Safety and Complications of Cervical Epidural Steroid Injections

Pharmacology of spinal interventions: review of agents used in spine pain procedures

Spine procedures are commonly performed to diagnose and treat various spinal conditions, ranging from degenerative disc disease to vertebral fractures. These procedures often involve the use of pharmaceutical agents to enhance the efficacy of the intervention and improve patient outcomes. This review provides an overview of the pharmaceuticals commonly utilized in spine procedures, including corticosteroids, anesthetics, antibiotics, radiographic contrast, neurolytic agents, and materials used in kyphoplasty and vertebroplasty. This review summarizes the utilization of these pharmaceutical agents in spine procedures in an effort to optimize patient outcomes. Understanding the pharmacological properties and appropriate uses of these pharmaceuticals is essential for interventionalist and healthcare providers involved in the care of patients undergoing spinal interventions.

FACTFINDERS FOR PATIENT SAFETY: Minimizing risks with cervical epidural injections

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections. Evidence in support of the following facts is presented. Minimizing Risks with Cervical Interlaminar Epidural Steroid Injections - 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks. Minimizing Risks with Cervical Transforaminal Epidural Steroid Injections - the Role of Preprocedural Review of Advanced Imaging -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes. Safety of Multi-level or Bilateral Fluoroscopically-Guided Cervical Transforaminal Epidural Steroid Injections -- Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.

Efficacity of CT-guided intra-articular cervical facet steroid injection for cervical radiculopathy

Background

Traditionally, transforaminal steroid injection is performed in the management of cervical radiculopathy in medical failure treatment but carried a true risk of catastrophic complication. Another approach currently used is to perform intra-articular facet steroid injection to reach the epidural space.

Purpose

The aim of this study was to describe the evolution of symptoms following intra-articular facet steroid injection in cervical radiculopathy.

Material and methods

We conducted a retrospective study. We assessed all patients who had a CT-guided intra-articular facet steroid injection in our center (xx, xx, xx) from December 2015 to February 2021. Cervical MR pretherapeutic images were analyzed and classified according to cervical pain etiology: uncodiscarthrosis, disk herniation or congestive cervical posterior osteo-arthritis. All patients had clinical initial evaluation and then follow-up at 1 and 6 months. Pain severity was rated on a visual analog scale and expressed as a percentage of improvement.

Results

Ninety-three patients were included. There were 56 patients with uncodiscarthrosis, 29 with a disk herniation and 8 with a cervical posterior congestive osteoarthritis. A significant improvement of the visual analog scale percentage was found for all patient at 1 and 6 months (p < 0.01). Visual analog scale percentage improvement was about 50 % for all etiologies. For all patients, no severe complications were reported.

Conclusion

Intra-articular facet steroid injection may be considered for the treatment of cervical radiculopathy when other medical treatments have failed.

Changes in the Utilization of Cervicothoracic Injections Between 2010 and 2020

STUDY DESIGN

Descriptive epidemiologic study.

OBJECTIVE

To analyze trends and patient characteristics of those undergoing cervicothoracic transforaminal, interlaminar, and facet injections over time.

BACKGROUND

Cervicothoracic transforaminal, interlaminar, and facet injections are considered for varied spinal pathologies. Evolving literature, changing physician preferences, insurance reimbursement policies, and patient factors may influence the utilization of such injections over time.

METHODS

Patients undergoing cervicothoracic transforaminal, interlaminar, and facet injections 2010-2020 were identified in the M151Ortho PearlDiver database using Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index, insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, and West) were extracted and assessed over study intervals based on prevalence per 100,000 covered lives.

