Dural Puncture and Subdural Injection: A
Complication of Lumbar Transforaminal
Epidural Injections

Case Report: Two cases are presented in which the complication of dural puncture is documented in the context of a lumbar transforaminal epidural steroid injection. The hazard of dural puncture during transforaminal epidural injections, the anatomy of the dural and thecal sac, the potential for subdural injections, and relevant literature are reviewed. Design: Report of two cases. Background: Lumbar transforaminal epidural steroid injections are a commonly employed procedure for the treatment of lumbar radiculopathy. The optimal target point lies at the “6 o’ clock” position of the pedicle. Contrast is injected to confirm proper placement of the needle and correct flow of the medication through the epidural space. Despite apparent proper placement of the needle, a potential complication exists of puncturing the dura while performing this procedure. Spinal injectionists should recognize the subsequent contrast patterns associated with this complication. Conclusion: Subdural and intrathecal spread of contrast is rarely seen with transforaminal injections and thus can be easily overlooked. Becoming familiar with the images presented in these cases may help alert the interventionalist of a dural puncture, and thus avoid injection of medications into the intrathecal and subdural spaces. Key words: Back pain, epidural steroid injection, subdural, intrathecal

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What Is the Role of Epidural Steroid Injections in Lumbar Spinal Disease with Moderate Disability?

January 2018 - Pain Physician ◽

10.36076/ppj/2019.19.293 ◽

2016 ◽

Vol 4;19 (4;5) ◽

pp. 293-298

Author(s):

Jae-Young Hong

Keyword(s):

Steroid Injection ◽

Radicular Pain ◽

Epidural Steroid Injection ◽

Spinal Disease ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Pain Scores ◽

One Year ◽

Lumbar Spinal ◽

Epidural Steroid

Epidural steroid injections have been gaining popularity as an alternative to surgical treatment of radicular pain with associated spinal derangement. To determine the effectiveness and indications of lumbar epidural steroid injections in patients with or without surgery, we performed a prospective observational study. We gathered data from 262 degenerative short-segment spinal disease patients (affected at one or 2 levels) with greater than 12 weeks of medication-resistant radicular pain without neurological deficits but with moderate disability (visual analog scale < 6.5; Oswestry Disability Index < 35). All patients received initial fluoroscopically guided transforaminal epidural steroid injections of the affected vertebral level(s) corresponding to their symptoms. Those with inadequate responses or who wanted subsequently surgery underwent decompression surgery. Clinical and demographic characteristics were assessed to compare the differences between the groups. Results: Of the 262 patients who received epidural steroid injections, 204 did not have operations for up to one year. However, 58 patients experienced inadequate relief of pain or wanted operations and therefore underwent surgery. At baseline, the 2 groups had similar mean disability indices and pain scores, as well as gender ratios, ages, and durations of symptoms (P > 0.05). In the patients who underwent surgery, the mean disability and pain scores were not significantly decreased after injection compared to those in the injection-alone group, although the scores for the injection plus surgery patients decreased significantly after surgery (P < 0.05). In contrast, patients who underwent epidural steroid injection alone experienced a significant decrease in disability and pain after injection, and that persisted up to one year of follow-up (P < 0.05). Epidural steroid injection can decrease the pain and disability in the majority of a moderate disability group for up to one year, although a significant number of patients underwent surgery regardless of injection. We recommend epidural steroid injection as a first-line treatment in patients with moderate disability that can be converted to surgery without significant delay. Key words: Epidural steroid injection, spinal surgery, lumbar spinal disease, lumbar radiculopathy, lumbar radicular pain

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Conus Medullaris Syndrome Days After A Single Epidural Steroid Injection

10.47363/jpmrs/2020(2)119 ◽

2020 ◽

pp. 1-2

Author(s):

Rafid Kasir ◽

◽

Jad Khalil ◽

Keyword(s):

Steroid Injection ◽

Cauda Equina ◽

Conus Medullaris ◽

Epidural Steroid Injection ◽

Chronic Lower Back Pain ◽

Unique Case ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Lower Back ◽

Epidural Steroid

Background: Epidural steroid injections (ESI) are commonly used in treatment of chronic lower back pain. Conus medullaris and cauda equina syndromes are rare complications of ESI. However, these typically occur after multiple injections within a few minutes to hours. Some reported cases are also transient, with patients completely regaining neurological function. We discuss a unique case of a patient developing conus medullaris syndrome over 24 hours after a single epidural steroid injection without resolution of symptoms.

