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Death After Transforaminal Cervical Epidural Steroid Injection

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Abstract

Epidural steroid injections (ESIs) are used to manage radicular pain in patients with spinal degenerative disk disease, spinal stenosis, and disk herniations.

Although rare, devastating neurological complications and death have been reported after cervical transforaminal epidural steroid injections (CTESIs). Knowledge of the anatomy of the cervical spine, careful review of the available images, the use of the appropriate technique, disciplined and accurate imaging while performing the procedure, and continuous patient monitoring are mandatory while performing these injections.

A low threshold for aborting the procedure should be considered if persistent venous runoff or vertebral artery outline is observed on plain fluoroscopy and digital subtraction angiography (DSA). Procedures should be aborted immediately if evidence of rapid vascular runoff ascending toward the vertebral artery or directed medially toward radicular arteries providing blood supply to the spinal cord is observed.

CTESIs should always be performed by physicians who have had specific training, have proven experience with interventional pain management techniques, and are able to manage eventual complications.

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References

  1. Slipman CW, Lipetz JS, Jackson HB, Rogers DP, Vresilovic EJ. Therapeutic selective nerve root block in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: a retrospective analysis with independent clinical review. Arch Phys Med Rehabil. 2000;81(6):741–6.

    Article  CAS  PubMed  Google Scholar 

  2. Anderberg L, Annertz M, Persson L, Brandt L, Savelund H. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomized study. Eur J Pain. 2007;16(3):321–8.

    Google Scholar 

  3. Costandi SJ, Azer G, Esheaghi Y, Zeyed Y, Atalla JE, Looka ME, Mekhail NA. Cervical transforaminal epidural steroid injections: diagnostic and therapeutic value. Reg Anesth Pain Med. 2015;40(6):674–80.

    Article  PubMed  Google Scholar 

  4. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994;75(3):342–52.

    Article  CAS  PubMed  Google Scholar 

  5. Lee HM, Weinstein JN, Meller ST, Hayashi N, Spratt KF, Gebhart GF. The role of steroids and their effects on phospholipase A2. An animal model of radiculopathy. Spine (Phila Pa 1976). 1998;23(11):1191–6.

    Article  CAS  Google Scholar 

  6. Furusawa N, Baba H, Miyoshi N, Maezawa Y, Uchida K, Kokubo Y, Fukuda M. Herniation of cervical intervertebral disc: immunohistochemical examination and measurement of nitric oxide production. Spine (Phila Pa 1976). 2001;26(10):1110–6.

    Article  CAS  Google Scholar 

  7. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia and chronically injured axons: a physiological basis for the radicular pain of nerve root compression. Pain. 1977;3(1):25–41.

    Article  CAS  PubMed  Google Scholar 

  8. Yabuki S, Kawaguchi Y, Nordborg C, Kikuchi S, Rydevik B, Olmarker K. Effects of lidocaine on nucleus pulposus induced nerve root injury. A neurophysiologic and histologic study of the pig cauda equina. Spine (Phila Pa 1976). 1998;23(22):2383–90; discussion 2389–90.

    Article  CAS  Google Scholar 

  9. Yabuki S, Kikuchi S. Nerve root infiltration and sympathetic block. An experimental study of intraradicular blood flow. Spine (Phila Pa 1976). 1995;20(8):901–6.

    Article  CAS  Google Scholar 

  10. Engel A, King W, MacVicar J, Standards Division of the International Spine Intervention Society. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014;15(3):386–402.

    Article  PubMed  Google Scholar 

  11. Slipman C, Lipetz J, De Palma M, Jackson H. Therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain. Am J Phys Med Rehabil. 2004;83(6):446–54.

    Article  PubMed  Google Scholar 

  12. Lin E, Lieu V, Halevi L, Shamie A, Wang J. Cervical epidural steroid injections for symptomatic disc herniations. J Spinal Disord Tech. 2006;19(3):183–6.

    Article  PubMed  Google Scholar 

  13. Razzaq A, O’Brien D, Matthew B, Bartlett R, Taylor D. Efficacy and durability of fluoroscopically guided cervical nerve root blocks. Br J Neurosurg. 2007;21(4):365–9.

    Article  CAS  PubMed  Google Scholar 

  14. Kumar N, Gowda V. Cervical foraminal selective nerve root block: a “two-needle technique” with results. Eur Spine J. 2008;17(4):576–84.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Chunk JY, Yim JH, Seo HY, Kim SK, Cho KJ. The efficacy and persistence of selective nerve root blocks under fluoroscopic guidance for cervical radiculopathy. Asian Spine J. 2012;6(4):227–32.

