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Spinal Cord Injury and Complications Related to Neuraxial Anaesthesia Procedures: A Systematic Review. Int J Mol Sci 2023; 24:ijms24054665. [PMID: 36902095 PMCID: PMC10003521 DOI: 10.3390/ijms24054665] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
The use of neuraxial procedures, such as spinal and epidural anaesthesia, has been linked to some possible complications. In addition, spinal cord injuries due to anaesthetic practice (Anaes-SCI) are rare events but remain a significant concern for many patients undergoing surgery. This systematic review aimed to identify high-risk patients summarise the causes, consequences, and management/recommendations of SCI due to neuraxial techniques in anaesthesia. A comprehensive search of the literature was conducted in accordance with Cochrane recommendations, and inclusion criteria were applied to identify relevant studies. From the 384 studies initially screened, 31 were critically appraised, and the data were extracted and analysed. The results of this review suggest that the main risk factors reported were extremes of age, obesity, and diabetes. Anaes-SCI was reported as a consequence of hematoma, trauma, abscess, ischemia, and infarction, among others. As a result, mainly motor deficits, sensory loss, and pain were reported. Many authors reported delayed treatments to resolve Anaes-SCI. Despite the potential complications, neuraxial techniques are still one of the best options for opioid-sparing pain prevention and management, reducing patients' morbidity, improving outcomes, reducing the length of hospital stay, and pain chronification, with a consequent economic benefit. The main findings of this review highlight the importance of careful patient management and close monitoring during neuraxial anaesthesia procedures to minimise the risk of spinal cord injury and complications.
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Maeda M, Maeda N, Masuda K, Kamatani Y, Takamasa S, Tanaka Y. Ligamentum Flavum Rupture by Epidural Injection Using Ultrasound with SMI Method. Tomography 2023; 9:285-298. [PMID: 36828375 PMCID: PMC9964737 DOI: 10.3390/tomography9010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
The loss of resistance (LOR) method has been used exclusively to identify epidural space. It is difficult to find the epidural space without the risk of dural puncture. Various devices have been developed to improve the accuracy of the LOR method; however, no method has overcome the problems completely. Therefore, we devised a ligamentum flavum rupture method (LFRM) in which the needle tip is placed only on the ligamentum flavum during the epidural injection, and the injection pressure is used to rupture the ligamentum flavum and spread the drug into the epidural space. We confirmed the accuracy of this method using ultrasound with superb microvascular imaging (SMI) to visualize the epidural space. Here, we report two cases of 63-year-old and 90-year-old males. The 63-year-old patient presented with severe pain in his right buttock that extended to the posterior lower leg. The 90-year-old patient presented with intermittent claudication every 10 min. LFRM was performed, and SMI was used to confirm that the parenteral solution had spread into the epidural space. Our results indicate that LFRM can be used for interlaminar lumbar epidural steroid injections.
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Affiliation(s)
- Manabu Maeda
- Department of Orthopedics, Maeda Orthopaedic Clinic, Nara 630-8306, Japan
- Correspondence: ; Tel.: +81-742-24-5595
| | - Nana Maeda
- Department of Orthopedics, Maeda Orthopaedic Clinic, Nara 630-8306, Japan
| | - Keisuke Masuda
- Department of Orthopedics, Higashiosaka Medical Center, Osaka 578-8588, Japan
| | - Yoshiyuki Kamatani
- Department of Orthopedics, Saiseikai Nara Hospital, Nara 630-8145, Japan
| | - Shimizu Takamasa
- Department of Orthopedics, Nara Medical University, Nara 634-8521, Japan
| | - Yasuhito Tanaka
- Department of Orthopedics, Nara Medical University, Nara 634-8521, Japan
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Lee SH, Choi HH, Chang MC. The Effectiveness of Facet Joint Injection with Steroid and Botulinum Toxin in Severe Lumbar Central Spinal Stenosis: A Randomized Controlled Trial. Toxins (Basel) 2022; 15:toxins15010011. [PMID: 36668831 PMCID: PMC9866817 DOI: 10.3390/toxins15010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Lumbar central spinal stenosis (LCSS) is a common disorder that causes disability and pain in the elderly. It causes pain in the radicular leg. Recently, transforaminal epidural steroid injection (TFESI) has been widely used to control radicular leg pain caused by LCSS. However, in cases of severe LCSS, drugs injected using TFESI cannot spread into the spinal canal and would have less therapeutic effects than in mild LCSS. To compensate for this limitation of TFESI, we injected steroids and botulinum toxin type A into the bilateral facet joints, evaluated their effects, and compared them with those of TFESI. One hundred patients with severe LCSS were included in the study and randomly allocated to either the facet injection (FI) or TFESI group. For 50 patients in the FI group, 30 mg (40 mg/mL) of triamcinolone with 50 IU of botulinum toxin type A mixed with a 1 mL solution of 100 mL of 50% dextrose water and 30 mL of 4% lidocaine were administered into the bilateral facet joints under fluoroscopy. For 50 patients in the TFESI group, 30 mg (40 mg/mL) of triamcinolone with 0.8 mL of 2% lidocaine and 2.5 mL of 50% dextrose water was injected bilaterally under fluoroscopy. Radicular leg pain (measured with a numeric rating scale) and pain-related disability (measured with the modified Oswestry Disability Index) due to severe LCSS were significantly reduced after facet joint injection. The therapeutic effects were greater after facet joint injection than after bilateral TFESI. The injection of a mixed solution of steroids and botulinum toxin type A into the bilateral facet joints would be a beneficial therapeutic option in patients with severe LCSS.
