Delayed onset paraparesis complicating epidural steroid injection with underlying spinal dural arteriovenous fistula

Moderate and deep procedural sedation-the role of proper monitoring and safe techniques in clinical practice

PURPOSE OF REVIEW

Interventional pain management procedures provide significant improvement to patient quality of life and functionality. In-office procedures are becoming an increasingly more common site of pain management intervention for patients with minimal risk of harm.

RECENT FINDINGS

Moderate and deep sedation techniques can be used in patients with high anxiety, complex pharmacotherapy, or a low pain threshold. Proper guidance and oversight by an attending anesthesiologist, in addition to appropriate monitoring, are key. Epidural steroid injection complications rates have been cited at 2.4%, with the most common complications noted as persistent pain and flushing.

SUMMARY

Serious complication errors can be avoided with proper supervision and monitoring. The adherence to published societal recommendations and guidelines for indications of when to use moderate to deep sedation techniques, and appropriate supervision and monitoring methods, can avoid errors in interventional pain management procedures.

Steroid-Associated Acute Clinical Worsening and Poor Outcome in Patients With Spinal Dural Arteriovenous Fistulas: A Prospective Cohort Study

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

We conducted a prospective cohort study to identify the association between steroids and clinical worsening and compare outcomes between patients with and without preoperative steroid administration.

SUMMARY OF BACKGROUND DATA

Patients with spinal dural arteriovenous fistulas (SDAVFs) often were misdiagnosed and treated with steroids which led to acute worsening.

METHODS

Patients with angiographically confirmed SDAVFs were recruited consecutively between March 2013 and December 2014 in two referral centers. We reviewed the history of all the patients to identify those patients who were treated with steroids before exclusion of the fistulas. Modified Aminoff & Logue scale (mALS) was used to evaluate the spinal cord function at different time points: before and after steroid administration, before operation, and at 1-year follow-up. Paired t tests were used to assess the mALS of patients with steroid administration at different time points. Unpaired t tests and Pearson chi-square test were used to assess differences between patients with and without steroid administration.

RESULTS

Eighteen patients with (18.2%) and 81 patients without (81.8%) steroid administration were included in this study. At baseline, there were no difference between both patient groups, in regards to age, sex, duration, location of fistula, treatment, and preoperative mALS. Patients without steroid administration, however, had statistically significant better outcome according to their mALS at 1-year follow-up (P < 0.05).

CONCLUSION

Steroid administration can induce acute clinical worsening in patients with SDAVFs that may persist despite successful obliteration of the fistula and should thus be avoided.

LEVEL OF EVIDENCE

3.