RESULTS

Cervicothoracic transforaminal, interlaminar, and facet injections were identified for 195,221 (11.3%), 951,191 (55.2%), and 575,228 (33.4%) patients, respectively. Patient characteristics for each injection type were defined. The annual number of injections performed per 100,000 covered lives decreased during the study period for transforaminal (17.1% decrease) and interlaminar (9.3% decrease) but increased for facet (3.7% increase) injections ( P <0.0001 for each). Stratifying by patient insurance type, administration of transforaminal, interlaminar, and facet injections per 100,000 covered lives was proportionally greatest for commercially insured patients (55%, 50%, and 45%, respectively), and proportionally smallest for Medicaid patients (10%, 13%, and 13%, respectively). Anesthesiology physicians performed the most injections, followed by physical medicine and rehabilitation physicians, with both provider types most frequently performing interlaminar injections, followed by facet and transforaminal injections.

CONCLUSION

Annual cervicothoracic transforaminal and interlaminar injection utilization declined by 17.1% and 9.3% from 2010 to 2020, whereas facet injection administration increased by 3.7% over the same interval. Evolving practice patterns are important to consider in characterizing the overall landscape of spine care.

Safety of cervical transforaminal epidural steroid injections

Background

In 2014 the FDA issued a drug safety warning that steroids in the epidural space may result in rare but serious neurological adverse events. The FDA identified 131 cases of neurological adverse events and most complications were related to cervical transforaminal epidural injections (TFESIs). These complications occurred before the standard use of non-particulate steroids. Many still consider cervical TFSEIs to be unsafe.

Objectives

The objective of this study was to evaluate the safety of cervical TFESIs with non-particulate steroids.

Methods

A review was done of all cervical TFESIs from 2004 to 2021 at an academic institution when non-particulate steroids became more commonly used by reviewing CPT code 64479 linked to the performing physician. All treating physicians and department directors were queried about catastrophic complications (stroke, spinal cord injury, death or other). A secondary analysis was done on 200 consecutive cervical TFESIs looking at immediate and delayed side-effects documented by the nurse in recovery, day-after phone calls and clinic follow-up notes.

Results

From 2004 to 2021 the CPT code 64479 was used 6967 times, with 6241 cervical TFESIs and 726 thoracic TFESIs. No catastrophic complications occurred. In the subset analysis of 200 consecutive cervical TFESIs, 7 patients (3.5 %, 95 % CI 1.0-6.0) had a transient increase in pain, 18 (9 %, 95 % CI 5.0-13.0) had no change in pain and 171 (85.5 %, 95 % CI 80.6-90.4) had a decrease in pain. The average pain score among all participants dropped 3.7 (95 % 3.0-4.4) points. A 2-point drop was seen in 75.5 % (95 % CI 69.5-81.5) and a 3-point drop was seen in 62.5 % (95 % CI 59.1-65.9). Five of the seven patients with transient increased pain had an increase of ≥ 3 points on numerical rating scale. There was one of each of the following reported: insomnia, glucose >500, transient thumb numbness with pain, and hypertension. Two cases of headaches were reported.

Conclusion

This study supports the safety of cervical TFESIs with non-particulate steroids as recommended by consensus opinions from medical societies.

Ultrasound-guided and CT-guided selective cervical nerve root injection for the treatment of cervical radicular pain: A retrospective clinical study

OBJECTIVE

To compare the clinical effects and safety of ultrasound (US)-guided selective cervical nerve root injection (SCNI) and computed tomography (CT)-guided SCNI for patients with cervical radicular pain (CRP).

METHODS

Forty-two CT-guided SCNI procedures (26 eligible patients) and forty-two US-guided SCNI procedures (25 eligible patients) performed to treat CRP were identified from the medical record system between October 2017 and July 2021 and enrolled in the study. The numeric rating scale was used to assess pre- and postprocedural pain levels, and the neck disability index was used to assess the level of function. All immediate and delayed clinical complications were also recorded. The cost of each procedure and the radiation dose of the CT procedure were documented. The follow-up data were obtained by telephone calls or outpatient visits.

RESULTS

Five patients in the CT group and one patient in the US group were lost to follow-up at 1 year. No procedure-related complications were observed in either group. Significant pain relief and cervical function improvement were achieved after treatment in both the CT-guided SCNI and US-guided SCNI groups; however, there were no significant differences between the two groups. The average cost per CT-guided SCNI procedure was 133.2 USD, which was higher than the cost per US-guided SCNI procedure (42.2 USD). Meanwhile, the necessary radiation dose per patient in the CT group was 0.36 ± 0.08 mGy.

