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Campbell DH, Dowling TJ, Hah R, Alluri RK, Wang JC. Surgical strategies for spinal infections: A narrative review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100293. [PMID: 38162170 PMCID: PMC10757275 DOI: 10.1016/j.xnsj.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024]
Abstract
The successful operative management of spinal infections necessitates a thoughtful approach. Ideal treatment combines the universal goals of any spine operation, which are decompression of the neural elements and stabilization of instability, with source control and eradication of infection. Techniques to treat infection have evolved independently and alongside advances in implant technology and surgical techniques. This review will seek to outline current thinking on approaches to both primary and secondary spinal infections.
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Affiliation(s)
- David H. Campbell
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Thomas J. Dowling
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - R. Kiran Alluri
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Jeffrey C. Wang
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
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Lo Bianco G, Tinnirello A, Papa A, Torrano V, Russo G, Stogicza A, Mercadante S, Cortegiani A, Mazzoleni S, Schatman ME. Interventional Pain Procedures: A Narrative Review Focusing on Safety and Complications. Part 1 Injections for Spinal Pain. J Pain Res 2023; 16:1637-1646. [PMID: 37223436 PMCID: PMC10202209 DOI: 10.2147/jpr.s402798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/15/2023] [Indexed: 05/25/2023] Open
Abstract
In recent years, there has been a considerable increase in the number of image-guided interventional procedures performed for the management of acute and chronic pain. Concomitantly, there has also been an increase in the complication rate related to these procedures. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopic- or ultrasound-guided) interventional procedures. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.
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Affiliation(s)
- Giuliano Lo Bianco
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
- Department of Anesthesiology and Pain, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Andrea Tinnirello
- Department of Anesthesiology and Pain Medicine, ASST Franciacorta, Ospedale di Iseo, Iseo, Italy
| | - Alfonso Papa
- Department of Pain Management– AO “Ospedali dei Colli” – Monaldi Hospital, Naples, Italy
| | - Vito Torrano
- Department of Anesthesia, Critical Care and Pain Medicine, Asst Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gianluca Russo
- Department of Anesthesia, Postoperative Intensive Care and Pain Therapy, Lodi Hospital, Lodi, Italy
| | - Agnes Stogicza
- Department of Anesthesiology Saint Magdolna Hospital, Budapest, Hungary
| | - Sebastiano Mercadante
- Department of Pain Relief and Supportive Care, Private Hospital La Maddalena, Palermo, Sicilia, Italy
| | - Andrea Cortegiani
- Department of Anesthesiology and Intensive Care, Università degli Studi di Palermo, Palermo, Italy
| | - Silvia Mazzoleni
- Department of Anesthesiology and Pain Medicine, ASST Franciacorta, Ospedale di Iseo, Iseo, Italy
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA
- Department of Population Health – Division of Medical Ethics, NYU School of Medicine, New York, NY, USA
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Kazarian GS, Steinhaus ME, Kim HJ. The Impact of Corticosteroid Injection Timing on Infection Rates Following Spine Surgery: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1524-1534. [PMID: 34569332 PMCID: PMC9393993 DOI: 10.1177/21925682211026630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN/SETTING Systematic review/meta-analysis. OBJECTIVES The objective of this review was to assess how the risk of infection following lumbar spine surgery varies as a function of the timing of preoperative corticosteroid spinal injections (CSIs). METHODS A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. PubMed and EMBASE databases were searched and data was pooled for meta-analysis. RESULTS Six studies were identified for inclusion. Two (33.3%) demonstrated a significant relationship between the timing of preoperative CSIs and the risk of postoperative infection, while 4 (66.7%) demonstrated no impact. A total of 2.5% (110/4,448) of patients who underwent CSI <1 month before surgery experienced a postoperative infection, as compared to 1.2% (1,466/120, 943) of controls, which was statistically significant (RR = 1.986 95% CI 1.202-3.282 P = 0.007). A total of 1.6% (25/1,600) of patients who underwent CSI 0-3 months before surgery experienced a postoperative infection, as compared to 1.6% (201/12, 845) of controls (RR = 0.887 95% CI 0.586-1.341, P = 0.569). A total of 1.1% (199/17 870) of patients who underwent CSI 3-6 months before surgery experienced a postoperative infection, as compared to 1.3% (1,382/102, 572) of controls (RR = 1.053 95% CI 0.704-1.575, P = 0.802). Differences in infection risk for 0-3 months and 3-6 months were not statistically significant. CONCLUSIONS CSIs <1 month prior to lumbar spine surgery are a significant risk factor for infection, while CSIs beyond that point showed no such association. Surgeons should consider avoiding CSIs <1 month of the use of CSIs of the spine.
