Skip to main content

Complications in image-guided musculoskeletal injections

Abstract

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.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. 1.

    Stephens MB, Beutler AI, O’Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician. 2008;78(8):971–6.

    PubMed  Google Scholar 

  2. 2.

    Monseau AJ, Nizran PS. Common injections in musculoskeletal medicine. Prim Care. 2013;40(4):987–1000 ix-x.

    PubMed  Article  Google Scholar 

  3. 3.

    Gutierrez M, Di Matteo A, Rosemffet M, Cazenave T, Rodriguez-Gil G, Diaz CH, et al. Short-term efficacy to conventional blind injection versus ultrasound-guided injection of local corticosteroids in tenosynovitis in patients with inflammatory chronic arthritis: a randomized comparative study. Joint Bone Spine. 2016;83(2):161–6.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Maricar N, Parkes MJ, Callaghan MJ, Felson DT, O’Neill TW. Where and how to inject the knee--a systematic review. Semin Arthritis Rheum. 2013;43(2):195–203.

    PubMed  PubMed Central  Article  Google Scholar 

  5. 5.

    Soh E, Li W, Ong KO, Chen W, Bautista D. Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review. BMC Musculoskelet Disord. 2011;12:137.

    PubMed  PubMed Central  Article  Google Scholar 

  6. 6.

    MacMahon PJ, Huang AJ, Palmer WE. Spine injectables: what is the safest cocktail? AJR Am J Roentgenol. 2016;207(3):526–33.

    PubMed  Article  Google Scholar 

  7. 7.

    Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med. 2008;1(3–4):212–22.

    PubMed  PubMed Central  Article  Google Scholar 

  8. 8.

    Khalilzadeh O, Baerlocher MO, Shyn PB, Connolly BL, Devane AM, Morris CS, et al. Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 2017;28(10):1432–1437 e3.

  9. 9.

    Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012;15(2):131–40.

    PubMed  Google Scholar 

  10. 10.

    Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician. 2012;15(2):E143–50.

    PubMed  Google Scholar 

  11. 11.

    Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36(9):1892–902. https://doi.org/10.3899/jrheum.090013.

    PubMed  Article  Google Scholar 

  12. 12.

    Wang DT, Dubois M, Tutton SM. Complications in musculoskeletal intervention: important considerations. Semin Intervent Radiol. 2015;32(2):163–73.

    PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Albert C, Brocq O, Gerard D, Roux C, Euller-Ziegler L. Septic knee arthritis after intra-articular hyaluronate injection. Two case reports. Joint Bone Spine. 2006;73(2):205–7.

    PubMed  Article  Google Scholar 

  14. 14.

    Weingarten TN, Hooten WM, Huntoon MA. Septic facet joint arthritis after a corticosteroid facet injection. Pain Med. 2006;7(1):52–6.

    PubMed  Article  Google Scholar 

  15. 15.

    Rhee YG, Cho NS, Kim BH, Ha JH. Injection-induced pyogenic arthritis of the shoulder joint. J Shoulder Elb Surg. 2008;17(1):63–7.

    Article  Google Scholar 

  16. 16.

    Petersen SK, Hansen I, Andreasen RA. Low frequency of septic arthritis after arthrocentesis and intra-articular glucocorticoid injection. Scand J Rheumatol. 2019;48(5):393–7.

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    Bruens ML, van der Zaag-Loonen HJ, Steenstra F, Stemerding AM, Wijngaarden S. Septic arthritis after intra-articular injection is rare: does the Taskforce Infection Prevention use a sledgehammer to crack a nut? Ned Tijdschr Geneeskd. 2016;160:D789.

    CAS  PubMed  Google Scholar 

  18. 18.

    Hooten WM, Mizerak A, Carns PE, Huntoon MA. Discitis after lumbar epidural corticosteroid injection: a case report and analysis of the case report literature. Pain Med. 2006;7(1):46–51.

    PubMed  Article  Google Scholar 

  19. 19.

    Simopoulos TT, Kraemer JJ, Glazer P, Bajwa ZH. Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar epidural steroid injection. Pain Physician. 2008;11(5):693–7.

    PubMed  Google Scholar 

  20. 20.

    Koka VK, Potti A. Spinal epidural abscess after corticosteroid injections. South Med J. 2002;95(7):772–4.

    PubMed  Article  Google Scholar 

  21. 21.

    Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. 2004;79(5):682–6.

    PubMed  Article  Google Scholar 

  22. 22.

    Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC, et al. Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and Canadian Interventional Radiology Association [corrected]. J Vasc Interv Radiol. 2010;21(11):1611–30 quiz 31.

    PubMed  Article  Google Scholar 

  23. 23.

    McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726–31.

    PubMed  Article  Google Scholar 

  24. 24.

    Stout A, Friedly J, Standaert CJ. Systemic absorption and side effects of locally injected glucocorticoids. PM R. 2019;11(4):409–19.

    PubMed  Article  Google Scholar 

  25. 25.

    Dort K, Padia S, Wispelwey B, Moore CC. Adrenal suppression due to an interaction between ritonavir and injected triamcinolone: a case report. AIDS Res Ther. 2009;6:10.

    PubMed  PubMed Central  Article  Google Scholar 

  26. 26.

    Maviki M, Cowley P, Marmery H. Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir: beware of iatrogenic Cushing’s syndrome. Skelet Radiol. 2013;42(2):313–5.

    CAS  Article  Google Scholar 

  27. 27.

    Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought? Radiology. 2019;293(3):656–63.

    PubMed  Article  Google Scholar 

  28. 28.

    Simeone FJ, Vicentini JRT, Bredella MA, Chang CY. Are patients more likely to have hip osteoarthritis progression and femoral head collapse after hip steroid/anesthetic injections? A retrospective observational study. Skelet Radiol. 2019;48(9):1417–26.

    Article  Google Scholar 

  29. 29.

    MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology. 2009;252(3):647–61.

    PubMed  Article  Google Scholar 

  30. 30.

    Phillips OC, Ebner H, Nelson AT, Black MH. Neurologic complications following spinal anesthesia with lidocaine: a prospective review of 10,440 cases. Anesthesiology. 1969;30(3):284–9.

    CAS  PubMed  Article  Google Scholar 

  31. 31.

    Jayaram P, Kennedy DJ, Yeh P, Dragoo J. Chondrotoxic effects of local anesthetics on human knee articular cartilage: a systematic review. PM R. 2019;11(4):379–400.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to John P. Hynes.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hynes, J.P., Fhlatharta, M.N., Ryan, J.W. et al. Complications in image-guided musculoskeletal injections. Skeletal Radiol 50, 343–349 (2021). https://doi.org/10.1007/s00256-020-03565-y

Download citation

Keywords

  • Musculoskeletal injection
  • Complications
  • Corticosteroid
  • Interventional radiology