Perspective: Risks/adverse events for epidural spinal injections.

Abstract

Despite the lack of FDA (Food and Drug Administration) approval, cervical and lumbar epidural spinal injections are frequently performed in the US to address back pain and/or painful radiculopathy. The three major types of injections include; interlaminar/translaminar (ESI), transforaminal (TFESI), or caudal injections. Notably, most studies document little to no clear short-term, and no long-term benefits/efficacy for these injections vs. various placebos. More adverse events (AE) occurred with cervical© rather than lumbar (L) injections, and more severe AE were attributed to C-TFESI vs. CESI injections. Acute post injection AE symptoms were observed immediately or within 72 post-injection hours. These symptoms included; hypotension, acute respiratory distress, chest pain, upper extremity numbness, weakness, paresthesias, paralysis, and fevers. More AE were attributed to cervical C-TFESI vs. cervical CESI. These AE included; intramedullary/cord injections, intravascular injections (i.e. vertebral artery) resulting in brain stem/cerebellar/cord strokes, epidural abscess/infection, confusion, epidural hematomas, intracranial hypotension, and/or 6th nerve cranial palsies. AE for lumbar LESI/L-TFESI included; infections/abscess, epidural hematomas/subdural hematomas, intravascular injections, cerebrospinal fluid (CSF) leaks/dural tears (DT), and intracranial/postural hypotension. Notably, the vast majority of studies showed little to no short-term, and no long-term benefits for cervical or lumbar ESI/TFESI vs placebos (i.e. mostly consisting of normal saline alone, or saline plus local anesthesia). Epidural cervical and lumbar ESI or TFESI spinal injections demonstrated minimal to no short-term, and no long-term benefits for the treatment of cervical and/or lumbar pain/radiculopathy vs. placebos. Further, more AE were observed for cervical vs. lumbar epidural injections overall, with more AE usually seen with TFESI vs. ESI procedures.