CONCLUSIONS

US-guided SCNI and CT-guided SCNI have similar efficacy in treating CRP, but US-guided SCNI is radiation free and less costly than the CT-guided procedure.

Contralateral oblique view can prevent dural puncture in fluoroscopy-guided cervical epidural access: a prospective observational study

INTRODUCTION

Although the contralateral oblique (CLO) view at 50°±5° is clinically useful for cervical epidural access, no previous studies have confirmed its safety. This prospective observational study was conducted to assess the safety profile, including the risk of dural puncture, in fluoroscopically guided cervical epidural access using the CLO view.

METHODS

In cervical epidural access using the CLO view, the incidence of dural puncture was investigated as the primary outcome. Other intraprocedural complications, including intravascular entry, subdural entry, spinal cord injury and vasovagal injury, and postprocedural complications were investigated as secondary outcomes. Procedural variables including first-pass success, final success, needling time, total number of needle passes and false loss of resistance (LOR) were evaluated.

RESULTS

Of the 393 patients who underwent cervical interlaminar epidural access were included for analysis, no instances of dural puncture or spinal cord injury were observed. The incidence of intravascular entry, vasovagal reaction and subdural entry were 3.1%, 0.5% and 0.3%, respectively. All procedures were successfully performed, with 85.0% of first-pass success rate. The mean needling time was 133.8 (74.9) s. The false-positive and false-negative LOR rates were 8.2% and 2.0%, respectively. All needle tips were visualized clearly during the procedure.

CONCLUSIONS

The fluoroscopy-guided CLO view at 50°±5° avoided dural puncture or spinal cord injury and decreased the incidence of false LOR during cervical epidural access with a paramedian approach.

TRIAL REGISTRATION NUMBER

NCT04774458.

2. Cervical radicular pain

INTRODUCTION

Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both.

METHODS

The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized.

RESULTS

The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered.

CONCLUSIONS

There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].

Epidural hematoma risks associated with ceasing vs maintaining anticoagulant and/or antiplatelet medications for cervical and thoracic interlaminar epidural steroid injections

Background

There is a lack of substantiated evidence to support or refute the risks of ceasing vs maintaining anticoagulant and/or antiplatelet medications (ACAP) prior to cervical and thoracic interlaminar epidural steroid injections. The ACAP medication is frequently stopped pre-procedure due to concerns for potential bleeding complications, particularly epidural hematomas (EH). This article provides evidence regarding EH incidence in this population.

Methods

Data for this study was collected retrospectively on all patients from September 19, 2009-Jun 16, 2017 who were scheduled for an Interlaminar Cervical and/or Thoracic Epidural Steroid Injections (IL-CTESI) and were on an ACAP medication at the time a procedure was scheduled. All possible adverse outcomes were then retrospectively analyzed via extensive data mining of the electronic medical record system with special emphasis on EHs.

Results

591 IL-CTESI were performed on patients taking ACAP medications. In total, 351 patients ceased their ACAP medication prior to the procedure and 240 maintained ACAP medication. Our findings demonstrate that there were no clinically relevant incidents of EHs in either cohort.

Conclusions

This data gives critical insight into the post-procedural EH risk for patients who had continued or stopped taking their ACAP medications prior to their IL-CTESI. The results from this study suggest re-evaluating the potential post-procedural EH risks associated with continuing vs ceasing these medications.

Image-Guided Spine Interventions for Pain: Ongoing Controversies

An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.

Spinal Cord Injury and Postdural Puncture Headache following Cervical Interlaminar Epidural Steroid Injection: A Case Report

Background: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. Case report: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient’s PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. Conclusions: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher.

