ABSTRACT
Cerebral venous sinus thrombosis (CVST) is an exceedingly rare complication of epidural anesthesia, with only a handful of known cases after epidural steroid injection (ESI). We report a case of CVST in a 33-year-old male patient that presented with headache after lumbar ESI. His clinical status initially improved on anticoagulation in the intensive care unit. However, he had a sudden worsening of cerebral edema that required an emergent hemicraniectomy. Ultimately, the patient was pronounced dead by neurologic criteria. This case highlights the importance of keeping this rare but potentially fatal diagnosis in the differential even in lower-risk patient populations.
Subject(s)
Sinus Thrombosis, Intracranial , Steroids , Humans , Male , Adult , Sinus Thrombosis, Intracranial/drug therapy , Sinus Thrombosis, Intracranial/chemically induced , Injections, Epidural/adverse effects , Steroids/administration & dosage , Steroids/therapeutic use , Fatal Outcome , Anticoagulants/adverse effects , Anticoagulants/administration & dosage , Anticoagulants/therapeutic useSubject(s)
Disease Progression , Intervertebral Disc Displacement , Humans , Injections, Epidural/adverse effects , Female , MaleABSTRACT
BACKGROUND: Transforaminal epidural steroid injection (TFESI) is commonly used for radicular pain, but can lead to an unintentional injection into the retrodural Space of Okada (RSO), an extradural space located dorsal to the ligamentum flavum, instead of the epidural space. OBJECTIVES: To determine the prevalence and describe the fluoroscopic imaging features of an unintentional injection into the RSO during a TFESI and to review the history of injections into the RSO. STUDY DESIGN: Observational study and original research. SETTING: This work was conducted at Jeju National University School of Medicine, Jeju, Republic of Korea. METHODS: A total of 5,429 lumbar TFESIs performed from the September 1, 2018 through October 31, 2021 were analyzed for unintentional RSO injections using fluoroscopic-guided contrast medium patterns. RESULTS: The rate of unintentional injection into the RSO was 0.20% (11 incidents). Contrast medium patterns in the RSO had a sigmoid or ovoid shape confined to the affected facet joint, or a butterfly-shaped pattern extending into the contralateral facet joint, but rarely extending beyond the upper or lower level. LIMITATION: The rarity of unintentional injection into the RSO prevented a randomized controlled study design. CONCLUSIONS: Careful fluoroscopic examination of contrast medium patterns during lumbar TFESI is crucial to identify needle placement in the RSO. If detected, the procedure can be corrected by slightly advancing the needle into the foramen.
Subject(s)
Steroids , Humans , Injections, Epidural/methods , Injections, Epidural/adverse effects , Fluoroscopy , Steroids/administration & dosage , Male , Female , Middle Aged , Adult , Ligamentum Flavum , Aged , Republic of Korea , Lumbar VertebraeABSTRACT
An epidural hematoma is a rare but devastating complication after interventional pain procedures. The etiology is multifactorial, including anatomical variations, inherited coagulation disorders, and consumption of anticoagulants or antiplatelet substances. Specifically, in regard to platelet aggregation, the consumption of herbal medicine is often forgotten as a potential cause for coagulation profile disorders, potentially leading to an epidural hematoma. We present the case of a patient who developed an epidural hematoma after a cervical epidural block, most likely associated with daily "red clover" consumption.
Subject(s)
Hematoma, Epidural, Spinal , Humans , Hematoma, Epidural, Spinal/etiology , Injections, Epidural/adverse effects , Trifolium/adverse effectsABSTRACT
Little is known about the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral radicular pain due to lumbar spinal stenosis (LSS). Using lumbar spine radiographs as input data, we trained a convolutional neural network (CNN) to predict therapeutic outcomes after lumbar TFESI in patients with lumbosacral radicular pain caused by LSS. We retrospectively recruited 193 patients for this study. The lumbar spine radiographs included anteroposterior, lateral, and bilateral (left and right) oblique views. We cut each lumbar spine radiograph image into a square shape that included the vertebra corresponding to the level at which the TFESI was performed and the vertebrae juxta below and above that level. Output data were divided into "favorable outcome" (≥ 50% reduction in the numeric rating scale [NRS] score at 2 months post-TFESI) and "poor outcome" (< 50% reduction in the NRS score at 2 months post-TFESI). Using these input and output data, we developed a CNN model for predicting TFESI outcomes. The area under the curve of our model was 0.920. Its accuracy was 87.2%. Our CNN model has an excellent capacity for predicting therapeutic outcomes after lumbar TFESI in patients with lumbosacral radicular pain induced by LSS.