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Affiliation(s)
| | | | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, NY, USA,Han Jo Kim, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E 70th St, NY 10021, USA.
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Levin J, Chan J, Gall N, Koltsov J, Huynh L. Retrospective analysis of cervical transforaminal versus interlaminar epidural steroid injections. INTERVENTIONAL PAIN MEDICINE 2022; 1:100102. [PMID: 39239365 PMCID: PMC11372919 DOI: 10.1016/j.inpm.2022.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/01/2022] [Accepted: 05/09/2022] [Indexed: 09/07/2024]
Abstract
Background Several studies have compared outcomes from lumbar epidural steroid injections (ESIs) based upon technique (transforaminal (TF) vs interlaminar (IL) vs caudal). However, little on this topic has been reported in the cervical spine, and results have been conflicting. Purpose To compare success rates of fluoroscopically-guided cervical TFESIs vs ILESIs. Study design/setting Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sample Consecutive patients who received a cervical TF or IL ESI between January 2010 and October 2018. Outcome measures NRS pain scores within 60 days of the ESI. Methods Current procedural terminology (CPT) codes were used to search all consecutive patients at a single outpatient academic spine center who received a cervical TF or IL ESI between January 2010 October 2018. All patients with pre and post injection NRS pain scores within 60 days of the injection were included in the analysis. Results A total of 178 TF and 185 ILESIs were analyzed. Success was defined as ≥ 50% improvement in NRS pain score. 52% [95% CI: 47 - 57%] of all patients receiving a cervical ESI achieved a successful outcome. There was a strong trend towards better results in the ILESI group with 59% [95% CI: 52 - 66%] of patients achieving at least 50% pain relief compared to 46% [95% CI: 39 - 53%] in the TF group. A higher proportion of patients in the IL group obtained at least 80% pain relief (37% [95% CI: 30 - 44%]) compared to those in the TF group (17% [95% CI: 11 - 23%]). Post-procedure median NRS pain scores, and improvement in median NRS pain scores were better in the ILESI group compared to the TFESI group (p<0.001). Conclusion This retrospective study demonstrated better results in the cervical ILESI group compared to the cervical TFESI group.
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Affiliation(s)
- Josh Levin
- Department of Orthopaedic Surgery, Stanford University, United States
- Department of Neurosurgery, Stanford University, United States
| | - John Chan
- Department of Orthopaedic Surgery, Stanford University, United States
| | - Nolan Gall
- Department of Orthopaedic Surgery, Stanford University, United States
| | - Jayme Koltsov
- Department of Orthopaedic Surgery, Stanford University, United States
| | - Lisa Huynh
- Department of Orthopaedic Surgery, Stanford University, United States
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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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Brunasso L, Basile L, Gerardo Iacopino D, Gulì C, Graziano F, Pino MA, Nicoletti GF, Tumbiolo S, Maugeri R. All that glitters is not gold: A spinal epidural empyema following epidural steroid injection. Surg Neurol Int 2020; 11:240. [PMID: 32874743 PMCID: PMC7451159 DOI: 10.25259/sni_340_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Therapeutic epidural spinal injections (ESIs) of steroids are one of the most common nonsurgical management modalities employed for alleviating pain due to chronic persistent lumbar spinal disease. However, it is well documented that they have significant risks and complications without any long-term efficacy. ESI may result in epidural empyema which may be difficult to diagnose with delays resulting in significant permanent neurological sequelae. Case Description: A 45-year-old female presented with a lumbar spinal epidural empyema after receiving ESI for low back and right leg pain due to a lumbar disc herniation. Laboratory studies showed elevations of multiple inflammatory markers, and the MR documented a significant lumbar epidural empyema contributing to significant thecal sac compression. Clinically, the patient had an acute cauda equina syndrome warranting emergency surgery consisting of a laminectomy for debridement/decompression followed by long-term antibiotic treatment. Conclusion: Epidural empyema is a major potential complication of lumbar ESI. Multiple markedly elevated inflammatory markers (WBC, ESR, CRP, and procalcitonin) and MRI evidence of an epidural empyema necessitates emergent surgical intervention to limit morbidity, neurological sequelae, and mortality.
