Alison Stout, D.O..Joshua Rittenberg, MDMichael Furman, MDMilton Landers, DO, PhDDavid Sibell, MDSIS Education Committee

Spine InterventionPreventing Complications

Alison Stout, D.O.Fellowship Director

Evergreen HealthSports and Spine Care

Disclosure Statement

Epidural steroids are not FDA approvedEpidural steroids are not FDA approved

SIS Education Committee Vice ChairSIS Education Committee Vice ChairNASS Exercise Committee ChairNASS Exercise Committee Chair

Common Side Effects, Lumbar TFESIRetrospective review , 322 lumbar TFESIs9.6% incidence of minor self limiting side effects:

transient non-positional headache back & leg painfacial flushingvasovagal reaction blood sugarone case of intra-operative hypertension

No dural punctures or hospitalizations

(Botwin KP: Arch Phys Med Rehabil; 81 (8) : 1045, 2000)

Patient Factors

Medications

Procedure/Technique

Spinal InjectionRisks and Complications

Minimizing Complications

Three Procedural Phases

Pre-Procedure Peri-Procedure

Post- Procedure

Care is required During Each

ConsentThe Informed Patient

Educate the patient

What are we doing?Why are we doing it?

Risks and complicationsOther Treatment Options

Document this discussion in your procedure note

Procedure Consent Form Risks

New painWorsening of pain

InfectionBleeding/Infarct

Permanent skin changesAllergic/unexpected drug reaction with minor/major consequences

Nerve injuryDural puncture

HeadacheParalysis

Death

“SUBSTANTIAL RISKS”

Pre-ProcedureInterim Patient History

Indications for procedureReview images

Current Complaint / any recent changes?Response to previous injections

Review of systemsActive Infections?

Pregnant?

Pre-ProcedureHistory

AllergiesMedications

Prior Adverse Reactions

Allergy history

Local anesthetics

Contrast

Steroids

Allergy vs. adverse reaction

Any Anaphylaxis Hx

Pre-Procedural: Medications

Anticoagulants/anti-plateletDiabetes medications

Narcotics/benzos

WITH ANTICOAGULANTS CEASING ANTICOAGULANTS

Risk of Spinal Complications

Nature of Spinal Complications

Risk of Systemic Thrombotic

Complications

Nature of Potential Systemic Thrombotic

ComplicationsRecommendation

Extraspinal very low minor very low severe continue anticoagulants

RF Neurotomy unknown minor very low severe continue anticoagulants

Lumbar Disc Stimulation

unknown, but theoretically low minor low severe continue

anticoagulants

Cervical or Thoracic Disc Stimulation

unknown, but theoretically low primarily minor low severe

anticoagulants = relative

contraindication*

Lumbar TFESI very low potentially significant very low severe

anticoagulants = relative

contraindication*

Cervical or Thoracic TFESI unknown potentially

serious very low severeanticoagulants =

relative contraindication*

Interlaminar ESI 3x greater potentially serious very low severe

anticoagulants = relative

contraindication*

*Relative contraindication means:Physicians should exercise discretion not only on whether or not to cease anticoagulants, but also whether or not the presumed therapeutic benefit of the procedure justifies the risk of ceasing anticoagulants.

ASRA Guidelines 2015

QuickTime™ and a decompressor

are needed to see this picture.

http://links.lww.com/AAP/A142

Narouze S et at. Interventional Spine and Pain Procedures in Patients onAntiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2015;40: 182–212 (AKA ASRA 2015)

ASRA Guidelines 2015

Pre-Procedure Diabetic patient

Blood Glucose MonitoringSteroids glucose, mean 136mg/dL x 3dCheck glucose pre-procedure

Metformin (Glucophage or Glucovance) renal impaired pts may have accumulation of

metformin lactic acidosisStop 48 hours after procedureConsider checking for renal insufficiency a couple days

after procedure before restarting metforminCommunicate with Managing Physician

Minimizing Complications

Three Procedural Phases

Pre-Procedure Peri-Procedure Post- Procedure

Care is required during each

Complications Peri-Procedure

Vaso-Vagal Response(3.9% overall incidence per RIC practice audit >2500 procedures)

Rapid onset BradycardiaHypotension

PallorSweatingNausea

Faintness

Interventional Medications

Local Anesthestics

Contrast Agents

Steroids

Allergic Reaction

Vasomotor (warmth, flushing)Cutaneous (hives, severe urticaria)

Bronchospasm (wheezing)Cardiovascular (hypotension)

Vasovagal (bradycardia, hypotension, nausea)Anaphylactoid reaction (angioedema, urticaria,

bronchospasm, hypotesion)

Local Anesthetics Toxicity

Intravascular – Immediate onset

Relative overdose – Slow onset withprogression of irritability

Local Anesthetics

CNS Toxicity

Numbness of tongue (initial)Foreign taste (initial)

