Inadvertent Disk Injection during Transforaminal Epidural Steroid Injection: Steps for Prevention and Management

Authors

  • Steven P. Cohen MD,

    Corresponding author
    1. Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland;
    2. Anesthesia Service, Dept. of Surgery, Walter Reed Army Medical Center, Washington, DC, Washington, USA
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    • 1

      Dr. Cohen receives salary support from the John P. Murtha Neuroscience and Pain Institute, Johnstown, PA, and the Army Regional Anesthesia & Pain Medicine Initiative, Washington, DC.

  • David N. Maine MD,

    1. Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland;
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  • Sean M. Shockey MD,

    1. Anesthesia Service, Dept. of Surgery, Walter Reed Army Medical Center, Washington, DC, Washington, USA
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  • Sapna Kudchadkar MD,

    1. Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland;
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  • Scott Griffith MD

    1. Anesthesia Service, Dept. of Surgery, Walter Reed Army Medical Center, Washington, DC, Washington, USA
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  • The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Dept. of the Army or the Dept. of Defense.

Steven P. Cohen, MD, 550 North Broadway, Suite 301, Baltimore, MD 21029, USA. Tel: 410-955-1818; Fax: 410-614-7597; E-mail: scohen40@jhmi.edu.

ABSTRACT

Objectives.  To report two cases of disk injection during transforaminal epidural steroid injection, and to discuss ways to prevent and manage this under-appreciated complication.

Design.  Case reports and literature reviews.

Patients.  Two patients with radicular symptoms underwent transforaminal epidural steroid injections under fluoroscopic guidance. The needle in both cases was placed in the center of the intervertebral foramen, about 1 cm above the inferior endplate. Injection of contrast in both cases revealed diskographic spread. Repeat magnetic resonance imaging revealed a large foraminal disk herniation in both patients.

Results.  A literature search identified three studies whereby the use of a single-needle technique to perform diskography was clearly noted in conjunction with the number of infectious complications. Comparing these data with the incidence of diskitis when a double-needle approach was used found the infectious risk to be considerably higher. There are no data regarding whether imaging studies affect outcomes following epidural steroid injections.

Conclusions.  These cases and similar complications following transforaminal epidural steroid injections provide anecdotal evidence that recent imaging studies, repeated not only for qualitatively new symptoms but after a sustained quantitative increase in pain, may reduce the complication risk. Data extrapolated from studies on diskitis suggest that administering parenteral, and possibly also intradiskal antibiotics, immediately after inadvertent disk injection is appreciated, may reduce the infectious risk.

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