Not a single spinal cord injury due to direct needle trauma in over 1.3 million epidural steroid injections

2021 ◽  
pp. rapm-2021-102904
Author(s):  
Christopher Gilligan ◽  
James Rathmell
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Cord Injury ◽  
Epidural Steroid

Transforaminal Lumbar and Thoracic Interventions and Ischemic Spinal Cord Injury

2016 ◽  
Author(s):  
Scott E. Glaser ◽  
Rinoo Shah
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Spinal Cord Infarction ◽  
Supporting Evidence ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Root Cause ◽  
Cord Injury ◽  
Epidural Steroid ◽  
Ischemic Spinal Cord Injury

Transforaminal epidural steroid injections have been shown to be associated with catastrophic neurologic complications secondary to spinal cord infarction. The reflexive, ad hoc response of practitioners to these injuries has been to recommend risk minimization strategies to prevent embolism of the injected particulate steroids and to use nonparticulate steroids. This focus on distal embolism as the sole or primary cause of catastrophic outcomes lacks conclusive supporting evidence and does not suffice to protect the patient from paraplegia as it fails to address the root cause of the complications. A root cause analysis of the procedure provides evidence that the injection technique itself—the “safe triangle”—creates a risk of arterial damage and sequelae leading to ischemia of the spinal cord. The evidence is strong that the only way to mitigate or eliminate the risk of paraplegia is to use a different technique to perform transforaminal injections: the Kambin triangle approach. This change in technique is the only definitive solution that addresses the root cause of these catastrophic sequelae associated with transforaminal epidural steroid injections. Key Words: Artery of Adamkiewicz, ischemic spinal cord injury, Kambin triangle, safe triangle, transforaminal epidural injection

Paraplegia Following Epidural Steroid Injection

2016 ◽  
Author(s):  
Devin Peck
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Epidural Hematoma ◽  
Epidural Abscess ◽  
Steroid Injection ◽  
Epidural Steroid Injection ◽  
Anterior Spinal Artery ◽  
Cord Injury ◽  
Artery Of Adamkiewicz ◽  
Epidural Steroid

Paraplegia following epidural steroid injection is, fortunately, an exceedingly rare complication. The differential diagnosis includes epidural hematoma, spinal cord injury/infarction, epidural abscess, and conversion disorder. Less likely diagnoses include worsening of underlying pathology, a new compressing lesion, or subarachnoid injection. The artery of Adamkiewicz enters the spinal canal via the neural foramen and provides blood supply to the lower two thirds of the spinal cord via the anterior spinal artery. Avoidance of the artery during a transforaminal epidural steroid injection is facilitated by entering the inferior portion of the foramen. Acute management of neurologic complications arising from an epidural steroid injection is facilitated by rapid identification of etiology. In the case of epidural hematoma, avoidance of permanent deficit is more likely when patients undergo prompt decompression. The role of intravenous steroids in acute spinal cord injury is controversial. Chronic management includes extensive rehabilitation, including physical and occupational therapy. Treatment of musculoskeletal nociceptive pain, such as due to shoulder overuse, and neuropathic pain is vital to optimize the patient’s participation in rehabilitative therapy.   Keywords: Epidural Steroid Injection; Complications; Spinal Cord Injury; Epidural Hematoma; Epidural Abscess; Artery of Adamkiewicz; Anterior Spinal Artery Syndrome; Particulate Steroid; Fluoroscopic Guidance

scholarly journals Digital Subtraction Angiography Use During Epidural Steroid Injections Does Not Reliably Distinguish Artery from Vein

2016 ◽  
Vol 4;19 (4;5) ◽  
pp. 255-266
Author(s):  
Jonathan A. Benfield
Keyword(s):  
Key Words ◽  
Digital Subtraction Angiography ◽  
Real Time ◽  
Narrative Review ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Objective Evidence ◽  
Cord Injury ◽  
Epidural Steroid

Background: Epidural steroid injections (ESIs) are among the most common procedures performed in an interventional pain management practice. It is well known that tragic complications may arise from ESIs, most commonly those performed using a transforaminal approach. Digital subtraction angiography (DSA) has been hailed as a fluoroscopic technique that can be used to detect arterial placement of the injection needle, and therefore as a safety measure that can decrease the incidence of catastrophic sequelae of these procedures. Objective: The objective of this article was to review existing scientific pain literature to determine if DSA can distinguish arterial vs. venous uptake. Study Design: Narrative review. Methods: The current narrative review of DSA in interventional spine was completed with a PUBMED search using the key words: digital subtraction angiography, epidural, fluoroscopy, intravascular injection, paraplegia, and quadriplegia in accordance with Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines. Results: After identification of duplicate articles, 383 articles were screened by title, abstract, and/or full article review. Ten of these articles were deemed appropriate, after applying inclusion and exclusion criteria, as they specifically looked at the use of digital subtraction angiography in interventional spine epidural injections. This included 4 case reports, 3 prospective studies, one retrospective analysis, one prospective cohort study, and one meta-analysis. All of the available studies claiming that DSA was capable of detecting vascular spread are likely accurate, but no significant detection of specifically arterial spread has been reported. The known catastrophic complications related to ESIs are purported to be due to arterial injection of insoluble steroids or local anesthetic and detection of arterial spread of contrast during fluoroscopy would be of obvious benefit to the interventionalist. Limitations: Small study size, non-randomized studies between DSA and real time fluoroscopy. Conclusion: Existing studies do not support that DSA can predict arterial spread. In fact, DSA exposes the practitioner and the patient to higher levels of radiation without objective evidence of any safety parameters. Key words: Digital subtraction angiography, real-time fluoroscopy, transforaminal epidural injection, particulate steroids, cervical radicular artery, lumbar radicular artery, spinal cord injury

scholarly journals Digital Subtraction Angiography Does Not Reliably Prevent Paraplegia Associated with Lumbar Transforaminal Epidural Steroid Injection

2012 ◽  
Vol 6;15 (6;12) ◽  
pp. 515-523
Author(s):  
Kenneth D. Candido
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Lower Extremity ◽  
Digital Subtraction Angiography ◽  
Test Dose ◽  
Spinal Cord Infarction ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epidural steroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately following the completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids. Key words: Digital subtraction angiography, transforaminal epidural steroid injections, paraplegia, chronic low back pain.

Sign in / Sign up

Export Citation Format

Share Document