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Affiliation(s)
- Sang Hoon Lee
- Department of Radiology, Madi Pain Management Center, Jeonju 54969, Republic of Korea
| | - Hyun Hee Choi
- Madi Research and Development Center, Jeonju 54969, Republic of Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
- Correspondence:
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Spinal epidural hematoma in antiphospholipid syndrome: case report and review of the literature. Spinal Cord Ser Cases 2022; 8:11. [PMID: 35042850 PMCID: PMC8766459 DOI: 10.1038/s41394-022-00476-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Spinal epidural hematomas are a surgical emergency, the delay in diagnosis can develop devastating sequelae due to its acute and progressive course. If not treated properly, it may lead to death or permanent neurological deficit. It is a rare condition that can occur in patients with hematologic pathology. CASE PRESENTATION We report a case report and literature review of a patient with antiphospholipid syndrome, who undergoes a diagnostic lumbar puncture for probable fungal meningitis. Developed a spinal acute epidural hematoma with neurological involvement that is evidenced in MRI. Urgent surgical decompression was performed with good results. DISCUSSION Despite the low incidence of an epidural hematoma in patients who undergo lumbar puncture, it is important to perform a thorough evaluation in any patient with coagulation abnormalities prior and after a lumbar puncture, by reason of the inherent possibility of developing an epidural hematoma at the site of the procedure. In the same way, early diagnosis and aggressive treatment is necessary in patients who develop progressive neurological symptoms to limit the damage and improve the prognosis for neurological recovery.
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Hobelmann JG, Huhn AS. Comprehensive pain management as a frontline treatment to address the opioid crisis. Brain Behav 2021; 11:e2369. [PMID: 34555260 PMCID: PMC8613403 DOI: 10.1002/brb3.2369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/31/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The opioid crisis continues to devastate individuals and communities in the United States and abroad. While there have been several measures to address the over-prescription of opioid analgesics, the number of overdose deaths related to prescription opioids has not changed appreciably in the last 10 years. Comprehensive (or multidisciplinary) pain recovery programs consist of providers from multiple backgrounds that treat pain on an individual level through a combination of approaches including physical therapy, emotional and spiritual support, cognitive behavioral therapy, and non-opioid pharmacotherapies. Because there is a dynamic interplay between a given chronic pain patient and multiple providers, comprehensive pain programs are not as "standardized" as other medical treatments because they are meant to meet the individual needs of each patient and their specific pain diagnoses Methods: Review of the literature. RESULTS There is evidence that comprehensive pain treatment can reduce pain severity and improve functioning; comprehensive pain treatment can be used to treat those with post-surgical pain, thus preventing the onset of non-medical opioid use and opioid use disorder, and in persons with chronic pain who are on long-term opioid therapy, as a method to reduce or eliminate opioid medication use. Comprehensive pain recovery programs were abundant for a period from the 1960s through the 1980s, but for a variety of reasons, they became financially unsustainable as the national reimbursement environment evolved. CONCLUSIONS In the context of the protracted and deadly opioid crisis, revitalizing and expanding comprehensive pain treatment should be considered as a frontline approach to treat chronic pain.
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Affiliation(s)
- Joseph Gregory Hobelmann
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Ashley Addiction TreatmentHavre de GraceMarylandUSA
| | - Andrew S. Huhn
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Ashley Addiction TreatmentHavre de GraceMarylandUSA
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Eworuke E, Crisafi L, Liao J, Akhtar S, Van Clief M, Racoosin JA, Wernecke M, MaCurdy TE, Kelman JA, Graham DJ. Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population. Reg Anesth Pain Med 2020; 46:203-209. [PMID: 33277405 DOI: 10.1136/rapm-2020-101778] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Epidural corticosteroid injections (ESIs) are widely performed and have an unquantified risk of serious spinal adverse events (SSAEs). We sought to determine the rate of SSAEs following ESI and to compare the rates by spinal level, injection approach and corticosteroid formulation. METHODS We included patients enrolled in Medicare parts A and B who had an ESI between 1 January 2009 and 30 September 2015. We identified potential cases as patients with spine-related diagnoses within 3 days after the first eligible ESI. Event categorization as probable, possible or non-case was based on review of medical records. The rates of probable and possible cases were expressed per 1 000 000 patients overall, and by spinal level, injection approach and corticosteroid formulation. A score test was used to compare these rates. RESULTS We identified 1 355 957 eligible ESIs during the study period. Of the 110 potential cases, 43 were selected for medical record review and 11 were categorized as probable, yielding a rate of 8.1 per 1 000 000 patients (95% CI 4.5 to 14.5). Risk of SSAEs was statistically higher with cervical/thoracic injections (29.4, 95% CI 12.5 to 68.8) compared with lumbar/sacral injections (5.1, 95% CI 2.3 to 11.0) (p value 0.001). Event rates for lumbar/sacral non-transforaminal injections was 8.8 (95% CI 4.0 to 19.1). Event rates for particulate (7.5, 95% CI 3.9 to 14.2) and non-particulate formulations (13.1, 95% CI 3.6 to 47.9) appeared similar (p value 0.47). CONCLUSION Between 2009 and 2015, rates of SSAEs following ESI in the Medicare population were low. Patients receiving cervical/thoracic ESIs were at higher risk of SSAE than those receiving lumbar/sacral ESIs. Event rates were similar for each corticosteroid formulation.
