alison stout, d.o. joshua rittenberg, md michael furman, md milton landers, do, phd david sibell, md...
TRANSCRIPT
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!