The annoyance of singultus: a case report of a rare adverse effect after epidural steroid injection.

OBJECTIVE: Cervical epidural steroid injections (ESIs) can provide effective pain management for patients suffering from chronic neck pain due to various pathological changes of the cervical spine. There are several rare adverse effects reported from interventional pain procedures, including persistent hiccups ("singultus"). Based on a limited number of cases, we propose a modified treatment algorithm for this adverse outcome (Fig. 3). CASE REPORT: Singultus has been documented as an adverse effect of interventional pain procedures, including epidural steroid, facet joint, and sacroiliac joint injections. We describe the case of a general contractor who presented to our clinic with chronic neck pain and central canal stenosis. The patient received an uncomplicated lumbar ESI in the past and was recommended for a cervical interlaminar ESI. After an uneventful C6-C7 interlaminar ESI with dexamethasone, 1% lidocaine, and normal saline the patient developed singultus. Baclofen was sent to his pharmacy, but this was unsuccessful at alleviating his hiccups. The patient was subsequently started on chlorpromazine and found relief from his symptomatology. CONCLUSION: Persistent hiccups after ESI or interventional pain procedures can be treated with conservative measures and non-pharmacologic methods, with escalation to therapy with baclofen, gabapentin, pregabalin, metoclopramide, chlorpromazine, other antipsychotic or antidopaminergic agents, and possible dual or triple therapy if further indicated.

Drug-induced aseptic meningitis after an interlaminar lumbar epidural steroid injection.

BACKGROUND: This case report describes a rare instance of drug-induced aseptic meningitis after an interlaminar lumbar epidural steroid injection. CASE PRESENTATION: A 74 year-old female patient presented to the ED post-procedure day three after an L4-L5 interlaminar lumbar epidural steroid injection with fever, nausea, and vomiting. The patient had previously undergone numerous lumbar epidurals without complications and used identical medications, which included 1% lidocaine, iohexol contrast, methylprednisolone (Depo-medrol), and normal saline. Pertinent labs included a WBC of 15,000 cells/µL. Lumbar MRI revealed L4-S1 aseptic arachnoiditis. Two bone scans with Gallium and T-99 confirmed no infectious process. The patient then had a second admission months later with similar presenting symptoms and hospital course after repeating the lumbar epidural steroid injection. Lumbar MRI and CSF studies confirmed aseptic meningitis. CONCLUSION: This patient's repeated admissions from aseptic meningitis were likely caused by irritation of the meningeal layers from a medication used during the procedure.

CT-guided Pulsed Radiofrequency Combined with Steroid Injection for Sciatica from Herniated Disk: A Randomized Trial.

Background Evidence regarding effective nonsurgical management of sciatica remains limited. Purpose To determine a difference in effectiveness between combined pulsed radiofrequency (PRF) and transforaminal epidural steroid injection (TFESI) treatment versus TFESI alone for sciatic pain due to lumbar disk herniation. Materials and Methods This prospective multicenter double-blind randomized clinical trial was conducted between February 2017 and September 2019 in participants with sciatica due to lumbar disk herniation lasting 12 weeks or longer that was not responsive to conservative treatment. Study participants were randomly assigned to undergo one CT-guided treatment with combined PRF and TFESI (n = 174) or TFESI alone (n = 177). The primary outcome was leg pain severity, as assessed with the numeric rating scale (NRS) (range, 0-10) at weeks 1 and 52 after treatment. Secondary outcomes included Roland-Morris Disability Questionnaire (RMDQ) score (range, 0-24) and Oswestry Disability Index (ODI) score (range, 0-100). Outcomes were analyzed according to the intention-to-treat principle via linear regression. Results Mean age of the 351 participants (223 men) was 55 years ± 16 (SD). At baseline, NRS was 8.1 ± 1.1 in the PRF and TFESI group and 7.9 ± 1.1 in the TFESI group. NRS was 3.2 ± 0.2 in the PRF and TFESI group and 5.4 ± 0.2 in the TFESI group (average treatment effect, 2.3; 95% CI: 1.9, 2.8; P < .001) at week 1 and 1.0 ± 0.2 and 3.9 ± 0.2 (average treatment effect, 3.0; 95% CI: 2.4, 3.5; P < .001), respectively, at week 52. At week 52, the average treatment effect was 11.0 (95% CI: 6.4, 15.6; P < .001) for ODI and 2.9 (95% CI: 1.6, 4.3; P < .001) for RMDQ, favoring the combined PRF and TFSEI group. Adverse events were reported in 6% (10 of 167) of participants in the PRF and TFESI group and in 3% (six of 176) of participants in the TFESI group (eight participants did not complete follow-up questionnaires). No severe adverse events occurred. Conclusion In the treatment of sciatica caused by lumbar disk herniation, pulsed radiofrequency combined with transforaminal epidural steroid injection is more effective for pain relief and disability improvement than steroid injection alone. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Jennings in this issue.