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Affiliation(s)
- Efe Eworuke
- Division of Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Leah Crisafi
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Martha Van Clief
- Division of Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Judith A Racoosin
- Division of Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Jeffrey A Kelman
- Centers for Medicare and Medicaid Services Washington DC Office, Washington, District of Columbia, USA
| | - David J Graham
- Division of Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
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Wibowo HA, Rhatomy S. Cauda equina syndrome after caudal epidural sacral injection in severe lumbar spinal stenosis: Case report. Int J Surg Case Rep 2020; 77:12-14. [PMID: 33137663 PMCID: PMC7610032 DOI: 10.1016/j.ijscr.2020.10.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022] Open
Abstract
Cauda Equina Syndrome. Caudal Epidural Sacral Injection. Severe Lumbal Spinal Stenosis. Complication.
Introduction Caudal epidural sacral injection is one of the most common conservative treatments for chronic low back pain with radiculopathy. Neurological deficit after injection is a rare complication that must be identified and treated properly. Presentation of case We report a case of cauda equina syndrome that persisted until 3 months after injection. A 63-year-old man came to our department with severe lumbar canal stenosis who experienced motor weakness, buttocks numbness and voiding difficulties immediately after injection. His lower extremities improved after 24 h, but his neurogenic bladder problems and perianal numbness still persisted. We collaborated with our interdisciplinary teams to do a rehabilitation program, and the symptoms were alleviated and he fully recovered within three months. Conclusion Patients with severe stenosis can be best described from magnetic resonance imagery scans, and clinicians should be careful about the risks after injection ranging from transient complications to persistent spinal cord injury.
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Affiliation(s)
- Hastomo Agung Wibowo
- Orthopaedic Traumatology Department, Soeradji Tirtonegoro General Hospital, Indonesia; Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Indonesia
| | - Sholahuddin Rhatomy
- Orthopaedic Traumatology Department, Soeradji Tirtonegoro General Hospital, Indonesia; Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Indonesia.
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Chang A, Wang D. Complications of Fluoroscopically Guided Cervical Interlaminar Epidural Steroid Injections. Curr Pain Headache Rep 2020; 24:63. [PMID: 32845404 DOI: 10.1007/s11916-020-00897-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Cervical interlaminar epidural steroid injection is a common intervention in the management of cervical radiculitis. Given the large number of injections done annually, it is important to assess the potential complications associated with this procedure. RECENT FINDINGS Based on current published studies, the overall complication rate varies. The vast majority are minor complications. However, this review also identified potentially catastrophic complications following cervical interlaminar epidural steroid injections. Based upon our review, cervical epidural steroid injection is considered a safe intervention. Nevertheless, catastrophic complications such as spinal cord injuries from needle placement, infections, and epidural hematoma can occur. It is prudent to take appropriate measures to minimize these complications.
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Affiliation(s)
- Andrew Chang
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Dajie Wang
- Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Palmer E. Management of Cervical Epidural Hematoma After Cervical Epidural Steroid Injection Using a Catheter Technique. PAIN MEDICINE 2019; 21:1301-1302. [DOI: 10.1093/pm/pnz220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Smith GA, Pace J, Strohl M, Kaul A, Hayek S, Miller JP. Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience. Oper Neurosurg (Hagerstown) 2019; 13:271-279. [PMID: 28927205 DOI: 10.1093/ons/opw014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neurosurgical complications from epidural injections have rarely been reported. OBJECTIVE To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention. METHODS A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed. RESULTS Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1). CONCLUSION A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
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Affiliation(s)
- Gabriel A Smith
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Madeleine Strohl
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Anand Kaul
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Salim Hayek
- Division of Pain Medicine, Depart-ment of Anesthesiology, University Hospi-tals Case Medical Center, Cleveland, Ohio
| | - Jonathan P Miller
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
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Schneider BJ, Maybin S, Sturos E. Safety and Complications of Cervical Epidural Steroid Injections. Phys Med Rehabil Clin N Am 2018; 29:155-169. [DOI: 10.1016/j.pmr.2017.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Schneider BJ, Sturos E. Safety and Risk Mitigation for Cervical Interlaminar Epidural Steroid Injections. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0166-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Smith CC, Schneider B, McCormick ZL, Gill J, Loomba V, Engel AJ, Duszynski B, King W. Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review. PAIN MEDICINE 2017; 19:438-448. [DOI: 10.1093/pm/pnx152] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Clark C Smith
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | | | - Jatinder Gill
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Wade King
- Manning Pain Management, Mayo Private Hospital, Taree, New South Wales, Australia
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Lagerkranser M. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain 2017; 15:118-129. [DOI: 10.1016/j.sjpain.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
Methods
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Results
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
Conclusions and implications
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
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Affiliation(s)
- Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institutet , 171 77 Stockholm Stockholm , Sweden
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Facet joint injection versus epidural steroid injection for lumbar spinal stenosis: intra-individual study. Clin Radiol 2017; 72:96.e7-96.e14. [DOI: 10.1016/j.crad.2016.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/26/2016] [Accepted: 08/09/2016] [Indexed: 12/19/2022]
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Abstract
BACKGROUND AND OBJECTIVE Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports. METHODS Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis. RESULTS Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating. CONCLUSIONS The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.
