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

The Use of Digital Hand Sympathectomies for the Treatment of Ischemia and Pain Following Inadvertent Corticosteroid Injection of the Radial Artery: Two Case Reports

Osteoarthritis of the carpometacarpal (CMC) joint of the thumb is commonly treated with intraarticular corticosteroid injections in clinic. In this case report, we present 2 patients who experienced immediate pain, pallor, and discoloration of their fingers distal to the site of attempted injection of the CMC joint of the thumb. It is believed that this occurred due to inadvertent injection of the dorsal branch of the radial artery as it branches to join both the superficial and deep palmar arches. This caused vasospasm and vasoocclusion leading to subsequent ischemia. To relieve symptomatic pain and prevent ischemic necrosis, both patients underwent sympathectomies of the radial and ulnar arteries and of the common palmar digital arteries. Both patients experienced relief of their pain and reperfusion of their hand and digits.

KECORT Study: An International e-Delphi Study on the Treatment of KEloids Using Intralesional CORTicosteroids in Clinical Practice

BACKGROUND

Intralesional corticosteroid administration (ICA) is a first-line keloid treatment. However, it faces significant variability in current clinical and scientific practice, which hinders comparability of treatment results.

OBJECTIVES

The aim of the study was to reach consensus on different aspects of ICA using hypodermic needles in keloids among an international group of dermatologists and plastic surgeons specialized in keloid treatment to provide consensus-based clinical treatment recommendations for all physicians treating keloids.

METHODS

The keloid expert panel of 12 dermatologists and 11 plastic surgeons rated 30 statements. Two online e-Delphi rounds were held, both with a response rate of 100%. Fifteen (65%) keloid experts participated in the final consensus meetings. Consensus was defined as ≥ 75% of the participants choosing agree or strongly agree on a 7-point Likert scale.

RESULTS

Consensus was reached on treatment goals, indication for ICA, triamcinolone acetonide (TAC) 40 mg/mL as the preferred corticosteroid administered at a maximum of 80 mg per month and at intervals of 4 weeks, minimizing pain during ICA, the use of 1 mL syringes and 25 or 27 Gauge needles, blanching as endpoint of successful infiltration, caution of not injecting subcutaneously, and the option of making multiple passes in very firm keloids prior to infiltration. Consensus could not be reached on TAC dosing, methods of prior local anesthesia, and location of injection.

CONCLUSIONS

This e-Delphi study provides important clinical treatment recommendations on essential aspects of ICA in keloids. By implementing these recommendations, uniformity of ICA in keloid treatment will increase and better treatment results may be achieved.

Comparative analysis of contrast distribution in cervical epidural steroid injections utilizing a modified paramedian interlaminar approach with varied needle tip positions: A randomized controlled trial

BACKGROUND

Recent advancements in cervical interlaminar epidural steroid injections have given rise to the modified paramedian interlaminar (mPIL) approach. The objective of this study was to perform an analysis of the contrast spread pattern within the cervical epidural space, taking into account different needle tip positions in the mPIL approach.

METHODS

A total of 48 patients were included in the study and randomly assigned to either the medial or lateral group based on the needle tip's position in the anterior-posterior view. The primary outcome measured was the contrast flow under fluoroscopic visualization. As a secondary outcome, we analyzed the location of the needle tip position in both lateral and contralateral oblique views. Clinical effectiveness was assessed by measuring pain intensity and functional disability post-procedure.

RESULTS

Significant disparities were noted in the ventral distribution of contrast between the medial and lateral groups. In the lateral images, needle tips in the lateral group were positioned more ventrally compared to those in the medial group. Both groups exhibited statistically significant improvements in neck and radicular pain, as well as functional status, 4 weeks after treatment, with no significant differences between them.

CONCLUSIONS

Our results suggest that the ventral dispersion of contrast material during cervical interlaminar epidural steroid injections using the mPIL approach may vary depending on the needle tip location.

Patient-Centric Long-Acting Injectable and Implantable Platforms─An Industrial Perspective

The increasing focus on patient centricity in the pharmaceutical industry over the past decade and the changing healthcare landscape, driven by factors such as increased access to information, social media, and evolving patient demands, has necessitated a shift toward greater connectivity and understanding of patients' unique treatment needs. One pharmaceutical technology that has supported these efforts is long acting injectables (LAIs), which lower the administration frequency for the patient's provided convenience, better compliance, and hence better therapeutical treatment for the patients. Furthermore, patients with conditions like the human immunodeficiency virus and schizophrenia have positively expressed the desire for less frequent dosing, such as that obtained through LAI formulations. In this work, a comprehensive analysis of marketed LAIs across therapeutic classes and technologies is conducted. The analysis demonstrated an increasing number of new LAIs being brought to the market, recently most as aqueous suspensions and one as a solution, but many other technology platforms were applied as well, in particular, polymeric microspheres and in situ forming gels. The analysis across the technologies provided an insight into to the physicochemical properties the compounds had per technology class as well as knowledge of the excipients typically used within the individual formulation technology. The principle behind the formulation technologies was discussed with respect to the release mechanism, manufacturing approaches, and the possibility of defining predictive in vitro release methods to obtain in vitro in vivo correlations with an industrial angle. The gaps in the field are still numerous, including better systematic formulation and manufacturing investigations to get a better understanding of potential innovations, but also development of new polymers could facilitate the development of additional compounds. The biggest and most important gaps, however, seem to be the development of predictive in vitro dissolution methods utilizing pharmacopoeia described equipment to enable their use for product development and later in the product cycle for quality-based purposes.

Selective ultrasound-guided nerve root block improves outcomes for discectomy in patients with cervical disc disease: a randomized, controlled, single-blinded study

BACKGROUND

We hypothesized that ultrasound-guided selective nerve root block could play a role in the prediction of clinical outcomes in patients with multilevel cervical disease following selective anterior cervical discectomy and fusion.