Cervical epidural hematoma with Brown-Sequard syndrome caused by an epidural injection: a case report

Epidural hematoma with Brown-Sequard syndrome caused by an epidural injection is a rarely found condition in the emergency department (ED). We report an unusual case of Brown-Sequard syndrome in a 55-year-old man who presented at the ED with right-sided weakness and contralateral loss of pain and temperature sensation after a cervical epidural injection for shoulder pain. Cervicla spine magnetic resonance imaging showed an epidural hematoma from C4 to C6. After admission, his right hemiparesis and contralateral sensory loss improved within eight days, and surgical decompression was not required. Diagnosing spinal lesions in the ED is challenging, especially in patients with acute neurological signs requiring immediate evaluation for stroke. In this case, definite hemiparesis and some contralateral sensory loss were noted. Therefore, a potential spinal lesion was suspected rather than a stroke. This case emphasized the importance of conducting a focused neurological examination after history taking.

Correlation Between Intravascular Injection Rate, Pain Intensity, and Degree of Cervical Neural Foraminal Stenosis During a Cervical Transforaminal Epidural Block

Purpose

Cervical transforaminal epidural blocks (CTEBs) are useful for the treatment of cervical radicular pain. However, during CTEBs, inadvertent intravascular injection can introduce particulate steroids into the bloodstream, thus leading to serious complications. Moreover, the risk factors associated with intravascular injection during CTEBs have not been identified. Cervical neural foraminal stenosis (CNFS) is a form of neural foraminal narrowing and a common cause of cervical radicular pain. In this study, we aimed to identify whether there is a correlation between the incidence of intravascular injection during CTEB, pain intensity, and the degree of CNFS.

Patients and Methods

A total of 126 patients were recruited. The patients were classified into two subgroups (group M and group S) based on the routine cervical T2-weighted axial magnetic resonance imaging (MRI) findings. Group M (n = 63) consisted of moderate CNFS patients, while group S (n = 63) consisted of severe CNFS patients. The occurrence of intravascular injection during CTEB was established using real-time fluoroscopy. The intravascular injection was determined by the spreading of the contrast medium through the vascular channel during the injection. Additionally, pain intensity was scored using a Numeric Rating Scale (NRS) before the procedure and 1 month after the procedure.

Results

There was no significant difference in the incidence of intravascular injection during CTEB between group M and group S (41.3% vs 39.7%, respectively; p = 0.99) and in the NRS scores before and 1 month after CTEB. However, both groups showed a significant decrease in the NRS scores at 1 month after the procedure compared with that before the procedure.

Conclusion

The degree of CNFS does not affect the incidence of intravascular injection during CTEB. Regardless of whether patients have moderate or severe CNFS, caution should be exercised during CTEB procedures.

Right hemidiaphragmatic paralysis after cervical transforaminal epidural steroid injection: illustrative case

BACKGROUND

Cervical radiculopathy is a common cause of neck pain, with radiation into the upper extremity in a dermatomal pattern. Corticosteroid injection is a conservative management option with a low risk of major adverse events. No reviewed literature or case reports have implicated phrenic nerve injury secondary to cervical transforaminal epidural steroid injection (CTFESI).

OBSERVATIONS

A 45-year-old man with severe right C6 radiculopathy secondary to a large right-sided C5–6 herniated intervertebral disc presented to the pain management clinic, where he received a right-sided C6 CTFESI. An hour after injection, the patient experienced shortness of breath, which was found to be caused by right diaphragmatic paralysis. The patient underwent a C5–6 anterior cervical discectomy and fusion, which provided complete relief of his radicular symptoms. However, the right hemidiaphragmatic paralysis remained at the 1-year postoperative visit.

LESSONS

Thorough literature review showed no established explanations for phrenic nerve injury after CTFESI. In this study, the authors explored the suspected mechanisms of possible injury to the phrenic nerve. Epidural corticosteroid injection is considered to be a safe option for conservative management of cervical radiculopathy. This study unveiled a unique and important adverse event that should be considered before a patient receives CTFESI.

Safety of fluoroscopically guided pain procedures in patients receiving cytotoxic chemotherapy: a retrospective analysis

PURPOSE

To examine the incidence of bleeding and infectious adverse events (AEs) in patients undergoing interventional, fluoroscopic-guided axial spine procedures to modulate pain.

