist must understand epidural and foraminal anatomy and imaging to insure delivery of medication to the target, the ventral epidural space at the site of neural compression. This obligates pre-procedural planning. When performed with appropriate risk mitigation strategies, epidural injections by either access are safe. For transforaminal access, the use of dexamethasone as the injectate, and infraneural approaches, provides safety advantages.

Risk of SARS-CoV-2 following joint and epidural corticosteroid injections: A retrospective study

OBJECTIVE

The immunosuppressive effects of corticosteroid (CS) injections have come under more scrutiny during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to explore any relationship between joint/epidural CS injection and SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) polymerase chain reaction (PCR) positivity.

METHODS

A retrospective chart review was conducted on patients 18 years or over who received at least one joint or epidural CS injection by physiatrists in a tertiary care center between January 1, 2020, and December 31, 2021. This cohort of patients was then compared to a control group who did not receive any CS injection during this time period.

RESULTS

A total of 766 patients were identified in the CS injection group and 1546 patients in the control group. Overall, 12.27% of patients turned SARS-CoV-2 PCR positive in the CS injection group, which was similar to 11.90% in the control group (p = 0.797). But 3-month SARS-CoV-2 PCR positivity rate showed a statistically significant higher rate among the CS injection group (3.30% in the CS injection group vs. 2.10% in the control group; p = 0.027). In multivariate regression analysis, after adjusting both groups for Charlson Comorbidity Index (CCI), there was statistically significant higher SARS-CoV-2 PCR positivity rate in the CS injection group (p = 0.024). However, after adjusting both groups for age and total number of comorbidities, there was no difference between the groups in regard to SARS-CoV-2 PCR positivity rate (p = 0.081). In the subgroup analysis of only COVID-19 vaccinated patients, there was an increased 3-month SARS-CoV-2 PCR positivity rate among patients with severe comorbidities in the CS injection group (p = 0.036).

CONCLUSION

The study was not conclusive on the effect of joint or epidural CS injection on SARS-CoV-2 PCR positivity rate, although adjusted analysis suggests higher 3-month SARS-CoV-2 PCR positivity rate after CS injection in patients with severe comorbidities with significant disease burden when compared to controls.

Interlaminar versus transforaminal epidural steroid injections: a review of efficacy and safety

Spine intervention is an important treatment option for the management of spinal pain, and the numbers of the most representative epidural steroid injection (ESI) procedures performed are expected to increase significantly in the future along with increased life expectancy and the increasing prevalence of spinal disorders. Therefore, it is important to understand the efficacy of ESIs according to each spinal disorder they are administered to treat, and one must be familiar with the possible complications. In fact, although numerous ESI-related articles have been published, there is still considerable controversy regarding the efficacy of ESI procedures. Furthermore, due to the rarity of serious complications, most instances have been recorded in the form of case reports. In this article, we aimed to review the indications of cervical and lumbar ESIs and to compare interlaminar ESI (ILESI) and transforaminal ESI (TFESI) techniques in terms of analgesic efficacy, possible complications, and safety profiles. This article includes opinions based on the authors' experience with ESI indications and efficacy, and presents practical tips for coping with specific situations related to each complication. By combining the dedicated anatomical understanding of radiologists with image-guided interventions, ESI is expected to stand out in the rapidly expanding field of spine intervention.

Comparative Effectiveness of Epidural Steroid İnjections in Patients With Disc Bulging and Disc Protrusion

