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Safety and Risk Mitigation for Cervical Transforaminal Epidural Steroid Injections

  • Interventional Pain Management (L Huynh and J Levin, Section Editors)
  • Published:
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Abstract

Purpose of Review

The purpose of this study is to describe the most common complications of cervical transforaminal epidural steroid injection and to differentiate these from rare but serious risks unique to cervical transforaminal epidural steroid injections (CTFESI). Relevant safety mitigation techniques will also be discussed.

Recent Findings

The largest available cohort of epidural steroid injections was recently published, without a single case of major neurologic damage captured.

Summary

A large body of evidence suggests that the risk of neurologic infarct following CTFESI is due to the embolic effect of inadvertent arterial injection of particulate steroids. The advent of safety techniques to mitigate this risk, namely restricting use of steroids to the non-particulate steroid dexamethasone, seems to have greatly improved the safety profile of CTFESI.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Ludwig MA, Burns SP. Spinal cord infarction following cervical transforaminal epidural injection: a case report. Spine. 2005;30(10):E266–8.

    Article  PubMed  Google Scholar 

  2. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine. 2007;32(11):1249–56.

    Article  PubMed  Google Scholar 

  3. Suresh S, Berman J, Connell DA. Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block. Skelet Radiol. 2007;36(5):449–52.

    Article  CAS  Google Scholar 

  4. Beckman WA, Mendez RJ, Paine GF, Mazzilli MA. Cerebellar herniation after cervical transforaminal epidural injection. Reg Anesth Pain Med. 2006;31(3):282–5.

    Article  PubMed  Google Scholar 

  5. Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol. 2003;24(4):351–5.

    Article  PubMed  Google Scholar 

  6. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001;91(3):397–9.

    Article  CAS  PubMed  Google Scholar 

  7. Research C for DE and drug safety and availability—FDA drug safety communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain [Internet]. [cited 2016 Mar 1]. Available from: http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm.

  8. Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep [Internet]. 2015 May [cited 2017 Apr 1];19(5). Available from: http://link.springer.com/10.1007/s11916-015-0482-3

  9. • El-Yahchouchi CA, Plastaras CT, Maus TP, Carr CM, McCormick ZL, Geske JR, et al. Adverse event rates associated with transforaminal and interlaminar epidural steroid injections: a multi-institutional study: adverse events epidural steroid injections. Pain Med. 2015 Nov;n/a-n/a. The largest published cohort of over 16,000 epidural steroid injections, showing the overall incidence of immediate adverse events was 2.4% and delayed adverse events was 4.9%.

  10. Ma DJ, Gilula LA, Riew KD. Complications of fluoroscopically guided extraforaminal cervical nerve blocks: an analysis of 1036 injections. J Bone Joint Surg Am. 2005;87(5):1025–30.

    Article  PubMed  Google Scholar 

  11. Huston CW, Slipman CW, Garvin C. Complications and side effects of cervical and lumbosacral selective nerve root injections. Arch Phys Med Rehabil. 2005;86(2):277–83.

    Article  PubMed  Google Scholar 

  12. Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013;9(1):30.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Gonzalez P, Laker SR, Sullivan W, Harwood JEF, Akuthota V. The effects of epidural betamethasone on blood glucose in patients with diabetes mellitus. PM R. 2009;1(4):340–5.

    Article  PubMed  Google Scholar 

  14. Even JL, Crosby CG, Song Y, McGirt MJ, Devin CJ. Effects of epidural steroid injections on blood glucose levels in patients with diabetes mellitus. Spine. 2012;37(1):E46–50.

    Article  PubMed  Google Scholar 

  15. Kim WH, Sim WS, Shin BS, Lee CJ, Jin HS, Lee JY, et al. Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus. Pain Physician. 2013;16(6):557–68.

    PubMed  Google Scholar 

  16. Ward A, Watson J, Wood P, Dunne C, Kerr D. Glucocorticoid epidural for sciatica: metabolic and endocrine sequelae. Rheumatol Oxf Engl. 2002;41(1):68–71.