METHODS

Patients were randomized to receive ultrasound-guided selected nerve root block as a diagnostic tool (study group) or not (control group), but both groups had surgery. Pain evaluation for arm and neck pain was recorded. The Visual Analog Scale (VAS) pain scores, Neck Disability Index, and MRI results were compared between groups. They were assessed every two weeks for three months, postoperatively. The percentage of patients who showed ≥ 50% reduction in their pain levels and a VAS rating of ≤2 was deemed an acceptable surgical outcome.

RESULTS

Patients in the study group had significantly lower VAS scores for pain intensity than control patients at nearly all periods. This baseline pain improved significantly in the study group. A more significant proportion of patients in the study group showed a ≥50% reduction in their pain scores from baseline at weeks four, eight, and 12, and this difference was significantly lower than in the control group (P<0.05). The study group improved significantly over baseline in Neck Disability Index scores compared to control patients. Patients were highly satisfied with no significant adverse events in the study group.

CONCLUSIONS

In patients with multilevel cervical disease, ultrasound-guided selective nerve root block is an excellent, safe, non-radiating, and reliable test to determine the appropriate level for operation.

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.

Functional Outcomes of Fluoroscopy-Guided Intra-articular Steroids in Lumbar Facet Arthropathy: A Retrospective Comparative Study of Dexamethasone Versus Triamcinolone Acetonide

Introduction  Mechanical low back pain frequently originates from the lumbar facet joint (LFJ). Axial low back discomfort can result from osteoarthritis in the LFJ. Depending on the severity of LFJ degeneration, the effect of intra-articular (IA) LFJ corticosteroid injection may vary. For LFJ discomfort, IA block with steroids and local anaesthetics has also been utilised, with varying degrees of success. The main objective of this study was to assess the efficacy of IA steroid injections dexamethasone vs. triamcinolone acetonide for the treatment of LFJ syndrome and to compare functional outcome in terms of Visual Analog Scale (VAS) score, Modified Oswestry Disability Index (MODI) score, and short-form McGill Pain Questionnaire between the two groups. Methodology Dexamethasone 8 mg or triamcinolone acetonide 40 mg was given intra-articularly to 27 patients comprising group A and 33 patients comprising group B, respectively (total 60 patients). Before intervention and at one, three, and six months, observation was conducted using the VAS score, short-form McGill pain questionnaire, and MODI score. Results There was a significant difference between both the groups after the procedure with pain alleviation and functional improvement, more in the group that received triamcinolone acetonide. A significant difference was observed in all three parameters that assessed pain with differences more pronounced at six months. Conclusion Pain reduction and clinical outcomes were better among the group that received triamcinolone acetonide. Injection of a steroid alone is associated with its own side effects. When a lumbar transforaminal epidural injection is used to treat radiculopathy in the lumbar area, particulate medication (triamcinolone) is more effective than non-particulate medication (dexamethasone) with no known drug-related complications.

Intralesional corticosteroid administration in the treatment of keloids: a survey among Dutch dermatologists and plastic surgeons

BACKGROUND

Intralesional corticosteroid administration (ICA) is a first-line therapy in keloid treatment. However, its clinical results are still highly variable and often suboptimal. Treatment results may strongly be influenced by various ways of ICA.

OBJECTIVE

To explore the prevailing practice of ICA in keloid treatment among dermatologists and plastic surgeons in the Netherlands.

METHODS

The survey was constructed based on a scoping review on ICA in keloid treatment. Members of the Dutch Society for Plastic surgery and the Dutch Society for Dermatology and Venereology were asked to participate.

RESULTS

One hundred and thirty-six responses were obtained. One hundred and thirty (95.6%) participants used triamcinolone acetonide. The majority (54.7%) did not use local anesthesia for pain reduction. Reported corticosteroid dosing that one would inject in one specific keloid differed by a factor of 40. Treatment intervals varied from 1 week to more than 8 weeks. The keloid center was most often injected (46.9%), followed by subepidermal (18.0%).

CONCLUSIONS

A wide variety in ICA for keloids is noted among dermatologists and plastic surgeons, even in a limited geographic region and when evidence points toward an optimal way of treatment. Future studies and better implementation of existing evidence may reduce variation in ICA and optimize its treatment results.

Intra-arterial injection of particulate corticosteroids: mechanism of injury

Mechanism of neurologic complications after epidural spinal injections (ESI) of particulate steroids at the cervical spine include intrathecal injection, epidural hematoma, direct spinal cord injury, and brain stem or cord infarction due to an arterial spasm or inadvertent intra-arterial injection of particulate steroids. At the lumbar spine, there is evidence that a spinal cord infarction secondary to an inadvertent intra-arterial injection of particulate steroids through a transforaminal approach is the leading mechanism.Variations in the arterial supply of the spinal cord help to understand how a lumbar ESI may lead to a spinal cord infarction at the thoracic level. A radiculomedullary artery arising from the lumbar or sacral spine may participate to the supply of the spinal cord. All radicular and radiculomedullary arteries penetrate the spinal canal through the intervertebral foramen. Therefore, its catheterization carries a risk of inadvertent intraarterial injection. An ex vivo animal study has shown that particulate steroids injected in the blood stream produce an immediate and unexpected change of red blood cells into spiculated cells which aggregate and cause arterioles obstruction, while no particulate steroid macroaggregates or vascular spasm were observed. Rare instances of neurologic complications also occurred after ESI performed through a posterior approach. All occurred in previously operated on patients suggesting a pathologic role for the epidural scar.

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.

Flushing After Lumbar Epidural Steroid Injection with Dexamethasone

PURPOSE OF REVIEW

Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%).

RECENT FINDINGS

There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.