    Article  Google Scholar 

  16. Shakir A, Ma V, Mehta B. Comparison of pain score reduction using triamcinolone vs. dexamethasone in cervical transforaminal epidural steroid injections. Am J Phys Med Rehabil. 2013;92(9):768–75.

    Article  PubMed  Google Scholar 

  17. Kolstad F, Leviseth G, Nygaard O. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir (Wien). 2005;147(10):1067–70.

    Article  Google Scholar 

  18. Persson L, Anderberg L. Repetitive transforaminal steroid injections in cervical radiculopathy: a prospective outcome study including 140 patients. Evid Based Spine Care J. 2012;6(4):13–20.

    Google Scholar 

  19. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6 nerve root. Pain. 2001;91(3):397–9.

    Article  CAS  PubMed  Google Scholar 

  20. Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, Dominick J, Wecht CH. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol. 2003;24(4):351–5.

    Article  PubMed  Google Scholar 

  21. 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(4):468–74.

    Article  PubMed  Google Scholar 

  22. McMillan MR, Crumpton C. Cortical blindness and neurologic injury complicating a cervical transforaminal injection for cervical radiculopathy. Anesthesiology. 2009;99(2):509–11.

    Article  Google Scholar 

  23. Windsor RE, Storm S, Sugar R, Nagula D. Cervical transforaminal injections: review of the literature, complications, and a suggested technique. Pain Physician. 2003;6(4):457–65.

    PubMed  Google Scholar 

  24. Ludwig MA, Burns SP. Spinal Cord infarction following cervical transforaminal epidural injection. A case report. Spine. 2005;30(10):E266–8.

    Article  PubMed  Google Scholar 

  25. Muro K, O’Shaughnessy B, Ganju A. Infarction of the cervical spinal cord following multilevel transforaminal epidural steroid injection: case report and review of the literature. J Spinal Cord Med. 2007;30(4):385–8.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Ruppen W, Hugli R, Reuss S, Aeschbach A, Urwyler A. Neurological symptoms after cervical transforaminal injection with steroids in a patient with hypoplasia of the vertebral artery. Acta Anaesthesiol Scand. 2008;52(1):165–6.

    Article  CAS  PubMed  Google Scholar 

  27. Beckman WA, Mendez RJ, Paine GF, Mazzilli MA. Cerebellar herniation after cervical transforaminal epidural injection. Reg Anesth Pain Med. 2006;31(3):282–5.

    Article  PubMed  Google Scholar 

  28. Kaplowitz K, Lee AG. Horner syndrome following a selective cervical nerve root block. J Neuroophthalmol. 2011;3(7):54–5.

    Article  Google Scholar 

  29. Karasek M, Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med. 2004;5(2):202–5.

    Article  PubMed  Google Scholar 

  30. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. Am J Roentgenol. 2007;188(5):1218–21.

    Article  Google Scholar 

  31. Lee JY, Nassr A, Ponnappan RK. Epidural hematoma causing paraplegia after a fluoroscopically guided cervical nerve root injection. A case report. J Bone Joint Surg Am. 2007;89(9):2037–9.

    Article  PubMed  Google Scholar 

  32. Schellhas KP, Pollei SR, Johnson BA, Golden MJ, Eklund JA, Pobiel RS. Selective cervical nerve root blockade: experience with a safe and reliable technique using an anterolateral approach for needle placement. Am J Neuroradiol. 2007;28(10):1909–14.

    Article  CAS  PubMed  Google Scholar 

  33. Lee MH, Cha YD, Song JH, An YM, Han JU, Lee du I. Transient quadriplegia after fluoroscopic-guided selective cervical nerve root block in a patient who received cervical interbody fusion—a case report. Korean J Anesthesiol. 2010;59(Suppl):S95–8.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kim W, Kim JS, Lim SC, Kim YI, Moon DE. Reversible posterior leukoencephalopathy syndrome after cervical transforaminal epidural steroid injection presenting as transient blindness. Anesth Analg. 2011;112(4):967–70.

    Article  PubMed  Google Scholar 

  35. Chung SG. Convulsion caused by a lidocaine test in cervical transforaminal epidural steroid injection. PM R. 2011;3(7):674–7.

    Article  PubMed  Google Scholar 

  36. Tofuku K, Koga H, Komiya S. Subdural spread of injected local anesthetic in a selective transforaminal nerve root block: a case report. J Med Case Rep. 2012;6(1):142.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Gilchrist R. Developmental and functional anatomy of the cervical spine. In: Slipman C, Derby R, editors. Interventional spine: an algorithmic approach. Philadelphia: Saunders Elsevier; 2008. p. 518–21.