Purpose Discogenic low back pain is a widespread disorder in the world. Many methods have been developed and continue to be developed in the treatment of discogenic low back pain. We aimed to examine the effect of epidural steroid administration on disc bulging and disc protrusion in patients with discogenic low back pain. Design The clinical effects of interlaminar epidural steroids administered to 71 patients who were admitted to our clinic and whose treatment did not require surgery were radiologically divided into two groups disc bulging and disc protrusion. Patients were followed up for six months and clinical results were recorded. Methods The scores of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured before the procedure, one week after the procedure, one month after the procedure, and six months after the procedure. The normal distribution of continuous variables was evaluated using the Kolmogorov-Smirnov test. Continuous variables were compared with the Mann-Whitney U test and categorical variables were compared using the Chi-square test or Fisher's exact test. Results There was no significant difference in demographic data in patients with disc bulging and disc protrusion. In the disc protrusion group, the VAS scores in the first week after, the first month after and the sixth month after the procedure showed a significant decrease compared to the pre-procedure. There was no significant difference between the disc bulging and protrusion groups in the first week of post-procedure VAS score reduction. In the Disc Bulging group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. In the Disc Protrusion group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. Conclusion There was strong evidence that lumbar interlaminar steroid injection is an effective treatment for disc bulging and discogenic pain due to protrusion. When the ODI and VAS scores of patients with both disc bulging and disc protrusion were evaluated, it was seen that they benefited from epidural steroid injection. In the disc protrusion group, except for the first week of injection, relief due to the use of epidural steroids was observed to be greater compared to disc bulging.

Interventional Pain Procedures: A Narrative Review Focusing on Safety and Complications. Part 1 Injections for Spinal Pain

In recent years, there has been a considerable increase in the number of image-guided interventional procedures performed for the management of acute and chronic pain. Concomitantly, there has also been an increase in the complication rate related to these procedures. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopic- or ultrasound-guided) interventional procedures. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.

Clinical features and outcome of vertebral osteomyelitis after spinal injection: is it worth the price?

PURPOSE

Spinal injections are increasingly used for back pain treatment. Vertebral osteomyelitis (VO) after spinal injection (SIVO) is rare, but patient characteristics and outcome have not been well characterized. The aim of this study was to assess patient characteristics of SIVO in comparison to patients with native vertebral osteomyelitis (NVO) and to determine predictors for 1-year survival.

METHODS

This is a single-center cohort study from a tertiary referral hospital. This is a retrospective analysis of Patients with VO who were prospectively enrolled into a spine registry from 2008 to 2019. Student's t-test, Kruskal-Wallis test or Chi-square test were applied for group comparisons. Survival analysis was performed using a log-rank test and a multivariable Cox regression model.

RESULTS

283 VO patients were enrolled in the study, of whom 44 (15.5%) had SIVO and 239 (84.5%) NVO. Patients with SIVO were significantly younger, had a lower Charlson comorbidity index and a shorter hospital stay compared to NVO. They also showed a higher rate of psoas abscesses and spinal empyema (38.6% [SIVO] vs. 20.9% [NVO]). Staphylococcus aureus (27%) and coagulase-negative staphylococci (CNS) (25%) were equally often detected in SIVO while S. aureus was more frequently than CNS in NVO (38.1% vs. 7.9%).Patients with SIVO (P = 0.04) had a higher 1-year survival rate (Fig. 1). After multivariate analysis, ASA score was associated with a lower 1-year survival in VO.

CONCLUSION

The results from this study emphasize unique clinical features of SIVO, which warrant that SIVO should be estimated as a separate entity of VO.

Lumbar Spinal Steroid Injections and Infection Risk after Spinal Surgery: A Systematic Review and Meta-Analysis

Lumbar spinal steroid injections (LSSI) are universally used as preferred diagnostic or therapeutic treatment options before major spinal surgeries. Some recent studies have reported higher risks of surgical-site infection (SSI) for spinal surgeries performed after injections, while others have overlooked such associations. The purpose of this study is to systematically review the literature and perform a meta-analysis to evaluate the associations between preoperative LSSI and postoperative infection following subsequent lumbar decompression and fusion procedures. Three databases, namely PubMed, Scopus, and Cochrane Library, were searched for relevant studies that reported the association of spinal surgery SSI with spinal injections. After the comprehensive sequential screening of the titles, abstracts, and full articles, nine studies were included in a systematic review, and eight studies were included in the meta-analysis. Studies were critically appraised for bias using the validated MINOR (methodological index for non-randomized studies) score. The odds ratio (OR) and 95% confidence interval (CI) were calculated. Subgroup analysis was performed according to the time between LSSI and surgery and the type of lumbar spine surgery. Meta-analysis showed that preoperative LSSI within 30 days of lumbar spine surgery was associated with significantly higher postoperative infection compared with the control group (OR,1.79; 95% CI, 1.08-2.96). Based on subgroup analysis, lumbar spine fusion surgery within 30 days of preoperative LSSI was associated with significantly high-infection rates (OR, 2.67; 95% CI, 2.12-3.35), while no association was found between preoperative LSSI and postoperative infection for lumbar spine decompression surgeries. In summary, given the absence of high-level studies in the literature, careful clinical interpretation of the results should be performed. The overall risk of SSI was slightly higher if the spinal surgery was performed within 30 days after LSSIs. The risk was higher for lumbar fusion cases but not for decompression-only procedures.