Ultrasound-guided injection technique of the equine cervical nerve roots

Radiculopathy in horses is often a diagnosis of exclusion because of the non-specific clinical signs related to neck pain and possible forelimb lameness. There are no reported treatment options in the equine veterinary literature. The purpose of the study was to describe an ultrasound-guided injection of the cervical nerve root C3 to C8, to evaluate accuracy, time and safety and to anticipate possible complications on clinical cases. Under general anesthesia and with ultrasound guidance, five horses were injected from C3 to C8 with 1.5mL mix of contrast and latex. Immediately after euthanasia, the necks were taken for CT examination and then dissection was performed 3 days later. Data regarding the accuracy of injection, the presence of injectate in the nerve root, vertebral vessel or vertebral canal were recorded from both CT and dissection. The time of injection and ability to visualize the nerve root prior to injection were also recorded. Out of 60 intended injections, 55 (CT images) and 57 (dissection) led to injectate deposited within the target zone with direct contact between contrast/latex and cervical nerve roots noted in 76.4% and 73.7%, respectively. Presence of contrast/latex injectate within nerves (≤11%), vertebral vessels (<4%) and canal (<4%) were rarely encountered. No variation on success rate or safety noted based on the site of injection. The technique described has excellent accuracy, with injectate deposition in direct contact (≈75%) or close vicinity (≈25%) of C3-C8 cervical nerve roots. Injectate diffusion is likely to further improve success rate. Rare presence of injectate within nerve/sheath, vertebral vessels/canal along with diffusion warrants caution when performing this procedure in clinical cases.

Ultrasound-guided cervical selective nerve block: A case series

BACKGROUND

Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective.

OBJECTIVE

This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG).

METHODS

We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications.

RESULTS

We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6.

CONCLUSION

SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

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.

American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement

The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.

Safety and Efficacy of CT-Guided Pulsed Radiofrequency Combined with Steroid and Ozone Injection-Treated Cervical 3-8 Herpes Zoster Neuralgia Using a Posterior and Upper Quarter of the Cervical Foramina Puncture Approach

Background

Herpes zoster neuralgia has a considerable impact on people’s quality of life, especially after the development of postherpetic neuralgia. There are many clinical reports on the treatment of herpes zoster neuralgia, but there have been no special reports on the treatment of herpes zoster involving the neck. Our research focuses on a posterior and upper quarter of the cervical foramina puncture approach for herpes zoster involving the cervical 3–8 (C3-8) nerve region and to consider the safety and efficacy of pulsed radiofrequency combined with steroid injection and ozone injection in this puncture path under CT guidance.

Materials and Methods

A total of 104 patients with herpes zoster neuralgia involved in the cervical 3–8 nerve region use a posterior and upper quarter of the cervical foramina puncture approach received pulsed radiofrequency combined with steroid and ozone injection to the dorsal root ganglion. The total number of injection procedures, complications, NRS collection (preprocedure, postprocedure at once, two, four and 12 weeks) and drug dose decreases were documented.

Results

During a total of 257 procedures, 254 procedures successfully completed PRF (3 cases failed to reach the C8 aim points), and the rate of puncture failure was 1.17%. Drug injection was successfully performed in 252 procedures (the injection success rate was 99.21%); the NRSs (preprocedure, postprocedure at once, two, four and twelve weeks) were 5.75 ± 0.682, 2.6 ± 1.023, 2.21 ± 0.925, 1.89 ± 1.162, and 1.43 ± 1.369, and the difference among them was statistically significant. Drug dosages decreased before and after operation and showed statistically significant differences.

Conclusion

Pulsed radiofrequency combined with steroid and ozone injection for herpes zoster neuralgia involving the C3-8 nerves under CT guidance through a posterior superior quarter approach showed safety and efficacy and had a high success rate, and the NRS decreased significantly.

Effect of lumbar epidural steroid injection on neuropathic pain: a prospective observational study

Background

Low back pain (LBP) is caused by disc herniation, spinal stenosis, facet syndrome or etc. This LBP could be either nociceptive or neuropathic pain (NP). In addition, these neuropathic pain is a major contributor to chronic low back pain. It is already known that lumbar epidural steroid injection (ESI) is effective for low back pain, but no study has assessed both nociceptive and neuropathic pain separately. This study investigated whether neuropathic or nociceptive pain was better improved after an epidural steroid injection.

Methods

This was a prospective study. Patients were classified according to the pre-procedure painDETECT questionnaire (PD-Q) score. If the PD-Q score was ≤12, it was considered as nociceptive pain, and it the PD-Q was ≥19, it was considered NP. The patients were given a transforaminal (TF) or interlaminar (IL) epidural steroid injection (ESI). The PD-Q was filled out by each patient prior to the ESI (baseline), and again at 4 weeks after the ESI. Outcomes was assessed using a numerical rating scale (NRS) score, short form McGill Pain Questionnaire (MPQ), and revised Oswestry Back Disability Index (ODI) at 1 month later.

Results

A total of 114 patients were enrolled and of these, 54 patients with a PD-Q score of ≤12 were classified into the nociceptive pain, and 60 patients with a PD-Q score ≥19 were classified into the neuropathic pain group. At 1 month after treatment, both groups had significantly lower than improved their mean NRS score. Not withstanding these improvements and difference between NRS, the differences in MPQ and ODI after treatment between the groups (nociceptive vs. neuropathic) not significant. After the procedure (TF-ESI or IL-ESI), the patients in group 1 (PD-Q score ≤12, n = 54) had no change in their PD-Q score. Among the patients in group 2 (pre-treatment PD-Q score ≥19, n = 41), 13 patients moved to a PD-Q score <12 and 15 patients had a PD-Q score of 13–18.

Conclusion

For the short-term relief of neuropathic pain, ESI was effective for both nociceptive and neuropathic pain, therefore ESI could be treat the try neuropathic pain component in patients with low back pain.