Subject(s)
Radiculopathy , Spinal Stenosis , Humans , Spinal Stenosis/complications , Spinal Stenosis/diagnostic imaging , Spinal Stenosis/drug therapy , Retrospective Studies , Treatment Outcome , Injections, Epidural/adverse effects , Back Pain/etiology , Lumbar Vertebrae/diagnostic imaging , Algorithms , Steroids/therapeutic use , Neural Networks, Computer , Radiculopathy/etiologyABSTRACT
OBJECTIVES: The aim of this study was to investigate the effect of epidural steroid injections on the menstrual cycle of women and to identify risk factors in those with changes. METHODS: A total of 78 women who had epidural steroid injections between the ages of 18 and 55 years were retrospectively analyzed. The patients were called by phone and asked whether there was any change in their menstrual cycles after the epidural injections. Data including demographic and clinical characteristics, body height and weight, education status, alcohol and smoking habits, comorbidities, number of children, birth control method, history of cesarean section, miscarriage, and abortion were recorded. RESULTS: Changes in the menstrual cycle were seen in five of 12 patients who underwent cervical interlaminar epidural steroid injection, in 27 of 56 patients who underwent lumbar transforaminal epidural steroid injection, in one of two patients who underwent lumbar interlaminar epidural steroid injection, and in three of eight patients who underwent caudal epidural steroid injection. The number of patients with obesity was higher in the patients with changes than those without, indicating a statistically significant difference (41.7% vs. 14.3%, respectively; p=0.007). CONCLUSION: Our study suggests that epidural steroid injections are associated with changes in the menstrual cycle. Obesity is a risk factor for menstrual cycle changes after epidural steroid injections.
Subject(s)
Menstrual Cycle , Steroids , Adolescent , Adult , Female , Humans , Middle Aged , Young Adult , Injections, Epidural/adverse effects , Injections, Epidural/methods , Obesity/etiology , Retrospective Studies , Treatment OutcomeABSTRACT
Background: Lumbar spinal stenosis (LSS) causes low back pain, leg pain, numbness in the leg, and neurogenic intermittent claudication. Epidural steroid injection (ESI) has been used for treating spinal stenosis symptoms. We hypothesized that dural pulsation was variable for lumbar spinal stenosis. In cases of the presence of dural pulsation, the pain relief after the ESI was better than in the absence of dural pulsation. This study aimed at investigating the relationships between the presence or absence of spinal dural pulsations and the efficacy of ESI. Methods: A total of 71 patients were enrolled in this prospective study. Prior to the ESI, the dural pulsation was measured using a 5-1 MHz array ultrasound transducer. The visual analogue scale (VAS) score was measured pre-ESI and 2 weeks post-ESI and 4 weeks post-ESI. At 4 weeks post-ESI, dural pulsation was rechecked. Results: The VAS scores improved after the ESI procedure regardless of the presence or absence of dural pulsation. There was a correlation between the pulsation of the dura and post-ESI VAS scores. However, VAS was not significantly different for different grades of stenosis. Conclusion: The ESI was effective in patients with spinal stenosis in short-term follow-up. Dural pulsation of the spinal cord was a positive predictive factor for the ESI effect, but the grade of spinal stenosis severity had no effect on the effectiveness of ESI.