    Article  CAS  Google Scholar 

  17. Younes M, Neffati F, Touzi M, Hassen-Zrour S, Fendri Y, Béjia I, et al. Systemic effects of epidural and intra-articular glucocorticoid injections in diabetic and non-diabetic patients. Jt Bone Spine Rev Rhum. 2007;74(5):472–6.

    Article  CAS  Google Scholar 

  18. Jacobs S, Pullan PT, Potter JM, Shenfield GM. Adrenal suppression following extradural steroids. Anaesthesia. 1983;38(10):953–6.

    Article  CAS  PubMed  Google Scholar 

  19. Chon JY, Moon HS. Salivary cortisol concentration changes after epidural steroid injection. Pain Physician. 2012;15(6):461–6.

    PubMed  Google Scholar 

  20. Kim S, Hwang B. Relationship between bone mineral density and the frequent administration of epidural steroid injections in postmenopausal women with low back pain. Pain Res Manag J Can Pain Soc J Société Can Pour Trait Douleur. 2014;19(1):30–4.

    Google Scholar 

  21. Dubois EF, Wagemans MF, Verdouw BC, Zwinderman AH, Van Boxtel CJ, Dekhuijzen PNR, et al. Lack of relationships between cumulative methylprednisolone dose and bone mineral density in healthy men and postmenopausal women with chronic low back pain. Clin Rheumatol. 2003;22(1):12–7.

    Article  CAS  PubMed  Google Scholar 

  22. Maillefert JF, Aho S, Huguenin MC, Chatard C, Peere T, Marquignon MF, et al. Systemic effects of epidural dexamethasone injections. Rev Rhum Engl Ed. 1995 Jun;62(6):429–32.

    CAS  PubMed  Google Scholar 

  23. Gitkind AI, Shah B, Thomas M. Epidural corticosteroid injections as a possible cause of menorrhagia: a case report. Pain Med Malden Mass. 2010;11(5):713–5.

    Article  Google Scholar 

  24. Suh-Burgmann E, Hung Y-Y, Mura J. Abnormal vaginal bleeding after epidural steroid injection: a paired observation cohort study. Am J Obstet Gynecol. 2013;209(3):206.e1–6.

    Article  Google Scholar 

  25. Danielson KD, Harrast MA. Focal spinal epidural lipomatosis after a single epidural steroid injection. PM R. 2011;3(6):590–3.

    Article  PubMed  Google Scholar 

  26. Tuel SM, Meythaler JM, Cross LL. Cushing’s syndrome from epidural methylprednisolone. Pain. 1990;40(1):81–4.

    Article  CAS  PubMed  Google Scholar 

  27. Dietrich TJ, Sutter R, Froehlich JM, Pfirrmann CWA. Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update. Skelet Radiol. 2015;44(2):149–55.

    Article  Google Scholar 

  28. O’Donnell CJ, Cano WG. Allergic reactions to gadodiamide following interventional spinal procedures: a report of 4 cases. Arch Phys Med Rehabil. 2007;88(11):1465–7.

    Article  PubMed  Google Scholar 

  29. American College of Radiology Manual on Contrast Media V10.2 [Internet]. 2016. Available from: https://www.acr.org/Quality-Safety/Resources/Contrast-Manual

  30. Schopp JG, Iyer RS, Wang CL, Petscavage JM, Paladin AM, Bush WH, et al. Allergic reactions to iodinated contrast media: premedication considerations for patients at risk. Emerg Radiol. 2013;20(4):299–306.

    Article  PubMed  Google Scholar 

  31. Safriel Y, Ali M, Hayt M, Ang R. Gadolinium use in spine procedures for patients with allergy to iodinated contrast—experience of 127 procedures. AJNR Am J Neuroradiol. 2006;27(6):1194–7.

    CAS  PubMed  Google Scholar 

  32. Li A, Wong CS, Wong MK, Lee CM, Au Yeung MC. Acute adverse reactions to magnetic resonance contrast media—gadolinium chelates. Br J Radiol. 2006;79(941):368–71.

    Article  CAS  PubMed  Google Scholar 

  33. Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Reg Anesth Pain Med. 2004;29(6):564–75. discussion 524

    CAS  PubMed  Google Scholar 

  34. Karasek M, Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med Malden Mass. 2004;5(2):202–5.

    Article  Google Scholar 

  35. Chung SG. Convulsion caused by a lidocaine test in cervical transforaminal epidural steroid injection. PM R. 2011;3(7):674–7.