A Case of Steroid-Associated Expressive Aphasia

Expressive aphasia (non-fluent aphasia) is characterized by the inability to produce words or sentences. The most common cause of expressive aphasia is stroke, usually due to thrombus or emboli in the middle cerebellar artery or internal carotid artery affecting Broca’s area. We present an important, reversible, and previously undescribed cause of a purely expressive aphasia secondary to steroid use. A case of a steroid-induced expressive aphasia has not yet been described in the medical literature. Recognition of this presentation is critical to appropriate therapy and excess morbidity, particularly as steroid (dexamethasone) utilization has increased since the COVID-19 pandemic.

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.

Vision Loss Secondary to Facial and Periorbital Steroid Injection: A Systematic Review

PURPOSE

The risk of ophthalmic and retinal artery occlusions following facial and periorbital steroid injection has not been explored. This systematic review examines the prevalence, risk factors, and treatment outcomes of steroid-induced vision losses.

METHODS

A literature search in Evidence Based Medicine Reviews, MEDLINE, Embase, Pubmed, ClinicalTrials, and WHO ICTRP was performed for vision loss following facial and periorbital corticosteroid injections through July 2020.

RESULTS

Of 35 case reports, series, and reviews, 49 patients (56 eyes) with steroid-induced vision loss were analyzed. Injection sites predominantly involved the nose (45%) and periocular regions (10%). The most common type of steroid is triamcinolone (54%). Most cases were unilateral, except 7 cases of bilateral vision losses, 4 of which resulted from unilateral steroid injection. Symptoms were reported during or immediately after injections in 49% of cases. Most occlusions occurred in the ophthalmic (53%) or central retinal artery (33%). Vision most commonly presented as no light perception (37%), and 90% were 20/200 or worse. Final visual outcomes varied from 20/200 or worse (56%), 20/40 or better (30%), to in between (13%).

CONCLUSION

Most vision losses resulted from steroid injections in the nasal and periorbital area. Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation. Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.

Image-guided spinal injection for pain management

Radiculopathy and spinal pain are debilitating conditions affecting millions of people worldwide each year. While most cases can be managed conservatively with physiotherapy and nonsteroidal anti-inflammatory medications, minimally invasive corticosteroid injections are the mainstay intervention for those not responsive to conservative treatment. Historically, spinal injections were performed in the absence of imaging guidance; however, imaging modalities, in particular fluoroscopy and computer tomography (CT), have become the standard of care in performing most of these procedures. Under imaging guidance, operators can accurately confirm needle placement and safely target localised pathologies.

Parasagittal Approach of Epidural Steroid Injection as a Treatment for Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Background: Epidural steroid injection (ESI) has proven benefits in controlling chronic low back pain and can be performed via the midline interlaminar (MIL) or transforaminal (TF) approach. A modified interlaminar approach, the parasagittal interlaminar (PIL), has surfaced as a more reliable, safe, and suitable approach to minimize complications related to MIL and TF. Objective: To conduct a systematic review and meta-analysis to assess and compare the effectiveness and safety of PIL with both MIL and TF approaches in adult patients with a history of chronic low back pain. Methods: A literature search was conducted using major electronic databases, such as PubMed, EMBASE, and Cochrane. Selected studies included patients with unilateral radicular symptoms, secondary to lumbar intervertebral disc hernias or degenerative lumbar disc disease, that, additionally, received ESIs via PIL or either MIL or TF under fluoroscopic guidance. Randomized and observational studies with pain relief score and/or functional disability assessment and at least a 2-week follow-up were included. Results: The search led to the initial identification of 174 studies. Following the screening, eight studies were included in the qualitative analysis and seven randomized controlled trials (RCTs) were included in the statistical analysis. PIL showed statistically significantly more pain relief and functional improvement than MIL at 1-, 3-, and 6-month post-procedure. Compared to TF, PIL showed statistically significantly more pain relief at 3- and 6-month after the procedure. Additionally, PIL showed benefits in terms of lower mean fluoroscopy time, less radiation exposure, zero adverse events in all the included studies, no cases of intravascular spread compared with the TF approach, and a higher anterior epidural spread (AES) of PIL compared with TF. Conclusions: Our systematic review and meta-analysis suggest that the PIL approach is an effective and safe alternative to the MIL and TF approaches in patients presenting with chronic low back pain when epidural injections are indicated, demonstrating a higher level of pain relief and a stronger improvement in functionality post-procedure.

Non-Particulate Steroids (Betamethasone Sodium Phosphate, Dexamethasone Sodium Phosphate, and Dexamethasone Palmitate) Combined with Local Anesthetics (Ropivacaine, Levobupivacaine, Bupivacaine, and Lidocaine): A Potentially Unsafe Mixture

Purpose

Particulate steroids used in epidural steroid injections have been suspected as a cause of post-procedural embolic events. Some particulate steroids have been suspended only when the transforaminal approach is used for an epidural block of the spine. In contrast, non-particulate steroids are generally accepted for safety during epidural steroid injections. However, the safety of using a mixture of non-particulate steroids and local anesthetics is unknown. This study analyzed whether mixtures of commonly used non-particulate steroids and local anesthetics form crystals in solution.

Methods

We mixed non-particulate steroids (betamethasone sodium phosphate, dexamethasone sodium phosphate, and dexamethasone palmitate) and local anesthetics (ropivacaine, levobupivacaine, bupivacaine, and lidocaine) at different ratios. We used fluorescence microscopy to observe whether crystals formed in mixed solutions; we also measured the pH of each steroid, local anesthetic, and the mixtures.

Results

Ropivacaine or levobupivacaine and betamethasone sodium phosphate produced large crystals (>50 µm). Ropivacaine or levobupivacaine and dexamethasone sodium phosphate produced small crystals (<10 µm). Lidocaine and all non-particulate steroids produced no identifiable crystals; dexamethasone palmitate and all local anesthetics did not form significant particulates. Betamethasone sodium phosphate and dexamethasone sodium phosphate demonstrated basic pH, while all local anesthetics demonstrated acidic pH. Mixtures showed a wide pH range.