Pro-Con Debate: Superior Versus Inferior Triangle Needle Placement in Transforaminal Epidural Injections.

Although transforaminal epidural injections have long been used for radicular pain, there is no universal standard injection approach to the neural foramen. The intervertebral foramen and its surrounding structures comprise an anatomically sensitive area that includes bone and joint structures, the intervertebral disk, blood vessels (in particular, the radicular arteries), the epidural sheath, and the spinal nerve root. Given the relatively high risk of inadvertent injury or injection to these nearby structures, image guidance for transforaminal epidural steroid injections (TFESIs) is standard of care. However, there is a lack of consensus regarding the optimal approach to the neural foramen: from the traditional superior ("safe") triangle or from the inferior (Kambin's) triangle. In this Pro-Con commentary article, we discuss the relative advantages and disadvantages of each approach for TFESIs.

Flushing After Lumbar Epidural Steroid Injection with Dexamethasone.

PURPOSE OF REVIEW: Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%). RECENT FINDINGS: There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.

"Platelet-Rich Plasma" epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial.

BACKGROUND: Lumbar herniated disc (HNP) is mainly treated by conservative management. Epidural steroid injection (ESI) has been an option to treat failed cases prior to surgery. Triamcinolone has been widely used due to its efficacy in bringing about pain reduction for up to three months. However, several reports have shown some severe adverse events. Platelet-rich plasma (PRP) is made from blood through centrifugation. Several studies supported the potential short to long-term effects, and safety of PRP injection in treating HNP. The study objective was to evaluate the efficacy of PRP in treatment of single-level lumbar HNP in comparison to triamcinolone. METHODS: Thirty patients were treated by transforaminal epidural injections. PRP was obtained from 24 ml venous blood through standardized double-spin protocol. Participants included fifteen patients each being in triamcinolone and PRP groups. The same postoperative protocols and medications were applied. The visual analogue scale of leg (LegVAS), collected at baseline, 2, 6, 12, and 24 weeks, was the primary outcome. The BackVAS, Oswestry Disability Index (ODI), adverse event, and treatment failure were the secondary endpoints. RESULTS: Platelet ratio of PRP in fifteen patients was 2.86 ± 0.85. Patients treated by PRP injections showed statistically and clinically significant reduction in LegVAS at 6, 12, and 24 weeks, and in ODI at 24 weeks. It demonstrated comparable results on other aspects. No adverse event occurred in either group. CONCLUSION: Noncommercial epidural double-spin PRP yielded superior results to triamcinolone. Due to its efficacy and safety, the procedure is recommended in treating single level lumbar HNP. TRIAL REGISTRATION: NCT, NCT05234840. Registered 1 January 2019, https://clinicaltrials.gov/ct2/show/record/NCT05234840 .

Safety of local anesthetics in cervical nerve root injections: a narrative review.

Severe neurological adverse events have been reported after fluoroscopically guided cervical nerve root injections. Particulate corticosteroids inadvertently injected intraarterially and iatrogenic vertebral artery trauma have been implicated in these outcomes. This has raised concern for the potential consequences of including local anesthetic with these injections. As a result, some providers have now discontinued the routine administration of local anesthetic with corticosteroid when performing cervical nerve root injections. At present, there is no consensus regarding whether the use of local anesthetic in this context is safe. Here, the current literature is synthesized into a narrative review aiming to clarify current perspectives of the safety of local anesthetics in cervical nerve root injections.

Intra-arterial injection of particulate corticosteroids: mechanism of injury.

