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Complications of fluoroscopically guided transforaminal lumbar epidural injections,☆☆,

https://doi.org/10.1053/apmr.2000.7166Get rights and content

Abstract

Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil 2000;81:1045-50. Objectives: To assess the incidence of complications of fluoroscopically guided lumbar transforaminal epidural injections. Design: A retrospective cohort design study. Patients presenting with radiculopathy, caused by either lumbar spinal stenosis or herniated nucleus pulposus confirmed by magnetic resonance imaging or computed tomography scanning, received transforaminal epidural steroid injections as part of a conservative care treatment plan. Setting: A multidisciplinary spine care center. Intervention: All injections were performed consecutively over a 4-month period by five physiatrists. An independent observer reviewed medical charts, which included a 24-hour postprocedure telephone call by an ambulatory surgery center nurse who had asked a standardized questionnaire about complications following the injections. Physician follow-up office notes 1 to 3 weeks after the injection, along with epiduragrams, were also reviewed. Results: Two hundred seven patients who received 322 injections were reviewed. Complications per injection seen included 10 transient nonpositional headaches that resolved within 24 hours (3.1%), 8 increased back pain (2.4%), 2 increased leg pain (0.6%), 4 facial flushing (1.2%), 1 vasovagal reaction (0.3%), 1 increased blood sugar (258mg/dL) in an insulin-dependent diabetic (0.3%), and 1 intraoperative hypertension (0.3%). No dural punctures occurred. Conclusions: There were no major complications. The incidence of minor complications was 9.6% per injection. All reactions resolved without morbidity, and no patient required hospitalization. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Method

Patients presented to a multidisciplinary spine care practice with complaints of lower back and radicular pain. As part of a nonoperative treatment plan, patients received a combination of anti-inflammatory analgesics, referral to physical therapy, and transforaminal epidural steroid injections. All epidural injections were performed at an ambulatory surgery center using fluoroscopic guidance. Charts of all injections performed over a 4-month period on consecutive patients were retrospectively

Results

From 350 charts, 235 met retrospective design parameters. Patients received between 1 and 3 injections, with an overall average of 1.6 injections per patient. Complications were evaluated after each injection. Twenty-eight patients (11.9%) were lost to follow-up, which resulted in an overall drop-out rate of 28 injections (8%). None of these patients reported any side-effects. Thus, the study group was composed of a total of 207 patients with either HNP or LSS who underwent 322 injections.

The

Discussion

Epidural steroid injections have been used in the treatment of lumbar radicular pain syndromes since 1952.18 First reported in the United States in 1960, it was found to benefit conditions causing nerve root irritation.19 These injections were performed “blind” (without fluoroscopic guidance) using a translaminar “loss of resistance” technique. Even in experienced hands, improper localization of the epidural space using the blind technique has occurred in 13% to 30% of attempted injections.5, 6

Conclusion

Our retrospective review of the safety profile of fluoroscopically guided LTE steroid injections in 207 patients who had a total of 322 injections revealed an overall incidence of complication per injection at 9.6%. The most common complication was a nonpositional headache, with an incidence of 3.1% per injection. The second most common complication was increased back pain at the injection site in 2.4% of patients per injection. None of the complications required hospitalization, all were

Acknowledgements

The authors thank Carol Barragan, Pat Keenan, RN, Toni Milliken, RN, Nicole Belsanti, RRT, and George Gerlach, RRT, for their assistance.

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    Reprint requests to Kenneth P. Botwin, MD, Florida Spine Institute, 2250 Drew Street, Clearwater, FL 33765.

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