cervical epidural corticosteroid injections

[Guest guest]

Perhaps a good next-to-last procedure (after conservative measures have failed-- but prior to surgery), but me thinks such procedures are the next MD option after the NSAIDS have failed and the corticosteroid shot in the butt didn't help. Seitz, DC Tuality Physicians 730-D SE Oak St Hillsboro, OR 97123 (503)640-3724Cervical Transforaminal Epidural Steroid

Injections: More Dangerous Than We Think?

Scanlon, Graham C. MD*;

Moeller-Bertram, Tobias MD*; Romanowsky, M. BS†; Wallace, Mark S. MD*

Abstract

Study Design. Survey/case series.

Objective. To survey pain physicians about neurologic infarctions

following cervical transforaminal epidural steroid injections (TF-ESIs).

Summary of Background Data. Cervical TF-ESIs are commonly

performed in patients with cervical radiculopathy, although there are no

randomized controlled studies supporting their efficacy. Eight case reports of

brain and spinal cord infarction have been published. In addition, one of the

investigators (M.S.W.) has reviewed 4 cases of major cerebellum/brainstem

infarction following cervical TF-ESIs with methylprednisolone.

Methods. To better characterize these complications, anonymous

surveys were sent to all U.S.

physician members of the American Pain Society. Respondents were asked about

awareness of complications, year of occurrence, practice setting and specialty

of the treating physician, use of fluoroscopy/contrast/local

anesthetic/corticosteroid, doses administered, and CT/MRI/autopsy findings.

Results. Overall response rate was 21.4% (287 of 1340). In all, 78

complications were reported, including 16 vertebrobasilar brain infarcts, 12

cervical spinal cord infarcts, and 2 combined brain/spinal cord infarcts. Brain

infarcts invariably involved the cerebellum, brainstem, or posterior cerebral

artery territory. Thirteen cases resulted in a fatal outcome: 5 with brain

infarcts, 1 with combined brain/spinal cord infarcts, 1 following high spinal

anesthesia, 1 associated with a seizure, and 5 with unspecified etiology. All 4

cases with corticosteroid alone involved methylprednisolone, resulting in 3

cerebellar infarcts and 1 posterior cerebral territory infarct. Of these, 3 had

fatal outcomes and 2 autopsies revealed no vertebral artery trauma.

Conclusions. This study demonstrates a significant risk of serious

neurologic injury after cervical TF-ESIs. A growing body of evidence supports

an embolic mechanism, whereby inadvertent intra-arterial injection of

particulate corticosteroid causes a distal infarct. Embolism to the distal

basilar artery region can cause midbrain, pons, cerebellum, thalamus, temporal

and occipital lobe infarctions. Other potential mechanisms of infarction

include vertebral artery perforation causing dissection/thrombosis and

needle-induced vasospasm.