    Article  PubMed  Google Scholar 

  36. Mahli A, Coskun D, Akcali DT. Aetiology of convulsions due to stellate ganglion block: a review and report of two cases. Eur J Anaesthesiol. 2002;19(5):376–80.

    Article  CAS  PubMed  Google Scholar 

  37. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J Off J North Am Spine Soc. 2004;4(4):468–74.

    Article  Google Scholar 

  38. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10(8):1389–94.

    Article  PubMed  Google Scholar 

  39. Benzon HT, Wong HY, Siddiqui T, Ondra S. Caution in performing epidural injections in patients on several antiplatelet drugs. Anesthesiology. 1999;91(5):1558–9.

    Article  CAS  PubMed  Google Scholar 

  40. Rathmell JP, Michna E, Fitzgibbon DR, Stephens LS, Posner KL, Domino KB. Injury and liability associated with cervical procedures for chronic pain. Anesthesiology. 2011;114(4):918–26.

    Article  PubMed  Google Scholar 

  41. Schreiber AL, McDonald BP, Kia F, Fried GW. Cervical epidural steroid injections and spinal cord injuries. Spine J Off J North Am Spine Soc. 2016;16(10):1163–6.

    Article  Google Scholar 

  42. McMillan MR, Crumpton C. Cortical blindness and neurologic injury complicating cervical transforaminal injection for cervical radiculopathy. Anesthesiol J Am Soc Anesthesiol. 2003;99(2):509–11.

    Google Scholar 

  43. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003;103(1–2):211–5.

    Article  PubMed  Google Scholar 

  44. Moon J, Kwon H-M. Spinal cord infarction after cervical transforaminal epidural steroid injection: case report and literature review. Case Rep Neurol. 2017;6:1–5.

    Article  Google Scholar 

  45. Ziai WC, Ardelt AA, Llinas RH. Brainstem stroke following uncomplicated cervical epidural steroid injection. Arch Neurol. 2006;63(11):1643.

    Article  PubMed  Google Scholar 

  46. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. Am J Roentgenol. 2007;188(5):1218–21.

    Article  Google Scholar 

  47. Lee J-H, Lee J-K, Seo B-R, Moon S-J, Kim J-H, Kim S-H. Spinal cord injury produced by direct damage during cervical transforaminal epidural injection. Reg Anesth Pain Med. 2008;33(4):377–9.

    Article  PubMed  Google Scholar 

  48. Gillilan LA. The arterial blood supply of the human spinal cord. J Comp Neurol. 1958;110(1):75–103.

    Article  CAS  PubMed  Google Scholar 

  49. • Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections☆. Pain. 2005;117(1):104–11. Landmark cadaveric study demonstrating that in 21 of cervical 95 foramina examined an at risk artery was within 2 mm of the needle path during a CTFESI, and 7 of these formed an anastomosis with a feeding medullary artery entering the foramen

    Article  PubMed  Google Scholar 

  50. Derby R, Lee S-H, Date ES, Lee J-H, Lee C-H. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227–34.

    Article  PubMed  Google Scholar 

  51. Benzon HT, Chew T-L, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology. 2007;106(2):331–8.

    Article  CAS  PubMed  Google Scholar 

  52. • Derby R, Lee S-H, Date ES, Lee J-H, Lee C-H. Size and aggregation of corticosteroids used for epidural injections. Pain Med Malden Mass. 2008;9(2):227–34. Important study that quantified the size of particle steroids and aggregates, adding to the body of evidence on the causative mechanism of injury of neurologic infarct following CTFESI

    Article  Google Scholar 

  53. Laemmel E, Segal N, Mirshahi M, Azzazene D, Le Marchand S, Wybier M, et al. Deleterious effects of intra-arterial administration of particulate steroids on microvascular perfusion in a mouse model. Radiology. 2016;13:142746.