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Affiliation(s)
- Lara Brunasso
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Luigi Basile
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Domenico Gerardo Iacopino
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Carlo Gulì
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Francesca Graziano
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Maria Angela Pino
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | | | - Silvana Tumbiolo
- Division of Neurosurgery, Villa Sofia Hospital, Palermo, Sicily, Italy
| | - Rosario Maugeri
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
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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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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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10
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Abstract
RATIONALE Spinal epidural abscess is an uncommon complication in clinical practice. If the abscess is large enough, the patient will rapidly develop neurologic signs of spinal injury, and urgent neurosurgical intervention may be required. PATIENT CONCERNS Rapid and correct diagnosis and treatment is important for spinal epidural abscess complication. DIAGNOSES This report describes a cervical epidural abscess (CEA) caused by epidural analgesia, wherein the patient was punctured twice. A CEA was suspected based on the patient's significant neck pain and elevated white blood cell and neutrophil counts. A CEA from C6 to T8 was confirmed by magnetic resonance imaging scan. INTERVENTIONS The patient was treated with a combination of intravenous vancomycin and imipenem/cilastatin for more than 4 weeks. OUTCOMES After more than 2 weeks of intensive antibiotic treatment, the epidural abscess gradually diminished in size, the white blood cell count, neutrophil count, hyperallergic C-reactive protein (CRP), and general CRP decreased, and the patient's neck and back pain resolved. After more than 4 weeks of anti-inflammation therapy, the epidural abscess was completely absorbed, and there was no relapse during the 3-month follow-up period. LESSONS Although an effective combination of intravenous antibiotics can cure an epidural abscess, caution is warranted when performing epidural steroid injections in immunocompromised patients.
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Affiliation(s)
- Jun-Hui Zhang
- 903 Hospital, Jiangyou City, Sichuan Province
- The Second Affiliated Hospital, State Key Clinical Specialty in Pain Medicine, Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Zhi-Li Wang
- 903 Hospital, Jiangyou City, Sichuan Province
| | - Li Wan
- The Second Affiliated Hospital, State Key Clinical Specialty in Pain Medicine, Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
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Virk S, Phillips FM, Khan S. Patterns of healthcare resource utilization prior to anterior cervical decompression and fusion in patients with radiculopathy. Int J Spine Surg 2017; 11:25. [PMID: 32373448 DOI: 10.14444/4025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Objective To assess patterns of healthcare resource utilization prior to anterior cervical decompression and fusion (ACDF) in patients diagnosed with radiculopathy with a retrospective cohort study design. Background ACDF is associated with improvement in quality of life among patients with cervical radiculopathy. However, little is known regarding utilization of healthcare services and total cost of care before ACDF surgery in the United States. Methods We analyzed a group of patients who received ACDF for radiculopathy during 2009-2011 using a healthcare database of over 20 million patients of all ages. Patients with fewer than two years of data prior to ACDF procedure were excluded. Inclusion criteria included patients with a diagnosis of disc displacement/degeneration and radiculopathy. All charges related to healthcare administration within two years prior to surgery were recorded and analyzed. Results Sixteen hundred seventy six patients met the inclusion criteria. Seventy-three percent of patients were in the 40-59 year age range; 55% were women and 45% were men. In the two years preceding the surgery, 34% of patients received prescription NSAIDs, and 98% received prescription narcotics for total charges of $101,188 ($174.46/patient) and $222,860 ($134.82/patient) respectively. Total pain-related interventions over two years (oral pharmacotherapy and injections) were charged at $4,368,900 at an average of $2,606/treatment. Total outpatient charges including physician office visits, other outpatient visits and emergency room visits amounted to $25,450,012. Mean total outpatient charges over the two years preceding ACDF was $15,556 per patient for 26,397 episodes of care. Injectable corticosteroids were provided for 84.7% of patients and charges related to this treatment totaled $1,137 per patient. Conclusions In the two years prior to ACDF, healthcare resource utilization is extremely high. Given that these patients ultimately undergo surgical intervention, opportunities to reduce charges of conservative care exist.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Frank M Phillips
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Safdar Khan
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques. Anesthesiology 2017; 126:585-601. [DOI: 10.1097/aln.0000000000001521] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text.