Fluoroscopic lumbar transforaminal epidural steroid injections for recurrent herniated intervertebral disc after discectomy: Effectiveness and outcome predictors

Background

Despite transforaminal epidural steroid injection (ESI) being the first choice in patient with recurrent herniated intervertebral disc (HIVD), efficacy of ESI in those patients are not well established. Herein, we evaluate the effectiveness and outcome predictors of fluoroscopic transforaminal ESI for recurrent HIVD.

Methods

Seventy-seven patients (48 male; mean age, 51.3 years) with recurrent lumbar HIVD were included and divided into three groups according to initial treatment: conservative treatment, transforaminal ESI, and immediate surgery. ESI effectiveness was evaluated by operation rates, injection numbers in 6 months, and pain reduction (visual analog scale (VAS) scores). Clinical and MRI variables were analyzed as possible outcome predictors. Each subject in the transforaminal ESI group was individually matched to two patients with initial HIVD (control group).

Results

In the transforaminal ESI group (n = 37), 20 patients (54.1%) did not undergo reoperation. The initial and follow-up VAS scores were significantly higher in the reoperation group (p = 0.014, p = 0.019, respectively). Patients with either paresthesia or motor weakness (12/19, 63.2%) had a significantly higher reoperation rate than patients with only pain (5/18, 27.8%; p = 0.031). Extruded disc ratios ≥2.0 were significantly higher in the reoperation group (10/17, 58.8%; p = 0.048). The reoperation rate in the transforaminal ESI group (17/37, 45.9%) was higher than the operation rate in the control group (6/73, 8.2%; p<0.001).

Conclusion

Transforaminal ESI was effective in reducing radicular pain in patients with recurrent HIVD. Approximately 54% of patients did not undergo reoperation. An extruded disc ratio ≥2.0 and paresthesia or motor weakness were poor outcome predictors.

The skeletal consequences of epidural steroid injections: a literature review

This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs.

PURPOSE

Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids.

METHODS

Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed.

RESULTS

Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes.

CONCLUSIONS

While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment.

The Immediate Adverse Events of Lumbar Interventional Pain Procedures in 4209 Patients; an Observational Clinical Study

OBJECTIVE

Lumbar interventional pain procedures (LIPP) are frequently used in low back pain and show an increasing trend in recent years. LIPP are highly effective when performed by properly trained physicians. However, some adverse events are seen during interventional procedures. Our aim in this study is to determine the immediate adverse events rates of LIPP and to inform our colleagues about possible adverse events.

STUDY DESIGN

Retrospective, observational study.

SETTING

A university hospital pain management center.

METHODS

After approval of the institutional ethics committee, a retrospectively evaluation of patients, who received fluoroscopy guided LIPP between January 2015 and December 2020, were performed. This observational study was conducted with 4209 patients who underwent LIPP including epidural steroid injections, sacroiliac and facet joint injections, medial branch blocks or RF, dorsal root ganglion pulse RF, epidural catheter or spinal cord stimulator applications.

RESULTS

No major adverse events were detected during the procedures. Minor adverse events were detected in a 60 patients and adverse events rate was found to be 1.4% (95% confidence interval [CI]: 1.0-1.8%). Minor adverse events rates vary between 0.7-2.3% according to the procedures type. The most common adverse events was determined as vasovagal reactions (26/60). Facial numbness, cramps, and seizures were detected as rare adverse events.

