Complications of Epidural Steroid Injection in Chronic Low Back Pain Patients at Krabi Hospital
Keywords:
Chronic low back pain, epidural steroid injection, complicationsAbstract
Background: Low back pain is the most common problem that lead the patients to clinic or hospital. There are varieties of treatment including medication, surgery. Epidural steroid injection is the most common modality performed for chronic low back pain treatment. Most of epidural steroid injection studies have been done in scope of efficacy measurement and guideline development. Complications of epidural steroid injection are uncommon and almost minor. The serious complications are extremely rare and found on few reported cases. However they can cause disability and death. Additional studies for complications of epidural steroid injection should be done for precise incidence reports, risk- benefit analysis and further evidence-based guidelines.
Objectives: To study the complications of epidural steroid injection in chronic low back pain patients at Krabi Hospital during 2010-2013
Methods: A retrospective study of chronic low back pain patients undergoing epidural steroid injections at Krabi Hospital during January 2010 – December 2013. The complications encountered during injection, postoperative period were evaluated. The data was analyzed in the number, percentage and severity of complications, then compared with previous studies for synthesize possible recommendation aiming to minimize the complications
Results: 272 epidural steroid injections in chronic low back pain patients were done. The common complication of epidural steroid injection was intravascular puncture (3.68%). Other minor complications were vasovagal reflex (0.37%), facial flushing (0.37%), headache (0.37%), insomnia (0.74%), weight loss (0.74%), rash (0.74%), lidocaine allergy (0.37%). All of them were temporary and self-remission. One patient got local infection at injected site and needed antibiotic treatment. Major complications including epidural hematoma, spinal cord infarction, nerve damage and severe infection or abscess were not found.
Conclusion: The complications of epidural steroid injection are rare, mostly minor, self remission, and result from procedure or medication. Vascular penetrations are common complication. Well-trained and experienced doctors should strictly done, followed epidural steroid injection guidelines and recommendations to minimize the complications.
References
1. Rosas HG, Lee KS. Performing fluoroscopically guided interlaminar lumbar epidural injections.Am J Roentgenol 2012;199(2):419.
2. Manchikanti L, Helm S, Singh V, Benyamin RM, Datta S, Hayek SM, et al. An algorithmic approach for clinical management of chronic spinal pain. Pain Physician 2009;12:e225-64.
3. Mathis JM. Epidural steroid injections. Neuroimaging Clin N Am 2010;20(2):193–202.
4. Lievre JA, Bloch MH, Pean G, Uno J. L’hydrocortisone en injection local. Rev Rhum Mal Osteoartic1953;20:300–1.
5. Barre L, Lutz GE, Southern D, Cooper G.Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a retrospective evaluation of long term efficacy.Pain Physician2004;7(2):187-93.
6. Roberts ST,Willick SE, Rho ME, Rittenberg JD.Efficacy of lumbrosacral transforaminal epidural steroid injections: a systematic review. PM R2009;1:657-68.
7. Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospectiverandomizeddouble-blinddose-response trial. Reg Anesth Pain Med 2011;36:572–8.
8. Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomaticlumbar intervertebral disc herniations. Pain Physician 2006;9:361–6.
9. Lee JH, An JH, Lee SH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain 2009;25:206–10.
10. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007;10:185-212.
11. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: Guidance and Recommendations. Pain Physician 2013;16(2 Suppl):S49-283.
12. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician 2012;15:e199-245.
13. Parr AT, Manchikanti L, Hameed H, Conn A, Manchikanti KN, Benyamin RM, et al. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician 2012;15:e159-98.
14. Patel VB, Wasserman R, Imani F. Interventional therapies for chronic low back pain: a focused review (efficacy and outcomes). Anesth Pain Med 2015;5(4):e29716.
15. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician 2012;15:e143–50.
16. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B.A prospective evaluation of complication of 10,000 fluoroscopically directed epidural injections.Pain Physician2012;15:131-40.
17. Epstein NE. The risk of epidural and transforaminal steroid injections in the spine: commentary and a comprehensive review of the literature. Surg Neurol Int2013;4Suppl 2:S74-93.
