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Spine Intervention
Preventing Complications
Alison Stout, D.O.
Fellowship Director
Evergreen Health
Sports and Spine Care
Alison Stout, D.O.
Joshua Rittenberg, MD
Michael Furman, MD
Milton Landers, DO, PhD
David Sibell, MD
SIS Education Committee
Disclosure Statement
Epidural steroids are not FDA approved
SIS Education Committee Vice Chair
NASS Exercise Committee Chair
Common Side Effects, Lumbar TFESI
Retrospective review , 322 lumbar TFESIs
9.6% incidence of minor self limiting side effects:
transient non-positional headache
 back & leg pain
facial flushing
vasovagal reaction
 blood sugar
one case of intra-operative hypertension
No dural punctures or hospitalizations
(Botwin KP: Arch Phys Med Rehabil; 81 (8) : 1045, 2000)
Spinal Injection
Risks and Complications
Patient Factors
Medications
Procedure/Technique
Minimizing Complications
Three Procedural Phases
Pre-Procedure
Peri-Procedure
Post- Procedure
Care is required During Each
Consent
The Informed Patient
Educate the patient
What are we doing?
Why are we doing it?
Risks and complications
Other Treatment Options
Document this discussion in your
procedure note
Procedure Consent Form Risks
“SUBSTANTIAL RISKS”
New pain
Worsening of pain
Infection
Bleeding/Infarct
Permanent skin changes
Allergic/unexpected drug reaction with minor/major consequences
Nerve injury
Dural puncture
Headache
Paralysis
Death
Pre-Procedure
Interim Patient History
Indications for procedure
Review images
Current Complaint / any recent changes?
Response to previous injections
Review of systems
Active Infections?
Pregnant?
Pre-Procedure
History
Allergies
Medications
Prior Adverse Reactions
Allergy history
Local anesthetics
Contrast
Steroids
Allergy vs. adverse reaction
Any Anaphylaxis Hx
Pre-Procedural: Medications
Anticoagulants/anti-platelet
Diabetes medications
Narcotics/benzos
WITH ANTICOAGULANTS
Risk of Spinal Nature of Spinal
Complications Complications
CEASING ANTICOAGULANTS
Risk of Systemic
Thrombotic
Complications
Nature of Potential
Systemic Thrombotic
Complications
Recommendation
Extraspinal
very low
minor
very low
severe
continue
anticoagulants
RF Neurotomy
unknown
minor
very low
severe
continue
anticoagulants
Lumbar Disc
Stimulation
unknown, but
theoretically low
minor
low
severe
continue
anticoagulants
Cervical or
Thoracic Disc
Stimulation
unknown, but
primarily minor
theoretically low
low
severe
Lumbar TFESI
very low
potentially
significant
very low
severe
Cervical or
Thoracic TFESI
unknown
potentially
serious
very low
severe
3x greater
potentially
serious
Interlaminar ESI
very low
severe
anticoagulants =
relative
contraindication*
anticoagulants =
relative
contraindication*
anticoagulants =
relative
contraindication*
anticoagulants =
relative
contraindication*
*Relative contraindication means:
Physicians should exercise discretion not only on whether or not to cease anticoagulants, but also whether or not the
presumed therapeutic benefit of the procedure justifies the risk of ceasing anticoagulants.
ASRA Guidelines 2015
Qui c k Ti m e™ and a
dec om pres s or
are needed to s ee thi s pi c ture.
http://links.lww.com/AAP/A142
ASRA Guidelines 2015
Narouze S et at. Interventional Spine and Pain Procedures in
Patients on
Antiplatelet and Anticoagulant Medications. Reg Anesth Pain
Med 2015;40: 182–212 (AKA ASRA 2015)
Pre-Procedure
Diabetic patient
Blood Glucose Monitoring
Steroids glucose, mean 136mg/dL x 3d
Check glucose pre-procedure
Metformin (Glucophage or Glucovance)
renal impaired pts may have accumulation of
metformin  lactic acidosis
Stop 48 hours after procedure
Consider checking for renal insufficiency a couple days
after procedure before restarting metformin
Communicate with Managing Physician
Minimizing Complications
Three Procedural Phases
Pre-Procedure
Peri-Procedure
Post- Procedure
Care is required during each
Complications Peri-Procedure
Vaso-Vagal Response
(3.9% overall incidence per RIC practice audit >2500 procedures)
Rapid onset
Bradycardia
Hypotension
Pallor
Sweating
Nausea
Faintness
Interventional Medications
Local Anesthestics
Contrast Agents
Steroids
Allergic Reaction
Vasomotor (warmth, flushing)
Cutaneous (hives, severe urticaria)
Bronchospasm (wheezing)
Cardiovascular (hypotension)
Vasovagal (bradycardia, hypotension, nausea)
Anaphylactoid reaction (angioedema, urticaria,
bronchospasm, hypotesion)
Local Anesthetics
Toxicity
Intravascular – Immediate onset
Relative overdose – Slow onset with
progression of irritability
Local Anesthetics
CNS Toxicity
Numbness of tongue (initial)
Foreign taste (initial)
Headache
Tinnitus
Blurred vision
Seizure – muscle twitching