METHODS

Retrospective data of patients undergoing fluoroscopically guided axial spine injections at a single tertiary care medical center Cancer Rehabilitation program in the USA were reviewed. AEs, type of chemotherapy, type of tumor, age, platelet and absolute neutrophil counts (ANC) prior to the procedure, and relevant past medical history were collected. Descriptive statistical analyses were performed.

RESULTS

Sixty-three separately identifiable procedures across 28 patients met inclusion criteria. Zero AEs were recorded. Platelet and ANC were generally above the recommended safety threshold, but granulocyte colony stimulating factor was administered prior to four procedures to boost ANC levels. Multiple myeloma was the most common cancer diagnosis (64.3%). Various solid tumors made up the remaining cancer diagnoses. Epidural steroid injections (n=23) and medial branch blocks (n=23) were the most common procedures performed and lumbar (n=35) was the most common location of procedures. Three patients died within 30 days of the procedures but their deaths were not directly attributable to the injections.

CONCLUSION

This provides preliminary data to support the safety of injections in patients receiving cytotoxic chemotherapy. Larger, multicenter studies are required before firm conclusions can be drawn.

Mania Induced by Epidural Steroid Injection in an Elderly Female With No Psychiatric History

The psychiatric risks of epidural steroid injections for chronic pain in a geriatric patient with no prior psychiatric history are presented here. A 76-year old Caucasian female presented to the emergency department with her family for an inability to sleep, confusion, and behavioral outbursts. The mood instability and psychosis were reported as having started a week after her third epidural steroid injection for low-back pain associated with a prior fall. After 12 days of mixed treatment outcomes and increasing paranoia without any localized neurological findings, the patient was transferred to the geriatric psychiatry unit. Upon admission to the inpatient unit, she was loud, grandiose, verbally aggressive, unable to sleep, hyper-religious, paranoid, and identified her husband and daughter as demons. The patient was started on risperidone and valproic acid for the management of psychosis and manic symptoms. Hyper-religiosity and paranoia greatly improved within a week, though the patient remained very talkative and tangential, with a disorganized thought process. Valproic acid was titrated to 500 mg twice a day, yielding a level of 56.2 ug/ml, accompanied by improvement to mild talkativeness and circumstantiality. She was able to interact appropriately, with minimal lorazepam requirement, and discharged with a linear thought process and absence of psychosis. On outpatient follow up, there were minimal residual mania and no recurrence of psychosis, allowing her to be weaned off valproic acid and to discontinue risperidone. Two months later, symptoms resolved completely. The persistence of this patient’s psychosis for nearly one month, and mania for about three months, underscores the importance of careful risk-benefit analysis before initiating epidural steroids. This is particularly important in elderly patients who may be more susceptible to psychiatric adverse effects that can outlast any analgesic benefits.

Cervical epidural steroid injections: incidence and determinants of subsequent surgery

BACKGROUND CONTEXT

Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.

PURPOSE

This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery.

STUDY DESIGN

Retrospective analysis of a large, national administrative claims database.

PATIENT SAMPLE

The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.

OUTCOME MEASURES

The primary outcome was the time from index CESI to surgery.

METHODS

Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.

RESULTS

Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.

CONCLUSIONS

Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

Infection Risk of Lumbar Epidural Injection in the Operating Theatre Prior to Lumbar Fusion Surgery

Purpose

To determine the association between preoperative lumbar epidural injections (LEIs) in the operating theater (OR) and the occurrence of surgical site infection (SSI) after posterior lumbar instrumented fusion surgery.

Methods

This study was performed from January 2015 to September 2019. We enrolled 2312 patients who underwent lumbar surgery without LEIs (control group) and 469 patients who underwent lumbar surgery after LEIs in the OR. We further separated the patients by the time interval between the LEIs and surgery: 1) for the 0–1 M group, lumbar surgery was performed within 1 month after the LEIs, and 2) for the >1 M group, it was performed more than 1 month after the LEIs.