Mechanism of neurologic complications after epidural spinal injections (ESI) of particulate steroids at the cervical spine include intrathecal injection, epidural hematoma, direct spinal cord injury, and brain stem or cord infarction due to an arterial spasm or inadvertent intra-arterial injection of particulate steroids. At the lumbar spine, there is evidence that a spinal cord infarction secondary to an inadvertent intra-arterial injection of particulate steroids through a transforaminal approach is the leading mechanism.Variations in the arterial supply of the spinal cord help to understand how a lumbar ESI may lead to a spinal cord infarction at the thoracic level. A radiculomedullary artery arising from the lumbar or sacral spine may participate to the supply of the spinal cord. All radicular and radiculomedullary arteries penetrate the spinal canal through the intervertebral foramen. Therefore, its catheterization carries a risk of inadvertent intraarterial injection. An ex vivo animal study has shown that particulate steroids injected in the blood stream produce an immediate and unexpected change of red blood cells into spiculated cells which aggregate and cause arterioles obstruction, while no particulate steroid macroaggregates or vascular spasm were observed. Rare instances of neurologic complications also occurred after ESI performed through a posterior approach. All occurred in previously operated on patients suggesting a pathologic role for the epidural scar.

MANIFESTATIONS AND TREATMENT OF LOWER BACK PAIN SYNDROME IN WARTIME.

OBJECTIVE: The aim: To improve treatment of patients with lower back pain through identification of pathogenetic factors in its formation. PATIENTS AND METHODS: Materials and methods: The early results of treatment of 84 patients with lower back pain (main group) were analysed. Patients of the main group were divided into two subgroups: one group involved patients with mental disorders, the other - patients not suffering from such disorders (the Spielberger-Hanin Anxiety Test used). The patients of the main group with mental disorders (49 patients) were administered with epidural steroid injections and antidepressants. The patients with no mental disorders (35 patients) were administered with epidural steroid injections only. The control group involved 36 patients with lower back pain who did not undergo any psychological testing and were administered with epidural steroid injections only. The Visual Analog Scale (VAS) and the Oswestry Disability Index questionnaire were used to assess pain syndrome. The assessment was carried out twice: in the pre-operative period and in three months after the treatment. RESULTS: Results: A significant difference in the early treatment results between the main and control groups was established according to both the Visual Analog Scale and the Oswestry Disability Index in favour of the main group patients, who were differentiated by pathogenetic factors of the pain syndrome formation. CONCLUSION: Conclusions: Lower back pain syndrome necessitates clarification of its components in order to develop pathogenically based treatment.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis.

PURPOSE: Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. METHODS: We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale. RESULTS: Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. CONCLUSION: Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. LEVEL OF EVIDENCE: II.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study.

BACKGROUND: A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS). METHODS: We selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated. RESULTS: The Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the follow-up period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success. CONCLUSION: The efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

Spinal Cord Injury and Postdural Puncture Headache following Cervical Interlaminar Epidural Steroid Injection: A Case Report.

Background: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. Case report: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient's PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. Conclusions: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher.

The skeletal consequences of epidural steroid injections: a literature review.

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.

Deep Spinal Infection after Outpatient Epidural Injections for Pain: A Retrospective Sample Cohort Study Using a Claims Database in South Korea.

BACKGROUND: Deep spinal infection is a devastating complication after epidural injection. This study aimed to investigate the incidence of deep spinal infection primarily after outpatient single-shot epidural injection for pain. Secondarily, this study assessed the national trends of the procedure and risk factors for said infection. METHODS: Using South Korea's National Health Insurance Service sample cohort database, the 10-yr national trend of single-shot epidural injections for pain and the incidence rate of deep spinal infection after the procedure with its risk factors were determined. New-onset deep spinal infections were defined as those occurring within 90 days of the most recent outpatient single-shot epidural injection for pain, needing hospitalization for at least 1 night, and receiving at least a 4-week course of antibiotics. RESULTS: The number of outpatient single-shot epidural injections per 1,000 persons in pain practice doubled from 40.8 in 2006 to 84.4 in 2015 in South Korea. Among the 501,509 injections performed between 2007 and 2015, 52 cases of deep spinal infections were detected within 90 days postprocedurally (0.01% per injection). In multivariable analysis, age of 65 yr or more (odds ratio, 2.91; 95% CI, 1.62 to 5.5; P = 0.001), living in a rural area (odds ratio, 2.85; 95% CI, 1.57 to 5.0; P < 0.001), complicated diabetes (odds ratio, 3.18; 95% CI, 1.30 to 6.7; P = 0.005), multiple epidural injections (three times or more) within the previous 90 days (odds ratio, 2.34; 95% CI, 1.22 to 4.2; P = 0.007), and recent use of immunosuppressants (odds ratio, 2.90; 95% CI, 1.00 to 6.7; P = 0.025) were significant risk factors of the infection postprocedurally. CONCLUSIONS: The incidence of deep spinal infection after outpatient single-shot epidural injections for pain is very rare within 90 days of the procedure (0.01%). The data identify high-risk patients and procedure characteristics that may inform healthcare provider decision-making.