HeadacheTinnitus

Blurred vision Seizure – muscle twitching

Local Anesthetics

Cardiovascular System ToxicityDysrythmias

Hypertension

~2X blood level compared with seizure dose

Except with Bupivacaine

Contrast must be used for all Spinal Injections = Contrast

Assure Validity of ProcedureReduce Risk

Inject with “live” fluoroscopy

Shellfish Allergy irrelevantNon-ionic contrastNon-ionic contrast

<1% had reaction = same as population

non-ionic less allergenicNO “crossover” with shellfish

allergyIodineIodine

Not an allergen

Contrast allergyContrast allergyAnaphylactoid reaction

GadoliniumOption for spinal procedures in patient with contraindications to iodinated contrast

Lower opacity - Consider use of digital subtraction to improve visualization of flow

AVOID Intrathecal Space

Iohexol 240 Gadolinium(gadodiamide)

(Safriel, AJNR 2006)

Corticosteroid Contraindications

AbsoluteAbsoluteLocal or systemic bacterial or fungal infection

RelativeRelativePregnancy (check w OBGYN usually okay)Diabetes (poorly controlled)OsteoporosisHistory of steroid psychosisPending surgery

Corticosteroid Systemic Effects

• Postinjection flare of pain (2-5%)

• Headache (3%)• Facial flushing (1-28%)• Insomnia• Fluid retention, HTN,

CHF• Gastric/peptic ulcer• Skin

atrophy/depigmentation (<1%)

• Adrenal suppression• Bone demineralization• Lymphocyte function• Cartilage attrition• Epidural lipomatosis• Hyperglycemia• Anxiety/psychosis

Corticosteroids

Use Judiciously

Not necessary for diagnostic blocksDose in patients at risk

Consider 6 month ≤ 5mg/Kg body weight(example 80kg pt=max 400 mg)

Critically evaluate patient response after EACH injection

ACR 2010 Guidelines

All cases of systemic GC: Education & evaluation modifiable risk factors

Ca++ & Vit D

# Exposures to ESI does overall risk of fragility fx

Corticosteroids

Transforaminal Injection

Particulate Matters!

12 cases (reported in literature) Spinal cord infarction subsequent to

Lumbar or Sacral Transforaminal injection of particulate steroids

Single most serious risk = Injection of particulate matter into a

reinforcing medullary artery

ISIS Practice Guidelines 2nd Edition Edited by N Bogduk 2013

Steroid Particle Size Compared to RBC (10 µm)

Methylprednisolone (Depo-Medrol), Triamcinolone Acetate (Kenalog), Betamethasoneacetate/sodium phosphate (CelestoneSoluspan)All with particles > size of RBC

Dexamethasone sodium phosphatePure liquid without particles (Benzon)0.5 µm particles, 5-10 x smaller than RBC (Derby)

(Derby 2006, Benzon 2007)

Particulate vs. Non-particulate

Pig vertebral arteries injected with methylprednisolone vs. dexamethasone

Methylprednisolone: All required ventilatory support and did not recover

Histologic evidence of hypoxic/ischemic brain damage

MRI with diffuse edema in upper cord and brainstem

Dexamethasone: None ventilated, no neuro changes evident

Okubadejo JBJS 2008

Minimize Risk

Use Non-particulate Steroids for Upper Lumbar or All Transforaminal Injections

Particulate Steroid is accepted for Interlaminar ESIs and Intraarticular injections

Spinal Injection Complications

Needle malposition

Any needle stick can cause problemsBleedingInfection

Optimal to Personally Review Imaging

Anatomic Barriers?Post Surgical?Perineural Cysts?

Procedural Risks Needle Malposition

Dependent on Specific ProcedureStructures to Avoid Piercing:

•Nerve Roots•Dura

•Spinal Cord•Arteries

•Peripheral Nerves

Spinal Injections Needle Placement

To prevent problems:

“It’s not only knowing where to put your needle,

It’s knowing where not to put it”

Know the Anatomy

Minimizing ComplicationsPeri-Procedure

• Maintain verbal contact with patient

• Heavy sedation should be avoided!

• Patient will be unable to report warning signs of needle to neuraxis contact

Neal et al. ASRA Practice Advisory, Reg Anes Pain Med 2008

Procedural RisksIntravascular Injection

Immediate onset Headache Tachycardia Anesthetic toxicity Vasovagal reaction Flushing Steroid side effects Spinal cord block/infarct

Intravascular Injection

Venous plexusRadicular artery

Radiculomedullary arteryArtery of Adamkiewicz

Artery of Adamkiewicz

• note characteristic “hairpin turn”• usually on left side, but side and level may vary• located in superior, anterior foramen • consider alternate approach at L3 and above, targeting the more inferior aspect of the foramen

Murthy 2010 Pain Medicine

Is the Safe Triangle really safe?

