COMPLICATIONS OF
EPIDURAL STEROID INJECTION
Nikolai Bogduk
Emeritus Professor of Pain Medicine
University of Newcastle
Australia
NO CONFLICTS OF INTEREST
EPIDURAL INJECTIONS
CERVICAL
LUMBAR
X
INTERLAMINAR
TRANSFORAMINAL
LUMBAR EPIDURAL INJECTIONS
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
subdural
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
intrathecal
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
The literature on complications of Lumbar Epidural injections
infection 1,2,3,4
allergy to local anaesthetic 5
hypotension 6,7
1.
2.
3.
4.
5.
6.
7.
Chan ST, Leung S. Spinal epidural abscess following steroid injection for sciatica: case report.
Spine 1989; 14:106-70.
Dougherty JH, Fraser RAR. Complications following intraspinal injections of steroids. J
Neurosurg 1978; 48:1023-1025.
Goucke CR, Graziotti P. Extradural abscess following local anaesthetic and steroid injection for
chronic low back pain. Brit J Anesth 1990; 65:427-490.
Shealy CN. Dangers of spinal injections without proper diagnosis. JAMA 1966; 197:1104-1106.
Goebert HW, Jallo SJ, Gardner WJ, Wasmuth CE. Painful radiculopathy treated with epidural
injections of procaine and hydrocortisone acetate: results in 113 patients. Anesth Analg 1961;
140:130-134.
Burn JMB, Langdon L. Lumbar epidural injection for the treatment of chronic sciatica. Rheum
Phys Med 1970; 10:368-374.
Berman AT, Garbarinbo JL, Fisher SM, Bosacco SJ. The effects of epidural injection of local
anesthetics and corticosteroids on patients with lumbosciatic pain. Clin Orthop 1984; 188:144-151.
The literature on complications of Lumbar Epidural injections
allergy to steroids 8
adrenal suppression 9,10
steroid overdose 11,12,13,14
8.
9.
10.
11.
12.
13.
14.
Simon DL, Kunz RD, German JD, Zivkovich V. Allergic or pseudoallergic reaction following
epidural steroid deposition and skin testing. Regional Anesth 1989; 253-255.
Burn JMB, Langdon L. Duration of action of epidural methyl prednisolone. A study in patients
with the lumbosciatic syndrome. Am J Phys Med 1974; 53:90-34.
Jacobs S, Pullan PT, Potter JM, Shenfield GM. Adrenal suppression following extradural steroids.
Anesthesia 1983; 38:953-956.
Knight CL, Burnell JC. Systemic side-effects of extradural steroids. Anaesthesia 1980; 35:593594.
Simon D, Carron H, Rowlingson J. Correspondence. J Bone Joint Surg 1985; 67A:981.
Stambough JL, Booth RE, Rothman RH: Transient hypercorticism after epidural steroid injection.
J Bone Joint Surg 1984; 66A:1115-1116.
Tuel SM, Meythaler JM, Cross LL. Cushing's syndrome from epidural methylprednisolone. Pain
The literature on complications of Lumbar Epidural injections
Intrathecal injection
with neurotoxicity 1,2,3
1.
Bogduk N, Christophidis N, Cherry D, et al. Epidural use of steroids in the management of back
pain and sciatica of spinal origin. Report of the Working Party on Epidural use of Steroids in the
Management of Back Pain. National Health and Medical Research Council, Canberra, 1993.
2.
Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH (ed), Spine Care, Volume
One: Diagnosis and Conservative Treatment. Mosby, St Louis, 1995, ch 22, pp 322-343.
3.
Bogduk N. Spine update: epidural steroids. Spine 1995; 20:845-848.
The literature on complications of Lumbar Epidural injections
temporary paralysis 1
ischaemic paraplegia 2,3
epidural haematoma 4
1.
Mclain RE, Fry M, Hecht ST. Transient paralysis associated with epidural steroid injection. J
spinal Disord 1997; 10: 441-444.
2.
Lenoir T, Deloin X, Dauzac C, Rillardon L, Guigui P. {Paraplegia after interlaminar epidural steroid
injection: a case report.] Rev Chir Orthop Reparatric Appar Mot 2008; 94: 697-701.
3.
Thefenne L. Dubecq C, Zing E, Rogez D, Soula M, Escobar E, Defluentes G, Lapeyre E, Berets O.
A rare case of paraplegia complicating a lumbar epidural infiltration. Ann Phys Rehabil Med 2010;
53: 575-583.