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Cancienne JM, Werner BC, Puvanesarajah V, Hassanzadeh H, Singla A, Shen FH, Shimer AL. Does the Timing of Preoperative Epidural Steroid Injection Affect Infection Risk After ACDF or Posterior Cervical Fusion? Spine (Phila Pa 1976) 2017; 42:71-77. [PMID: 28072635 DOI: 10.1097/brs.0000000000001661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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 retrospective database analysis. OBJECTIVE The aim of this study was to determine whether any association exists between preoperative cervical epidural steroid injections (CESIs) at various time intervals before anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF) and the incidence of postoperative infection. SUMMARY OF BACKGROUND DATA Although infectious complications following CESI are uncommon, the association between preoperative CESI and postoperative infection following ACDF or PCF has yet to be evaluated in the current literature. METHODS A national insurance database was utilized to compare postoperative infection rates within 90 days in patients who received a CESI before ACDF or PCF. Three cohorts were created for each procedure: PCF (n = 402) or ACDF (n = 4354) within 3 months, PCF (n = 586) or ACDF (n = 5183) between 3 and 6 months, and PCF (n = 629) or ACDF (3648) between 6 and 12 months following a CESI. These cohorts were compared with control cohorts who underwent PCF (n = 61,253) or ACDF (n = 241,678) without prior CESI. Postoperative infection rates within 90 days were assessed using International Classification of Disease, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Odds ratios (ORs), 95% confidence intervals (95% CIs), and P values were then calculated using SPSS. A multivariate binomial logistic regression analysis was performed to determine the independent effect of preoperative injection on postoperative infection following ACDF or PCF controlling for known risk factors for infection, including age, gender, obesity, diabetes, and smoking. RESULTS Patients who underwent CESI within 3 months (OR 2.21, P < 0.0001) and within 3 to 6 months (OR 1.95, P = 0.0002) before PCF had significantly increased odds of developing a postoperative infection. Patients who underwent CESI within 3 months (OR 1.83, P < 0.0001) before ACDF had significantly increased odds of developing a postoperative infection. CONCLUSION The present study demonstrates that cervical ESI within 6 months of PCF, and within 3 months of ACDF, is independently associated with significantly increased rates of postoperative infection. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
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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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Al-Hourani K, Al-Aref R, Mesfin A. Upper Cervical Epidural Abscess in Clinical Practice: Diagnosis and Management. Global Spine J 2016; 6:383-93. [PMID: 27190742 PMCID: PMC4868579 DOI: 10.1055/s-0035-1565260] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 08/31/2015] [Indexed: 12/17/2022] Open
Abstract
Study Design Narrative review. Objective Upper cervical epidural abscess (UCEA) is a rare surgical emergency. Despite increasing incidence, uncertainty remains as to how it should initially be managed. Risk factors for UCEA include immunocompromised hosts, diabetes mellitus, and intravenous drug use. Our objective is to provide a comprehensive overview of the literature including the history, clinical manifestations, diagnosis, and management of UCEA. Methods Using PubMed, studies published prior to 2015 were analyzed. We used the keywords "Upper cervical epidural abscess," "C1 osteomyelitis," "C2 osteomyelitis," "C1 epidural abscess," "C2 epidural abscess." We excluded cases with tuberculosis. Results The review addresses epidemiology, etiology, imaging, microbiology, and diagnosis of this condition. We also address the nonoperative and operative management options and the relative indications for each as reviewed in the literature. Conclusion A high index of suspicion is required to diagnose this rare condition with magnetic resonance imaging being the imaging modality of choice. There has been a shift toward surgical management of this condition in recent times, with favorable outcomes.
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Affiliation(s)
- Khalid Al-Hourani
- Department of Orthopaedic Surgery, Bristol Royal Infirmary, Bristol, England, United Kingdom
| | - Rami Al-Aref
- Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, United States,Address for correspondence Addisu Mesfin, MD Department of Orthopaedic Surgery and OncologyUniversity of Rochester School of Medicine and Dentistry601 Elmwood Avenue, Box 665Rochester, NY 14642
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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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Method to Reduce the False-Positive Rate of Loss of Resistance in the Cervical Epidural Region. Pain Res Manag 2016; 2016:9894054. [PMID: 27445637 PMCID: PMC4904629 DOI: 10.1155/2016/9894054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/30/2015] [Indexed: 01/09/2023]
Abstract
Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.
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DeFroda SF, DePasse JM, Eltorai AEM, Daniels AH, Palumbo MA. Evaluation and management of spinal epidural abscess. J Hosp Med 2016; 11:130-5. [PMID: 26540492 DOI: 10.1002/jhm.2506] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/29/2015] [Accepted: 10/06/2015] [Indexed: 11/12/2022]
Abstract
Spinal epidural abscess (SEA) is an uncommon and potentially catastrophic condition. SEA often presents a diagnostic challenge, as the "classic triad" of fever, spinal pain, and neurological deficit is evident in only a minority of patients. When diagnosis is delayed, irreversible neurological damage may ensue. To minimize morbidity, an appropriate level of suspicion and an understanding of the diagnostic evaluation are essential. Infection should be suspected in patients presenting with axial pain, fever, or elevated inflammatory markers. Although patients with no known risk factors can develop SEA, clinical concern should be heightened in the presence of diabetes, intravenous drug use, chronic renal failure, immunosuppressant therapy, or a recent invasive spine procedure. When the clinical profile is consistent with the diagnosis of SEA, gadolinium-enhanced magnetic resonance imaging of the spinal column should be obtained on an emergent basis to delineate the location and neural compressive effect of the abscess. Rapid diagnosis allows for efficient treatment, which optimizes the potential for a positive outcome.