Local Anesthetics
Cardiovascular System Toxicity
Dysrythmias
Hypertension
~2X blood level
compared with seizure dose
Except with Bupivacaine
Contrast must be used for all
Spinal Injections = Contrast
Assure Validity of Procedure
Reduce Risk
Inject with “live” fluoroscopy
Shellfish Allergy irrelevant
Non-ionic contrast
<1% had reaction = same as
population
non-ionic less allergenic
NO “crossover” with shellfish
allergy
Iodine
Not an allergen
Contrast allergy
Anaphylactoid reaction
Gadolinium
Option for spinal procedures in
patient with contraindications to
iodinated contrast
Lower opacity - Consider use of
digital subtraction to improve
visualization of flow
Iohexol 240
Gadolinium
(gadodiamide)
AVOID Intrathecal Space
(Safriel, AJNR 2006)
Corticosteroid Contraindications
Absolute
Local or systemic bacterial or fungal infection
Relative
Pregnancy (check w OBGYN usually okay)
Diabetes (poorly controlled)
Osteoporosis
History of steroid psychosis
Pending surgery
Corticosteroid Systemic Effects
• Postinjection flare of
pain (2-5%)
• Headache (3%)
• Facial flushing (1-28%)
• Insomnia
• Fluid retention, HTN,
CHF
• Gastric/peptic ulcer
• Skin
atrophy/depigmentati
on (<1%)
•
•
•
•
•
•
•
Adrenal suppression
Bone demineralization
 Lymphocyte function
Cartilage attrition
Epidural lipomatosis
Hyperglycemia
Anxiety/psychosis
Corticosteroids
Use Judiciously
Not necessary for diagnostic blocks
Dose in patients at risk
Consider 6 month ≤ 5mg/Kg body weight
(example 80kg pt=max 400 mg)
Critically evaluate patient response after EACH
injection
ACR 2010 Guidelines
All cases of systemic GC:
Education & evaluation modifiable risk factors
Ca++ & Vit D
# Exposures to ESI does  overall risk of
fragility fx
Corticosteroids
Transforaminal Injection
Particulate Matters!
12 cases (reported in literature)
Spinal cord infarction subsequent to
Lumbar or Sacral Transforaminal injection
of particulate steroids
Single most serious risk =
Injection of particulate matter into a
reinforcing medullary artery
ISIS Practice Guidelines 2nd Edition Edited by N Bogduk 2013
Steroid Particle Size
Compared to RBC (10 µm)
Methylprednisolone (Depo-Medrol),
Triamcinolone Acetate (Kenalog),
Betamethasoneacetate/sodium phosphate
(CelestoneSoluspan)
All with particles > size of RBC
Dexamethasone sodium phosphate
Pure liquid without particles (Benzon)
0.5 µm particles, 5-10 x smaller than RBC (Derby)
(Derby 2006, Benzon 2007)
Particulate vs. Non-particulate
Pig vertebral arteries injected
with methylprednisolone vs.
dexamethasone
Methylprednisolone: All required ventilatory
support and did not recover
Histologic evidence of hypoxic/ischemic brain
damage
MRI with diffuse edema in upper cord and
brainstem
Dexamethasone: None ventilated, no neuro
changes evident
Okubadejo JBJS 2008
Minimize Risk
Use Non-particulate Steroids for Upper
Lumbar or All Transforaminal Injections
Particulate Steroid is accepted for
Interlaminar ESIs and Intraarticular
injections
Spinal Injection Complications
Needle malposition
Any needle stick can cause problems
Bleeding
Infection
Optimal to Personally Review
Imaging
Anatomic Barriers?
Post Surgical?
Perineural Cysts?
Procedural Risks
Needle Malposition
Dependent on Specific Procedure
Structures to Avoid Piercing:
•Nerve Roots
•Dura
•Spinal Cord
•Arteries
•Peripheral Nerves
Spinal Injections Needle Placement
To prevent problems:
“It’s not only knowing where to put your needle,
It’s knowing where not to put it”
Know the Anatomy
Minimizing Complications
Peri-Procedure
• Maintain verbal
contact with patient
• Heavy sedation
should be avoided!
• Patient will be
unable to report
warning signs of
needle to neuraxis
contact
Neal et al. ASRA Practice Advisory, Reg Anes Pain Med 2008
Procedural Risks
Intravascular Injection
Immediate onset
Headache
Tachycardia
Anesthetic toxicity
Vasovagal reaction
Flushing
Steroid side effects
Spinal cord block/infarct
Intravascular Injection
Venous plexus
Radicular artery
Radiculomedullary artery
Artery of Adamkiewicz
Is the Safe Triangle really safe?
Artery of Adamkiewicz
• note characteristic “hairpin
turn”
• usually on left side, but side
and level may vary
• located in superior, anterior
foramen
• consider alternate approach
at L3 and above, targeting the
more inferior aspect of the
foramen
Murthy 2010 Pain Medicine
Why Use Fluoroscopy
Confirm needle-contrast-medication is in,
and is covering, the desired target-area
Avoid placing needle / medication in
unintended location
Intravascular Injection
Simultaneous epidural and
vascular uptake occurs ≈ 75% of
vascular injections
(Smuck 2006)
Minimum of live fluoro contrast injection
Is DSA necessary?