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Elgafy H, Peters N, Lea JE, Wetzel RM. Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature. World J Orthop 2016; 7:452-457. [PMID: 27458557 PMCID: PMC4945513 DOI: 10.5312/wjo.v7.i7.452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/12/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications.
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Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections. Expert Opin Drug Saf 2016; 15:1031-9. [DOI: 10.1080/14740338.2016.1184246] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Byron Schneider
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Patricia Zheng
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Ryan Mattie
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - David J. Kennedy
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
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Ideal Cervical Epidural Injection Route: Interlaminar or Transforaminal. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ji GY, Oh CH, Choi WS, Lee JB. Three cases of hemiplegia after cervical paraspinal muscle needling. Spine J 2015; 15:e9-13. [PMID: 25459742 DOI: 10.1016/j.spinee.2014.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 09/22/2014] [Accepted: 11/08/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Muscle needling therapy is common for chronic pain management, but the development of unusual complications such as hemiplegia is not well understood. PURPOSE We report on three cases with hemiplegia after cervical paraspinal muscle needling and propose possible explanations for these unusual complications. STUDY DESIGN Case report. METHODS The authors retrospectively reviewed the medical charts from a decade (2002-2013) at Korea University Hospital. The records were systematically searched, and the cases with hemiplegia (grade<3) after needing therapy were collected. No conflict of interest reported. No funding received. RESULTS A 54-year-old woman, a 38-year-old woman, and a 60-year-old man with hemiplegia by cervical subdural or epidural hematoma after cervical posterior paraspinal muscle needling without direct invasion (intramuscular stimulation, acupuncture, or intramuscular lidocaine) were observed. All patients were taken for emergent decompressive laminectomy, and their postoperative motor function improved substantially. CONCLUSION Spinal hematoma after muscle needling is unusual but was thought to result after a rupture of the epidural or subarachnoid veins by a sharp increase in blood pressure delivered in the intraabdominal or intrathoracic areas after needling therapy.
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Affiliation(s)
- Gyu Yeul Ji
- Depatment of Neurosurgery, Spine and Spinal Cord Research Institute, Yonsei University, College of Medicne, 50 Yonsei-ro, Seodamun-gu, 120-752 Seoul, Korea; Department of Neurosurgery, Guro Teun Teun Hospital, 547 Siheungdae-ro, Guro-gu, 152-880 Seoul, Korea
| | - Chang Hyun Oh
- Department of Neurosurgery, Guro Teun Teun Hospital, 547 Siheungdae-ro, Guro-gu, 152-880 Seoul, Korea
| | - Won-Seok Choi
- Department of Neurosurgery, Guro Teun Teun Hospital, 547 Siheungdae-ro, Guro-gu, 152-880 Seoul, Korea
| | - Jang-Bo Lee
- Department of Neurosurgery, Korea University Anam Hospital, College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705 Seoul, Korea.