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Affiliation(s)
- Steven F DeFroda
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Mason DePasse
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adam E M Eltorai
- Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopaedics, Division of Spine Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mark A Palumbo
- Department of Orthopaedics, Division of Spine Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
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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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Cervical radicular pain: the role of interlaminar and transforaminal epidural injections. Curr Pain Headache Rep 2014; 18:389. [PMID: 24338702 DOI: 10.1007/s11916-013-0389-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic neck pain and cervical radicular pain are relatively common in the adult population. Treatment for chronic radicular pain recalcitrant to conservative management includes surgical management as well as interventional techniques with epidural injections utilizing either an interlaminar approach or transforaminal approach. Although there have been multiple systematic reviews and randomized clinical trials of cervical interlaminar epidural injections, the literature is sparse in reference to cervical transforaminal epidural injections. Overall, there is good evidence for the effectiveness of cervical interlaminar epidural injections in managing cervical disc herniation and fair evidence in managing central spinal stenosis and postsurgery syndrome. The evidence is poor, however, for cervical transforaminal epidural injections. Complications with cervical interlaminar epidural injections are rare, but more commonly occur with transforaminal epidural injections and can be fatal. Emerging concepts in pain include further randomized trials; proper placebo design; focus on control design (either active control or placebo control); and appropriate methodologic quality assessment and evidence synthesis.
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Abstract
Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.
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Morelli JN, Porbandarwala N, Patel DV. Spinal cord needle tract following epidural steroid injection. J Vasc Interv Radiol 2013; 23:1543-4. [PMID: 23101928 DOI: 10.1016/j.jvir.2012.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 07/16/2012] [Accepted: 07/24/2012] [Indexed: 10/27/2022] Open
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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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Kainer MA, Reagan DR, Nguyen DB, Wiese AD, Wise ME, Ward J, Park BJ, Kanago ML, Baumblatt J, Schaefer MK, Berger BE, Marder EP, Min JY, Dunn JR, Smith RM, Dreyzehner J, Jones TF. Fungal infections associated with contaminated methylprednisolone in Tennessee. N Engl J Med 2012; 367:2194-203. [PMID: 23131029 PMCID: PMC4669562 DOI: 10.1056/nejmoa1212972] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We investigated an outbreak of fungal infections of the central nervous system that occurred among patients who received epidural or paraspinal glucocorticoid injections of preservative-free methylprednisolone acetate prepared by a single compounding pharmacy. METHODS Case patients were defined as patients with fungal meningitis, posterior circulation stroke, spinal osteomyelitis, or epidural abscess that developed after epidural or paraspinal glucocorticoid injections. Clinical and procedure data were abstracted. A cohort analysis was performed. RESULTS The median age of the 66 case patients was 69 years (range, 23 to 91). The median time from the last epidural glucocorticoid injection to symptom onset was 18 days (range, 0 to 56). Patients presented with meningitis alone (73%), the cauda equina syndrome or focal infection (15%), or posterior circulation stroke with or without meningitis (12%). Symptoms and signs included headache (in 73% of the patients), new or worsening back pain (in 50%), neurologic symptoms (in 48%), nausea (in 39%), and stiff neck (in 29%). The median cerebrospinal fluid white-cell count on the first lumbar puncture among patients who presented with meningitis, with or without stroke or focal infection, was 648 per cubic millimeter (range, 6 to 10,140), with 78% granulocytes (range, 0 to 97); the protein level was 114 mg per deciliter (range, 29 to 440); and the glucose concentration was 44 mg per deciliter (range, 12 to 121) (2.5 mmol per liter [range, 0.7 to 6.7]). A total of 22 patients had laboratory confirmation of Exserohilum rostratum infection (21 patients) or Aspergillus fumigatus infection (1 patient). The risk of infection increased with exposure to lot 06292012@26, older vials, higher doses, multiple procedures, and translaminar approach to epidural glucocorticoid injection. Voriconazole was used to treat 61 patients (92%); 35 patients (53%) were also treated with liposomal amphotericin B. Eight patients (12%) died, seven of whom had stroke. CONCLUSIONS We describe an outbreak of fungal meningitis after epidural or paraspinal glucocorticoid injection with methylprednisolone from a single compounding pharmacy. Rapid recognition of illness and prompt initiation of therapy are important to prevent complications. (Funded by the Tennessee Department of Health and the Centers for Disease Control and Prevention.).
