Complications

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The problems seen with epidural injections can be divided into two categories: true complications and side effects. The side effects are related to the medications used while the complications are related to the procedure itself.

The side effects of intrathecal steroids have already been addressed. When injected into the epidural space, corticosteroids can and do cause systemic effects, although these are generally much less prominent than those seen when systemic treatment with steroids is used. There is a depression of the hypothalamic-pituitary-adrenal access with ESIs. There is depression of plasma cortisol levels up to 3 wk after an epidural administration of the commonly used doses of steroids (38). Insomnia, anxiety, fluid retention, and headache have all been recorded as complaints by patients following epidural steroid injections, but these are limited in time and severity in almost all cases. Diabetic patients can experience a transient elevation of their blood sugar although this has been rarely reported (39).

Complications seen with ESIs include: dural puncture with resulting spinal headache, epidural hematoma, infection, epidural abscess, worsening of pain, nerve injury, intravascular injection of medication, allergic reaction to medications or contrast medium, and vasovagal reactions during the initial needle placement and intradural or intramedullary injection of medications (39,40).

Intradural Injection
Fig. 10. Transforaminal ESI in a postoperative patient.

The overall complication rate is below 1% in experienced hands (41), but will be higher for the inexperienced operator (11). There are numerous studies that have reported no major complications from ESIs (17,40,4244). The incidence of inadvertent dural puncture has been reported at 2.5% when using the sublaminar approach in the lumbar region and is the most commonly reported complication (45). It has also been reported when performing cervical sublaminar injections (46). The risk of dural puncture has been reported to be less when using the caudal technique (47). Major complications have rarely been reported with the caudal technique. The trans-foraminal route of delivery also has a reported risk of dural puncture, which is lower than the rate reported for the sublaminar approach (39). No major complications have been reported with this technique. The complications specifically related to cervical or thoracic epidural injections have not been studied as extensively. In one series, the leading complication was minor and self-limited. This complaint of a stiff neck was reported in 13% of the patients (46). Dural puncture has also been reported and in isolated cases required treatment with a blood patch (46,48). Injury to the spinal cord or an inadvertent injection into the cord has been rarely reported (49). Meticulous attention to needle placement, adequate fluoroscopy, and careful choice of the puncture site will all help to avoid this serious complication. This reinforces the importance of reviewing the preprocedure imaging for areas of significant spinal stenosis when choosing the site of the injection.

Table 1

Results of Epidural Steroid Trials

Year Author

1969 Sayle-Creer and Swerdlow (S)

1970 Burn and Langdon (ll)

1971 Beliveau (l2) 1973 Dilke et al. (53)

1984 Klenerman et al. (42)

1991 Bush and Hillier (l6)

1999 Buchner et al. (l5)

2001 Papagelopoulos (lS)

R, Randomized; DB, double blind.

Study design No. of patients

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