Pneumocephalus during cervical transforaminal epidural steroid injections: a case report

Iatrogenic Pneumocephalus Resolved by Oxygen Therapy

Iatrogenic pneumocephalus and dural puncture are some causes of headache following cervical epidural injection. A 50-year-old woman presented with a sharp headache at the base of her skull following a cervical epidural injection for chronic neck pain. It was not relieved by lying down and was associated with nausea, vomiting, and photophobia without fever or neck rigidity. Neurological examination failed to show any abnormalities. A head CT scan showed newly evident pneumocephalus in the ventricular system and the extra-axial subarachnoid space within the sulci of the right frontal lobe. Oxygen supplementation was started with the help of a non-rebreather mask connected to 15 liters of oxygen and was slowly down titrated to room air. Repeat CT scan of the head after 48 hours showed complete resolution of the intracranial pneumocephalus. Normobaric oxygen therapy via a non-rebreather mask and a high-flow nasal cannula is effective for the treatment of intracranial pneumocephalus.

Feasibility of Using the Epidural Space Detecting Device (EPI-DetectionTM) for Interlaminar Cervical Epidural Injection

Cervical epidural injection (CEI), which is widely used for the treatment of cervical radiculopathy, sometimes has been associated with post-operative complications. Recently, EPI-Detection^TM, which detects the negative pressure of the epidural space and notifies the proceduralist by flashing a light and producing a beeping sound, was introduced. We assumed that the newly developed device could be as safe and efficient as the conventional loss of resistance (LOR) method. Therefore, we aimed to evaluate the effectiveness of the EPI-Detection^TM and compare it to that of the conventional LOR method. We randomly assigned 57 patients to the LOR and EPI-Detection groups (29 and 28 patients, respectively). Subjects were treated with interlaminar CEI (ILCEI) using one of two methods. The measured parameters, i.e., operation time and radiation dose were lower in the EPI-Detection^TM group (4.6 ± 1.2 min vs. 6.9 ± 2.1 min; and 223.2 ± 206.7 mGy·cm² vs. 380.3 ± 340.9 mGy·cm², respectively; all p < 0.05) than in the LOR group. There were no complications noted in either group. Both the EPI-Detection^TM and LOR methods were safe and effective in detecting the epidural space, but the former was superior to the latter in terms of operation time and radiation exposure. The EPI-Detection^TM may help perform ILCEI safely.

Intracranial Hemorrhage and Pneumocephaly After Cervical Epidural Injection

Cervical epidural injections are commonly used to treat patients with radicular neck pain. The following is a description of a case of subarachnoid hemorrhage, subdural hemorrhage, and pneumocephaly following cervical epidural injection.

Safety of CT-guided cervical nerve root corticosteroid injections

INTRODUCTION

Computed tomography-guided cervical nerve root corticosteroid injections are a commonly performed procedure for cervical radiculopathy. There have been major complications such as spinal cord infarction and posterior circulation stroke reported mostly with X-ray fluoroscopic-guided methods, however, there is relatively little data on the safety of newer CT-guided methods. The purpose of this study was to identify any major complications and evaluate the rate of minor complications from CT-guided cervical nerve root corticosteroid injections performed in a tertiary public hospital.

METHODS

Four hundred and three CT-guided cervical nerve root injection procedures were identified over a period from July 2015 to January 2018 using the radiology information system (RIS) and data collected about the technique and any immediate complications. Patient follow-up and delayed complications were then reviewed, either via outpatient clinic records or telephone consultation.

RESULTS

Two hundred and eighty-six procedures were performed by radiology registrars or fellows, and 117 by radiologists, most commonly via an anterolateral approach and injecting 4 mg (in 1 mL) of dexamethasone. Follow-up data were obtained for all 403 procedures and identified 16 minor complications, but no major neurovascular complications.

CONCLUSION

The overall recorded rate of minor complications with CT-guided nerve root injection was 4.0% with no major neurovascular complications, suggesting that CT-guided transforaminal cervical corticosteroid injection is a safe procedure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety of Epidural Corticosteroid Injections

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.