Subject(s)
Chronic Pain , Low Back Pain , Spinal Stenosis , Humans , Spinal Stenosis/complications , Spinal Stenosis/drug therapy , Prospective Studies , Back Pain , Low Back Pain/drug therapy , Low Back Pain/etiology , Low Back Pain/diagnosis , Chronic Pain/complications , Injections, Epidural/adverse effects , Steroids/therapeutic use , Treatment OutcomeABSTRACT
INTRODUCTION: Intravascular injection of a local anesthetic can lead to life-threatening complications, such as deficits in neurological function after caudal epidural block. This study aimed to determine whether the intravascular injection rate of the Tuohy needle is lower than that of the Quincke needle during an ultrasound-guided caudal block. METHODS: Two-hundred and thirty patients were randomized into the Quincke (n=115) and the Tuohy (n=115) needle groups. The randomly selected needle was introduced at a 45° angle until it penetrated the sacrococcygeal ligament under ultrasound guidance, and intravenous injections were analyzed using contrast-dyed digital subtraction angiography. The relationship between the incidence of intravascular injection and independent variables, including needle type, patient demographics, history of lumbosacral surgery, use of anticoagulants, anatomic variables of the sacrum, presence of bony contact during the procedure, and the number of needle repositioning under ultrasound guidance, were examined. RESULTS: Intravascular uptake of contrast medium was surveyed in 25/230 (10.9%) caudal blocks using digital subtraction angiography (DSA). The incidence of intravascular uptake was 13.9% (16/115) using the Quincke needle and 7.8% (9/115) using the Tuohy needle (p=0.14). Although the needle tip type was not associated with the rate of intravascular injection, the occurrence of bony contact during the procedure demonstrated a relationship with the intravenous injection (p<0.01). CONCLUSIONS: The overall incidence of inadvertent intravascular injections during ultrasound-guided caudal block confirmed using DSA was 10.9%. Tuohy needles did not reduce intravascular injection rates during the ultrasound-guided caudal block. TRIAL REGISTRATION NUMBER: NCT05504590.
Subject(s)
Anesthesia, Epidural , Injections, Epidural , Humans , Contrast Media , Incidence , Injections, Epidural/adverse effects , Injections, Epidural/methods , Needles , Prospective Studies , Ultrasonography, InterventionalABSTRACT
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.
Subject(s)
Meningitis, Aseptic , Female , Humans , Aged , Meningitis, Aseptic/chemically induced , Meningitis, Aseptic/diagnosis , Methylprednisolone , Magnetic Resonance Imaging , Lidocaine , Injections, Epidural/adverse effectsABSTRACT
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.
Subject(s)
Spinal Nerve Roots , Spine , Arteries , Injections, Epidural/adverse effects , Needles , Lumbar Vertebrae/diagnostic imagingABSTRACT
Background: Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbar radiculopathy. In clinical settings, patients often undergo repeated transforaminal epidural injections with or without steroid administration. Objectives: To examine whether a positive response to TFESI at the first month, can in clinical settings, identify patients with radiculopathy who can avoid surgery for two years. Study Design/Setting. This prospective observational study was conducted at an academic medical center. Methods: Individuals aged ≥20 years who had been referred to our pain center by spine surgeons were enrolled. All patients were assessed using the Numerical Rating Scale (NRS) at baseline and 1 month after the first TFESI. Patients were divided into two groups according to the NRS decrement: the positive response (PR) group achieved a ≥2.0 decrease on the NRS 1 month after the first TFESI compared to baseline and the no response (NR) group achieved a <2.0 decrease on the NRS. The incidence rates of surgery over two years were compared between the two groups. In addition, we calculated the hazard ratio of the PR group to the NR group regarding the incidence of surgery over two years using the Cox proportional hazard model, adjusting for baseline NRS. Results: Seventy-six patients completed the two-year follow-up. In total, 8 and 68 patients had bilateral and unilateral radiculopathy, respectively. The PR and NR groups included 35 and 41 patients, respectively. The rate of surgery avoidance was 85.7% and 73.2% in the PR and NR groups, respectively. This difference was not statistically significant (p=0.26). After adjusting for baseline NRS, the hazard ratio of the PR group to the NR group regarding the incidence of surgery within two years was 0.35 (95% confidence interval: 0.11-1.11, p=0.08). Conclusion: A positive response to TFESI may not identify patients who can avoid surgery for two years.
Subject(s)
Radiculopathy , Humans , Treatment Outcome , Radiculopathy/drug therapy , Radiculopathy/etiology , Radiculopathy/surgery , Prospective Studies , Lumbar Vertebrae , Injections, Epidural/adverse effects , Steroids/therapeutic useABSTRACT
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.