18. Plastaras C, McCormick ZL, Garvan C, Macron D, Joshi A, Chimes G, et al. Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. Spine J 2015;15(10):2157–65.
19. Pountos I, Panteli M, Walters G, Bush D, Giannoudis PV. Safety of Epidural Corticosteroid Injections. Drugs R D. 2016;16:19–34.
20. Furman MB, O'Brien EM, Zgleszewski TM. Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections. Spine (Phila Pa 1976) 2000;25:2628–32.
21. Manchikanti L, Cash KA, Pampati V, Falco FJ. Transforaminal epidural injections in chronic lumbar disc herniation: a randomizeddouble-blindactive-control trial. Pain Physician2014;17:e489–501.
22. SullivanWJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, et al. Incidence of intravascular uptake in lumbar spinal injection procedures. Spine (Phila Pa 1976) 2000;25(4):481–6.
23. Landa J, Kim Y. Outcomes of interlaminar and transforminal spinal injections. Bull NYU Hosp Jt Dis 2012;70(1):6–10.
24. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28:172–97.
25. Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American society of regional anesthesia and pain medicine, the European society of regional anaesthesia and pain therapy, the American academy of pain medicine, the international neuromodulation society, the North American neuromodulation society, and the world institute of pain. Reg Anesth Pain Med2015;40(3):182–212.
26. Hong J, Jung S, Chang H. Whitacre needle reduces the incidence of intravascular uptake in lumbar transforaminal epidural steroid injections. Pain Physician 2015 Jul-Aug;18(4):325-31.
27. Özcan U, Sahin S, Gurbet A, Türker G, Özgür M, Çelebi S. Comparison of blunt and sharp needles for transforaminal epidural steroid injections. Agri 2012;24(2):85–9.
28. Shin J, Kim YC, Lee SC, Kim JH. A comparison of Quincke and Whitacre needles with respect to risk of intravascular uptake in S1 transforaminal epidural steroid injections: a randomized trial of 1376 cases. Anesth Analg 2013;117(5):1241–7.
29. Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labor epidural analgesia. Can J Anaesth 1998;45(2):110–4.
30. Webb CA, Weyker PD, Zhang L, Stanley S, Coyle DT, Tang T, et al. Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg 2012;115:124–32.
31. Ergenoglu P,Bali C, Akin S, Ozyilkan NB, Aribogan A. Pneumorrhachis and pneumocephalus with severe chest pain symptom: a rare complication of epidural steroid injection. Pain Medicine 2014 Jul;15(7):1239-40.
32. Riley CA, Spiegel JE. Complications following large-volume epidural blood patches for postdural puncture headache. Lumbar subdural hematoma and arachnoiditis: initial cause or final effect? J Clin Anesth 2009;21:355–9.
33. Ain RJ, Vance MB. Epidural hematoma after epidural steroid injection in a patient withholding enoxaparin per guidelines. Anesthesiology 2005 Mar;102(3):701–3.
34. Shah P, Carpenter DJ, DeWald TP, Hinderer SR. Poster 471 anticoagulation in new onset atrial fibrillation directly after epidural steroid injection causing epidural hematoma: a case report. PM&R2014 Sep;6(9):S351.
35. Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections.Expert Opin Drug Saf 2016 Aug;15(8):1031-9.
36. Centers for Disease Control and Prevention (CDC). Multistate outbreak of fungal infection associated with injection of methylprednisolone acetate solution from a single compounding pharmacy-United States, 2012. MMWR Morb Mortal Wkly Rep 2012;61(41):839–42.
37. Windsor RE, Storm S, Sugar R. Prevention and management of complications resulting from common spinal injections. Pain Physician 2003;6:473–83.
38. Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M.Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212–22.
39. Zimmerer SM,Conen A, Müller AA, Sailer M, Taub E, Flückiger U, et al. Spinal epidural abscess: etiology, predisponent factors and clinical outcomes in a 4-year prospective study. Eur Spine J 2011;20:2228–34.
40. Lee JW, Lee E, Lee GY, Kang Y, Ahn JM, Kang HS. Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre.Eur Radiol 2017. Epub 2017 Jul 19.
41. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology 2007;106:331–8.
42. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J2002;2:70–5.