CONCLUSION

There were no major adverse events were seen during 4209 patients. The rate of minor adverse events were 1.4% with no sequelae in any of the events. When evidence-based guidelines are followed, interventional pain procedures are performed safely.

Deep Spinal Infection after Outpatient Epidural Injections for Pain: A Retrospective Sample Cohort Study Using a Claims Database in South Korea

BACKGROUND

Deep spinal infection is a devastating complication after epidural injection. This study aimed to investigate the incidence of deep spinal infection primarily after outpatient single-shot epidural injection for pain. Secondarily, this study assessed the national trends of the procedure and risk factors for said infection.

METHODS

Using South Korea's National Health Insurance Service sample cohort database, the 10-yr national trend of single-shot epidural injections for pain and the incidence rate of deep spinal infection after the procedure with its risk factors were determined. New-onset deep spinal infections were defined as those occurring within 90 days of the most recent outpatient single-shot epidural injection for pain, needing hospitalization for at least 1 night, and receiving at least a 4-week course of antibiotics.

RESULTS

The number of outpatient single-shot epidural injections per 1,000 persons in pain practice doubled from 40.8 in 2006 to 84.4 in 2015 in South Korea. Among the 501,509 injections performed between 2007 and 2015, 52 cases of deep spinal infections were detected within 90 days postprocedurally (0.01% per injection). In multivariable analysis, age of 65 yr or more (odds ratio, 2.91; 95% CI, 1.62 to 5.5; P = 0.001), living in a rural area (odds ratio, 2.85; 95% CI, 1.57 to 5.0; P < 0.001), complicated diabetes (odds ratio, 3.18; 95% CI, 1.30 to 6.7; P = 0.005), multiple epidural injections (three times or more) within the previous 90 days (odds ratio, 2.34; 95% CI, 1.22 to 4.2; P = 0.007), and recent use of immunosuppressants (odds ratio, 2.90; 95% CI, 1.00 to 6.7; P = 0.025) were significant risk factors of the infection postprocedurally.

CONCLUSIONS

The incidence of deep spinal infection after outpatient single-shot epidural injections for pain is very rare within 90 days of the procedure (0.01%). The data identify high-risk patients and procedure characteristics that may inform healthcare provider decision-making.

EDITOR’S PERSPECTIVE

Outbreak of Pseudomonas aeruginosa infections after CT-guided spinal injections

BACKGROUND

Meningitis and spinal infections with Gram-negative bacteria after local injections for treatment of chronic back pain are rare. This study investigated an outbreak of Pseudomonas aeruginosa infections following computed tomography (CT)-guided spinal injections (SI).

METHODS

A case was defined as a spinal infection or meningitis with P. aeruginosa after SI between 10^th January and 1^st March 2019 in the same outpatient clinic. Patients without microbiological evidence of P. aeruginosa but with a favourable response to antimicrobial therapy active against P. aeruginosa were defined as probable cases.

FINDINGS

Twenty-eight of 297 patients receiving CT-guided SI during the study period developed meningitis or spinal infections. Medical records were available for 19 patients. In 15 patients, there was microbiological evidence of P. aeruginosa, and four patients were defined as probable cases. Two of 19 patients developed meningitis, while the remaining 17 patients developed spinal infections. The median time from SI to hospital admission was 8 days (interquartile range 2-23 days). Patients mainly presented with back pain (N=18; 95%), and rarely developed fever (N=3; 16%). Most patients required surgery (N=16; 84%). Seven patients (37%) relapsed and one patient died. Although the source of infection was not identified microbiologically, documented failures in asepsis when performing SI probably contributed to these infections.

CONCLUSIONS

SI is generally considered safe, but non-adherence to asepsis can lead to deleterious effects. Spinal infections caused by P. aeruginosa are difficult to treat and have a high relapse rate.