Results

The postoperative infection rate in the 0–1 M group was considerably higher than that in the control group (p = 0.0101). We further subdivided the 0–1 M and >1 M groups into four subgroups: a) the 0–1 MNS group included patients in the 0–1 M group who did not receive steroids; b) the 0–1 MS group who received steroids; c) the >1 MNS group included patients in the >1 M group who did not receive steroids; d) the >1 MS group who received steroids. The postoperative infection rate in the 0–1 MS subgroup was considerably higher than that in the control group (p = 0.0018). However, the infection rate was lower in the >1 MS subgroup (p = 0.1650). There were no statistically significant differences in the postoperative infection rate between the control group and the two non-steroid groups (0–1 MNS group, p = 0.4961; 1 MNS group, p = 0.7381).

Conclusion

The administration of LEIs without steroids in the OR before lumbar instrumented fusion does not significantly increase patients’ risk of postoperative infection. We recommend avoiding steroid injections administered within 1 month before lumbar instrumented fusion.

Segmental Spinal Myoclonus After a Cervical Transforaminal Epidural Steroid Injection

In clinical practice, cervical transforaminal epidural steroid injection is commonly used for alleviating pain. We report a case of segmental spinal myoclonus that developed after cervical transforaminal local anesthetic and steroid injection. A 39-yr-old man presented involuntary movements of the bilateral upper trapezius muscles after cervical transforaminal epidural steroid injection on the right C6 and C7 roots with a 5 mg of dexamethasone injectate mixed with 0.5 ml of 1% lidocaine and 0.5 ml of normal saline at each level. His myoclonus was semirhythmic and continuously persisted at a frequency of approximately 30 episodes per minute. The myoclonus continued even at rest and during sleep. In addition, it was resistive to stimulus, such as touch and voluntary action. Based on the clinical features, the patient was diagnosed as having a segmental spinal myoclonus. Clonazepam 0.25 mg was administered three times daily. The myoclonus gradually improved and resolved completely within 2 wks. Segmental spinal myoclonus is one of rare complications after cervical transforaminal epidural steroid injection. Clinicians should be aware of the likelihood of this potential complication.

Anesthesia and Chronic Pain Management

The reasons for development of chronic pain are poorly understood. Chronic postoperative pain is linked to severe acute postoperative pain. Head and neck pain is often a complex phenomenon that requires meticulous diagnosis and treatment. Institution of early multimodal analgesic regimens by multidisciplinary teams may attenuate chronic pain formation and propagation in the otolaryngologic patient.

Cross-sectional CT Assessment of the Extent of Injectate Spread at CT Fluoroscopy-guided Cervical Epidural Interlaminar Steroid Injections

Background Previous studies analyzed contrast agent spread during cervical interlaminar epidural steroid injections (CILESIs) by using planar fluoroscopy and reported wide variance of the rate of spread to the ventral epidural space (VES). Cross-sectional CT allows for direct viewing of contrast agent in the VES, providing improved spread assessment and thereby informing needle placement decisions when targeting pain generators. Purpose To determine the extent of injectate spread at CT fluoroscopy-guided CILESI, with particular attention to the VES and bilateral neuroforamina, by using cross-sectional CT. Materials and Methods This study reviewed 83 consecutive CT fluoroscopy-guided CILESIs at which a postprocedural cervical spine CT was performed (June 2016 to December 2017). All procedures used the same injectate (2 mL corticosteroid, 3 mL contrast agent). Postprocedural CT scans were reviewed for the presence of contrast within the VES, dorsal epidural space, ipsilateral neuroforamen, and contralateral neuroforamen in every cervical interlaminar level. Descriptive data are presented as frequencies or means. McNemar tests or hierarchical logistic models were used to assess associations between covariates and contrast agent spread to particular locations. Results The study cohort included 73 individual patients (59% women; 43 of 73) (mean patient age, 57.6 years ± 11.5 [standard deviation]). Mean number of levels of cranial spread were 0.6 level for VES, 1.9 levels for contralateral neuroforamen, 2.1 levels for ipsilateral neuroforamen, and 3 levels for dorsal epidural space. No VES spread in any level was found with 35% (29 of 83) of injections. VES spread was more likely to occur in the level of needle placement (43%; 36 of 83) than in other interlaminar levels (19.5%; 97 of 498; P < .001). Spread was more likely to occur in the neuroforamen ipsilateral to the needle approach compared with contralateral (P < .001). Conclusion Cervical interlaminar epidural steroid injections have injectate spreads with a mean of less than one level cranially in the ventral epidural space (VES) and approximately two levels in the neuroforamen. VES spread occurs more frequently at the level of needle placement and within the ipsilateral neuroforamen. © RSNA, 2019.

