Delayed onset of a spinal epidural hematoma after facet joint injection

Incidence and pattern of epidural spread during lumbar facet joint injection: a prospective study

Background

In clinical practice, we have often observed contrast material spreading into the epidural space during lumbar facet joint injection. However, the exact incidence of epidural spread and contrast pattern have not been reported.

Purpose

To evaluate the incidence and pattern of epidural spread in lumbar facet joint injection.

Material and Methods

One hundred consecutive patients (38 men, 62 women; mean age 68 years; age range 20–88 years) who underwent lumbar facet joint injection at two sites between April 2014 and June 2014 were investigated in this prospective study. Initial oblique, final anteroposterior, and lateral fluoroscopic images were obtained and evaluated for the presence of epidural spread and its contrast pattern (based on direction and extent) with the consensus of three radiologists. The relationship between epidural spread and its potential predictors was analyzed using the chi-squared test, Fisher’s exact test, and the t-test.

Results

The incidence of epidural spread during lumbar facet joint injection was 64.6% (n=64) in 99 patients and 49.5% (n=95) in 192 procedures; ventral spread occurred in 29.2% and foraminal spread in 18.8%. When epidural spread occurred, the most commonly identified distributions were unilateral (73.7%), dorsal (92.6%), and cephalad (92.6%). Epidural spread increased significantly in the caudocephalic direction ( P < 0.0001), in men (relative risk [RR]=1.478), in the adjacency of posterior fusion level (RR=1.545), in patients with spondylolisthesis (RR=1.454), and when there was no other leakage (RR=0.334).

Conclusion

Epidural spread occurred at about half the number of lumbar facet joint injections and showed a contrast pattern similar to that seen with the interlaminar approach.

Facet joint syndrome: from diagnosis to interventional management

Abstract

Low back pain (LBP) is the most common pain syndrome, and is an enormous burden and cost generator for society. Lumbar facet joints (FJ) constitute a common source of pain, accounting for 15–45% of LBP. Facet joint degenerative osteoarthritis is the most frequent form of facet joint pain. History and physical examination may suggest but not confirm facet joint syndrome. Although imaging (radiographs, MRI, CT, SPECT) for back pain syndrome is very commonly performed, there are no effective correlations between clinical symptoms and degenerative spinal changes. Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as neurolysis, by radiofrequency or cryoablation. The purpose of this review is to describe the anatomy, epidemiology, clinical presentation, and radiologic findings of facet joint syndrome. Specific interventional facet joint management will also be described in detail.

Teaching points

• Lumbar facet joints constitute a common source of pain accounting of 15–45%.

• Facet arthrosis is the most frequent form of facet pathology.

• There are no effective correlations between clinical symptoms, physical examination and degenerative spinal changes.

• Diagnostic positive facet joint block can indicate facet joints as the source of pain.

• After selection processing, patients may benefit from facet joint neurolysis, notably by radiofrequency or cryoablation.