    Google Scholar 

  38. Hong JT, Park D, Lee MJ, Kim SW, An HS. Anatomical variations of the vertebral artery segment in the lower cervical spine: analysis by three-dimensional computed tomography angiography. Spine. 2008;33(22):2422–6.

    Article  PubMed  Google Scholar 

  39. Bruneau M, Cornelius J, Marneffe V. Anatomical variations of the V2 segment of the vertebral artery. Neurosurgery. 2006;59(1 Suppl 1):ONS20–4.

    PubMed  Google Scholar 

  40. Furman M, Lee T, Berkowitz L. Atlas of image-guided spinal procedures. Philadelphia: Elsevier Saunders; 2013. p. 243–9.

    Google Scholar 

  41. Gitkind AI, Olson TR, Downie SA. Vertebral artery anatomical variations as they relate to cervical transforaminal epidural steroid injections. Pain Med. 2014;15(7):1109–14.

    Article  PubMed  Google Scholar 

  42. Beckworth WJ, Sood R, Katzer AF, Wu B. Anomalous location of the vertebral artery in relation to the neural foramen. Implications for cervical transforaminal epidural steroid injections. Pain Med. 2013;14(8):1119–25.

    Article  PubMed  Google Scholar 

  43. Gillilan LA. The arterial blood supply of the human spinal cord. J Comp Neurol. 1958;110(1):75–103.

    Article  CAS  PubMed  Google Scholar 

  44. Turnbull IM, Brieg A, Hassler O. Blood supply of cervical spinal cord in man: a microangiographic study. J Neurosurg. 1966;26(6):951–65.

    Article  Google Scholar 

  45. Dommisse GF. The blood supply of the spinal cord: a critical vascular zone in spinal surgery. J Bone Joint Surg Br. 1974;56(2):225–35.

    CAS  PubMed  Google Scholar 

  46. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005;117(1–2):104–11.

    Article  PubMed  Google Scholar 

  47. Hoeft MA, Rathmell JP, Monsey RD, Fonda BJ. Cervical transforaminal injection and the radicular artery: variation in anatomical location within the cervical intervertebral foramina. Reg Anesth Pain Med. 2006;31(3):270–4.

    PubMed  Google Scholar 

  48. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of steroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003;103(1–2):211–5.

    Article  PubMed  Google Scholar 

  49. Smuck M, Fuller B, Yoder B, Huerta J. Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal and epidural injections. Spine J. 2007;7(1):79–82.

    Article  PubMed  Google Scholar 

  50. Kranz PG, Amrhein TJ, Gray L. Incidence of inadvertent intravascular injection during CT fluoroscopy-guided epidural steroid injections. Am J Neuroradiol. 2015;36(5):1000–7.

    Article  CAS  PubMed  Google Scholar 

  51. El Abd O, Amadera J, Pimentel D, Gomba L. Immediate and acute adverse effects following transforaminal epidural steroid injections with dexamethasone. Pain Physician. 2015;18(3):277–86.

    PubMed  Google Scholar 

  52. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician. 2004;7(4):445–9.

    PubMed  Google Scholar 

  53. Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician. 2003;6(3):369–72.

    PubMed  Google Scholar 

  54. McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PM R. 2009;1(7):636–42.

    Article  PubMed  Google Scholar 

  55. Verrills P, Nowesenitz G, Barnard A. Penetration of a cervical radicular artery during a transforaminal epidural injection. Pain Med. 2010;11(2):229–31.

    Article  PubMed  Google Scholar 

  56. Maddela R, Wahezi SE, Sparr S, Brook A. Hemiparesis and facial sensory loss following cervical epidural steroid injection. Pain Physician. 2014;17(6):E761–7.

    PubMed  Google Scholar 

  57. 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(19):2144–215.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesiology and Perioperative Care, University of California San Francisco—UCSF, UCSF Pain Management Center, San Francisco, CA, 94143-1654, USA

    Irina Khrenova M.D. & Mario De Pinto M.D.

Authors
  1. Irina Khrenova M.D.
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  2. Mario De Pinto M.D.
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Corresponding author

Correspondence to Mario De Pinto M.D. .

Editor information

Editors and Affiliations

  1. Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois, USA

    Magdalena Anitescu

  2. Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA

    Honorio T. Benzon

  3. Division of Pain Medicine, Department of Anesthesiology, University of California San Diego School of Medicine, La Jolla, California, USA

    Mark S. Wallace

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Khrenova, I., De Pinto, M. (2018). Death After Transforaminal Cervical Epidural Steroid Injection. In: Anitescu, M., Benzon, H., Wallace, M. (eds) Challenging Cases and Complication Management in Pain Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-60072-7_13

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  • DOI: https://doi.org/10.1007/978-3-319-60072-7_13

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