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Hemorrhagic Infarction of Cerebellum and Brainstem Due to Cervical Epidural Steroid Injection – Case Report and Review of the Literature

Academic Forensic Pathology ◽

10.1177/1925362118821494 ◽

2018 ◽

Vol 8 (4) ◽

pp. 952-956

Author(s):

Connie Bao ◽

Shiping Bao

Keyword(s):

Steroid Injection ◽

Adverse Event Reporting System ◽

Cervical Radiculopathy ◽

Adverse Event Reporting ◽

Review Literature ◽

Epidural Steroid Injection ◽

Serious Adverse Events ◽

Painful Condition ◽

Epidural Steroid Injections ◽

Epidural Steroid

Radiculopathy is a painful condition usually due to a compressed nerve in the spine. It is reported that cervical radiculopathy has an annual incidence of 83.2 cases per 100 000 people. Cervical epidural steroid injection is one of the main treatments, but it can result in serious adverse events, including loss of vision, stroke, paralysis, and death. A 69-year-old female died after receiving the second of three planned C5/C6 epidural steroid injections. The autopsy revealed extensive hemorrhage and necrosis of the entire right side of the cerebellum and nearby brainstem, and extensive petechial hemorrhage of the left side of the cerebellum. This report discusses the importance of a complete autopsy in the case of death due to cervical epidural steroid injection and reporting the case either to peer review literature or to the Food and Drug Administration Adverse Event Reporting System (F AERS) database.

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Dural puncture during lumbar epidural access in the setting of degenerative spondylolisthesis: case series and risk mitigation strategies

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2021-102963 ◽

2021 ◽

pp. rapm-2021-102963

Author(s):

Vivek Sindhi ◽

Christine G Lim ◽

Anver Khan ◽

Carlos Pino ◽

Steven P Cohen

Keyword(s):

Dural Puncture ◽

Steroid Injection ◽

Risk Mitigation ◽

Degenerative Spondylolisthesis ◽

Epidural Steroid Injection ◽

Mitigation Strategies ◽

Epidural Needle ◽

Blood Patch ◽

Risk Mitigation Strategies ◽

Epidural Steroid

Degenerative spondylolisthesis is a common back pathology in the general adult population. Patients with this condition may present for epidural steroid injection, epidural blood patch, or epidural analgesia. We report five patients with degenerative spondylolisthesis who experienced inadvertent dural puncture during interlaminar epidural steroid injection attempts: four with intrathecal contrast spread or cerebrospinal backflow into the epidural needle and one with subdural contrast spread. Patients with degenerative spondylolisthesis may be at higher risk for dural puncture due to stretching of the dura and contraction of the epidural space at the translated spinal level. In the following report, we summarize the cases and suggest risk mitigation strategies for both chronic and acute pain physicians.

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Pre-Contrast Injection Multiple Needle Placement Technique: An Alternative Method for Performing Challenging Transforaminal Epidural Steroid Injections for Radicular Pain

Pain Management Case Reports ◽

10.36076/pmcr.2020/4/39 ◽

2020 ◽

pp. 39-44

Author(s):

Sanjeeva Gupta

Keyword(s):