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Affiliation(s)
- Marion A Kainer
- Division of Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Health, 1st Fl., Cordell Hull Bldg., 425 5th Ave. N., Nashville, TN 37243, USA.
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Cohen-Adad J, Buchbinder B, Oaklander AL. Cervical spinal cord injection of epidural corticosteroids: comprehensive longitudinal study including multiparametric magnetic resonance imaging. Pain 2012; 153:2292-2299. [PMID: 22964435 PMCID: PMC3472087 DOI: 10.1016/j.pain.2012.07.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 07/05/2012] [Accepted: 07/25/2012] [Indexed: 10/27/2022]
Abstract
Despite widespread use, the efficacy of epidural corticosteroid injections (ESI) for osteoarthritis-associated neck or radicular pain remains uncertain, so even rare serious complications enter into discussions about use. However, various factors impede investigation and publication of serious adverse events. To that end, we developed new magnetic resonance imaging (MRI) techniques for spinal cord white matter quantification and used the best available physiological tests to characterize a cervical spinal cord lesion caused by inadvertent intramedullary injection of Depo-Medrol. A 29-year-old woman with mild cervical osteoarthritis had 2 years of headache and neck pain (concussion and whiplash) after 2 minor motor vehicle accidents. During C5-6 ESI, she developed new left-sided motor and sensory symptoms, and MRI demonstrated a new left dorsal spinal cord cavity. Mild left-sided motor and sensory symptoms have persisted for more than 2.5 years, during which time we performed serial neurological examinations, standard electrodiagnostics, somatosensory evoked potentials, and transcranial measurement of corticospinal central motor conduction time (CMCT). We used 3-Tesla MRI with a 32-channel coil developed for high-resolution cervical spinal cord structural imaging, diffusion tensor imaging (DTI), and magnetization transfer (MT). T(2)(∗)-weighted signal and DTI and MT metrics showed delayed spread of the lesion across 4 vertebral levels rostrally, consistent with Wallerian degeneration within the ascending left dorsal columns. However, only CMCT metrics detected objective correlates of her left hemiparesis and bilateral hyperreflexia. DTI and MT metrics may better distinguish between post-traumatic demyelination and axonal degeneration than conventional MRI. These tests should be considered to better characterize similar spinal cord injuries.
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Affiliation(s)
- Julien Cohen-Adad
- A.A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Electrical Engineering, Ecole Polytechnique de Montreal, QC, Canada
| | - Bradley Buchbinder
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Anne Louise Oaklander
- Harvard Medical School, Boston, MA, USA
- Departments of Neurology and Neuropathology, Massachusetts General Hospital, Boston, MA, USA
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Abstract
IMPORTANCE OF THE FIELD Local injections of steroids have been widely practiced to provide regional analgesia for the treatment of a wide variety of musculoskeletal pain syndromes. However, evidence regarding the effectiveness of steroid injections is not substantial. Also, there have been reports of catastrophic complications associated with their use. AREAS COVERED IN THIS REVIEW The evidence currently available in the literature (Database: Ovid MEDLINE 1950 to 2010) is reviewed. The areas covered include the analgesic mechanisms of steroids, indications for steroid injections and their effectiveness, as well as the risks and precautions for steroid injections. WHAT THE READER WILL GAIN This is an up-to-date review on the clinical application of steroid injections for regional analgesia, which will give the reader an insight on how to maximize the benefits of steroids while minimizing their side effects and complications. TAKE HOME MESSAGE Although steroid injections are generally considered effective and safe in the treatment of painful condition of limbs, their use in the treatment of chronic back pain is still controversial and serious complications have been reported. More studies on outcome and safety are warranted.
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Affiliation(s)
- Steven H S Wong
- Queen Elizabeth Hospital, Department of Anaesthesiology, Hong Kong.
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Affiliation(s)
- Rabih O Darouiche
- Center for Prostheses Infection, Baylor College of Medicine, Houston, TX 77030, USA.
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Benedetti EM, Siriwetchadarak R, Stanec J, Rosenquist RW. Epidural steroid injections: Complications and management. ACTA ACUST UNITED AC 2009. [DOI: 10.1053/j.trap.2009.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Smuck M, Rosenberg JM, Akuthota V. The use of epidural corticosteroids for cervical radiculopathy: an interlaminar versus transforaminal approach. PM R 2009; 1:178-84. [PMID: 19627891 DOI: 10.1016/j.pmrj.2008.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 12/04/2008] [Indexed: 01/27/2023]
Affiliation(s)
- Matthew Smuck
- Department of Orthopaedic Surgery, Director, Stanford Interventional Spine Center Stanford University, Stanford, CA, USA
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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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Heran MKS, Smith AD, Legiehn GM. Spinal injection procedures: a review of concepts, controversies, and complications. Radiol Clin North Am 2008; 46:487-514, v-vi. [PMID: 18707959 DOI: 10.1016/j.rcl.2008.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.