Complications in image-guided musculoskeletal injections.

OBJECTIVE: To establish the incidence and define the nature of complications occurring following image-guided musculoskeletal injections at our institution. MATERIALS AND METHODS: All patients undergoing image-guided musculoskeletal injection during the study period (16/3/2016 to 24/01/2020) were included. Departmental records were reviewed to identify all patients describing possible complications following injection, what therapy was required (if any) and what the outcome was. No patients were excluded. Complications were classified as minor or major. Injections were categorised as follows: cervical spine, lumbar facet joint, lumbar nerve root, caudal epidural and 'other'. The complication rate for each individual category of procedure was compared with the combined complication rate for all other categories by constructing contingency tables and using Fisher's exact test. RESULTS: A total of 8226 patients underwent image-guided musculoskeletal injections within the study period. Exactly 100 patients were identified as having reported a complication, producing an overall complication rate of 1.2%. One complication was categorised as 'major', with the patient requiring expedited surgery. The remainder (99 patients) were categorised as having experienced minor complications. The incidence of complications after 'other' injections was significantly greater than for other categories of injection (1.86%, p = 0.028). There was no significant difference in the complication rate for cervical spine (0.93%, p = 0.257), lumbar nerve root (0.85%, p = 0.401), lumbar facet joint (0.67%, p = 0.326) or caudal epidural (1.29%, p = 0.687) injections. 'Other' injections were subsequently further sub-categorised by anatomical site and imaging modality used. Glenohumeral (2.97%, p = 0.0361) and sacro-iliac (3.51%, p = 0.0498) joint injections were associated with a significantly increased risk of complications. There was no difference in the incidence of complications with fluoroscopic or ultrasound guidance. CONCLUSION: In conclusion, image-guided musculoskeletal injections are safe and well-tolerated procedures. Complications are rare, occurring in just 1.2% of patients. 99% of complications are minor, either not requiring intervention or resolving with simple supportive treatment.

Absence of Iodinated Contrast Hypersensitivity and Characterization of Gadolinium Utilization in an Interventional Pain Population.

BACKGROUND: Iodinated contrast media (ICM) allergy labels pose a unique clinical problem for the interventional pain physician due to the drawbacks of gadolinium for enhancement during pain procedures, as well as the reluctance to add to the cumulative steroid burden with steroid premedication. However, the risks of ICM hypersensitivity specific to this setting have not been previously described. METHODS: We aimed to describe the incidence of ICM-induced hypersensitivity during the performance of epidural injections in a large healthcare system. We also sought to characterize preexisting ICM allergy labels and how these affected consequent gadolinium utilizations in this population. RESULTS: 6,471 epidural pain procedures requiring contrast enhancement were performed during the 18-month study period. There were no reported contrast-induced hypersensitivity reactions in this time. 108 patients (1.6%) had a preexisting ICM allergy; a shellfish/seafood allergy was recorded in 118 patients (1.82%), and 51 charts (0.78%) were labeled with "iodine" allergy. 183 individuals received gadolinium for enhancement during epidural steroid injections. 96.7% of gadolinium utilization occurred in the context of preexisting allergy labels in the electronic medical record. Of note, 20 patients (18.5%) with ICM allergy labels also received iodinated contrast, and this was uneventful in all cases. CONCLUSION: Our results suggest that ICM-associated hypersensitivity is very rare during epidural procedures and the incidence is significantly lower than expected based on reaction rates during intravascular administration. This may be related to both dose as well as route of administration. The establishment of a protocol for safe workup of ICM allergy labels would be useful in optimizing pain procedures.

Posterior Reversible Encephalopathy Syndrome after caudal epidural steroid injection: A case report.