Conclusion

Non-particulate steroids can form crystals upon combination with local anesthetics. Crystal formation may be caused by alkalinization of steroids. The mixing of ropivacaine or levobupivacaine and betamethasone sodium phosphate may require caution during an epidural steroid injection. Lidocaine or bupivacaine is recommended as a local anesthetic. Dexamethasone palmitate is a candidate for a mixture, but additional studies on its safety and effectiveness are needed.

Contrast flow patterns based on needle tip position during cervical transforaminal epidural injections

BACKGROUND

Few studies have evaluated the effect of final needle position on contrast flow patterns during the performance of cervical transforaminal epidural steroid injections (TFESIs).

OBJECTIVE

To analyze fluoroscopically guided cervical TFESI contrast flow patterns based upon final needle tip position.

DESIGN

Retrospective, observational in vivo study.

SETTING

Outpatient private practice physical medicine and rehabilitation spine clinic.

PARTICIPANTS

One hundred consecutive patients undergoing cervical TFESIs.

INTERVENTIONS

Cervical TFESIs.

MAIN OUTCOME MEASURES

Categories of contrast flow patterns including epidural, intraforaminal, "sufficient to inject," and "predominantly epidural and/or intraforaminal," based upon final needle tip position.

RESULTS

Two independent observers reviewed images from 100 consecutive patients and classified injectate flow patterns stratified by needle tip position. The interrater reliability for all categories of interest was moderate, with kappa values from 0.61 to 0.76. More medially placed needles (middle third and lateral third of the articular pillars) resulted in higher rates of epidural contrast flow (75%; 95% confidence interval [CI]: 56%-94%; and 60%; 95% CI: 47%-73%) compared to needles placed lateral to the articular pillars (26%; 95% CI: 8%-44%), and higher rates of "predominantly epidural and/or intraforaminal" flow patterns with needles placed in the middle one third (75%; 95% CI: 56%-94%) and lateral one third of the articular pillars (47%; 95% CI: 34%-60%) compared to flow patterns when needles were placed lateral to the articular pillars (17%; 95% CI: 2%-32%). No needles were placed in the medial third of the articular pillars.

CONCLUSIONS

More medially placed needle tips result in more optimal flow patterns during cervical TFESIs. The importance of this finding is unknown as clinical outcomes were not measured.

Differential rates of intravascular uptake and pain perception during lumbosacral epidural injection among adults using a 22-gauge needle versus 25-gauge needle: a randomized clinical trial

Background

Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception.

Methods

This was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study – 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale.

Results

Fisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375].

Conclusions

The study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections.

Trial registration

ClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered).

Pathogenic Mechanisms of a Stroke-like attack Elicited by Epidural Steroid Injection Therapy

BACKGROUND

The pathogenic mechanisms involved in a disastrous scenario, following epidural steroid injections (ESI), remain unclarified. Intra-arterial injection of steroids with needlepenetrating vascular injury would be the culprit, as particulate medicine elicits a brain or spinal cord stroke-like attack.

METHODS

On the other hand, the limited experimental approaches simulating an accidental steroid intra-arterial injection for ESI conflicted in their results: hemorrhage vs. ischemia.

RESULTS

This article dissects the potential pathogenic mechanisms at a neurovascular unit. Noticeably, a schematic representation provides an explanation of how emboli formed by particulate steroids elicit either hemorrhagic, or ischemic lesion.

CONCLUSION

In addition, the development of a rat model with intravertebral artery steroid injection is a proposal to address the unmet need in evaluating steroids and vascular injury in ESI.

Incidence of Extravascular Perivertebral Artery Contrast Flow During Cervical Transforaminal Epidural Injections

Background

During a cervical transforaminal epidural injection, injectate flows along the path of least resistance. Given the proximity of the vertebral artery to the intervertebral foramen, injected contrast may flow along the external wall of the artery. The incidence of this contrast flow pattern during cervical transforaminal epidural injections is unknown.

Purpose

To determine the incidence of extravascular perivertebral artery contrast flow patterns during cervical transforaminal epidural injections.

Study Design/Setting

Retrospective, observational, in vivo study.

Patient Sample

Patients receiving cervical transforaminal epidural injections at a single outpatient spine clinic.

Outcome Measures

The presence or absence of extravascular perivertebral artery contrast flow.

Methods

The saved images from 100 consecutive patients were reviewed by two independent observers and classified with or without extravascular perivertebral artery contrast flow. The incidence was determined and kappa was used to examine inter-rater reliability. All disagreements were reviewed, and the final classification was determined by consensus.

Results

The inter-rater reliability was moderate, with a kappa value of 0.69. The incidence of extravascular perivertebral artery contrast flow patterns was 49% by consensus. No statistically significant differences in incidence were present when comparing three different final needle tip positions.

Conclusions

During a cervical transforaminal epidural injection, an extravascular perivertebral artery contrast flow pattern is frequently encountered. This includes flow along the exiting nerve and then around the vertebral artery, as suggested by this study. Although this contrast pattern does not represent an intravascular injection into the vertebral artery, practitioners should remain cautious to exclude intravascular needle placement before injecting medication.

Ischemia of the fingers after carpal tunnel syndrome treatment

We present a case in which a depot triamcinolone acetonide (Kenacort) was unintentionally injected intra-arterially into the ulnar artery, resulting in microembolic capillary occlusion in the digits supplied by the artery. Ischemic changes and subungual petechial hemorrhages were seen in the ulnar three digits. Angiography confirmed microembolic occlusion. The patient was treated with systemic vasodilative agents and a brachial plexus blockade. Tissue necrosis did not develop, however, the patient suffered lasting cold intolerance in the affected digits. Steroid suspension particles injected to treat CTS or other indications, can cause capillary occlusion and thereby microembolic tissue ischemia if injected intra-arterially. Choosing the right injection site and aspirating prior to injection is a simple though effective and indispensable measure to help prevent intra-arterial injection of steroid suspensions.