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Affiliation(s)
- Manraj K S Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, Canada.
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Horlocker TT, Wedel DJ. Infectious complications of regional anesthesia. Best Pract Res Clin Anaesthesiol 2008; 22:451-75. [DOI: 10.1016/j.bpa.2008.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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34
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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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Reid PJ, Holman PJ. Iatrogenic pyogenic osteomyelitis of C-1 and C-2 treated with transoral decompression and delayed posterior occipitocervical arthrodesis. Case report. J Neurosurg Spine 2008; 7:664-8. [PMID: 18074694 DOI: 10.3171/spi-07/12/664] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a case of osteomyelitis of the craniocervical junction caused by iatrogenic infection of the spine during corticosteroid injection therapy. This 58-year-old diabetic man presented with acute exacerbation of neck pain that had began 4 months prior to admission. He did not experience the associated fever, chills, or sweats, but he did notice transient weakness in the right upper extremity. A computed tomography (CT) scan of the cervical spine demonstrated a destructive process involving the odontoid and the left occipitocervical and atlantoaxial joints that was not present on a CT obtained 2 months earlier, just before trigger-point and left-sided C1-2 facet joint corticosteroid injections. A diagnosis of staphylococcal osteomyelitis was made, and initial treatment with external immobilization and appropriate antibiotic therapy failed to control radiographically demonstrated and clinical progression. The patient was successfully treated using staged anterior decompression and posterior instrumented fusion with prolonged antibiotic therapy. To the authors' knowledge this case is the first reported instance of iatrogenic pyogenic osteomyelitis of the craniocervical junction successfully treated with anterior decompression and delayed posterior arthrodesis.
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Affiliation(s)
- Patrick J Reid
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York 14642-8670, USA.
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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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Kwon JW, Lee JW, Kim SH, Choi JY, Yeom JS, Kim HJ, Kwack KS, Moon SG, Jun WS, Kang HS. Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol 2007; 36:431-6. [PMID: 17340166 DOI: 10.1007/s00256-006-0258-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Revised: 08/14/2006] [Accepted: 01/15/2007] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To verify the usefulness of a fluoroscopy guided cervical interlaminar epidural steroid injection (CIESI) in patients with neck pain and cervical radiculopathy and to evaluate outcome predictors. DESIGN We retrospectively analyzed 91 patients from July 2004 to June 2005 in whom CIESI was initially performed for neck pain and cervical radiculopathy. Therapeutic effects were evaluated 2 weeks after the administration of CIESI, and CIESI effectiveness was graded using a five-point scale, namely, whether the pain had disappeared, was much improved, slightly improved, the same, or aggravated. We also used a visual analog scale (VAS) for the clinical evaluation. According to documentation and follow-up charts, we categorized treatments as effective or ineffective. Possible outcome predictors, namely, diagnosis (spinal stenosis vs herniated disc), primary symptoms (neck pain vs radiculopathy vs both), age, gender, and duration of pain (more or less than 6 months) were also analyzed. Fisher's exact test, the chi-square test, and multiple logistic regression analysis were used for the statistical analysis. PATIENTS After their medical records had been reviewed, 76 patients were included in this study. Inclusion criteria were: the availability of a cross-sectional image, such as a CT scan or an MR image, and a follow-up record after injection. RESULTS AND CONCLUSIONS The medical records of 76 patients (male:female = 41 : 35) of mean age 53.1 years (range 32 years to 82 years) were reviewed. Two weeks after injection, 55 patients (72.4%) had experienced effective pain relief. Patients with herniated discs had significantly better results than patients with spinal stenosis (86.1% vs 60.0%) (P < 0.05). Other non-significant predictors of an improved outcome included: a symptom duration of <6 months, a young age, and the presence of cervical radiculopathy. Multiple regression analysis showed that the only factor that was significantly associated with outcome was the cause of the pain, i.e., herniated disc or spinal stenosis. Fluoroscopy guided CIESI is a safe and effective means of treating patients with neck pain and cervical radiculopathy. The most important outcome predictor was cause of pain, and patients with herniated disc experienced better pain relief than those with spinal stenosis.