Subject(s)
Low Back Pain , Humans , Low Back Pain/drug therapy , Low Back Pain/etiology , Injections, Epidural/adverse effects , Injections, Epidural/methods , Treatment Outcome , Steroids/adverse effectsABSTRACT
INTRODUCTION: Post-dural puncture headache (PDPH) is the most common complication of intraspinal nerve block in gravida. PDPH may be accompanied by neck stiffness, tinnitus, hearing loss, photophobia or nausea. PATIENT CONCERNS: A 33-year-old woman whose dura was accidentally punctured during labor analgesia complained of severe headache, dizziness, and nasal congestion; these symptoms aggravated when she looked up, and her sense of smell was normal 8 hours after catheter removal. DIAGNOSES: Based on the patient's complaints and clinical appearance, diagnosis of PDPH was considered. INTERVENTIONS: Nasal congestion disappeared with headache and dizziness after epidural injections of saline. The puerpera received saline injections 4 times; after treatment, she was discharged from the hospital when the symptoms did not limit her daily movement. OUTCOMES: The symptoms disappeared completely on the seventh day of telephone follow-up visit. The mechanism of her nasal obstruction is not very clear. CONCLUSION: We believe it is caused by the pulling of the intracranial nerve as the brain tissue sinks and shifts due to the decrease in intracranial pressure.
Subject(s)
Post-Dural Puncture Headache , Humans , Female , Adult , Post-Dural Puncture Headache/etiology , Post-Dural Puncture Headache/therapy , Dizziness/therapy , Headache/therapy , Injections, Epidural/adverse effects , Analgesics , Blood Patch, Epidural/adverse effects , Spinal PunctureABSTRACT
BACKGROUND: Epidural steroid injections (ESIs) involve the administration of steroids and local anesthetics into the spinal epidural space, and they are performed by inserting a needle between the ligamentum flavum and dura. This procedure is suitable for patients with lumbosacral radiculopathy secondary to disc herniation or postsurgical radicular pain. The relief period of the analgesic medications may be prolonged by > 6 weeks, resulting in nonsurgical management becoming a suitable option. However, the negative effect of ESIs on bone mineral density has been reported. OBJECTIVES: We aimed to clarify the association between ESIs and osteoporosis risk by analyzing a nationwide population database. STUDY DESIGN: This study is a nationwide retrospective cohort study. SETTING: Data on 1 million cases randomly selected from the 2000 Registry for Beneficiaries of the National Health Insurance Research Database (NHIRD) were collected. METHODS: In total, 4,957 patients who were diagnosed with lumbar spondylosis and received ESIs between 2000 and 2013 were identified from the NHIRD. Subsequently, another 4,957 patients with lumbar spondylosis were randomly selected from the same database and frequency matched by age, gender, and index year with the patients who received ESIs. RESULTS: The mean age of the patients were 50.3 ± 17.1 years. The incident rates of osteoporosis in the ESI and non-ESI groups were 7.95 and 7.01 per 1,000 person-years, respectively. Osteoporosis risk was significantly higher in the ESI cohort than in the non-ESI cohort (absolute standardized hazard ratio = 1.23, 95% confidence interval = 1.05-1.45, P = 0.01). The risk factors for osteoporosis were old age, being female, and undergoing ESIs. Osteoporosis risk was significantly higher in the ESI cohort than in the non-ESI cohort in the male, lowest-urbanization-level (fourth level), other-occupations, and comorbidity-free subgroups. LIMITATIONS: The NHIRD did not provide information on osteoporosis-related scales, renal function, blood pressure, smoking habit, pulmonary function, daily activities, and dosage of injected steroids. CONCLUSIONS: For patients diagnosed with lumbar spondylosis, ESIs are associated with a high osteoporosis risk. Thus, this therapy should be recommended with caution, especially for patients with correlated risk factors (e.g., high risk of osteoporotic fracture, low socioeconomic status, and retired or unemployed status).