Apoptosis Induced by Prednisolone Occurs without Altering the Promoter Methylation of BAX and BCL-2 Genes in Acute Lymphoblastic Leukemia Cells CCRF-CEM

Objective:

one of the main mechanisms in which cancer cells are resistant to chemotherapy drugs and therapeutic strategies is resistance to apoptosis due to these anticancer factors. Regulating the expression of genes through epigenetics, especially regulation through methylation, is one of the key aspects of regulating gene expression and the function of genes, which is also regulated by the pathways regulating the pathway of apoptosis. The epigenetic regulatory phenomenon in cancer cells can undergo a change in regulation and induces resistance to apoptosis against chemotherapy and anticancer factors. The purpose of the present scrutiny was defined to probe the effect of subtoxic prednisolone dose on the level of promoter methylation and gene expression of BAX and BCL2 in the CCRF-CEM cells.

Methods:

The treated cells by prednisolone, cultured in RPMI 1640 medium in standard condition. Alteration in promoter DNA methylation was analyzed by use of methylation specific-PCR (MSP) technique after the defined intervened time of Prednisolone treatment with a subtoxic dose.

Results:

Prednisolone can induce apoptosis via alteration in BAX and BCL2 genes, based on our previous scrutiny. This essay shows no varies in the Pattern of DNA methylation of examined genes; however, prednisolone changes the expression of examined genes.

Conclusion:

Lack of alteration through prednisolone treatment in DNA methylation template of BAX and BCL2 genes make this possible that Prednisolone affects apoptotic gene expression via different pathways, which need more research to be done about it.

Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review

OBJECTIVE

Lumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS).

METHODS

An elaborate search on PubMed, Google and Medline databases was made using keywords "lumbar selective nerve root block", "lumbar trans-foraminal epidural steroid injection", "selective nerve root block in lumbar disc prolapse", "trans-foraminal epidural steroid injection in lumbar prolapse", "selective nerve root block in lumbar radiculopathy", and "trans-foraminal epidural steroid injection in lumbar radiculopathy" The articles were selected based on specific inclusion criteria.

RESULTS

Our search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks' duration. It has been reported to yield better results than caudal or inter-laminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include "arm", "arrow", "linear" and "splash". Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial.

CONCLUSION

The overall success rate of SNRB is reported to be 76-88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram "splash" pattern is associated with poor outcomes.

Acute cervical myelopathy with quadriparesis after cervical transforaminal epidural steroid injection: A case report

RATIONALE

Cervical transforaminal epidural steroid injection (TFESI), can be an effective tool to improve pain associated with cervical radiculopathy. However, complications related to the procedure have been reported.

PATIENT CONCERNS

A 50-year-old woman who experienced acute cervical myelopathy with quadriparesis after cervical TFESI under fluoroscopic guidance.

DIAGNOSES

The initial post-procedure cervical MRI revealed acute cervical myelopathy INTERVENTIONS:: She received 1000 mg of methylprednisolone was injected intravenously daily for 3 days OUTCOMES:: Improvement in pain, with the only remaining complaints consisting of lingering mild pain in the left hand and occasional hypoesthesia LESSONS:: Cervical TFESI, despite careful fluoroscopic localization, resulted in spinal cord injury. A spinal cord injury may be treated with conservative treatments, such as medication and rehabilitation.

Comparative Efficacy of Methylprednisolone Acetate and Dexamethasone Disodium Phosphate in Lumbosacral Transforaminal Epidural Steroid Injections

Objective

Transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. But in view of accidental intravascular injections and consequent neurological injuries, the safety profile of particulate steroids has been questioned. Dexamethasone (DEXA), being non-particulate, is presumed to be a safe replacement for earlier particulate agents. However, the efficacy of DEXA is still doubtful as compared to particulate steroids. The present study aims to determine the comparative efficacy of DEXA and methylprednisolone (MP) in terms of pain relief and improvement of disability.

Methods

Seventy-six patients were sorted into two groups (MP and DEXA) to receive lumbar TFESI. A protocol of one-time single- or two-level TFESI with equipotent doses of MP or DEXA was followed. Numeric Rating Scale (NRS) and Roland-Morris Disability Questionnaire (RMDQ) scores were collected pre-treatment and at different times for a duration of 6 months at follow-up appointments.

Results

Overall, the extent of pain relief (determined from NRS) and quality of life (determined from RMDQ) were significantly better (p<0.01) in patients belonging to MP group following TFESI. NRS was 2.8±1.2, 3.3±1, 5.1±1.6 and 3.9±1.4, 4.5±1.3, 6.2±1.1 respectively in MP and DEXA group at 1 month, 3 months and 6months of follow-up, whereas RMDQ was 7.9±2.8, 7.4±2.3, 8.5±2.4 and 10±2.2, 11.4±2.6, 12.4±2.7 respectively in MP and DEXA group at similar time points.

Conclusion

The immediate and short term pain relief following TFESI in lumbar radicular pain remained satisfactory and is comparable between MP and DEXA groups, but the long term benefit is significantly more with the use of MP, as evidenced by the NRS and RMDQ scores.

Aggregation properties of triamcinolone acetonide injection in human serum: considerations when performing epidural steroid injections

Background

Morbidity has been reported as a sequelae of crystalline steroid epidural steroid injections (ESIs), and particulate steroid size, aggregation, and embolization in brain and spinal cord may be the mechanism related to these neurologic effects.

Objective

The objective of the study was to examine the aggregation properties of triamcinolone acetonide in commonly used local anesthetics with and without human serum.

