Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging.

Related collections

Most cited references 62

Record: found
Abstract: found
Article: not found

Post-dural puncture headache: pathogenesis, prevention and treatment.

D Turnbull, Keith Shepherd (2003)

Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache.

0 comments Cited 111 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome.

Michael Lawton, Glenn Jacobowitz, C Dickman … (1995)

Thirty patients were treated surgically for spinal epidural hematoma (SEH). Twelve of these cases resulted from spinal surgery, seven from epidural catheters, four from vascular lesions, three from anticoagulation medications, two from trauma, and two from spontaneous causes. Pain was the predominant initial symptom, and all patients developed neurological deficits. Eight patients had complete motor and sensory loss (Frankel Grade A); six had complete motor loss but some sensation preserved (Frankel Grade B); and 16 had incomplete loss of motor function (10 patients Frankel Grade C and six patients Frankel Grade D). The average interval from onset of initial symptom to maximum neurological deficit was 13 hours, and the average interval from onset of symptom to surgery was 23 hours. Surgical evacuation of the hematoma was performed in all patients; 26 of these improved; four remained unchanged, and no patients worsened (mean follow up 11 months). Complete recovery (Frankel Grade E) was observed in 43% of the patients and functional recovery (Frankel Grades D or E) was observed in 87%. One postoperative death occurred from a pulmonary embolus (surgical mortality 3%). Preoperative neurological status correlated with outcome; 83% of Frankel Grade D patients recovered completely compared to 25% of Frankel Grade A patients. The rapidity of surgical intervention also correlated with outcome; greater neurological recovery occurred as the interval from symptom onset to surgery decreased. Patients taken to surgery within 12 hours had better neurological outcomes than patients with identical preoperative Frankel grades whose surgery was delayed beyond 12 hours. This large series of SEH demonstrates that rapid diagnosis and emergency surgical treatment maximize neurological recovery. However, patients with complete neurological lesions or long-standing compression can improve substantially with surgery.

0 comments Cited 109 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention.

C.Seth Landefeld, Rebecca Beyth (1993)

To review (1) the clinical epidemiology of bleeding during anticoagulant therapy with heparin or warfarin, (2) data useful in estimating the risk for bleeding in individual patients, and (3) the efficacy of methods for its prevention. Relevant literature was identified by a computerized search of the Medline database and by review of the bibliographies of original and review articles. Studies were classified according to their design. Estimates of the risk for bleeding during anticoagulant therapy, compared with the risk without therapy, were obtained from randomized trials. Estimates of the frequency of bleeding during the course of anticoagulant therapy and information about risk factors for bleeding were obtained primarily from longitudinal studies of inception cohorts of patients followed from the start of therapy. The average daily frequencies of fatal, major, and major or minor bleeding during heparin therapy were 0.05%, 0.8%, and 2.0%, respectively; these frequencies are approximately twice those expected without heparin therapy. The average annual frequencies of fatal, major, and major or minor bleeding during warfarin therapy were 0.6%, 3.0%, and 9.6%, respectively; these frequencies are approximately five times those expected without warfarin therapy. The risk for anticoagulant-related bleeding is highest at the start of therapy: during warfarin therapy, the risk for major bleeding during the first month of therapy is approximately 10 times the risk after the first year of therapy. An individual patient's risk for major anticoagulant-related bleeding can be estimated on the basis of specific risk factors such as the intensity of the anticoagulant effect achieved and the presence of serious comorbid diseases, especially cerebrovascular, kidney, heart, and liver disease; older age and concurrent medicines may also be independent risk factors. Major bleeding most often affects the gastrointestinal tract, soft tissues, and urinary tract. Diagnostic evaluation of gastrointestinal bleeding and gross hematuria leads to identification of previously unknown lesions in approximately one-third of cases, even when the prothrombin time is elevated. Intracranial bleeding is rare, but it is frequently fatal. The frequency of bleeding during warfarin therapy is reduced by less intense therapy achieving a prothrombin time with an International Normalized Ratio of 2.0 to 3.0, which is efficacious for most indications. Anticoagulant-related bleeding is common and often serious. The risk for bleeding can be estimated in an individual patient, giving the primary physician a quantitative basis for weighing the risks and benefits of therapy and for optimizing patient management. The frequency of anticoagulant-related bleeding is reduced by less intense warfarin therapy. Future studies should evaluate new approaches to management that may further reduce complications while maintaining efficacy.

0 comments Cited 88 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Contributors

: +1-205-8383900 , +1-205-8360422 , drspudhead@aol.com

Journal

Journal ID (nlm-ta): Curr Rev Musculoskelet Med

Title: Current Reviews in Musculoskeletal Medicine

Publisher: Humana Press Inc (New York )

ISSN (Print): 1935-973X

ISSN (Electronic): 1935-9748

Publication date (Electronic): 15 August 2008

Publication date PMC-release: 15 August 2008

Publication date Collection: December 2008

Volume: 1

Issue: 3-4

Pages: 212-222

Affiliations

Department of Physical Medicine and Rehabilitation, University of Missouri- Columbia; and the Alabama Orthopedic, Spine and Sports Medicine Associates, 52 Medical park East Drive, Suite 115, Birmingham, AL 35235 USA

Article

Publisher ID: 9035

DOI: 10.1007/s12178-008-9035-2

PMC ID: 2682416

PubMed ID: 19468908

SO-VID: ed4ed1ec-8da8-478f-8139-04061b5491d1

History

Date received : 11 March 2008

Date accepted : 23 July 2008

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: risk management,epidural steroid injection,complications,lumbar transforaminal epidural,spinal injection,lumbar interlaminar epidural,back pain,safety

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: risk management, epidural steroid injection, complications, lumbar transforaminal epidural, spinal injection, lumbar interlaminar epidural, back pain, safety

Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections

Read this article at

Abstract

Related collections

Orthopedics

Most cited references 62

Post-dural puncture headache: pathogenesis, prevention and treatment.

Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome.

Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention.

Author and article information

Contributors

Journal

Affiliations

Article

History

Categories

Custom metadata

Comments

Comment on this article

Similar content 423

Cited by 38

Most referenced authors 436