4.
Chung JY, Han JH, Kang JM, Lee BJ. Paraplegia after epidural steroid injection. Anaesth Intesive
Care 2012; 40: 1074-1076.
CERVICAL EPIDURAL INJECTIONS
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
The literature on complications of Cervical Epidural injections
spinal cord injection 1
spinal cord compression 2
epidural haematoma 3,4,5,6,7
1.
Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with
intrinsic spinal cord damage: two case reports. Spine 1998; 23:2137-2140.
2.
Bose B. Quadriparesis following cervical epidural steroid injections: case report and review of
the literature. The Spine J 2005; 5:558-563.
3.
Stoll A, Sanchez M. Epidural hematoma after epidural block: implications for its use in pahoin
management. Surg Neurol 2002: 57:235-240.
4.
Horlocker TT, Wedel DJ. Anticoagulation and neuraxial block:historical perspective, anesthetic
implications, and risk management. Reg Anesth Pain Med 1998; 23 (Supp 2): 129-134.
5.
Williams KN, Jackowski A, Evans PJD. Epidural haematoma requiring surgical decompression
following repeated cervical epidural steroid injections for chronic pain. Pain 1990; 42:197–199.
6.
Ghaly RF. Recovery after high-dose methylprednisolone and delayed evacuation: a case of spinal
epidural hematoma. J Neurosrug Anaesthesiol 2001; 13:323-328.
The literature on complications of Cervical Epidural injections
retinal haemorrhage 1
epidural granuloma 2
epidural abscess 3
subdural haematoma 4
subdural injection 5
pneumocephalus 6
neuropathic reaction to steroid 7
1.
2.
3.
4.
5.
6.
7.
8.
CRPS 8
Kushner FH, Olson JC. Retinal hemorrhage as a consequence of epidural steroid injection. Arch
Ophthalmol 1995; 113: 309-313.
Dietrich CL, Smith CE. Epidural granuloma and intracranial hypotension resulting from cervical
epidural steroid injection. Anesthesiology 2004; 100: 445-447.
Huang RC, Shapiro GS, Lim M, Sandhu HS, Lutz GE, Herzog RJ. Cervical epidural abscess after
epidural steroid injection. Spine 2004; 29: E7-E8.
Reitman CA, Watters W. Subdural hematoma after cervical epidural steroid injection. Spine 2002;
27:E174-E176.
Bansal S, Turtle MJ. Inadvertent subdural spread complication cervical epidural steroid injection
with local anaesthetic agent. Anaesth Intesive Care 2003; 31: 750-572.
Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection.
Anesth Analg 2001; 92: 1576-1577.
Field J, Rathmell JP, Stephenson JH, Katz NP. Neuropathic pain following cervical epidural
steroid injection. Anesthesiology 2000; 93: 885-888.
Siegfried RN. Development of complex regional pain syndrome after a cervical epidural steroid
injection. Anesthesiology 1997; 86: 1394-1396.
The Closed Claims Database of the American Society of Anaesthesia:
spinal cord injuries
= leading cause of claims against anesthesiologists in the 1990s,
epidural hematomas = 50% of these cases 1.
in 14 cases (of 276 claims pertaining to pain management) 2
in 20 cases (of 294 claims pertaining to pain management) 3
Some patients have felt no symptoms when a needle has entered the
spinal cord 4
1.
Cheney FW, Domino KB, Caplan RA, Psner KL. Nerve injury associated with anesthesia: a closed
claims analysis. Anesthesiology 1999; 90:1062-1069.
2.
Fitzgibbon DR, Posner KL, Domino KB, Caplan RA, Lee LA, Cheney FW. Chronic pain maagment:
American Soceity of Anesgthesiologists closed Claims Project. Anesthesiology 2004; 100: 98-105.
3.
Rathmell JP, Michna E, Fitzgibbon DR, Stephens LS, Psner KL, domino KB. Injury and liability
associated with cervical procedures for chornic pain. Anesthesiology 2011; 114: 918-926.
4.
Pounder D. , Elliott S. An awake patient may not detect spinal cord puncture. Anesthesia 2000;
55:194.
Cervical TRANSFORAMINAL INJECTIONS of steroids
C6
vb
ZJ
C7
vb
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
A
C6
C6
C7
C7
B
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
A
B
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
A
B
Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn.
International Spine Intervention Society, San Francisco, 2013.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Baker et al. Pain 2002; 103:211-215.