Setting

This study was conducted in an academic tertiary care center.

Hypothesis

Triamcinolone acetonide shows different aggregation characteristics in serum compared to a non-physiologic solution.

Design

Triamcinolone acetonide was mixed with lidocaine 1% (first group) and bupivacaine 0.5% (second group) in a 1:1 ratio and then mixed with either distilled water (control group) or serum ex vivo. A pathologist blinded to our hypothesis inspected all solutions under light microscopy with 100× and 400× magnifications. Total number of particulate steroid aggregates and the number of particles forming each aggregate (recorded as single,1 double,2 triple,3 quadruple,4 or large [>4} crystals) were counted. Particle size and aggregate size were measured (in μm). The ratios of quadruple to total aggregates, large to total, and quadruple with large to total aggregates were calculated. Steroid-serum solutions and steroid-sterile water were then compared.

Results

Triamcinolone aggregates showed an increased crystal and aggregate size when compared with other steroids. Within the triamcinolone subgroup, the mixture of lidocaine 1% and serum resulted in the largest crystal aggregates.

Limitations

Whole blood analysis may have provided a more physiologically accurate model but was not chosen due to poor microscopic analysis. Serum donor variability may also have affected particle characteristics.

Conclusion

Fewer large triamcinolone aggregates were noted in the presence of serum when compared to the non-serum control groups. However, when compared to previously studied particulate steroids, it had the largest aggregates when added to serum.

Rare Case of Ischaemic Stroke Following Cervical Transforaminal Injection

We report a case of brainstem infarction following a C5–C6 cervical transforaminal injection, a rare and serious neurological complication of this procedure. Cervical transforaminal steroid injection is a common therapy for patients with persistent cervical radiculopathy not relieved by conservative treatment, and is effective in 65–70% of cases. Unfortunately, this procedure may lead to serious complications such as neurological damage. These complications are rare but potentially fatal, as reported in our case. Complications could be due to three mechanisms: the technique itself, the cervical vascular anatomy and the properties of the product (corticoids). The neurological complications can be diagnosed through brain MRI. This case report focuses on the importance of a risk/benefit evaluation when performing this medical procedure.

Digital subtraction angiography vs. real-time fluoroscopy for detection of intravascular injection during transforaminal epidural block

Background

Transforaminal epidural block (TFEB) is an effective treatment option for radicular pain. To reduce complications from intravascular injection during TFEB, use of imaging modalities such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA) has been recommended. In this study, we investigated whether DSA improved the detection of intravascular injection during TFEB at the whole spine level compared to RTF.

Methods

We prospectively examined 316 patients who underwent TFEB. After confirmation of final needle position using biplanar fluoroscopy, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under RTF; 30 s later, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under DSA.

Results

Thirty-six intravascular injections were detected for an overall rate of 11.4% using RTF, with 45 detected for a rate of 14.2% using DSA. The detection rate using DSA was statistically different from that using RTF (p=0.004). DSA detected a significantly higher proportion of intravascular injections at the cervical level than at the thoracic (p=0.009) and lumbar (p=0.011) levels.

Conclusion

During TFEB at the whole spine level, DSA was better than RTF for the detection of intravascular injection. Special attention is advised for cervical TFEB, because of a significantly higher intravascular injection rate at this level than at other levels.

Ultrasound-guided selective nerve root block versus fluoroscopy-guided interlaminar epidural block for the treatment of radicular pain in the lower cervical spine: a retrospective comparative study

PURPOSE

Recent studies have compared the therapeutic efficacy and safety of the procedure using ultrasound and fluoroscopy. However, there are no published studies comparing the therapeutic efficacy and safety of fluoroscopy (FL)-guided cervical interlaminar epidural steroid injection (CIESI) with that of ultrasound (US)-guided selective nerve root block (SNRB). This study aimed to compare the mid-term effects and advantages of US-guided SNRB with FL-guided CIESI for radicular pain in the lower cervical spine through assessment of pain relief and functional improvement.

METHODS

Patients with radicular pain in the lower cervical spine who received US-guided SNRB (n = 51) or FL-guided CIESI (n = 61) were included in this retrospective study. All procedures were performed using FL or US. The complication frequencies during the procedures, adverse events, treatment effects, and functional improvement were compared at intervals of 1, 3, and 6 months after the last injection.

RESULTS

Both the neck disability index and verbal numeric scale showed improvements at 1, 3, and 6 months after the last injection in both groups, with no significant differences between groups (p < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), sex, analgesic use, pain duration, number of injections, and age were not independent predictors of treatment success. Blood was aspirated before injection in 8% (n = 5) and 0% of patients in the FL-guided and US-guided groups, respectively. In seven patients of the FL-guided group, intravascular contrast spread was noted during injection.

CONCLUSIONS

Our results suggest that, compared with FL-guided CIESI, US-guided SNRB requires a shorter administration duration while providing similar pain relief and functional improvements.

The preliminary results of a new CT-guided periradicular cervical steroid injection technique: safety and feasibility of the lateral peri-isthmic approach in 28 patients

BACKGROUND

Computed tomography (CT)-guided cervical nerve injections are broadly being used in the treatment of cervical radiculopathy; however, catastrophic complications have been reported. Herein, we aimed to evaluate the efficacy, feasibility, and safety of a novel CT-guided cervical injection technique.

MATERIALS AND METHODS

We prospectively performed cervical injections in 28 patients with cervical radiculopathies using a novel CT-guided cervical transforaminal injection technique; lateral peri-isthmic approach in which the tip of the needle advanced to the lateral cortex of the isthmus instead of the foraminal area. Patients' pain reduction rates were evaluated using visual analog scores (VAS) at pre-treatment, immediately after treatment, at 3 weeks and 6 months after the treatment. Intra-vascular contrast medium injections and distribution of the contrast material into the foraminal, epidural or extraforaminal area during the procedure were noted.