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Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015; 5:129-46. [DOI: 10.2217/pmt.14.53] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
SUMMARY Epidural steroid injections (ESIs), which can provide significant but temporary pain relief in well-selected patients, are the most commonly performed procedure in pain management. The anatomy of the epidural space provides a framework for understanding risks associated with ESIs, a topic relevant to both patients and physicians in interventional pain, surgery and primary care. Safety considerations of epidural steroids include drug preparation and myriad physiological effects stemming from steroid exposure. Although major complications associated with ESI occur rarely, potentially catastrophic events resulting from infectious, hematologic and neurologic morbidity may lead to permanent injury. The safety profile of ESIs may improve with development and dissemination of sound injection technique, safer compounds manufactured in a sterile manner and deficient of thromboembolic potential and the application of existing technology.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology, Critical Care & Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - David Chang
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - Steven P Cohen
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, 707 North Broadway, Baltimore, MD 21205, USA
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Should antiplatelet medications be held before cervical epidural injections? PM R 2015; 6:442-50. [PMID: 24863733 DOI: 10.1016/j.pmrj.2014.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 01/08/2023]
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Cervical foraminal steroid injections under CT guidance: retrospective study of in situ contrast aspects in a serial of 248 cases. Skeletal Radiol 2015; 44:1-8. [PMID: 25316168 DOI: 10.1007/s00256-014-2028-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 08/08/2014] [Accepted: 09/29/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe all the CT findings after in situ contrast injection just before steroid injection and to recognize the abnormal aspects associated with intravascular contamination. MATERIAL AND METHODS We retrospectively evaluated 248 cervical transforaminal steroid injections done at the university hospital in Dijon, France, in 2008-2012, to treat cervicobrachial neuralgia inadequately improved by optimal medical treatment for at least 3 weeks. Features describing the opacification patterns were recorded. RESULTS Five main nonvascular opacification patterns were identified: clumps of contrast agent outside the foramen (16 %), a crab claw pattern surrounding the ganglion (13 %), a "French" circumflex accent pattern (15 %), reflux along the needle (7 %), and facet joint capsule opacification (22 %). Concerning the situations requiring a change in needle position, intravenous injection occurred in 26 % of the patients, with a crab claw pattern in half the cases and a clump pattern in half the cases. Intraarteriolar injection was noted in two patients. CONCLUSION CT after in situ contrast injection ensures proper needle positioning outside the blood vessels before steroid injection. Penetration of the needle tip into a vein is very common, whereas arteriolar puncture is extremely rare.
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Comparison of pain score reduction using triamcinolone vs. dexamethasone in cervical transforaminal epidural steroid injections. Am J Phys Med Rehabil 2013; 92:768-75. [PMID: 23370580 DOI: 10.1097/phm.0b013e318282c9f2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to compare the effectiveness of triamcinolone vs. dexamethasone used in transforaminal epidural steroid injections for the treatment of cervical radiculopathy. DESIGN This is a retrospective cohort study of patients with cervical radiculopathy who underwent cervical transforaminal epidural steroid injections performed by a single physician from February 2005 through January 2010. Data from the subjects were divided into two groups on the basis of the type of corticosteroid preparation used during treatment. A two-sample t test with equivalent variance was used to compare the effectiveness of dexamethasone to triamcinolone. RESULTS Triamcinolone (40 mg per injection) was used in 220 subjects during the period of February 2005 through August 2007, with a mean reduction in pain score of 2.33 points on a 10-point scale. Dexamethasone (15 mg per injection) was used in 221 subjects during the period of September 2007 through January 2010, with a mean reduction in pain score of 2.38 points on a 10-point scale. A two-sample F test for variance showed no statistically significant difference in the variance of these two groups. The two-sample t test with equivalent variance showed no statistically significant difference in the mean reduction in pain score between the two groups. CONCLUSIONS The mean reduction in pain score in this set of 441 patients with cervical radiculopathy treated with transforaminal epidural steroid injections was independent of the type of corticosteroid formulation used. Triamcinolone (40 mg) and dexamethasone (15 mg) produced similar benefits as measured by the patients' self-reported pain scores.
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Wang J, Lau ME, Gulur P. Delayed spinal epidural hematoma after epidural catheter removal with reinitiation of warfarin. J Cardiothorac Vasc Anesth 2013; 28:1566-9. [PMID: 24075636 DOI: 10.1053/j.jvca.2013.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Jingping Wang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Mary E Lau
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Padma Gulur
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.
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Caputo AM, Gottfried ON, Nimjee SM, Brown CR, Michael KW, Richardson WJ. Spinal Epidural Hematoma Following Epidural Steroid Injection in a Patient Treated with Dabigatran: A Case Report. JBJS Case Connect 2013; 3:e64. [PMID: 29252220 DOI: 10.2106/jbjs.cc.m.00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Adam M Caputo
- Department of Orthopaedic Surgery (A.M.C., C.R.B., K.W.M., W.J.R.), Department of Surgery (O.N.G., S.M.N.), Duke University Medical Center, Box 2807, 335 Baker House, 200 Trent Drive, Durham, NC 27710.