Ultrasound-Guided Transforaminal Injections of Platelet-Rich Plasma Compared with Steroid in Lumbar Disc Herniation: A Prospective, Randomized, Controlled Study

Transforaminal steroid injection is extensively used as a treatment in cases of herniated disc, but it is associated with complications. In comparison, platelet-rich plasma (PRP) injection has been used in musculoskeletal disorders and could be another option. This study is aimed at comparing the efficacy and safety aspects between ultrasound-guided transforaminal injections of PRP and steroid in patients who suffer from radicular pain due to lumbar disc herniation. In a randomized controlled trial, ultrasound-guided transforaminal injections of either PRP (n = 61) or steroid (n = 63) were administered to a total of 124 patients who suffer from radicular pain due to lumbar disc herniation. Patients were assessed by the visual analogue scale (VAS), pressure pain thresholds (PPTs), Oswestry disability index (ODI), and the physical function (PF) and bodily pain (BP) domains of the 36-item short form health survey (SF-36) before operation and 1 week, 1 month, 3 months, 6 months, and 12 months after operation. The rate and latency of F-wave were obtained before operation and 12 months postoperation. There was no statistical difference in terms of age and sex between both groups. Statistically significant improvements from the patients' data before operation to data obtained 1-month postoperation were observed in VAS, PPTs, ODI, and PF and BP of SF-36 in both groups and kept for 1 year. F-wave rate and latency were improved significantly at 1-year postoperation in both groups. Intergroup differences during follow-ups over a period of 1 year were not found to be significant in all the above assessment between the PRP and steroid groups. No complications were reported. The results showed similar outcome for both transforaminal injections using PRP and steroid in the treatment of lumbar disc herniation, suggesting the possible application of PRP injection as a safer alternative. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-17011825).

Safety of epidural steroids: a review

Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.

Ultrasound-guided interventions during pregnancy for lumbosacral pain unresponsive to conservative treatment: A retrospective review

PURPOSE

Current conventional therapeutic strategies for lumbosacral pain during pregnancy are usually inadequate and data regarding interventional analgesic procedures feasible in pregnant women is scarce. We decided to retrospectively review our experience of ultrasound-guided pain management procedures in pregnant women with lumbosacral pain unresponsive to conservative treatment.

METHODS

Twenty women in the second trimester of pregnancy with lumbosacral pain developed during pregnancy unresponsive to conservative treatments who underwent the following ultrasound-guided pain interventions were included: sacroiliac joint, caudal epidural, interlaminar epidural, and trigger point injections. All patients were followed up until early postnatal period using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores.

RESULTS

All but one patient achieved satisfactory pain control throughout the pregnancy with a single injection. Significant declines in ODI and VAS scores was attained within the first 2 weeks and first week of intervention, respectively, which was maintained thereafter until early postnatal period.

CONCLUSIONS

Injections used for effective interventional pain management in nonpregnant populations seem to represent an effective and safe method also for pregnant women when performed under ultrasound guidance, with rapid onset and enduring duration of action until the time of delivery.

Antiplatelet and Anticoagulant Risk for Select Spine Interventions: A Retrospective Cohort

OBJECTIVES

To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagulation effect.

DESIGN

Retrospective chart review of a 12-month period.

SETTING

Outpatient academic medical practice.

INTERVENTIONS

Injections during outpatient interventional spine clinical encounters, including 14 cervical transforaminal epidural steroid injections, 26 cervical medial branch blocks, seven cervical radiofrequency neurotomies, three cervical facet joint injections, 88 lumbar transforaminal epidural steroid injections, 66 lumbosacral medial branch blocks, 18 lumbosacral radiofrequency neurotomies, 13 lumbar facet joint injections, one caudal epidural steroid injection, 11 sacral transforaminal epidural steroid injections, and 32 sacroiliac joint injections.

MAIN OUTCOME MEASURE

Epidural hematoma or other serious bleeding.