43. Huntoon MA, Martin DP. Paralysis after transforaminal epidural injection and previous spinal surgery. Reg Anesth Pain Med2004;29:494–5.
44. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10:1389–94.
45. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology2015 May;122(5):974–84.
46. Manchikanti L, Pampati V, Beyer C, Damron K, Cash K, Moss T. The effect of neuraxial steroids on weight and bone mass density: a prospective evaluation. Pain Physician2000;3:357–66.
47. Kay J, Findling JW, Raff H. Epidural triamcinolone suppresses the pituitary-adrenal axis in human subjects. Anesth Analg1994;79:501–5.
48. El-Yahchouchi CA, Plastaras CT, Maus TP, Carr CM, McCormick ZL, Geske JR et al. Adverse event rates associated with transforaminal and interlaminar epidural steroid injections: a multi-institutional study. Pain Med 2016 Feb;17(2):239-49.
49. Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015;5(2):129-46.
2. Manchikanti L, Helm S, Singh V, Benyamin RM, Datta S, Hayek SM, et al. An algorithmic approach for clinical management of chronic spinal pain. Pain Physician 2009;12:e225-64.
3. Mathis JM. Epidural steroid injections. Neuroimaging Clin N Am 2010;20(2):193–202.
4. Lievre JA, Bloch MH, Pean G, Uno J. L’hydrocortisone en injection local. Rev Rhum Mal Osteoartic1953;20:300–1.
5. Barre L, Lutz GE, Southern D, Cooper G.Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a retrospective evaluation of long term efficacy.Pain Physician2004;7(2):187-93.
6. Roberts ST,Willick SE, Rho ME, Rittenberg JD.Efficacy of lumbrosacral transforaminal epidural steroid injections: a systematic review. PM R2009;1:657-68.
7. Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospectiverandomizeddouble-blinddose-response trial. Reg Anesth Pain Med 2011;36:572–8.
8. Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomaticlumbar intervertebral disc herniations. Pain Physician 2006;9:361–6.
9. Lee JH, An JH, Lee SH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain 2009;25:206–10.
10. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007;10:185-212.
11. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: Guidance and Recommendations. Pain Physician 2013;16(2 Suppl):S49-283.
12. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician 2012;15:e199-245.
13. Parr AT, Manchikanti L, Hameed H, Conn A, Manchikanti KN, Benyamin RM, et al. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician 2012;15:e159-98.
14. Patel VB, Wasserman R, Imani F. Interventional therapies for chronic low back pain: a focused review (efficacy and outcomes). Anesth Pain Med 2015;5(4):e29716.
15. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician 2012;15:e143–50.
16. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B.A prospective evaluation of complication of 10,000 fluoroscopically directed epidural injections.Pain Physician2012;15:131-40.
17. Epstein NE. The risk of epidural and transforaminal steroid injections in the spine: commentary and a comprehensive review of the literature. Surg Neurol Int2013;4Suppl 2:S74-93.
18. Plastaras C, McCormick ZL, Garvan C, Macron D, Joshi A, Chimes G, et al. Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. Spine J 2015;15(10):2157–65.
19. Pountos I, Panteli M, Walters G, Bush D, Giannoudis PV. Safety of Epidural Corticosteroid Injections. Drugs R D. 2016;16:19–34.
20. Furman MB, O'Brien EM, Zgleszewski TM. Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections. Spine (Phila Pa 1976) 2000;25:2628–32.
21. Manchikanti L, Cash KA, Pampati V, Falco FJ. Transforaminal epidural injections in chronic lumbar disc herniation: a randomizeddouble-blindactive-control trial. Pain Physician2014;17:e489–501.
22. SullivanWJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, et al. Incidence of intravascular uptake in lumbar spinal injection procedures. Spine (Phila Pa 1976) 2000;25(4):481–6.
23. Landa J, Kim Y. Outcomes of interlaminar and transforminal spinal injections. Bull NYU Hosp Jt Dis 2012;70(1):6–10.
24. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28:172–97.
25. Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American society of regional anesthesia and pain medicine, the European society of regional anaesthesia and pain therapy, the American academy of pain medicine, the international neuromodulation society, the North American neuromodulation society, and the world institute of pain. Reg Anesth Pain Med2015;40(3):182–212.
