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LETTER TO THE EDITOR

Minimizing Complications in Epidural Steroid Injections

Orthopaedic and Spine Specialists, York, PA, mbfurman{at}hotmail.com

To the Editor:

We applaud the authors for sharing their unfortunate experience after a lower thoracic epidural steroid injection (1). We agree that earlier reports (2) attributing these poor outcomes to the use of sedation are simplistic. We also concur that the use of fluoroscopy will decrease the incidence of potential complications such as intracord injections (3–5) and that a patient should only be discharged after it has been confirmed that there are no new sensory or motor deficits.

There are many precautions that can and should be taken to avoid these unfortunate events. We agree with the authors' use of an anesthetic test dose to identify whether there was an intradural injection. However, on reading the case report and subsequent discussion, questions arise that should be considered when reviewing a spinal procedure case with unfortunate outcomes: Was biplanar imaging, (i.e., a lateral view) used to confirm optimal needle tip placement? Was there negative aspiration of cerebrospinal fluid? Was needle placement further confirmed with a radio-opaque contrast agent?

Clearly, contrast-enhanced fluoroscopy is more precise than a blind technique. Biplanar imaging (i.e., more than one view) adds even more accuracy and associated safety and is often under-used. With proper positioning during an interlaminar epidural steroid injection, the posterior border of the epidural space can be clearly visualized under lateral projection and unfortunate events such as this can be avoided. Careful attention should be made to the proper use of biplanar, contrast-enhanced, fluoroscopic guidance, and injection techniques to decrease the risk of an intrathecal or intracord injection or other avoidable bad outcomes.

Footnotes

Dr. Tripathi does not wish to respond.

References

1. Tripathi M, Nath SS, Gupta RK. Paraplegia after intracord injection during attempted epidural steroid injection in an awake patient. Anesth Analg 2005;101:1209–11.[Abstract/Free Full Text]
2. Hodges SD, Castleberg RL, Miller T, et al. Cervical epidural steroid injection with intrinsic spinal cord damage: two case reports. Spine 1998;23:2137–40.[Web of Science][Medline]
3. Bartynski WS, Grahovac SZ, Rothfus WE. Incorrect needle position during lumbar epidural steroid administration: inaccuracy of loss of air pressure resistance and requirement of fluoroscopy and epidurography during needle insertion. Ajnr: Am J Neuroradiol 2005;26:502–5.[Abstract/Free Full Text]
4. El-Khoury G, Ehara S, Weinstein JN, et al. Epidural steroid injection: a procedure ideally performed with fluoroscopic control. Radiology 1988;168:554–7.[Abstract/Free Full Text]
5. Mehta M. Extradural block: confirmation of the injection site by x-ray monitoring. Anaesthesia 1985;40:1009–12.[Web of Science][Medline]

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