Thoracic Epidural Steroid Injections Research Articles

Epidural hematoma risks associated with ceasing vs maintaining anticoagulant and/or antiplatelet medications for cervical and thoracic interlaminar epidural steroid injections

BackgroundThere is a lack of substantiated evidence to support or refute the risks of ceasing vs maintaining anticoagulant and/or antiplatelet medications (ACAP) prior to cervical and thoracic interlaminar epidural steroid injections. The ACAP medication is frequently stopped pre-procedure due to concerns for potential bleeding complications, particularly epidural hematomas (EH). This article provides evidence regarding EH incidence in this population. MethodsData for this study was collected retrospectively on all patients from September 19, 2009–Jun 16, 2017 who were scheduled for an Interlaminar Cervical and/or Thoracic Epidural Steroid Injections (IL-CTESI) and were on an ACAP medication at the time a procedure was scheduled. All possible adverse outcomes were then retrospectively analyzed via extensive data mining of the electronic medical record system with special emphasis on EHs. Results591 IL-CTESI were performed on patients taking ACAP medications. In total, 351 patients ceased their ACAP medication prior to the procedure and 240 maintained ACAP medication. Our findings demonstrate that there were no clinically relevant incidents of EHs in either cohort. ConclusionsThis data gives critical insight into the post-procedural EH risk for patients who had continued or stopped taking their ACAP medications prior to their IL-CTESI. The results from this study suggest re-evaluating the potential post-procedural EH risks associated with continuing vs ceasing these medications.

P56. Outcomes of thoracic transforaminal epidural steroid injections: A case series

<h3>BACKGROUND CONTEXT</h3> There is extremely sparse literature reporting on the outcomes of thoracic transforaminal epidural steroid injections, including the efficacy and safety of this approach. There have been a few studies looking at the outcomes of interlaminar thoracic epidural steroid injections, with Benyamin et al concluding that the evidence behind thoracic epidural steroid injections is considered fair. <h3>PURPOSE</h3> To investigate the outcomes of patients with thoracic radicular pain who underwent thoracic transforaminal epidural steroid injections. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series study from January, 2016 to December, 2019 at a single academic medical center. <h3>PATIENT SAMPLE</h3> Patients who underwent thoracic transforaminal epidural steroid injections for thoracic radicular pain during the months selected above. <h3>OUTCOME MEASURES</h3> Primary outcome: pain score using a numeric rating score. Secondary outcomes: need for repeat injection, progression to surgery, complications of the injections <h3>METHODS</h3> Retrospective chart review of patients who underwent thoracic transforaminal epidural steroid injection. <h3>RESULTS</h3> Six patients (mean age = 60.3 years with a SD = 11.8 years) underwent thoracic transforaminal epidural steroid injection for the treatment of thoracic radicular pain that was non-responsive to conservative care. Three out of 6 patients had pain duration of 6 months or less, and 5/6 patients had pain duration of 16 months or less. All injections were performed in accordance with Spine Intervention Society technique guidelines. Dexamethasone was used for all injections. The patient's thoracic MRIs underwent independent review by two physicians; it was determined that 3 patients had thoracic disc herniation, 2 with spondylitic stenosis, and 1 MRI was no longer available for review. Five of the 6 patients underwent a single level unilateral injection, with the other undergoing a two-level unilateral injection. Median pain score using a numeric rating scale prior to injection was 5 (IQR = 4-7.5). At follow-up (mean = 29.5 days), median pain score was 3 (IQR = 0.25-5.75), three patients received greater than 75% pain reduction, and 2 patients had complete resolution of their pain. Five patients underwent repeat injection with a mean time to repeat injection of 77 days (SD = 107 days). None of the patients progressed to surgery. One symptomatic but transient vasovagal reaction occurred, with no other complications noted. <h3>CONCLUSIONS</h3> Although only a case series, this is significant in reporting outcomes for the transforaminal approach in the thoracic spine. Of note, 50% of our patients experienced greater than 75% relief, which appears promising despite the limited ‘n'. Thoracic transforaminal epidural steroid injection is known to have an inherit risk of pneumothorax; however, of the 11 injections performed, this was not an observed complication. Further research is needed, including multisite cohort studies to obtain a larger ‘n', as well as prospective studies. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Reliability and Accuracy of MRI Laminar Angle Measurements to Determine Intra-Procedural Contralateral Oblique View Angle for Cervical or Thoracic Interlaminar Epidural Steroid Injections.

Contralateral oblique (CLO) angle view has been a useful addition to standard views in fluoroscopically guided interlaminar epidural injections. Determination of the appropriate CLO angle is paramount in the usefulness of this technique. Using MRI laminar angle measurements as a pre-procedural guide for the intra-procedural fluoroscopic CLO angle has been proposed. The purpose of this study was to help determine if using axial MRI laminar measurements prior to a cervical or thoracic epidural steroid injection would be useful in predicting the appropriate fluoroscopic CLO angle. A retrospective review was performed for patients who underwent cervical or thoracic interlaminar injections. In the performance of interlaminar injections, the authors had routinely determined the true fluoroscopic contra-lateral oblique angle after epidural access was confirmed, for use during any potential future injections. The fluoroscopic CLO angle measurements were obtained from a chart review and compared blindly to each patient's MRI axial laminar angle measurements. 34 injections were included. Inter-rater reliability comparing the two authors' MRI angle measurements was considered fair, ICC = 0.395. Accuracy was only 57% comparing MRI laminar angle measurements to within five degrees of the true fluoroscopic CLO angle as determined during the injection procedure. Accuracy by ICC showed only fair agreement, 0.47 and 0.22, for the two authors. The findings of this study indicate fair inter-rater reliability in manual measurements of laminar angle on axial MRI images. MRI laminar angle measurements do not appear to be highly accurate in determining the appropriate fluoroscopic CLO angle.