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Hwang SY, Lee JW, Lee GY, Kang HS. Lumbar facet joint injection: feasibility as an alternative method in high-risk patients. Eur Radiol 2013; 23:3153-60. [DOI: 10.1007/s00330-013-2921-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 04/25/2013] [Accepted: 05/05/2013] [Indexed: 12/14/2022]
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Cervical Foraminal Versus Interlaminar Epidurals: Risks, Benefits, and Alternatives. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0013-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Desai MJ, Dua S. Perineural hematoma following lumbar transforaminal steroid injection causing acute-on-chronic lumbar radiculopathy: a case report. Pain Pract 2013; 14:271-7. [PMID: 23464852 DOI: 10.1111/papr.12047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 01/02/2013] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Transforaminal epidural steroid injections (TFESI) are commonly performed for the treatment of lumbar herniated nucleus pulposus and lumbosacral radiculopathy. Although rare, documented complications including spinal cord infarction, paraparesis, epidural abscess, paraplegia, and epidural hematoma have been reported. Here, we present a case of perineural hematoma affecting the L4 nerve root resulting in progressive acute-on-chronic lumbar radiculopathy following TFESI. CASE REPORT A 72-year-old female presented with 3 months of low back and right anterior thigh pain. She subsequently underwent right L3 and L4 TFESI for physical examination findings concordant with radiographic right foraminal stenosis at L3-4 and L4-5 with L3-4 spondylolisthesis. Over the following week, the patient reported progressive right lower extremity weakness, worsening sensory loss, and ambulatory dysfunction. Examination revealed mild L3/4 myotomal weakness, sensory changes, and areflexia at the right patella. A gadolinium-enhanced MRI was ordered, which showed focal abnormal signal with involvement of the right L4-L5 neuroforamina and extending slightly far laterally, consistent with a small hematoma, affecting the L4 nerve root. Within 2 months, her strength and reflexes normalized and sensory loss diminished following medical management. DISCUSSION Although extremely rare, perineural or foraminal hematomas may occur as a serious complication of TFESI, even in the setting of a standardized procedure. Hematoma may cause worsening of symptoms in the acute and subacute phase following TFESI. Further investigation into the etiologies of such injuries is warranted and must be added to the considerations of pain physicians performing these procedures.
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Affiliation(s)
- Mehul J Desai
- The GW Spine & Pain Center, George Washington University Medical Center, Washington, District of Columbia, U.S.A
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Depriester C, Setbon S, Larde A, Malaquin E, Vanden Abeele B, Bocquet J. CT-guided transforaminal cervical and lumbar epidural injections. Diagn Interv Imaging 2012; 93:704-10. [PMID: 22925592 DOI: 10.1016/j.diii.2012.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Transforaminal injections are widely used. Serious complications including strokes and paraplegia have been reported after transforaminal injections of corticosteroids, and the Afssaps (2011) has issued a warning about their use [1]. The needle must be positioned in the posterior aspect of foramen, and its correct placement validated by an injection of contrast product. It is preferable to choose cortivazol (Altim(®)) as the corticoid for injection. This procedure is simple, reproducible, and durably effective in 60 to 70% of cases. Complications and adverse effects are rare but potentially serious: allergies, blood pressure surge, vasovagal syncope, transient exacerbation of pain, infection, stroke, and paraplegia. The aim of this course is to stress the need for rigor - in the indication, the technical performance of the procedure, and the overall management of the patient.
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Affiliation(s)
- C Depriester
- Service de radiologie, Polyclinique du Bois, Lille, France.
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Kranz PG, Raduazo P, Gray L, Kilani RK, Hoang JK. CT fluoroscopy-guided cervical interlaminar steroid injections: safety, technique, and radiation dose parameters. AJNR Am J Neuroradiol 2012; 33:1221-4. [PMID: 22322610 DOI: 10.3174/ajnr.a2954] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Cervical epidural steroid injections are approached with trepidation because of concerns over safety, including direct spinal cord injury. CT fluoroscopy is an alternative to conventional fluoroscopy that could potentially help reduce the risk of injury by providing improved localization of the needle tip. We sought to determine rates of technical success and risk of complications in our initial cohort of patients treated with cervical interlaminar ESI performed under CTF guidance. MATERIALS AND METHODS In this retrospective case series, we reviewed procedural details and CTF images of 53 consecutive cervical interlaminar ESIs performed on 50 patients over a period of 8 months. Rates of technical success, incidence of complications, procedure times, and factors that influence radiation exposure were examined. RESULTS No symptomatic procedural complications were observed. A single case of intrathecal contrast injection was observed, from which the patient was asymptomatic. The remaining injections were all technically successful. Injections were performed at every cervical level, as high as C1-C2. Total procedure times averaged less than 20 minutes. Average CT fluoroscopic time was 24 seconds and median tube current was 70 mA. CONCLUSIONS CTF-guided cervical interlaminar ESI can be performed at all levels in the cervical spine with a low rate of procedural complications. Short total procedure times, CT-fluoroscopy times, and reduced tube current make this procedure a practical alternative to cervical ESI performed under conventional fluoroscopy.
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Affiliation(s)
- P G Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Goswami D, Das J, Deuri A, Deka AK. Epidural haematoma: Rare complication after spinal while intending epidural anaesthesia with long-term follow-up after conservative treatment. Indian J Anaesth 2011; 55:71-3. [PMID: 21431059 PMCID: PMC3057252 DOI: 10.4103/0019-5049.76596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Epidural anaesthesia (EA) is an extensively used procedure for many surgeries. Increase incidence of bleeding in the epidural space [epidural haematoma (EH)] is reportedly more common in patients with altered coagulation and patients on anticoagulation treatment. EH secondary to spinal while intending EA for caesarean section (C-section) in a healthy individual leading to transient or persistent neurological problems is very rare. We report a case of EH after spinal while intending EA for C-section in a healthy young female along with 5-yrs follow-up after conservative treatment.