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Affiliation(s)
- Jong Won Kwon
- Department of Radiology, Seoul National University Bundang Hospital, 300 Gumidong, Bundang-Gu, Seongnam-si, Gyeonggi-do, South Korea
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Industrial medicine and acute musculoskeletal rehabilitation. 4. Interventional procedures for work-related cervical spine conditions. Arch Phys Med Rehabil 2007; 88:S18-21. [PMID: 17321843 DOI: 10.1016/j.apmr.2006.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED This self-directed learning module outlines the use of interventional techniques in the treatment of neck pain with and without referred pain into the arm. It is part of the supplement on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on interventions used to diagnose or treat the conditions commonly seen in patients with neck pain or referred pain into the upper limb. Techniques reviewed include the use of botulinum toxin injections in the treatment of myofascial pain, cervical zygapophyseal joint injections and radiofrequency neuroablation in the treatment of posterior column disorders, and epidural steroid injections in the treatment of cervical radicular and referred upper-limb pain. OVERALL ARTICLE OBJECTIVE To give an overview of the current state of the art regarding diagnostic and nonsurgical invasive treatment procedures for neck pain with and without referred upper-limb pain.
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Sizer PS, Phelps V, Azevedo E, Haye A, Vaught M. Diagnosis and management of cervicogenic headache. Pain Pract 2006; 5:255-74. [PMID: 17147589 DOI: 10.1111/j.1533-2500.2005.05312.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Upper cervical pain and/or headaches originating from the C0 to C3 segments are pain-states that are commonly encountered in the clinic. The upper cervical spine anatomically and biomechanically differs from the lower cervical spine. Patients with upper cervical disorders fall into two clinical groups: (1) local cervical syndrome; and (2) cervicocephalic syndrome. Symptoms associated with various forms of both disorders often overlap, making diagnosis a great challenge. The recognition and categorization of specific provocation and limitation patterns lend to effective and accurate diagnosis of local cervical and cervicocephalic conditions.
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Affiliation(s)
- Phillip S Sizer
- Texas Tech University Health Science Center, School of Allied Health, Doctorate of Science Program in Physical Therapy, Lubbock, Texas 79430, USA.
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Affiliation(s)
- Rabih O Darouiche
- Infectious Disease Section, the Michael E. DeBakey Veterans Affairs Medical Center, and the Center for Prostheses Infection, Baylor College of Medicine, Houston, TX 77030, USA.
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Lin EL, Lieu V, Halevi L, Shamie AN, Wang JC. Cervical epidural steroid injections for symptomatic disc herniations. ACTA ACUST UNITED AC 2006; 19:183-6. [PMID: 16770215 DOI: 10.1097/01.bsd.0000190558.13248.e1] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs. METHODS Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention. RESULTS Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series. CONCLUSIONS Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.
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Affiliation(s)
- Eric L Lin
- Department of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, CA, USA.
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Abstract
Epidural abscess following epidural analgesia is an unusual event especially in pediatric patients. Two patients presented with fever and local signs of infection without neurological deficit on day 4 after the initiation of epidural analgesia. Neuro-imaging studies revealed epidural abscess. Both pediatric patients were treated successfully with intravenous antibiotics. One of the patients' initial MRI was normal. However, the symptoms persisted and a followed-up scan revealed epidural abscess. The other patient presented with worsening local indurations over the epidural insertion site and positive blood culture with Hemolytic streptococcus. Our experience suggests that neuro-imaging study should be strongly considered to evaluate pediatric patients with suspicion of epidural abscess.
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Affiliation(s)
- Yuan-Chi Lin
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
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Schütze M, Piek J. Paracervical abscesses as life-threatening complications of outpatient pain treatment. Report of three cases. Neurosurg Focus 2004; 17:E13. [PMID: 15636570 DOI: 10.3171/foc.2004.17.6.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present three cases of iatrogenic paracervical abscesses caused by infiltration therapy of pain medications used in conservative treatment in patients with chronic cervicobrachialgia. All three patients had received this therapy several times before presenting with clinical signs of a local infection. The diagnosis was made based on results of the clinical examination, laboratory tests, and magnetic resonance imaging. The organism isolated was Staphylococcus aureus in all cases. After immediate surgery and long-term antibiotic therapy, all patients had a good outcome. The authors conclude that infectious complications after invasive outpatient treatment often go undiagnosed, but as shown in these three cases can lead to acute and sometimes life-threatening complications. If the disease is diagnosed early, immediate surgical evacuation combined with antibiotic therapy results in recovery. For medicolegal reasons it should kept in mind that even a routine injection may lead to such complications.
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