BACKGROUND: Caudal epidural injections are easy, effective, and safe methods and are good options for patients with low back pain and radicular lower extremity pain. Although various complications related to the technique of the procedure or the drugs used in the procedure have been described, Posterior Reversible Encephalopathy Syndrome (PRES) has not yet been defined for this intervention. CASE: In this case report, we describe a case of PRES, which we supported with MRI findings in our patient who developed convulsions, changes in consciousness, and vision loss after being administered with caudal epidural steroid, and whose imaging findings regressed with the regression of clinical symptoms during the treatment process. CONCLUSION: Although PRES is rarely reported, it should be kept in mind that it is a complication that can develop after caudal epidural steroid injection.

Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain.

INTRODUCTION: The treatment of persistent lumbar radicular pain (LRP) by CT-guided epidural steroid injection (ESI) is extensively used and associated with rare but serious complications. Platelet-rich plasma (PRP), which has recently been shown to favor healing and the anti-inflammatory process by delivering growth factors and cytokines, might be an alternative and potentially safer option. We compared the efficacy of interlaminar CT-guided epidural PRP injections (EPRPI) and ESI in the treatment of persistent LRP (> 6 weeks). METHODS: In this non-randomized comparative study, patients were prospectively assessed for pain using the numerical rating scale (NRS) and for function with the Oswestry Disability Index (ODI) before and 6 weeks after treatment. Related paired and independent t tests were used for intra- and inter-group comparisons. RESULTS: A total of 60 patients were included in 2 groups (n = 30 EPRPI, n = 30 ESI). A statistically significant improvement was found in both groups at 6 weeks (mean NRS values 5.7 (± 2.36) at D0 and 3.7 (± 2.3) at 6 weeks (p < 0.01); mean ODI values 30 (± 11) at D0 and 21 (± 13) at 6 weeks (p < 0.01)). No significant difference was observed in the decrease in NRS and ODI scores between the 2 groups at 6 weeks (p = 0.848 and p = 0.314 for the NRS and ODI, respectively). No major complications were noted. CONCLUSION: The results of CT-guided interlaminar EPRPI are similar to ESI for the treatment of persistent LRP and could be a safer option. KEY POINTS: • Treatment of persistent lumbar radicular pain by CT-guided epidural steroid injections is associated with rare but serious complications. • By promoting an anti-inflammatory process, epidural platelet-rich plasma injections might be an alternative treatment of persistent radicular pain. • Platelet-rich plasma CT-guided epidural injections are similar to steroid for the treatment of lumbar radicular pain at 6 weeks post-procedure and could be a safer option.

Permanent Paraplegia as a Complication of Injection of Contrast Media at L2-L3 Vertebral Level.

BACKGROUND: The lumbar intrathecal (subarachnoid) space is accessed for both therapeutic and diagnostic purposes. Occasionally, the needle may unintentionally enter the intrathecal space during lumbar interlaminar epidural steroid injections (LESIs)-one of the most commonly performed medical procedures in the United States. Ordinarily, this merely constitutes a minor complication or even a desired placement (in the case of some diagnostic procedures). However, some patients have a rare condition wherein the spinal cord terminates below the L2 vertebral level (tethered cord). In such cases, injections administered at the lumbar level may potentially result in spinal cord damage and irreversible paraplegia if the physician performing the intervention does not recognize the intramedullary position of the needle. OBJECTIVE: The aim of this study is to describe and analyze an unintentional L2-L3 injection of contrast medium into a tethered spinal cord. Many physicians may consider lumbar injections "safe" because the spinal cord usually terminates at or above the L2 vertebral level. However, complacency stemming from this false impression of safety contributes to nonadherence to practice guidelines, which may lead to catastrophic neurological complications. Presented here is the first published occurrence of paraplegia that resulted from contrast medium injection into the spinal cord during a myelography study performed below the L2 vertebral level. CONCLUSIONS: Disregard of the procedural guidelines by the physicians performing an elective diagnostic intervention may cause devastating neurological complications. The described casualty occurred because of failure to review previous imaging studies, injection of the contrast medium despite unsuccessful attempts to aspirate cerebrospinal fluid, and an unwillingness to terminate the procedure immediately when the patient reported an unusual sensation in both of his lower extremities. Consequently, we suggest that not only for cervical and thoracic but also for lumbar interlaminar ESIs, previous imaging studies should be reviewed before the injection.

Epidural corticosteroid injections for lumbosacral radicular pain.

BACKGROUND: Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. OBJECTIVES: To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. SEARCH METHODS: We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. SELECTION CRITERIA: We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. DATA COLLECTION AND ANALYSIS: Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. MAIN RESULTS: We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. AUTHORS' CONCLUSIONS: This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.