A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections

Pain Physician

Volumn 15, Issue 2, 2012, Pages 131-140

  Manchikanti, Laxmaiah ^a,b   Malla, Yogesh ^a   Wargo, Bradley W ^a,c   Cash, Kimberly A ^a   Pampati, Vidyasagar ^a   Fellows, Bert ^a  

^a PAIN MANAGEMENT CENTER OF PADUCAH   (United States)

^b UNIVERSITY OF LOUISVILLE   (United States)

^c Mary Greeley Medical Center   (United States)

Author keywords

And steroids; Caudal epidural; Complications; Epidural injections; Interlaminar epidural; Percutaneous adhesiolysis; Spinal pain; Transforaminal epidural

Indexed keywords

ABSCESS; ADULT; BLEEDING; CAUDAL ANESTHESIA; CERVICAL INTERLAMINAR EPIDURAL INJECTION; CONTROLLED STUDY; EPIDURAL ANESTHESIA; EPIDURAL HEMATOMA; FEMALE; FLUOROSCOPY; FLUSHING; HEMATOMA; HUMAN; INFECTION; INTERMETHOD COMPARISON; LUMBAR INTERLAMINAR EPIDURAL INJECTION; LUMBAR TRANSFORAMINAL EPIDURAL INJECTION; MAJOR CLINICAL STUDY; MALE; NERVE ROOT INJURY; PERCUTANEOUS ADHESIOLYSIS; POSTDURAL PUNCTURE HEADACHE; POSTOPERATIVE PERIOD; PROSPECTIVE STUDY; REVIEW; SKIN BRUISING; SPINAL CORD INJURY; SYNCOPE; THORACIC INTERLAMINAR EPIDURAL INJECTION; UNITED STATES;

FLUOROSCOPY; HEMATOMA; HUMANS; INCIDENCE; INJECTIONS, EPIDURAL; PROSPECTIVE STUDIES; SPINE; UNITED STATES; WOUNDS AND INJURIES;

EID: 84859124839     PISSN: 15333159     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (93)

1. Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine (Phila Pa 1976) 2009; 34:2077-2084.
2. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med 2009; 169:251-258.
3. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA. Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician 2009; 12:E35-E70.
4. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: Time to back off? J Am Board Fam Med 2009; 22:62-68.
5. Manchikanti L, Pampati V, Boswell MV, Smith HS, Hirsch JA. Analysis of the growth of epidural injections and costs in the Medicare population: A comparative evaluation of 1997, 2002, and 2006 data. Pain Physician 2010; 13:199-212.
6. Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine (Phila Pa 1976) 2007; 32:1754-1760.
7. Chou R, Huffman L. Guideline for the Evaluation and Management of Low Back Pain: Evidence Review. American Pain Society, Glenview, IL, 2009. www.ampainsoc.org/pub/pdf/LBPEvidRev. pdf
8. Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: An updated Cochrane review. Spine (Phila Pa 1976) 2009; 34:49-59.
9. Manchikanti L, Falco FJE, Boswell MV, Hirsch JA. Facts, fallacies, and politics of comparative effectiveness research: Part 1. Basic considerations. Pain Physician 2010; 13:E23-E54.
10. Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, Benyamin RM, Sharma ML, Helm II S, Fellows B, Hirsch JA. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: Part 2. Therapeutic interventions. Pain Physician 2010; 13:E215-E264.
11. Manchikanti L, Falco FJE, Boswell MV, Hirsch JA. Facts, fallacies, and politics of comparative effectiveness research: Part 2. Implications for interventional pain management. Pain Physician 2010; 13:E55-E79.
12. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009; 12:699-802.
13. Helgeson MD, Albert TJ. Surgery for failed cervical spine surgery. Spine (Phila Pa 1976) 2011 Nov 8. [Epub ahead of print]
14. Abbott ZI, Nair KV, Allen RR, Akuthota VR. Utilization characteristics of spinal interventions. Spine J 2011; 1:35-43.
15. Ivanova JI, Birnbaum HG, Schiller M, Kantor E, Johnstone BM, Swindle RW. Real-world practice patterns, healthcare utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine J 2011; 11:622-632.
16. Manchikanti L, Pampati V, Singh V, Boswell MV, Smith HS, Hirsch JA. Explosive growth of facet joint interventions in the Medicare population in the United States: A comparative evaluation of 1997, 2002, and 2006 data. BMC Health Serv Res 2010; 10:84.
17. Helgeson MD, Albert TJ. Surgery for failed cervical spine surgery. Spine (Phila Pa 1976) 2011 Nov 8. [Epub ahead of print]
18. Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976) 2012; 37:67-76.
19. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303:1259-1265.
20. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Management of pain of post lumbar surgery syndrome: Oneyear results of a randomized, double double-blind, active controlled trial of fluoroscopic caudal epidural injections. Pain Physician 2010; 13:509-521.
21. Manchikanti L, Cash KA, McManus CD, Pampati V, Smith HS. One year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis. Pain Physician 2011; 14:25-36.
22. Manchikanti L, Cash RA, McManus CD, Pampati V, Fellows B. Fluoroscopic caudal epidural injections with or without steroids in managing pain of lumbar spinal stenosis: One year results of randomized, double-blind, active-controlled trial. J Spinal Disord 2011; April 5 [Epub ahead of print].
23. Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: A randomized, double-blind, controlled trial. Pain Physician 2010; 13:343-355.
24. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. Preliminary results of a randomized, double-blind, controlled trial of fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar discogenic pain without disc herniation or radiculitis. Pain Physician 2010; 13:E279-E292.
25. Manchikanti L, Cash KA, McManus CD, Damron KS, Pampati V, Falco FJE. Lumbar interlaminar epidural injections in central spinal stenosis: Preliminary results of a randomized, double-blind, active control trial. Pain Physician 2012; 15:51-63.
26. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. A preliminary report of a randomized double-blind, active controlled trial of fluoroscopic thoracic interlaminar epidural injections in managing chronic thoracic pain. Pain Physician 2010; 13:E357-E369.
27. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. Cervical epidural injections in chronic discogenic neck pain without disc herniation or radiculitis: Preliminary results of a randomized, double-blind, controlled trial. Pain Physician 2010; 13:E265-E278.
28. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. The effectiveness of fluoroscopic cervical interlaminar epidural injections in managing chronic cervical disc herniation and radiculitis: Preliminary results of a randomized, double-blind, controlled trial. Pain Physician 2010; 13:223-236.
29. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic epidural injections in cervical spinal stenosis: Preliminary results of a randomized, double-blind, active control trial. Pain Physician 2012; 15:E59-E70.
30. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic cervical interlaminar epidural injections in managing chronic pain of cervical postsurgery syndrome: Preliminary results of a randomized, double-blind, active control trial. Pain Physician 2012; 15:13-26.
31. Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. A randomized, controlled, double-blind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis. Spine (Phila Pa 1976) 2011; 36:1897-1905.
32. Manchikanti L, Cash KA, McManus CD, Pampati V, Singh V, Benyamin RM. The preliminary results of a comparative effectiveness evaluation of adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis: A randomized, equivalence controlled trial. Pain Physician 2009; 12:E341-E354.
33. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syn drome: A randomized, equivalence controlled trial. Pain Physician 2009; 12:E355-E368.
34. Karaman H, Kavak GO, Tüfek A, Yldrm ZB. The complications of transforaminal lumbar epidural steroid injections. Spine (Phila Pa 1976) 2011; 36:E819-E824.
35. Goodman BS, Posecion LWF, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008; 1:212-222.
36. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image guided transforaminal lumbar spine epidural steroid injection: Two case reports. Pain Med 2009; 10:1389-1394.
37. Glaser SE, Shah RV. Root cause analysis of paraplegia following transforaminal epidural steroid injections: The 'unsafe' triangle. Pain Physician 2010; 13:237-244.
38. Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine (Phila Pa 1976) 2009; 34:731-739.
39. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: The role of corticosteroids. Spine J 2004; 4:468-474.
40. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. AJR Am J Roentgenol 2007; 188:1218-1221.
41. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: More dangerous than we think? Spine (Phila Pa 1976) 2007; 32:1249-1256.
42. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: Report of three cases. Spine J 2002; 2:70-75.
43. Linn AJ, DeSilva C, Peeters-Asdourian C. Thromboembolic stroke: A rare complication associated with peri-procedural management of an epidural steroid injection. Pain Physician 2009; 12:159-162.
44. Lenoir T, Deloin X, Dauzac C, Rillardon L, Guigui P. Paraplegia after interlaminar epidural steroid injection: a case report. Rev Chir Orthop Reparatrice Appar Mot 2008; 94:697-701.
45. White AH, Derby R, Wynne G. Epidural injections for the diagnosis and treatment of low back pain. Spine (Phila Pa 1976) 1980; 5:78-86.
46. Manchikanti L, Cash KA, Pampati V, Mc-Manus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician 2004; 7:81-92.
47. Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: An analysis of contrast dispersal patterns. Spine (Phila Pa 1976) 2002; 27:509-514.
48. Goel A, Pollan JJ. Contrast flow characteristics in the cervical epidural space: An analysis of cervical epidurograms. Spine (Phila Pa 1976) 2006; 31:1576-1579.
49. Choi YK, Barbella JD. Evaluation of epidurographic contrast patterns with fluoroscopic-guided lumbar interlaminar ventral epidural injection. Pain Pract 2009; 9:275-281.
50. Kim KS, Shin SS, Kim TS, Jeong CY, Yoon MH, Choi JI. Fluoroscopically guided cervical interlaminar epidural injections using the midline approach: An analysis of epidurography contrast patterns. Anesth Analg 2009; 108:1658-1661.
51. Botwin KP, Natalicchio J, Hanna A. Fluoroscopic guided lumbar interlaminar epidural injections: A prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician 2004; 7:77-80.
52. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil 2000; 81:1045-1050.
53. Neal JM, Bernards CM, Hadzic A, Hebl JR, Hogan QH, Horlocker TT, Lee LA, Rathmell JP, Sorenson EJ, Suresh S, Wedel DJ. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med 2008; 33:404-415.
54. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med 2011; 12:726-731.
55. Trentman TL, Rosenfeld DM, Seamans DP, Hentz JG, Stanek JP. Vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections. Pain Pract 2009; 9:59-64.
56. Ziai WC, Ardelt AA, Llinas RH. Brainstem stroke following uncomplicated cervical epidural steroid injection. Arch Neurol 2006; 63:1643-1646.
57. Huston CW, Slipman CW, Garvin C. Complications and side effects of cervical and lumbosacral selective nerve root injections. Arch Phys Med Rehabil 2005; 86:277-283.
58. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976) 1998; 23:2137-2142; discussion 2141-2142.
59. Manchikanti L, Singh V, Boswell MV. Interventional pain management at crossroads: The perfect storm brewing for a new decade of challenges. Pain Physician 2010; 13:E111-E140.
60. Benyamin RM, Datta S, Falco FJE. A perfect storm in interventional pain management: Regulated, but unbalanced. Pain Physician 2010; 13:109-116.
61. Abbasi A, Malhotra G, Malanga G, Elovic EP, Kahn S. Complications of interlaminar cervical epidural steroid injections: A review of the literature. Spine (Phila Pa 1976) 2007; 32:2144-2151.
62. Xu R, Bydon M, Gokaslan ZL, Wolinsky JP, Witham TF, Bydon A. Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines. J Neurosurg Spine 2009; 11:358-364.