26. Hong J, Jung S, Chang H. Whitacre needle reduces the incidence of intravascular uptake in lumbar transforaminal epidural steroid injections. Pain Physician 2015 Jul-Aug;18(4):325-31.
27. Özcan U, Sahin S, Gurbet A, Türker G, Özgür M, Çelebi S. Comparison of blunt and sharp needles for transforaminal epidural steroid injections. Agri 2012;24(2):85–9.
28. Shin J, Kim YC, Lee SC, Kim JH. A comparison of Quincke and Whitacre needles with respect to risk of intravascular uptake in S1 transforaminal epidural steroid injections: a randomized trial of 1376 cases. Anesth Analg 2013;117(5):1241–7.
29. Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labor epidural analgesia. Can J Anaesth 1998;45(2):110–4.
30. Webb CA, Weyker PD, Zhang L, Stanley S, Coyle DT, Tang T, et al. Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg 2012;115:124–32.
31. Ergenoglu P,Bali C, Akin S, Ozyilkan NB, Aribogan A. Pneumorrhachis and pneumocephalus with severe chest pain symptom: a rare complication of epidural steroid injection. Pain Medicine 2014 Jul;15(7):1239-40.
32. Riley CA, Spiegel JE. Complications following large-volume epidural blood patches for postdural puncture headache. Lumbar subdural hematoma and arachnoiditis: initial cause or final effect? J Clin Anesth 2009;21:355–9.
33. Ain RJ, Vance MB. Epidural hematoma after epidural steroid injection in a patient withholding enoxaparin per guidelines. Anesthesiology 2005 Mar;102(3):701–3.
34. Shah P, Carpenter DJ, DeWald TP, Hinderer SR. Poster 471 anticoagulation in new onset atrial fibrillation directly after epidural steroid injection causing epidural hematoma: a case report. PM&R2014 Sep;6(9):S351.
35. Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections.Expert Opin Drug Saf 2016 Aug;15(8):1031-9.
36. Centers for Disease Control and Prevention (CDC). Multistate outbreak of fungal infection associated with injection of methylprednisolone acetate solution from a single compounding pharmacy-United States, 2012. MMWR Morb Mortal Wkly Rep 2012;61(41):839–42.
37. Windsor RE, Storm S, Sugar R. Prevention and management of complications resulting from common spinal injections. Pain Physician 2003;6:473–83.
38. Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M.Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212–22.
39. Zimmerer SM,Conen A, Müller AA, Sailer M, Taub E, Flückiger U, et al. Spinal epidural abscess: etiology, predisponent factors and clinical outcomes in a 4-year prospective study. Eur Spine J 2011;20:2228–34.
40. Lee JW, Lee E, Lee GY, Kang Y, Ahn JM, Kang HS. Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre.Eur Radiol 2017. Epub 2017 Jul 19.
41. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology 2007;106:331–8.
42. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J2002;2:70–5.
43. Huntoon MA, Martin DP. Paralysis after transforaminal epidural injection and previous spinal surgery. Reg Anesth Pain Med2004;29:494–5.
44. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10:1389–94.
45. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology2015 May;122(5):974–84.
46. Manchikanti L, Pampati V, Beyer C, Damron K, Cash K, Moss T. The effect of neuraxial steroids on weight and bone mass density: a prospective evaluation. Pain Physician2000;3:357–66.
47. Kay J, Findling JW, Raff H. Epidural triamcinolone suppresses the pituitary-adrenal axis in human subjects. Anesth Analg1994;79:501–5.
48. El-Yahchouchi CA, Plastaras CT, Maus TP, Carr CM, McCormick ZL, Geske JR et al. Adverse event rates associated with transforaminal and interlaminar epidural steroid injections: a multi-institutional study. Pain Med 2016 Feb;17(2):239-49.
49. Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015;5(2):129-46.
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2018-12-05
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บุญกิตติชัยพันธ์ ส. Complications of Epidural Steroid Injection in Chronic Low Back Pain Patients at Krabi Hospital. udhhosmj [internet]. 2018 Dec. 5 [cited 2025 Dec. 19];26(1):29-38. available from: https://he02.tci-thaijo.org/index.php/udhhosmj/article/view/159094
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