Steroid Injection ◽

Epidural Injection ◽

Radicular Pain ◽

Epidural Steroid Injection ◽

Needle Placement ◽

Contrast Injection ◽

Epidural Steroid Injections ◽

Key Words Epidural ◽

Epidural Steroid ◽

Placement Technique

Abstract: A subpedicular transforaminal epidural steroid injection (TFESI) at the L5-S1 level can be technically challenging due to lumbar spondylosis. As described in the cases below, in challenging cases, placing multiple needles (normally 2 needles, occasionally 3 needles) before injecting the radiocontrast dye can improve the chances of depositing the steroid in the area of pathology responsible for pain. This will, of course, add to the risk of the procedure due to multiple needles being close to the nerve root. On balance, however, it may be less risky than not placing the steroid at the appropriate pathological site, which may fail to provide pain relief leading to unnecessary suffering and, in some cases, surgical intervention. However, if the spread of contrast medium and the subsequent steroid injection through the first needle is satisfactory, then the other needles can be removed without injecting. The “pre-contrast injection multiple needle placement” technique has been used by the author on multiple occasions and 3 cases are described below. Key words: Epidural steroid injection, transforaminal epidural injection, sciatica, radicular pain, multiple needle technique

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Comparison of Caudal Epidural Steroid Injection with Interlaminar Lumbar Inj. Epidural in Spinal Stenosis

10.53350/pjmhs211581877 ◽

2021 ◽

Vol 15 (8) ◽

pp. 1877-1879

Author(s):

Muhammad Akram ◽

Faheem Mubashir Farooqi ◽

Shumaila Jabbar

Keyword(s):

Spinal Stenosis ◽

Oswestry Disability Index ◽

Steroid Injection ◽

Epidural Steroid Injection ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Group I ◽

Group Ii ◽

Epidural Steroid ◽

Caudal Epidural

Background: Lumbar spinal stenosis is a condition caused by narrowing of spinal canal. Steroid injection either lumbar or caudal can improve the functional outcome and low back pain. Aim: To compare the outcome of caudal epidural steroid injection with lumbar epidural steroid injection in treating spinal stenosis in patients suffering from sciatica. Methods: In this prospective study 338 patients having low backache due to spinal stenosis with sciatica were included from June 2013 to December 2014. Patients were randomly divided into two groups. Group I and II. Patients in Group I (160 patients) received caudal epidural steroid injections while the patients in Group II (178 patients) received lumbar epidural steroid injections. Visual analog scale (VAS) and Oswestry Disability Index (ODI) was used to assess outcome of the Caudal and Lumbar steroid injections and was measured at 2 weeks, at 3months, and improvement was declared if VAS decrease ≥50% of baseline and Oswestry disability index decrease ≥40% at 3 months. Results: In group I, there were 70(43.75%) males and 90(56.25%) females, while in group II there were 98(55.1%) males and 80(44.9%) females. The mean age of the patients in group I was 46.46±10.37 (18-75 years) years and was 43.77±15.27 years (18-75 years) in group II (P=0.0619). The change in pain score (>50%) was observed in 159 (89.33%) in group II compared with 121 (75%) in group I (P=0.0008). Conclusion: Lumbar epidural of steroids injections are more effective then caudal epidural injection of steroids in treating spinal stenosis. MeSH words: Caudal epidural, Lumbar epidural, Sciatica

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Caudal Epidural Steroid Injection under Fluoroscopy in Management of Chronic Low Back Pain with or without Radiculopathy

Journal of Nobel Medical College ◽

10.3126/jonmc.v9i1.29382 ◽

2020 ◽

Vol 9 (1) ◽

pp. 3-7

Author(s):

Rupak Bhattarai ◽

Bandana Paudel ◽

Sangeeta Subba ◽

Kumud Pyakurel ◽

Bijay K. C. ◽

...