Good needle position.
Arterial filling observed.
Procedure abandoned.
Karasek. Pain Medicine 2004; 5:202-205.
Good needle position.
Local anesthetic only, first.
Anterolateral column loss.
Temporary
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of
spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34.
Mechanisms of injury
Embolism of particulate steroids
Neurotoxic effect of additive
The literature on complications of Cervical Transforaminal injections
spinal cord injection 1
spinal cord infarction 2,3,4
cortical blindness 5
cerebral infarction, death 6
cerebellar infarction, death 7
brainstem infarction, death 8,9
transient ischaemia 9
1.
2.
3.
4.
5.
6.
7.
8.
9.
Lee JH, Lee JK, Seo BR, Moon SJ, Kim JH, Kim SH (2008). Spinal cord injury produced by direct
damage during cervical transforaminal epidural injection. Reg Anesth Pain Med 33:377-379.
Brouwers PJAM, Kottnik EJBL, Simon MAM, et al. (2001). A cervical anterior spinal artery
syndrome after diagnostic blockade of the right C6-nerve root. Pain 91:397–399.
Ludwig MA, Burns SP (2005). Spinal cord infarction following cervical transforaminal injection. A
case report. Spine 30:E266-E268.
Windsor RE, Strom S, Sugar R, Nagula D (2003). Cervical transforaminal injection: review of the
literature, complications, and a suggested technique. Pain Physician 6:457-465.
McMillan MR, and Crumpton C (2003). Cortical blindness and neurologic injury complicating
cervical transforaminal injection for cervical radiculopathy. Anesthesiology 99:509–511.
Rozin L, Rozin R, Koehler SA, et al. (2003). Death during a transforaminal epidural steroid nerve
root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Path 24:351–355.
Tiso RL, Cutler T, Catania JA, et al. (2004). Adverse central nervous system sequelae after
selective transforaminal block: The role of corticosteroids. The Spine J 4:468–474.
Suresh S, Berman J, Connell DA (2007). Cerebellar and brainstem infarction as a complication of
CT-guided transforaminal cervical nerve root block. Skeletal Radiol 36:449-452.
Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P (2007). Complications of cervical selective
nerve root blocks performed with fluoroscopic guidance. Am J Roentgenol 188:1218-1221.
The literature on complications of Cervical Transforaminal injections
vertebrobasilar infarction
16
spinal cord infarction
12
spinal + vertebrovasilar infarction
2
Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical
transforaminal epidural steroid injections. More dangerous than we think?
Spine 2007; 32:1249-1256.
LUMBAR TRANSFORAMINAL INJECTIONS
P
P
L4
L5
A
B
Reproduced from: Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures. International
Spine Intervention Society, San Franciscoc, 2004. © International Spine Intervention Society 2004
L4
L5
Reproduced from: Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures. International
Spine Intervention Society, San Franciscoc, 2004. © International Spine Intervention Society 2004
needle
L4
L4
L5
A
L5
B
Reproduced from: Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures. International
Spine Intervention Society, San Franciscoc, 2004. © International Spine Intervention Society 2004
c
c
b
b
needle
a
A
a
B
Reproduced from: Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures. International
Spine Intervention Society, San Franciscoc, 2004. © International Spine Intervention Society 2004
The literature on complications of Lumbar Transforaminal injections
ischaemic paraplegia
1.
Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N (2009). Paraplegia following image-guided
transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med; 19:1389-1394.
2.
Houten JK, and Errico TJ (2002). Paraplegia after lumbosacral nerve root block: Report of three
cases. The Spine J 2:70–75.
3.
Somyaji HS, Saifuddin A, Casey ATH, et al. (2005). Spinal cord infarction following therapeutic
computed tomography-guided left L2 nerve root injection. Spine 30:E106–E108.
4.
Huntoon M, Martin D (2004). Paralysis After Transforaminal Epidural Injection and Previous Spinal
Surgery. Regional Anesthesia and Pain Medicine; 29: 494-495.
5.
Glaser SE, Falco FM (2005). Paraplegia Following a Thoracolumbar Transforaminal Epidural
Steroid Injection: A Case Report. Pain Physician; 8:309-314.
PRECAUTIONS
1. Care and attention
2. Image guidance
to know where your needle is
3. Test dose of contrast medium
to know where it goes
4. Under DSI
to see it better
5. Test dose of local anesthetic
? just in case
6. Using non-particulate steroid
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