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Affiliation(s)
- Devalina Goswami
- Departments of Anaesthesiology and Critical Care, Gauhati Medical College, Guwahati, Assam, India
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34
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Metastatic testicular cancer presents as spinal injection complication. Spine (Phila Pa 1976) 2011; 36:E370-2. [PMID: 20847711 DOI: 10.1097/brs.0b013e3181f39b9e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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35
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Hematoma epidural cervical yatrogénico. Presentación de un caso clínico y revisión de la literatura. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70029-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Nam KH, Choi CH, Yang MS, Kang DW. Spinal epidural hematoma after pain control procedure. J Korean Neurosurg Soc 2010; 48:281-4. [PMID: 21082060 DOI: 10.3340/jkns.2010.48.3.281] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 06/04/2010] [Accepted: 09/09/2010] [Indexed: 12/20/2022] Open
Abstract
Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.
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Affiliation(s)
- Kyoung Hyup Nam
- Department of Neurosurgery, School of Medicine, Pusan National University, Busan, Korea
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Abstract
Spinal epidural hematoma is a rare condition that usually presents with acute, severe pain at the location of the hemorrhage, with radiation to the extremities. It can rapidly develop to include progressive and severe neurologic deficit. The pathophysiology often remains unclear. However, epidural hematoma in the lumbar spine is best described as the result of internal rupture of the Batson vertebral venous plexus. Clinical evaluation of pain control and neurologic deficit is the most important tool in early diagnosis. Currently, MRI is the diagnostic method of choice. Regardless of the setting, symptomatic spinal epidural hematoma is typically managed with urgent surgical decompression of the spinal canal.
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38
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Ahn SS, Song YJ. Clinical experience and management of cervico-thoracic epidural hematoma. J Korean Neurosurg Soc 2010; 47:381-4. [PMID: 20539799 DOI: 10.3340/jkns.2010.47.5.381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 02/05/2010] [Accepted: 02/08/2010] [Indexed: 12/31/2022] Open
Abstract
Spinal epidural hematoma (SEH) causing acute myelopathy is rare. The usual clinical presentation of a SEH is sudden severe neck or back pain that progresses toward paraparesis or quadriparesis, depending on the level of the lesion. Recent studies have shown that early decompressive surgery is very important for patient's recovery. We experienced five patients of cervico-thoracic epidural hematomas associated with neurologic deficits that were treated successfully with surgical intervention.
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Affiliation(s)
- Sang-Soak Ahn
- Department of Neurosurgery, College of Medicine, Dong-A University, Busan, Korea
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39
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Xu R, Bydon M, Gokaslan ZL, Wolinsky JP, Witham TF, Bydon A. Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines. J Neurosurg Spine 2009; 11:358-64. [PMID: 19769520 DOI: 10.3171/2009.3.spine0916] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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40
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Arcas-Bellas JJ, Cassinello F, Cercós B, del Valle M, Leal V, Álvarez-Rementería R. Delayed Quadriparesis After an Interscalene Brachial Plexus Block and General Anesthesia: A Differential Diagnosis. Anesth Analg 2009; 109:1341-3. [DOI: 10.1213/ane.0b013e3181b572cd] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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41
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Kaya A, Ozgocmen S. Thoracic disc herniation causing transient paraplegia coincident with epidural anesthesia: a case report. CASES JOURNAL 2009; 2:6228. [PMID: 19918563 PMCID: PMC2769273 DOI: 10.4076/1757-1626-2-6228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 07/16/2009] [Indexed: 01/30/2023]
Abstract
Neurological deficits following epidural or spinal anesthesia are extremely rare. Transient paraplegia following epidural anesthesia in a patient with thoracic disc herniation has been presented. A 44-year-old woman developed paraplegia during the operation for vascular surgery of her legs under epidural anesthesia. Epidural hematoma or spinal cord ischemia was ruled out by magnetic resonance imaging of the thoracic and lumbar spine in which protruded disc at T11-12 level compressing the spinal cord has been verified. Patient responded well to steroid treatment and rehabilitation interventions. Physicians should be aware of preceding disc protrusions, which may have detrimental effects on spinal cord perfusion, as a cause of persistent or transient paraplegia before epidural anesthesia procedure. MRI is a valuable imaging option to rule out epidural anesthesia complications and coexisting pathologies like disc herniations.
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Affiliation(s)
- Arzu Kaya
- Department of Physical Medicine and Rehabilitation, Firat UniversityFaculty of Medicine, 23119 ElazigTurkey
| | - Salih Ozgocmen
- Department of Physical Medicine and Rehabilitation, Firat UniversityFaculty of Medicine, 23119 ElazigTurkey
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42
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Huston CW. Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review. Curr Rev Musculoskelet Med 2009; 2:30-42. [PMID: 19468916 PMCID: PMC2684951 DOI: 10.1007/s12178-008-9041-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 11/24/2008] [Indexed: 12/13/2022]
Abstract
There has been recent concern regarding the safety of cervical epidural steroid injections. The decision to proceed with treatment requires balancing the risk and benefits. This article is an in depth review of the efficacy, complications, and technique of both interlaminar and transforaminal cervical epidural steroid injections in the management of cervical radiculitis.