Keyword(s):

Steroid Injection ◽

Epidural Steroid Injection ◽

Pain Clinic ◽

Low Back ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Vas Score ◽

Epidural Steroid ◽

Caudal Epidural

Background: Low back pain with or without radiculopathy is most common presentations of chronic pain. Caudal epidural steroid injection is one of the treatment modalities of this type of pain syndromes. Materials and Methods: The study was conducted in 100 patient who presented in our pain clinic. These patients were given caudal epidural steroid injections under fluoroscopy guidance with 60 mg depo-methylprednisolone added to 0.5% lignocaine making a volume of 10 ml. All these patients were asked to follow up at pain clinic at 1 month, 3 months & 6 months to assess the visual analogue scale (VAS) score, Oswestry disability index (ODI), Straight leg Raise test (SLRT) & Patient satisfaction scale. Results: There was significant reduction in VAS score in one month, three months and six months follow up after caudal epidural steroid injection. The 50% reduction in pain was seen in 72 patients, 69 patients and 62 patients in one month, three months and six months respectively. The mean VAS score were 7.84 before pre-injection, 4.32 at one hour, 4.06 at one month, 4.18 at 3 months and 4.64 at 6 months after the procedure.The mean ODI were 35.16 before pre-injection, 32.12 at one hour, 28.14 at one month, 28.57 at 3 months and 28.68 at 6 months after the procedure. Conclusion: Caudal epidural steroid injections causes significant relief in pain symptoms of backache with or without radiculopathy and increases the quality of life.

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Flushing Following Interlaminar Lumbar Epidural Steroid Injection with Dexamethasone

January 2018 - Pain Physician ◽

10.36076/ppj.2010/13/481 ◽

2010 ◽

Vol 5;13 (5;9) ◽

pp. 481-484

Author(s):

Chong H. Kim

Keyword(s):

Back Pain ◽

Side Effects ◽

Steroid Injection ◽

Treatment Plan ◽

Epidural Steroid Injection ◽

Steroid Injections ◽

Epidural Steroid Injections ◽

Interlaminar Approach ◽

Epidural Steroid

Background: Epidural steroid injections are commonly used in managing radicular pain. Most complications related to epidural injections are minor and self-limited. Flushing is considered as one such minor side effect. Flushing has been studied using various steroid preparations including methylprednisone, triamcinolone, and betamethasone but its frequency has never been studied using dexamethasone. Objective: This study evaluates the frequency of flushing associated with fluoroscopyguided lumbar epidural steroid injections using dexamethasone. Study Design: Retrospective cohort design study. Patients presenting with low back pain were evaluated and offered a fluoroscopically guided lumbar epidural steroid injection using dexamethasone via an interlaminar approach as part of a conservative care treatment plan. Setting: University-based Pain Management Center. Intervention: All injections were performed consecutively over a 2-month period by one staff member using 16 mg (4 mg/mL) of dexamethasone. A staff physician specifically asked each participant about the presence of flushing following the procedure prior to discharge on the day of injection and again on follow-up within 48 hours after the injections. The answers were documented as “YES” or “NO.” Results: A total of 150 participants received fluoroscopically guided interlaminar epidural steroid injection. All participants received 16 mg (4 mg/mL) of dexamethasone with 2 mL of 0.2% ropiviciane. Overall incidence of flushing was 42 out of 150 cases (28%). Of the 42 participants who experienced flushing, 12 (28%) experienced the symptom prior to discharge following the procedure. Twenty-seven of the 42 (64%) were female (P < 0.05). All the participants who experienced flushing noted resolution by 48 hours. No other major side effects or complications were noted. Limitations: Follow-up data were solely based on subjective reports by patients via telecommunication. Follow-up time was limited to only 48 hours, which overlooks the possibility that more participants might have noted flushing after the 48 hour limit. Conclusions: Flushing is commonly reported following epidural steroid injections. With an incidence of 28%, injections using dexamethasone 16 mg by interlaminar epidural route appear to be associated with more flushing reaction than previously reported with other steroid preparations. Additionally, female participants are more likely to experience flushing though the reactions seem to be self-limiting with resolution by 48 hours. Key words: flushing, side effects, epidural, back pain, lumbar, steroid, dexamethasone, injections.

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