Safety of Epidural Corticosteroid Injections.

BACKGROUND AND OBJECTIVE: Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports. METHODS: Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis. RESULTS: Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating. CONCLUSIONS: The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.

Survey of assessment criteria prior to implantation of spinal cord stimulators in United Kingdom pain management centres.

Spinal cord stimulation (SCS) is a useful option in selected patients with chronic neuropathic pain. The aim of this questionnaire-based survey was to determine what assessment methods are used for patients being considered for SCS in pain management centres in the United Kingdom. This was in relation to the recommendations produced by the Task Force of the European Federation of IASP chapters (1998) on neuromodulation. Questionnaires were sent out to previously identified individual SCS implanters. The response rate was 64% (n=44). The results of the survey were generally encouraging. Just over half of respondents use some form of guideline to assess patients for SCS, most trying opioid and co-analgesia before proceeding to SCS insertion. There was significant variation concerning absolute contraindications. The majority of respondents worked in a multi-disciplinary team and 61% stated their patients received a psychological assessment but although 96% of individuals worked with a specialist nurse only 25% reported that the nurse had an active role in the pre-assessment of patients for SCS. The development of national guidelines may provide a more standardised approach but further research into the role of the specialist nurse and the benefits of psychological assessment would also be useful.

The use of patient-controlled boluses of local anaesthetic via a psoas sheath catheter in the management of malignant pain.

Patients who develop malignant infiltration of the psoas muscle and the lumbar plexus often experience a severe complex pain syndrome characterised by deep somatic pain, neuropathic pain and psoas spasm. Conventional analgesic regimes may not relieve these symptoms adequately. We describe the use of patient-controlled boluses of local anaesthetic via a psoas sheath catheter in this scenario. The recent availability of portable infusion pumps with the capability to deliver large volume boluses with long lockout times made this intervention possible and allowed the patient to be discharged home with effective relief of pain.