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Affiliation(s)
- Christopher W Huston
- The Orthopedic Clinic Association, 2222 E. Highland Avenue, Suite 300, Phoenix, AZ 85016, USA.
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43
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Goodman BS, Posecion LWF, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008; 1:212-22. [PMID: 19468908 PMCID: PMC2682416 DOI: 10.1007/s12178-008-9035-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 07/23/2008] [Indexed: 12/13/2022]
Abstract
Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging.
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Affiliation(s)
- Bradly S Goodman
- Department of Physical Medicine and Rehabilitation, University of Missouri- Columbia, USA.
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44
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Bloodworth DM, Perez-Toro MR, Nouri KH. Neurological Deficits after Epidural Steroid Injection: Time Course, Differential Diagnoses, Management, and Prognosis Suggested by Review of Case Reports. PAIN MEDICINE 2008. [DOI: 10.1111/j.1526-4637.2008.00439.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of Spinal Diagnostic and Treatment Procedures. PAIN MEDICINE 2008. [DOI: 10.1111/j.1526-4637.2008.00437.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lasbleiz J, Siegfried D, Chales G, Marin F, Sighetti M, Duvauferrier R. Évaluation des infiltrations épidurales cervicales sous contrôle tomodensitométrique dans le traitement des névralgies cervico-brachiales mécaniques. ACTA ACUST UNITED AC 2008; 89:317-23. [DOI: 10.1016/s0221-0363(08)93006-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Delayed symptomatic presentation of epidural hematoma after epidural catheter anesthesia: case report. Spine (Phila Pa 1976) 2007; 32:E649-51. [PMID: 18090075 DOI: 10.1097/brs.0b013e31815743e2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The authors present a case report of a 70-year-old woman who presented with delayed symptoms of epidural hematoma after epidural catheter anesthesia. OBJECTIVE We intend to report a unique case of delayed presentation of epidural hematoma after epidural catheter anesthesia. SUMMARY OF BACKGROUND DATA The authors present a case of a 70-year-old woman who received epidural anesthesia via spinal catheter infusion before right knee replacement surgery. After an unremarkable postoperative course, she presented 6 weeks later with worsening middle and lower back pain, prompting a workup and lumbar MR imaging. MRI of her lumbar spine demonstrated a lower thoracic epidural fluid collection with significant radiographic mass effect on the thoracic spine. The fluid was diagnosed as chronic breakdown of an initially asymptomatic epidural hematoma. Symptomatic epidural hematoma formation after epidural block is rare but commonly reported in the literature. The incidence of asymptomatic hematoma formation is probably much higher and unrecognized. METHODS This is a retrospective review of a case seen at our institution. RESULTS A persistent epidural fluid collection in a normocoagulable patient presenting with symptoms of back pain more than a month after spinal block has not been reported in the literature. CONCLUSION In the absence of focal neurologic symptoms, conservative therapy and observation are appropriate.
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Abbasi A, Malhotra G, Malanga G, Elovic EP, Kahn S. Complications of interlaminar cervical epidural steroid injections: a review of the literature. Spine (Phila Pa 1976) 2007; 32:2144-51. [PMID: 17762818 DOI: 10.1097/brs.0b013e318145a360] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A comprehensive literature review. OBJECTIVES To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with interlaminar cervical epidural steroid injection (ICESI). The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications, their presentations, and management. SUMMARY OF BACKGROUND DATA Although ICESI is considered a relatively safe procedure, a number of minor and major complications have been reported across the literature. Thus far, reports of complications are limited to retrospective studies, case reports, and data extrapolated from lumbar and thoracic procedures. As a result, the past literature has been of limited value with regard to facilitating both clinical care and future research efforts. METHODS Medical databases were searched for studies of ICESI. The bibliographies of these papers were then searched as well. Papers focusing on cervical techniques that did not involve injection into the epidural space were discarded, as were studies of thoracic and lumbar spine injections. Reports of complications associated with ICESI were further subdivided into major and minor categories. RESULTS The reported rate of complications associated with ICESI varied between 0 and 16.8%. CONCLUSION There are significant limitations in the available literature discussing the complications associated with ICESI, but they strongly suggest that ICESI is a relatively safe procedure. Numerous potential adverse reactions have been associated with ICESI, with the vast majority being minor and transient in nature. However, serious complications may also result and may be technique related. Injectionists should be aware of the clinical presentations, rates, potential consequences, and appropriate techniques to avoid these complications. More studies are needed with specific focus on cervical complication rates, standardization of injection techniques, and differentiation between complications and poor efficacy. In addition, the use of a prospective randomized blinded controlled design would be beneficial.
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Affiliation(s)
- Arjang Abbasi
- Long Island Spine Specialists, Commack, NY 11725, USA.
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LaBan MM, Kasturi G, Wang IM. Epidural Corticosteroid Injections Precipitating Epidural Hematomas with Spinal Paresis. Am J Phys Med Rehabil 2007; 86:166-7. [PMID: 17251699 DOI: 10.1097/phm.0b013e31802f0385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Myron M LaBan
- Department of Physical Medicine and Rehabilitation, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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