RESULTS

Pre-treatment pain scores were reduced by 4.2 ± 1.4 (p < 0.001), 3.9 ± 1.37 (p < 0.001) and 3.25 ± 1.53 (p < 0.001) immediately after the treatment, 3 weeks and 6 months after the treatment respectively. The number of patients with >50% pain relief as measured by VAS were 21 (75%) immediately after the procedure, 19 (67.8%) at 3 weeks and 17 (60%) at 6 months after the procedure. The injected contrast material was dispersed into the neural foramen in 9 cases (32.1%), the foraminal and epidural area in 14 cases (50%) and the extraforaminal area in 5 cases (17.9%).

CONCLUSION

The CT-guided lateral peri-isthmic approach seems to be a secure and feasible method for cervical injections with satisfactory pain reduction.

Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain?

Corticosteroids have played a standard role in the multimodal pain management in the treatment of chronic spinal pain (cervical and lumbar) and osteoarthritis pain over the past three decades. In this review we discuss different types of injectable steroids that are mainly used for injection into the epidural space (for the treatment of radicular back and neck pain), and as intra-articular injections for different types of osteoarthritis related pain conditions. Furthermore, we discuss different approaches taken for epidural corticosteroid injections and spinal surgical rates when injections fail to resolve painful conditions, as well as the possibility of using local anesthetics alone for neuraxial injections, instead of in combination with corticosteroids. While we present some beneficial effects of newly available treatment options for low back pain and osteoarthritis pain, such as use of PRP and hyaluronic acid, corticosteroids remain important considerations in the management of these chronic pain conditions.

Distribution Patterns of Vasculature Around Cervical Nerve Roots

BACKGROUND

To the authors' knowledge, there has not been an ultrasound study of the vulnerable vessels in a C3-7 cervical nerve root block (CNRB).

OBJECTIVES

To evaluate the prevalence of vulnerable vessels around the target of a CNRB at the cervical nerve root of C3-7 levels in a clinical setting.

DESIGN

Retrospective, cross-sectional study.

SETTING

General teaching hospital, rehabilitation unit.

PARTICIPANTS

A total of 104 patients complaining of neck or arm pain with no prior surgical history and who had undergone a CNRB at an outpatient clinic from May 2015 to December 2017 were included.

MAIN OUTCOME MEASUREMENTS

The prevalence of vulnerable vessels as seen on a preprocedure ultrasound scan around the target of a CNRB at the cervical nerve root of C3-7 levels.

RESULTS

Out of 104 cases, the C3 level had 7 blood vessels (8.33%), the C4 level had 14 blood vessels (13.86%), the C5 level had 17 blood vessels (16.35%), the C6 level had 27 blood vessels (25.96%), and the C7 level had 31 blood vessels (29.81%) either at the targeted cervical nerve root or at the site of the imaginary needle's projected pathway to the targeted cervical nerve root.

CONCLUSION

There was a substantial prevalence of vulnerable vessels either at the targeted nerve root or at the site of the needle's projected pathway to the nerve root.

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

Design and in vivo evaluation of entecavir-3-palmitate microcrystals for subcutaneous sustained delivery

The objectives of this study were to formulate microcrystals of entecavir-3-palmiate (EV-P), a palmitic acid ester of entecavir (EV), and evaluate the influence of particle size on its pharmacokinetic behavior following subcutaneous (SC) injection. Systemic toxicity and local tolerability of the hepatitis B anti-viral suspension were further evaluated in normal rats. EV-P microcrystals possessing median diameters of 2.1, 6.3, and 12.7 µm were fabricated using anti-solvent crystallization technique with polysorbate 20 and polyethylene glycol 4000 as steric stabilizer. Dissolution rate of EV-P microcrystals was controlled by adjusting the particle size, under sink condition. Pharmacokinetic profiles of 2.1 µm-sized and 6.3 µm-sized EV-P microcrystals were quite comparable (1.44 mg/kg as EV), over 46 days in rats. The absorption rate and extent of EV after SC injection of 12.7 µm-sized microcrystals were significantly retarded, due to its slower dissolution rate in aqueous media. No single-dose systemic toxicity was observed after SC injection of high dose of EV-P microcrystal suspension (30-300 mg/kg as EV). The microcrystals were tolerable in the injected site, showing mild inflammatory responses at a dose of 30 mg/kg. Therefore, the novel microcrystal system with median particle size of below 6.3 µm is expected to be a unique long-acting system of the anti-viral agent, improving patient's compliance with chronic disease.

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.

Outcomes of C1-2 joint injections

Objective

Intra-articular injections of the C1–2 joint are an effective therapeutic option for pain generated from degenerative and inflammatory conditions affecting the joint. Limited information exists about the adverse events (AEs) associated with these injections. The primary aim of this study is to describe the frequency and type of AEs associated with C1–2 joint injections. The secondary aim is to identify clinical factors associated with the occurrence of AEs of C1–2 joint injections.

Design/methods

A retrospective chart review was conducted on all C1–2 joint injections performed at the Mayo Pain Medicine Clinic in Rochester, MN, from January 1, 2005 through July 31, 2015. AE data were extracted from procedural and post-procedural clinical notes. Analysis was conducted to determine correlations between any AE and demographic and clinical characteristics. Using univariate and multivariate logistic regression analyses, associations were determined.

Results

From January 1, 2005 to July 31, 2015, 135 C1–2 injections were performed on 72 patients. Overall, at least 1 AE was reported in 18.5% of the injections. The most common AEs were post-procedural increase in pain and procedural vascular contrast uptake. There was a significant association between AE occurrence and greater pre-procedural maximum pain score.

Conclusions

AEs from C1–2 joint injections occurred commonly, but there were no persistent or serious AEs associated with these injections. The data also demonstrate that patients with higher pre-procedural maximum pain scores are more likely to experience an AE.