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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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Krez A, Liu Y, Kanbour S, Clare S, Waldman S, Stein EM. The skeletal consequences of epidural steroid injections: a literature review. Osteoporos Int 2021; 32:2155-2162. [PMID: 34089066 DOI: 10.1007/s00198-021-05986-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022]
Abstract
UNLABELLED This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs. PURPOSE Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids. METHODS Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed. RESULTS Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes. CONCLUSIONS While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment.
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Affiliation(s)
- A Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Y Liu
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Kanbour
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Clare
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Waldman
- Department of Anesthesiology, Critical Care, & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - E M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Moderate and deep procedural sedation-the role of proper monitoring and safe techniques in clinical practice. Curr Opin Anaesthesiol 2021; 34:497-501. [PMID: 34039848 DOI: 10.1097/aco.0000000000001011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Epstein NE. Unnecessary Cervical Epidural Injection in An Octogenarian. Surg Neurol Int 2019; 10:108. [PMID: 31528446 PMCID: PMC6744805 DOI: 10.25259/sni-197-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Epidural spine injections (ESI) have no documented long-term efficacy. Furthermore, cervical ESI uniquely risk intramedullary injections with resultant neurological deficits (e.g. monoplegia to quadriplegia), and intravascular vertebral injections (e.g. which potentially contribute to stroke, brain stem infarction). Case Description: A patient in his mid-eighties presented with 1 year’s duration of neck pain without any accompanying numbness, tingling or weakness in the upper or lower extremities. He had no radiculopathy, myelopathy, or neurological deficit. Two years earlier, the patient sustained a myocardial infarction (MI), requiring over 5 stents and a defibrillator. At the time of presentation, he was still on a baby ASA (81 mg/day), on anti-hypertensives, and cholesterol-lowering medications. His non-contrast cervical CT scan (patient had a pacemaker/defibrillator and could not have an MR) from the summer of 2018 showed no significant spinal cord or nerve root compression at any level. Nevertheless, he was subjected to two cervical epidural injections in the early fall; his baby ASA was stopped 5 days prior to each of these injections. Notably, this placed him at increased risk of MI and/or stroke. When he was seen by neurosurgery, without any neurological deficit or significant cervical radiographic findings, he was referred back to neurology for continued conservative management. Conclusions: Patients are increasingly subjected to epidural cervical spinal injections that have no documented long-term efficacy, and expose them to significant risks/complications. This 80+ year-old patient, without a neurological deficit or significant cervical CT-documented pathology, underwent 2 cervical ESI that unnecessarily exposed him to potential cardiac-stent related thrombosis (e.g. stopping ASA for 5 days-a bona-fide requirement for ESI to avoid acute epidural hematomas).
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, New York, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, United States
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Sun X, Liu S, Liu C, Xu J, Sun J, Pan Y. An inadvertent subarachnoid injection reversed by cerebrospinal fluid lavage for the treatment of chronic low back pain: A case report. Medicine (Baltimore) 2019; 98:e14406. [PMID: 30732190 PMCID: PMC6380745 DOI: 10.1097/md.0000000000014406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE We present a case of high spinal anesthesia after inadvertent injection of local anesthetics and corticosteroids into the subarachnoid space during attempted epidural injection. Cerebrospinal fluid (CSF) lavage is a suitable method for treatment. PATIENT CONCERNS A 45-year-old woman presented with posterior thigh, leg, and ankle pain for >6 months and was treated with epidural injection. Five minutes after the third time of epidural injection, the patient complained loss of sensation and muscle strength in the lower extremities and abdominal area. DIAGNOSES A high spinal anesthesia was confirmed by the patient loss of sensation and muscle strength in the lower extremities and abdominal area. INTERVENTIONS CSF lavage was performed for treatment. OUTCOMES After CSF lavage, the patient gradually returns to normal sensory and motor functions of lower limbs. On the fourth day, the patient sensed her physical function restoring gradually and was discharged uneventfully. At 4-month follow-up, the patient could have normal activities without obvious subsequent complications and any pain. LESSONS We conclude that CSF lavage could be a helpful maneuver to clear lidocaine and betamethasone and avoid potential nerve damage caused by an unintentional intrathecal injection during an epidural injection for the treatment of chronic low back pain.