63. Gaul C, Neundörfer B, Winterholler M. Iatrogenic (para-) spinal abscesses and meningitis following injection therapy for low back pain. Pain 2005; 116:407-410.
64. Manchikanti L. Role of neuraxial steroids in interventional pain management. Pain Physician 2002; 5:182-199.
65. Botwin KP, Castellanos R, Rao S, Hanna AF, Torres-Ramos FM, Gruber RD, Bouchlas CG, Fuoco GS. Complications of fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil 2003; 84:627-633.
66. Botwin KP, Baskin M, Rao S. Adverse effects of fluoroscopically guided interlaminar thoracic epidural steroid injections. Am J Phys Med Rehabil 2006; 85:14-23.
67. Kim CH, Issa MA, Vaglienti RM. Flushing following interlaminar lumbar epidural steroid injection with dexamethasone. Pain Physician 2010; 13:481-484.
68. Lee YS, Yi JS, Kim HJ, Kim JO, Choi ES. Epidural block-induced ligamentum flavum hematoma mimicking epidural hematoma in the lumbar spine: A case report. Spine J 2011; 11:E23-E27.
69. Guarino AH, Wright NM. Pneumocephalus after a lumbar epidural steroid injection. Pain Physician 2005; 8:239-241.
70. Bilir A, Gulec S. Cauda equina syndrome after epidural steroid injection: A case report. J Manipulative Physiol Ther 2006; 29:492. e1-3.
71. McLain RF, Fry M, Hecht ST. Transient paralysis associated with epidural steroid injection. J Spinal Disord 1997; 10:441-444.
72. Candido KD, Katz JA, Chinthagada M, McCarthy RA, Knezevic NN. Incidence of intradiscal injection during lumbar fluoroscopically guided transforaminal and interlaminar epidural steroid injections. Anesth Analg 2010; 110:1464-1467.
73. Simopoulos TT, Kraemer JJ, Glazer P, Bajwa ZH. Vertebral osteomyelitis: A potentially catastrophic outcome after lumbar epidural steroid injection. Pain Physician 2008; 11:693-697.
74. Moon HJ, Kim JH, Kim JH, Kwon TH, Chung HS, Park YK. Spontaneous spinal epidural hematoma: An urgent complication of adding clopidogrel to aspirin therapy. J Neurol Sci 2009; 285:254-256.
75. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Hanna A, Rittenberg J, Thomas SA. Complications of fluoroscopically guided caudal epidural injections. Am J Phys Med Rehabil 2001; 80:416-424.
76. Manchikanti L, Malla Y, Wargo BW, Cash KA, McManus CD, Damron KS, Jackson SD, Pampati V, Fellows B. A prospective evaluation of bleeding risk of interventional techniques in chronic pain. Pain Physician 2011; 14:317-329.
77. Manchikanti L, Malla Y, Wargo BW, Fellows B. Preoperative fasting before interventional techniques: Is it necessary or evidence-based? Pain Physician 2011; 14:459-467.
78. Manchikanti L, Malla Y, Wargo BW, Fellows B. Infection control practices (safe injection and medication vial utilization) for interventional techniques: Are they based on relative risk management or evidence? Pain Physician 2011; 14:425-434.
79. Smuck M, Fuller BJ, Yoder B, Huerta J. Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections. Spine J 2007; 7:79-82.
80. Furman MB, O'Brien ME, Zgleszewski TM. Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections. Spine(Phila Pa 1976) 2000; 25:2628-2632.
81. Fredrickson MJ. Case report: Neurological deficit associated with intraneural needle placement without injection. Can J Anaesth 2009; 56:935-938.
82. Goodman BS, Bayazitoglu M, Mallempati S, Noble BR, Geffen JF. Dural puncture and subdural injection: A complication of lumbar transforaminal epidural injections. Pain Physician 2007; 10:697-705.
83. Kim Do W, Han KY, Kim C, Chae YJ. Intravascular flow patterns in transforaminal epidural injections: A comparative study of the cervical and lumbar vertebral segments. Pain Med 2009; 109:233-239.
84. Lewandowski EM. The efficacy of solutions used in caudal neuroplasty. Pain Digest 1997; 7:323-330.
85. Kim RC, Porter RW, Choi BH, Kim SW. Myelopathy after intrathecal administration of hypertonic saline. Neurosurgery 1988; 22:942-945.
86. Manchikanti L, Bakhit CE. Removal of a torn Racz catheter from lumbar epidural space. Reg Anesth 1997; 22:579-581.
87. Perkins WJ, Davis DH, Huntoon MA, Horlocker TT. A retained Racz catheter fragment after epidural neurolysis: Implications during magnetic resonance imaging. Anesth Analg 2003; 96:1717-1719.
88. Kushner FH, Olson JC. Retinal hemorrhage as a consequence of epidural steroid injection. Arch Ophthalmol 1995; 113:309-313.
89. Manchikanti L, Cash KA, Moss TL, Rivera JJ, Pampati V. Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: A prospective evaluation. BMC Anesthesiol 2003; 3:2.
90. Manchikanti L, Cash KA, Moss TL, Pampati V. Effectiveness of protective measures in reducing risk of radiation exposure in interventional pain management: A prospective evaluation. Pain Physician 2003; 6:301-305.
91. Bromage RP, Benumof JL. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med 1998; 23:104-107.
92. Furlan AD, Pennick V, Bombardier C, van Tulder M; Editorial Board, Cochrane Back Review Group. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976) 2009; 34:1929-1941.
93. Sox HC, Helfand M, Grimshaw J, Dickersin K, Tovey D, Knottnerus JA, Tugwell P. Comparative effectiveness research: Challenges for medical journals. PLoS Med 2010; 7:e1000269.