Stress-Induced (Takotsubo) Cardiomyopathy Following Thoracic Epidural Steroid Injection for Postherpetic Neuralgia

We present what may be the first documented case of takotsubo cardiomyopathy following a thoracic epidural steroid injection. The 77-year-old patient had many risk factors predisposing her to takotsubo cardiomyopathy, including gender, postmenopausal status, and numerous recent stressful events in her life. Although she presented to the emergency department with symptoms of an acute myocardial infarction, her findings on electrocardiography, echocardiography, coronary angiography, and cardiac enzymes supported the diagnosis of takotsubo cardiomyopathy. While takotsubo cardiomyopathy is rare, it is important for the clinician to distinguish it from an acute myocardial infarction, as the two conditions present similarly but may have distinctly different clinical outcomes.

Thoracic Epidural Steroid Injection for Rib Fracture Pain

Treatment for rib fracture pain can be broadly divided into pharmacologic approaches with oral and/or parenteral medication and interventional approaches utilizing neuraxial analgesia or peripheral nerve blocks to provide pain relief. Both approaches attempt to control nociceptive and neuropathic pain secondary to osseous injury and nerve insult, respectively. Success of treatment is ultimately measured by the ability of the selected modality to decrease pain, chest splinting, and to prevent sequelae of injury, such as pneumonia. Typically, opioids and NSAIDs are the drugs of first choice for acute pain because of ease of administration, immediate onset of action, and rapid titration to effect. In contrast, neuropathic pain medications have a slower onset of action and are more difficult to titrate to therapeutic effect. Interventional approaches include interpleural catheters, intercostal nerve blocks, paravertebral nerve blocks, and thoracic and lumbar epidural catheters. Each intervention has its own inherent advantages, disadvantages, and success rates. Rib fracture pain management practice is founded on the thoracic surgical and anesthesiology literature. Articles addressing rib fracture pain are relatively scarce in the pain medicine literature. As life expectancy increases, and as healthcare system modifications are implemented, pain medicine physicians may be consulted to treat increasing number of patients suffering rib fracture pain and may need to resort to novel therapeutic measures because of financial constraints imposed by those changes. Here we present the first published case series of thoracic epidural steroid injections used for management of rib fracture pain.

Persistent Hiccups After Interventional Pain Procedures: A Case Series and Review

Interventional spine procedures are nonsurgical interventions that are commonly used to treat acute and chronic pain. These procedures generally are considered to be safe, but patients may experience transient and minor complications. Hiccups previously have been reported in the pain management setting as a complication after lumbar and thoracic epidural steroid injections and an intrathecal morphine pump infusion. In this case series of 8 patients, we describe hiccups after various interventional procedures, including cervical and lumbar epidural steroid injections, facet joint injections, and sacroiliac joint injections. A comprehensive literature review of hiccups associated with interventional pain procedures is provided, along with the known pathophysiology, etiologies, and treatment options for hiccups. The objective of this case series presentation and literature review is to highlight the importance of recognizing hiccups as a potentially under-reported adverse reaction in the setting of various interventional spine procedures.

Zoster Sine Herpete with Thoracic Motor Paralysis Temporally Associated with Thoracic Epidural Steroid Injection

Reactivation of latent varicella-zoster virus can occur when the immune system is weakened leading to the typical presentation seen with herpes zoster or shingles. In a small percentage of these patients, motor paralysis can be seen in the affected myotomal distribution. Zoster sine herpete, or shingles without the typical vesicular rash, is an uncommon variant of zoster. Systemic steroids are known to weaken the immune response. Two previous case reports have implicated epidural steroid injections as a precipitating cause of zoster. We present a case of serologically verified zoster sine herpete producing an abdominal wall bulge, which occurred 1 wk after thoracic epidural steroid injection. Electromyography documented the presence of abdominal wall denervation. Given the low incidence of serologically proven zoster sine herpete--especially with thoracic motor paralysis--and the equally rarely documented incidence of zoster related to epidural steroids, we present what we believe to be the first reported case of zoster sine herpete with a neuropathic abdominal wall bulge occurring in close temporal association to receiving epidural steroids.

Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections

To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections. A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed. A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137). No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.

Persistent Hiccup after Epidural Steroid Injection -Case reports-

Caudal and lumbar epidural steroid injections have been widely used in patients with lower back pain and lumbosacral radicular pain. In most instances, complications from an epidural steroid injection are rare, so epidural steroid injections are considered a safe therapeutic intervention. To date, there has only been one report of persistent hiccup associated with a thoracic epidural steroid injection. We describe two cases of persistent hiccup associated with an epidural steroid injection. Our experiences indicated that persistent hiccup can occur with the administration of an epidural steroid injection via lumbar or caudal routes.