Complications following cervical epidural steroid injections by expert interventionalists in 2003

Abstract

Background: Two major portals are available for delivery of medication into the cervical epidural space: interlaminar and transforaminal. The choice of which approach to use is commonly made by assessing the patient's structural pathology, one's skill in performing each procedure, and then weighing the advantages versus the risk associated with the particular technique. Over the past several years, a growing number of cases involving serious complications following cervical transforaminal epidural steroid injections have led some to question the safety of the procedure and to preferentially perform interlaminar epidural injections.

Objective: To explore the prevalence of complications caused by transforaminal versus interlaminar injections.

Design: Retrospective survey.

Methods: We selected the list of course instructors of the International Spine Intervention Society (ISIS) as our source for expert spine injection specialists. All data were collected by survey during a period from April 2004 through June 2004. Questions were asked about the type of cervical epidural injections performed and any complications during the preceding 12 months, January through December 2003.

Results: All 29 ISIS course instructors were surveyed. Seventeen instructors replied. In 2003, an estimated total of 5968 cervical epidural injections were performed by 17 instructors for neck and/or arm pain. The interlaminar approach was performed in 4389 cases by 14 instructors and the transforaminal approach was used in 1579 cases by 16 of the instructors. Of the 4389 interlaminar injections there were 23 cases (0.52%) of various minor complications including headaches caused by dural puncture, transient vagal episodes, and prolonged complaints of new or increased numbness and paresthesias. In the 1579 transforaminal there were five cases (0.32%) of minor complications including aggravated radicular pain, prolonged paresthesias, and skin rashes. In addition, 2 cases of radicular artery injection were confirmed by digital subtraction angiography during 354 transforaminal approaches performed by one physician. The rates of complication were not different between interlaminar and transforaminal approaches.

Conclusion: When performed by experienced interventionalists, major complications are probably rare and it could take years for a significant complication to occur. We must however all be aware that these complications can occur.