RESULTS

In this cohort of 275 consecutive encounters with available records in which patients underwent a spinal injection while continuing medications with antiplatelet or anticoagulant effect, zero of the 275 clinical encounters (0%, 95% confidence interval = 0-1.4%) resulted in epidural hematoma or other serious bleeding. For antiplatelet medication, nonsteroidal anti-inflammatory drugs were continued in 102 procedures, aspirin in 142, clopidogrel in 21, and meloxicam and/or Celebrex in 81; for anticoagulation medication, warfarin was continued in four procedures, apixaban in six, dabigatran in one, and fondaparinux in two. Of note, one patient suffered a deep vein thrombosis, which was identified at two-week follow-up despite continuing aspirin therapy.

CONCLUSIONS

This cohort adds to the growing evidence that the risk of serious bleeding complications from select spine interventions while continuing medications with antiplatelet or anticoagulant effect appears low.

Value of ultrasound-guided transforaminal nerve block in the treatment of lumbar disc herniation

Objective

This study was performed to investigate the effectiveness and safety of ultrasound-guided transforaminal nerve block in the treatment of lumbar disc herniation.

Methods

Sixty patients who underwent treatment for protrusion of a lumbar intervertebral disc in Wangjing Hospital from January 2016 to December 2017 were divided into the study group and the control group. The visual analog scale (VAS) pain scores, the Japanese Orthopaedic Association (JOA) scores of the lumbar vertebra, PRI (pain rating index), and PPI (present pain intensity) were recorded at 30 minutes, 1 week, and 3 months after the operation.

Results

There were significant differences in the VAS, JOA, PRI, and PPI scores between the study group and control group.

Conclusion

Ultrasound guidance can improve the efficacy and safety of transforaminal nerve block in the treatment of lumbar disc herniation and shorten the operative duration.

Neurological Complication Rates of Epidural Injections and Selective Nerve Blocks: A Comparison of Steroid Use Patterns

OBJECTIVES

Epidural injections and selective nerve blocks are widely used for pain relief, but steroid usage is controversial due to safety concerns. We carried out this retrospective cohort study to estimate the incidence rates of neurological complications associated with epidural and selective nerve blocks, in relation to steroid use patterns.

MATERIALS AND METHODS

Using a national insurance claims database, we identified patients who received at least one epidural injection or nerve block from 2009 to 2013. We estimated incidence rates and hazard ratios in propensity score-matched cohorts stratified by steroids, using the Charlson comorbidity index, age, sex, anesthetics, and antithrombotics as variables. We included cases attending hospital within 24 hours after injection and treated for neurological complications.

RESULTS

Incidence rates of neurological complications per 100,000 person-days for injections with and without steroids were 1.48 (95% confidence interval [CI]: 1.25-1.65) and 0.86 (95% CI: 0.66-1.30), respectively; rates for particulate steroid injections and nonparticulate steroid injections were 1.73 (95% CI: 1.41-1.95) and 0.90 (95% CI: 0.43-1.47), respectively. The adjusted hazard ratio (aHR) of neurological complications for injections with versus without steroids was 1.71 (95% CI: 0.96-2.49). The aHR of particulate versus nonparticulate steroid injections was 4.98 (95% CI: 1.01-262.35), at the cervicothoracic level. The aHR of neurological complications for nonparticulate steroids compared with nonsteroidal injections was 0.97 (95% CI: 0.46-3.01).

DISCUSSION

At the cervicothoracic level, the incidence rate of neurological complications with particulate steroid injections was higher than that with nonparticulate steroid injections. Injections with nonparticulate steroids and without steroids were equally safe.

Clinical and imaging characteristics of patients with extreme low back pain or sciatica referred for spinal injection

PURPOSE

To analyze the causes of pain, imaging characteristics, and therapeutic effect of spinal injection in patients with extreme low back pain or sciatica.

METHODS

We analyzed 381 consecutive patients with extreme low back pain or sciatica visiting our spinal intervention center between January and December 2017. Clinical and imaging characteristics were analyzed. The treatment response, defined as a numerical pain rating scale decrease of ≥ 30%, was measured. Fisher's exact test was performed to identify the association between the injection response and subsequent lumbar surgery rate.