Digital subtraction
angiography (DSA)
superior to live fluoro for
detecting vascular flow
during lumbar
transforaminals
Only 60% of cases of vascular
flow detected with DSA
were seen with live fluoro
(Lee MH. Korean J Pain. 2010
Mar;23(1):18-23.)
DSA rate of detection also
better with cervical TFESI
(McLean 2009)
QuickTime™ and a
decompressor
are needed to see this pi cture.
Cervical TFESI with venous
flow
Lidocaine Test Dose
• Inject 0.5-1 ml of lidocaine after confirming
contrast flow
• Wait > 1.5 min
• Monitor any neurologic changes, dizziness,
weakness, tinnitus, headache…
• Ask patient to move fingers and toes
• If everything okay, then proceed with
injecting steroid
Risks of
Intrathecal Injection
Increase in pain
Spinal block
Prolonged anesthesia
Hypotension
Vasovagal reaction
Headache
Meningitis
Arachnoiditis
Intrathecal
Intrathecal
Dural Puncture
< 0.5% incidence (experienced injectionists)
Spinal headache
Not all dural punctures = spinal headache
Headache is positional
Onset several hours to 48 hours
Most resolve spontaneously
Rarely, uncal herniation and death
Dural Puncture
Prevention
Interlaminar ESI
Smaller gauge epidural needle (Lambert)
17 gauge: 75% required blood patch
25-27 gauge: 13-39% require blood patch
Use AP and Lateral/contralateral views!
Don’t use interspace with prior laminectomy
Avoid stenotic level (review the MR)
Keep bevel parallel to longitudinal dural fibers
Higher incidence with multiple attempts
Transforaminal ESI
Lumbar: Do not advance beyond 6 o’clock position of
Pedicle (AP view)
Dural Puncture
Spinal anesthesia
From local anesthetics
Subdural injection produces similar result
Loss of consciousness, hypotension, apnea, cardiac
arrest, death
Prevention
Don’t inject local anesthetics if
unsure
Procedural Risks
Subdural Injection
“Slow” spinal
Increase in pain
Prolonged anesthesia
Hypotension
Vasovagal reaction
Headache
Meningitis
(Arachnoiditis)
Subdural
Injection between
Dura and Arachnoid Layers
Small Volume of Local Anesthetic can
Cause neurologic impairment
Subdural
injection
Note
“Railroad
tracks”
Subdural
injection
Note
“Railroad tracks”
No space between
vertebral body and
thecal sac
From Levy, D. Pain Medicine Volume 11, Issue 5, pages 716–718, May 2010
Minimizing Complications
Three Procedural Phases
Pre-Procedure
Peri-Procedure
Post- Procedure
Post Procedure
Recover patient
Assess pain and provocative maneuvers
Good documentation
Written instructions
Will save you from after hours calls about routine
or minor complaints!
Schedule follow-up for evaluating procedure
Post Procedure Complaints
If problem evaluate and treat without delay
Pain – Assess if increased
Fever/Chills – CBC/ESR/CRP
Weakness/Numbness, Bowel/Bladder
Secondary to LA? – reassure patient
Other cause suspected? - evaluate ASAP!
Make sure the patient knows how to contact
you after regular hours!
Epidural hematoma
Neck or back pain
Neurological deficits
↑Risk
Coagulopathy
Epidural vascular
malformations
Recent surgery/injection
Time is critical!
Guffey PJ. Anesth Analg. 2010 Oct;111(4):992-5.
Lawton MT. J Neurosurg. 1995 Jul;83(1):1-7
Epidural Abscess
Fever, tenderness
Radiculitis → myelopathy/cauda
equina syndrome
↑ WBC, ESR, CRP
MRI very sensitive, CT not
Gram + cocci in ~80%
↑Risk
Immunocompromised/Diabetes
Skin disruption/colonization
Time is critical!
Tompkins M. J Emerg Med. 2010 Sep;39(3):384-90.
Kumar K. Neurocrit Care. 2005;2(3):245-51.
Facet Infection
50 year old male,, worsening LBP, admitted to hospital 10
days following lumbar facet joint injection
Kim, SY Korean J Anesthesiol. 2010 April; 58(4): 401–404.
Case Report
64 yo PMH multiple pulmonary infections
L5-S1 interlaminar ESI fluoro guided
6 wks later => 4 weeks of worsening low back
pain, hospitalized with severe LBP, fever
ESR 82 and CRP 17.4 mg/L
Hooten, et al. Discitis after Lumbar Epidural Corticosteroid Injection: A Case
Report and Analysis of the Case Report Literature. Pain Medicine 2006
Hooten, et al. Discitis after Lumbar Epidural Corticosteroid Injection: A Case
Report and Analysis of the Case Report Literature. Pain Medicine 2006
Thank You!