- Professor of Clinical Neurosurgery, School of Medicine, State University of N.Y. at Stony Brook, New York, USA
- Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience, Mineola, New York, USA
Nancy E. Epstein
Professor of Clinical Neurosurgery, School of Medicine, State University of N.Y. at Stony Brook, New York, USA
Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience, Mineola, New York, USA
DOI:10.4103/sni.sni_85_18Copyright: © 2018 Surgical Neurology International This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to cite this article: Nancy E. Epstein. Major risks and complications of cervical epidural steroid injections: An updated review. 23-Apr-2018;9:86
How to cite this URL: Nancy E. Epstein. Major risks and complications of cervical epidural steroid injections: An updated review. 23-Apr-2018;9:86. Available from: http://surgicalneurologyint.com/surgicalint-articles/major-risks-and-complications-of-cervical-epidural-steroid-injections-an-updated-review/
Background:Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications.
Methods:Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.
Results:Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature.
Conclusions:Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.
Keywords: Cervical, coma, death, epidural steroid injections, infection, intramedullary, intravascular, paralysis, quadriplegia
Many patients with even minor cervical complaints without significant magnetic resonance/computed tomography (MR/CT) documentation of significant cervical pathology are increasingly being subjected to high-risk cervical epidural steroid injections (CESIs) [e.g., interlaminar (ICESI) and transforaminal (TF-CESI)]. Major complications of these injections include; epidural hematoma, infection (abscess, meningitis), new neurological deficits (e.g., monoparesis to quadriplegia) due to intramedullary injections, and strokes to the spinal cord, brain stem, and/or cerebellum attributed to intravascular injections among others. Further, these cervical injections are still not approved by the Food and Drug Administration (FDA), and have not been proven to be either safe or effective in the cervical or lumbar spine.
Here we reviewed the literature between 2004–2013 and 2017–2018 regarding the severe risks/complications/mortality of CESIs, interlaminar (ICESI), and TF-CESI along with selective lumbar ESI (LESI) and TF-LESI. Further, cervical and lumbar epidural injections are still not approved by FDA as their safety/efficacy have never been established. In 2007, Abbasi et al. recommended performing prospective blinded randomized controlled trials (RCTs) to document such safety/efficacy; to date, none have yet been adequately completed [
Multiple risk and complications of CESI (ICESI, TF-CESI) were reported between 2004 and 2013. In 2004, Tiso et al. quoted the major morbidity/mortality of TF-CESI that included; paresthesias, hematoma, epidural abscess, meningitis, arachnoiditis, subdural/subarachnoid injections, and intraarterial injections resulting in stroke [
In 2017, Epstein (2017) again focused on the continued risks/complications of both cervical (CESI, ICESI, TF-CESI) and lumbar (LESI, ILESI, TF-LESI) ESI [
Cervical ESIs and rarely high LESIs (e.g., CESI, ICESI, TF-CESI, TF-LESI) may result in inadvertent intramedullary cervical and thoracic/conus cord injections [Tables
Several articles identified intravascular CESI resulting in major morbidity/mortality [
UTILIZING ULTRASOUND TO IDENTIFY VESSELS SURROUNDING C5-C7 CERVICAL NERVE ROOTS PRIOR TO SELECTIVE CERVICAL C5-C7 NERVE ROOT BLOCKS
Lee et al. (2017) utilized ultrasound (US) to document the size/location/number of vulnerable and susceptible perineural blood vessels prior to performing selective nerve root blocks from C5 to C7 (2012–2014) [
In 2004, Huntoon and Matin (2004) identified a 64-year-old male with a history of multiple prior lumbar operations, who underwent a left L1 TF-LESI; it contained 1 mL of iopamidol (Isovue), 5 mL of 0.125% bupivacaine, and 40 mg of triamcinolone [
Two studies cited the risks of peri-procedural hematomas in patients undergoing CESI and LESI [
Zhang et al. (2017) noted that CESI rarely result in cervical epidural abscess (CEA).[
Cervical ESI (CESI, ICESI, TF-CESI) and lumbar ESI (LESI, ILESI, TF-LESI) are not FDA-approved and have no RCT-documented long-term safety or efficacy. Further, CESI and occasionally high LESI (e.g., TF-LESI at the L1 level) risks include severe morbidity and mortality. Intramedullary or intravascular injections result in irreversible paralysis and/or strokes (e.g., cord, brain stem, and cerebellar strokes).
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Conflicts of interest
There are no conflicts of interest.
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