Subject(s)
Osteoporosis , Spondylosis , Humans , Male , Female , Adult , Middle Aged , Aged , Retrospective Studies , Cohort Studies , Osteoporosis/epidemiology , Steroids , Spondylosis/epidemiology , Injections, Epidural/adverse effects , Injections, Epidural/methodsABSTRACT
Introduction: Epidural injections are frequent and safe procedures. Severe complications are infrequent, and they have been reported in elderly comorbid patients with predisposing factors. The objectives of this work are to present a case of an extensive epidural lumbar abscess in a young non-comorbid male patient after a therapeutic L5-S1 injection and a literature review about this subject. Case Presentation: An otherwise healthy 24-year-old man who present a case of an extensive epidural lumbar abscess after a therapeutic nerve root block due to a disc herniation. After 7 days of fever and low back pain, he required two surgical interventions and intravenous antibiotic therapy. We reviewed 18 patients with epidural abscess consequence of spinal injections. Their mean age was 54.5 y.o, 66.5% were male, and 66.5% had at least one predisposing risk factor. Symptoms Onset occurred at 8 days on average after the procedure, but the correct diagnosis was made at the 25th-day average. Only 22% presented the classic diagnostic triad, the most frequently isolated germ was Staphylococcus Aureus (66%) and 89% were treated surgically with a 33% rate of complete recovery, 17% mortality and 28% remained with neurological sequelae. Conclusion: Epidural abscesses are infrequent and serious, complication after spinal diagnostic and therapeutic injections, even in young patients without comorbidities. We consider it fundamental to maintain a diagnostic suspicion, even in this subgroup of patients.
Introducción: Los bloqueos perirradiculares son una práctica habitual y segura. Las complicaciones severas, como los abscesos epidurales, son infrecuentes y han sido reportadas en pacientes añosos con comorbilidades o factores predisponentes. El objetivo de este trabajo es presentar un paciente joven sin antecedentes con diagnóstico de absceso epidural posterior a un bloqueo terapéutico y la revisión de la literatura al respecto. Presentación del caso: Un hombre de 24 años, previamente sano, presenta un caso de absceso epidural lumbar extenso, luego de un bloqueo perirradicular por una hernia de disco. Tras 7 días de fiebre y lumbalgia, precisó dos intervenciones quirúrgicas y antibioticoterapia intravenosa. Recabamos la información de 18 casos junto al nuestro, de pacientes con diagnóstico de absceso epidural como consecuencia de una infiltración espinal. El promedio de edad de los pacientes fue de 54,5 años, 66,5% fueron de sexo masculino y 66,5% presentaba al menos un factor de riesgo predisponente. La aparición de síntomas luego del bloqueo ocurrió en promedio a los 8 días, pero el diagnóstico de absceso se realizó a los 24 días en promedio. La tríada diagnóstica clásica solo estuvo presente en el 22%, el germen más frecuentemente aislado fue el Staph. aureus (66%) y un 89% fue tratado de manera quirúrgica con una tasa del 33% de recuperación completa, 17% de mortalidad y 28% de secuela neurológica. Conclusión: Los abscesos epidurales son una complicación infrecuente, grave y rara de los procedimientos diagnósticos y terapéuticos espinales, incluso en pacientes jóvenes sin comorbilidades. Consideramos menester mantener la sospecha diagnóstica, incluso en este subgrupo de pacientes.
Subject(s)
Epidural Abscess , Intervertebral Disc Displacement , Low Back Pain , Humans , Male , Aged , Middle Aged , Young Adult , Adult , Female , Epidural Abscess/complications , Epidural Abscess/drug therapy , Low Back Pain/complications , Low Back Pain/drug therapy , Intervertebral Disc Displacement/complications , Intervertebral Disc Displacement/drug therapy , Lumbosacral Region , Injections, Epidural/adverse effectsABSTRACT
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 .
Subject(s)
Intervertebral Disc Displacement , Humans , Intervertebral Disc Displacement/drug therapy , Intervertebral Disc Displacement/complications , Treatment Outcome , Pain/etiology , Triamcinolone/therapeutic use , Injections, Epidural/adverse effects , Lumbar Vertebrae/diagnostic imaging , Lumbar Vertebrae/surgeryABSTRACT
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.
Subject(s)
Low Back Pain , Humans , Male , Female , Prospective Studies , Treatment Outcome , Low Back Pain/drug therapy , Low Back Pain/etiology , Steroids , Dexamethasone/therapeutic use , Injections, Epidural/adverse effects , Lumbar VertebraeABSTRACT
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.
Subject(s)
Intervertebral Disc Displacement , Pulsed Radiofrequency Treatment , Sciatica , Male , Humans , Middle Aged , Intervertebral Disc Displacement/complications , Intervertebral Disc Displacement/diagnostic imaging , Intervertebral Disc Displacement/therapy , Sciatica/drug therapy , Sciatica/etiology , Prospective Studies , Treatment Outcome , Injections, Epidural/adverse effects , Injections, Epidural/methods , Pain/etiology , Steroids , Tomography, X-Ray ComputedABSTRACT
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.