    Google Scholar 

  54. Okubadejo GO, Talcott MR, Schmidt RE, Sharma A, Patel AA, Mackey RB, et al. Perils of intravascular methylprednisolone injection into the vertebral artery: an animal study. J Bone Joint Surg Am. 2008;90(9):1932–8.

    Article  PubMed  Google Scholar 

  55. Dawley JD, Moeller-Bertram T, Wallace MS, Patel PM. Intra-arterial injection in the rat brain: evaluation of steroids used for transforaminal epidurals. Spine. 2009;34(16):1638–43.

    Article  PubMed  Google Scholar 

  56. Bogduk N. Practice guidelines for spinal diagnostic and treatment procedures. 2nd ed. San Francisco; 2013.

  57. •• Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974–84. Recommendations on the epidural use of steroids by the Multisociety Pain Workgroup, which is composed of 13 different medical societies. For CTFESI, there was a unanimous statement that particulate steroids should not be used in CTFESI and only the non-particulate steroid dexamethasone be used

    Article  CAS  PubMed  Google Scholar 

  58. Watkins TW, Dupre S, Coucher JR. Ropivacaine and dexamethasone: a potentially dangerous combination for therapeutic pain injections. J Med Imaging Radiat Oncol. 2015;59(5):571–7.

    Article  PubMed  Google Scholar 

  59. Hwang H, Park J, Lee WK, Lee WH, Leigh J-H, Lee JJ, et al. Crystallization of local anesthetics when mixed with corticosteroid solutions. Ann Rehabil Med. 2016;40(1):21.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Gharibo CG, Fakhry M, Diwan S, Kaye AD. Conus medullaris infarction after a right L4 transforaminal epidural steroid injection using dexamethasone. Pain Physician. 2016;19(8):E1211–4.

    PubMed  Google Scholar 

  61. Hoeft MA, Rathmell JP, Monsey RD, Fonda BJ. Cervical transforaminal injection and the radicular artery: variation in anatomical location within the cervical intervertebral foramina. Reg Anesth Pain Med. 2006;31(3):270–4.

    PubMed  Google Scholar 

  62. Wald JT, Maus TP, Geske JR, Carter RE, Diehn FE, Kaufmann TJ, et al. Safety and efficacy of CT-guided transforaminal cervical epidural steroid injections using a posterior approach. AJNR Am J Neuroradiol. 2012;33(3):415–9.

    Article  CAS  PubMed  Google Scholar 

  63. Furman MB, Giovanniello MT, O’Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine. 2003;28(1):21–5.

    Article  PubMed  Google Scholar 

  64. Kranz PG, Raduazo P, Gray L, Kilani RK, Hoang JK. CT fluoroscopy-guided cervical interlaminar steroid injections: safety, technique, and radiation dose parameters. AJNR Am J Neuroradiol. 2012;33(7):1221–4.

    Article  CAS  PubMed  Google Scholar 

  65. Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician. 2003 Jul;6(3):369–72.

    PubMed  Google Scholar 

  66. McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PM R. 2009;1(7):636–42.

    Article  PubMed  Google Scholar 

  67. Rubens A, Pino C, Ivie C. Utility of digital subtraction angiography in cervical transforaminal epidural steroid injections: does digital subtraction improve safety over live fluoroscopy? 14th Annu Pain Med Meet. 2015;Miami, Florida.

  68. Smuck M, Maxwell MD, Kennedy D, Rittenberg JD, Lansberg MG, Plastaras CT. Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections. Spine J. 2010;10(10):857–64.

    Article  PubMed  Google Scholar 

  69. Schneider B, Maybin S. Safety and risk mitigation for cervical interlaminar epidural steroid injections. Curr Phys Med Rehabil Rep. 2017 Dec.

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  1. Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 Children’s Way Suite 1318, Nashville, TN, 37212, USA

    Byron J. Schneider & Simone Maybin

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Correspondence to Byron J. Schneider.

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This article is part of the Topical Collection on Interventional Pain Management

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Schneider, B.J., Maybin, S. Safety and Risk Mitigation for Cervical Transforaminal Epidural Steroid Injections. Curr Phys Med Rehabil Rep 5, 186–192 (2017). https://doi.org/10.1007/s40141-017-0165-6

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