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Affiliation(s)
- Xiaodi Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shijiang Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Cunming Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jijun Xu
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jie Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yinbing Pan
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Ohno K, Samaranch L, Hadaczek P, Bringas JR, Allen PC, Sudhakar V, Stockinger DE, Snieckus C, Campagna MV, San Sebastian W, Naidoo J, Chen H, Forsayeth J, Salegio EA, Hwa GGC, Bankiewicz KS. Kinetics and MR-Based Monitoring of AAV9 Vector Delivery into Cerebrospinal Fluid of Nonhuman Primates. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2018; 13:47-54. [PMID: 30666308 PMCID: PMC6330508 DOI: 10.1016/j.omtm.2018.12.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/03/2018] [Indexed: 12/11/2022]
Abstract
Here we evaluated the utility of MRI to monitor intrathecal infusions in nonhuman primates. Adeno-associated virus (AAV) spiked with gadoteridol, a gadolinium-based MRI contrast agent, enabled real-time visualization of infusions delivered either via cerebromedullary cistern, lumbar, cerebromedullary and lumbar, or intracerebroventricular infusion. The kinetics of vector clearance from the cerebrospinal fluid (CSF) were analyzed. Our results highlight the value of MRI in optimizing the delivery of infusate into CSF. In particular, MRI revealed differential patterns of infusate distribution depending on the route of delivery. Gadoteridol coverage analysis showed that cerebellomedullary cistern delivery was a reliable and effective route of injection, achieving broad infusate distribution in the brain and spinal cord, and was even greater when combined with lumbar injection. In contrast, intracerebroventricular injection resulted in strong cortical coverage but little spinal distribution. Lumbar injection alone led to the distribution of MRI contrast agent mainly in the spinal cord with little cortical coverage, but this delivery route was unreliable. Similarly, vector clearance analysis showed differences between different routes of delivery. Overall, our data support the value of monitoring CSF injections to dissect different patterns of gadoteridol distribution based on the route of intrathecal administration.
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Affiliation(s)
- Kousaku Ohno
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | - Lluis Samaranch
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | - Piotr Hadaczek
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | - John R Bringas
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | | | - Vivek Sudhakar
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | | | - Christopher Snieckus
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | | | - Waldy San Sebastian
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | - Jerusha Naidoo
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | | | - John Forsayeth
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
| | | | | | - Krystof S Bankiewicz
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94103, USA
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Epstein NE. Major risks and complications of cervical epidural steroid injections: An updated review. Surg Neurol Int 2018; 9:86. [PMID: 29740507 PMCID: PMC5926212 DOI: 10.4103/sni.sni_85_18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 12/13/2022] Open
Abstract
Background Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications. Methods Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches. Results Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature. Conclusions Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of N.Y. at Stony Brook, New York, USA.,Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience, Mineola, New York, USA
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Abstract
The identification of epidural space with loss of resistance (LOR) is commonly performed. But it lacks specificity. Epidural pressure waveform analysis (EPWA) provides a simple confirmative adjunct for LOR. If the needle is located within the epidural space, measurement of the pressure at its tips shows a pulsatile waveform. Previous studies demonstrated satisfactory sensitivity and specificity of EPWA. However, success or failure of epidural injection was confirmed by the pinprick test, which is limited for patients in the setting of the pain clinic. In this study, we evaluated the sensitivity, specificity, as well as positive and negative predictive values of EPWA for cervical epidural steroid injection (CESI) confirmed by fluoroscopy.One hundred and five CESIs of 75 patients suffering from neck and radicular arm pain of over 3 months duration were enrolled. The physician injected 5 mL of normal saline after a feeling of satisfactory LOR. Saline filled extension tubing, connected to a pressure transducer, was attached to the needle. A 3 mL bolus of contrast medium was injected to confirm the success of CESI.The incorrect identification of epidural space with LOR (false LOR) was 29.5%. Of these 31 failed CESIs, 2 showed epidural waveform and 29 did not. The sensitivity, specificity, positive and negative predictive value of EPWA was 94.5%, 93.5%, 97.2%, and 87.7%, respectively.EPWA shows satisfactory reliability and is a simple adjunct to decrease false LOR for CESI. Further confirmative studies are required before its routine use in clinical practice.
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Affiliation(s)
- Ji H. Hong
- Department of Anesthesiology and Pain Medicine
| | - Sung W. Jung
- Department of Psychiatry, Keimyung University DongSan Hospital, DaeGu, Korea
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