RESULTS

The most frequent cause of pain was spinal stenosis, followed by herniated intervertebral disc, facet osteoarthritis, and osteoporotic compression fracture. A herniated intervertebral disc was the most common disorder in patients < 50 years of age, while spinal stenosis was the most common in patients ≥ 50 years of age. Women comprised 66.4% of the study population. The majority of lumbar pathologies occurred below L3/4. Spinal injection was found to be effective in 44.2% of cases. Those who responded to the injection showed a significantly lower rate of lumbar surgery within 6 months (P = 0.004).

CONCLUSIONS

Those with extreme low back pain or sciatica had clinical and imaging characteristics similar to those with typical low back pain referred for spinal injection. Spinal injection could be an effective method of pain control for patients with extreme low back pain or sciatica.

Influence of Epidural Steroid Injection on Adrenal Function

Background

Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients.

Methods

This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7-28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test.

Results

There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015).

Conclusions

Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.

Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis

BACKGROUND

Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP).

METHODS

PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values.

RESULTS

58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias.

CONCLUSION

No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.

MRI guidance technology development in a large animal model for hyperlocal analgesics delivery to the epidural space and dorsal root ganglion

BACKGROUND

Development of new analgesic drugs or gene therapy vectors for spinal delivery will be facilitated by "hyperlocal" targeting of small therapeutic injectate volumes if spine imaging technology can be used that is ready for future clinical translation.

NEW METHOD

This study provides methods for MRI-guided drug delivery to the periganglionic epidural space and the dorsal root ganglion (DRG) in the Yucatan swine.

RESULTS

Phantom studies showed artifact-corrected needle localization with frequency encoding parallel to the needle shaft, while maximizing bandwidth (125 KHz) minimized needle artifact. A custom constructed 8-12 element surface coil (phased array) wrapped over the spine in conjunction with lateral recumbent positioning achieved diagnostic quality signal to noise ratio at the depth of the DRG and afforded transforaminal access via anterolateral or posterolateral vectors, as well as interlaminar access. Swine epidural anatomy was homologous with human anatomy. Injectate containing 2% gadolinium allowed imaging of injectate volumes in increments as small as 10 microliters and discrimination of epidural flow from intraparenchymal injectate delivery into a DRG. All technical and technological elements of the procedure appear clinically translatable.

COMPARISON WITH EXISTING METHODS

Computed tomographic or fluoroscopic guidance cannot directly visualize drug delivery into the DRG due to contrast medium toxicity, nor reliably identify epidural injection volumes of < 50 microliters.

CONCLUSIONS

MRI-guided hyperlocal delivery in swine provides a translatable and faithful model of future human spinal novel drug- or gene therapy vector delivery.

An epidural steroid injection in the 6 months preceding a lumbar decompression without fusion predisposes patients to post-operative infections

Background

To determine if the timing of a lumbar epidural steroid injection (LESI) effects rates of post-operative infection in patients receiving a non-fusion lumbar decompression (LDC) due to degenerative disc disease (DDD). Lumbar pain due to DDD can frequently be temporized or definitively treated with epidural injections. While there is ample literature regarding the infection risks associated with corticosteroid injections prior to hip/knee replacements, there are few studies relating to the spine.

Methods

A nationwide insurance database was queried to identify those who underwent LDC for DDD without instrumentation [2005-2014]. Lumbar fusion procedures were excluded. From this group those with a history of a LESI were identified and matched to a control group without a history of LESI. Four separate cohorts were examined: (I) LDC and no LESI within 6 months (control); (II) LDC performed within 0-1 month after LESI; (III) LDC between 1 and 3 months after LESI; (IV) LDC performed between 3 and 6 months after LESI.

Results

There was an increased odds of a 90-day postoperative infection if the LESI was within the 1-3 months (OR =4.69; P<0.001) and 3-6 months (OR =5.33; P<0.001) interval prior to the LDC.

Conclusions

While LESI is helpful for possibly delaying or avoid lumbar surgery, it may predispose patients to higher infection rates following lumbar decompressions without fusion. Surgeons and pain management specialist should counsel patients on these risks and.