The effectiveness of ultrasound-guided cervical transforaminal epidural steroid injections in cervical radiculopathy: a prospective pilot study

Background

Cervical transforaminal epidural steroid injection (CTFESI) is used to provide pain relief and restore function in patients with cervical radiculopathy. Traditionally, it is performed under the guidance of fluoroscopy or computed tomography. Here, we introduce a novel technique - ultrasound-guided CTFESI - with which operators can easily distinguish the close soft tissue (nerve, vessels) around the cervical foramina to avoid intravascular injection during the procedure.

Objective

To present the immediate and long-term effectiveness of ultrasound-guided CTFESI in patients with cervical radiculopathy in an academic pain-management center with prospective clinic experiments.

Methods

Fifteen patients with cervical radiculopathy who were resistant to conservative therapies and ultrasound-guided selective cervical spinal nerve-root injections, were treated with ultrasound-guided CTFESI. During the injection procedures, the needle tips were reconfirmed by real-time fluoroscopy. Pain numeric rating-scale and neck-disability-index scores were assessed from onset to six months after the procedures.

Results

During the procedures, based on real-time fluoroscopic confirmation, the injection solution outlined the spinal nerve root and spread into the epidural space in most cases (14 of 15). All patients reported pain relief within 10 minutes after the injection. The majority of patients (eleven of 15) experienced pain relief and neck-disability index-score improvement throughout the 6-month study period. No patient experienced any complication.

Conclusion

We suggest that ultrasound-guided CTFESI is an effective, safe, and simple procedure free of radiation or magnetization and provides sustained pain relief in patients with cervical radiculopathy who have failed previous conservation therapies.

Needle Entry Angle to Prevent Carotid Sheath Injury for Fluoroscopy-Guided Cervical Transforaminal Epidural Steroid Injection

OBJECTIVE

To suggest rotation angles of fluoroscopy that can bypass the carotid sheath according to vertebral levels for cervical transforaminal epidural steroid injection (TFESI).

METHODS

Patients who underwent cervical spine magnetic resonance imaging (MRI) from January 2009 to October 2017 were analyzed. In axial sections of cervical spine MRI, three angles to the vertical line (α, angle not to insult carotid sheath; β, angle for the conventional TFESI; γ, angle not to penetrate carotid artery) were measured.

RESULTS

Alpha (α) angles tended to increase for upper cervical levels (53.3° in C6-7, 65.2° in C5-6, 75.3° in C4-5, 82.3° in C3-4). Beta (β) angles for conventional TFESI showed a constant value of 45° to 47° (47.5° in C6-7, 47.4° in C5-6, 45.7° in C4-5, 45.0° in C3-4). Gamma (γ) angles increased at higher cervical levels as did α angles (25.2° in C6-7, 33.6° in C5-6, 43.0° in C4-5, 56.2° in C3-4).

CONCLUSION

The risk of causing injury by penetrating major vessels in the carotid sheath tends to increase at upper cervical levels. Therefore, prior to cervical TFESI, measuring the angle is necessary to avoid carotid vessels in the axial section of CT or MRI, thus contributing to a safer procedure.

Major risks and complications of cervical epidural steroid injections: An updated review

Background

Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications.

Methods

Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.

Results

Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature.

Conclusions

Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.