Why Use Fluoroscopy

Confirm needle-contrast-medication is in,and is covering, the desired target-area

Avoid placing needle / medication inunintended location

Intravascular Injection

Simultaneous epidural and vascular uptake occurs ≈ 75% of

vascular injections (Smuck 2006)

Minimum of live fluoro contrast injection

Is DSA necessary?Digital subtraction

angiography (DSA) superior to live fluoro for detecting vascular flow during lumbar transforaminalsOnly 60% of cases of vascular

flow detected with DSA were seen with live fluoro

(Lee MH. Korean J Pain. 2010 Mar;23(1):18-23.)

DSA rate of detection also better with cervical TFESI (McLean 2009)

QuickTime™ and a decompressor

are needed to see this picture.

Cervical TFESI with venous flow

Lidocaine Test Dose• Inject 0.5-1 ml of lidocaine after confirming

contrast flow• Wait > 1.5 min • Monitor any neurologic changes, dizziness,

weakness, tinnitus, headache…• Ask patient to move fingers and toes• If everything okay, then proceed with

injecting steroid

Risks ofIntrathecal Injection

Increase in painSpinal blockProlonged anesthesiaHypotensionVasovagal reactionHeadacheMeningitis Arachnoiditis

Intrathecal

Intrathecal

Dural Puncture< 0.5% incidence (experienced injectionists)Spinal headache

Not all dural punctures = spinal headacheHeadache is positionalOnset several hours to 48 hoursMost resolve spontaneouslyRarely, uncal herniation and death

Dural PuncturePrevention

Interlaminar ESISmaller gauge epidural needle (Lambert)

17 gauge: 75% required blood patch25-27 gauge: 13-39% require blood patch

Use AP and Lateral/contralateral views!Don’t use interspace with prior laminectomyAvoid stenotic level (review the MR)Keep bevel parallel to longitudinal dural fibers Higher incidence with multiple attempts

Transforaminal ESILumbar: Do not advance beyond 6 o’clock position

ofPedicle (AP view)

Dural Puncture

Spinal anesthesiaFrom local anestheticsSubdural injection produces similar resultLoss of consciousness, hypotension, apnea, cardiac

arrest, deathPrevention

Don’t inject local anesthetics if unsure

Procedural RisksSubdural Injection

“Slow” spinalIncrease in painProlonged anesthesiaHypotensionVasovagal reactionHeadacheMeningitis (Arachnoiditis)

Subdural

Injection between Dura and Arachnoid Layers

Small Volume of Local Anesthetic can Cause neurologic impairment

Subdural injection

Note“Railroad tracks”

Subdural injection

Note“Railroad tracks”

No space betweenvertebral body and

thecal sac

From Levy, D. Pain Medicine Volume 11, Issue 5, pages 716–718, May 2010

Minimizing Complications

Three Procedural Phases

Pre-Procedure Peri-Procedure

Post- Procedure

Post Procedure

Recover patientAssess pain and provocative maneuversGood documentationWritten instructions

Will save you from after hours calls about routine or minor complaints!

Schedule follow-up for evaluating procedure

Post Procedure ComplaintsIf problem evaluate and treat without delay

Pain – Assess if increasedFever/Chills – CBC/ESR/CRP

Weakness/Numbness, Bowel/BladderSecondary to LA? – reassure patientOther cause suspected? - evaluate ASAP!

Make sure the patient knows how to contact you after regular hours!

Epidural hematoma

Neck or back painNeurological deficits↑Risk

CoagulopathyEpidural vascular malformationsRecent surgery/injection

Time is critical!

Guffey PJ. Anesth Analg. 2010 Oct;111(4):992-5.Lawton MT. J Neurosurg. 1995 Jul;83(1):1-7

Epidural AbscessFever, tendernessRadiculitis → myelopathy/cauda equina syndrome↑ WBC, ESR, CRPMRI very sensitive, CT notGram + cocci in ~80%↑Risk

Immunocompromised/DiabetesSkin disruption/colonization

Time is critical!

Tompkins M. J Emerg Med. 2010 Sep;39(3):384-90.Kumar K. Neurocrit Care. 2005;2(3):245-51.

Facet Infection

Kim, SY Korean J Anesthesiol. 2010 April; 58(4): 401–404.

50 year old male,, worsening LBP, admitted to hospital 10 days following lumbar facet joint injection

Case Report64 yo PMH multiple pulmonary infections

L5-S1 interlaminar ESI fluoro guided

6 wks later => 4 weeks of worsening low back pain, hospitalized with severe LBP, fever

ESR 82 and CRP 17.4 mg/L

Hooten, et al. Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the Case Report Literature. Pain Medicine 2006

Hooten, et al. Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the Case Report Literature. Pain Medicine 2006

Thank You!