The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature

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The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature Nancy E Epstein DOI:10.4103/2152-7806.109446 PMID: 23646278 [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [PubMed]     Abstract   Background: Multiple type of spinal injections, whether epidural/translaminar or transforaminal, facet injections, are offered to patients with/without surgical spinal lesions by pain management specialists (radiologists, physiatrists, and anesthesiologists). Although not approved by the Food and Drug Administration (FDA), injections are being performed with an increased frequency (160%), are typically short-acting and ineffective over the longer-term, while exposing patients to major risks/complications. Methods: For many patients with spinal pain alone and no surgical lesions, the "success" of epidural injections may simply reflect the self-limited course of the disease. Alternatively, although those with surgical pathology may experience transient or no pain relief, undergoing these injections (typically administered in a series of three) unnecessarily exposes them to the inherent risks, while also delaying surgery and potentially exposing them to more severe/permanent neurological deficits. Results: Multiple recent reports cite contaminated epidural steroid injections resulting in meningitis, stroke, paralysis, and death. The Center for Disease Control (CDC) specifically identified 25 deaths (many due to Aspergillosis), 337 patients sickened, and 14,000 exposed to contaminated steroids. Nevertheless, many other patients develop other complications that go unreported/underreported: Other life-threatening infections, spinal fluid leaks (0.4-6%), positional headaches (28%), adhesive arachnoiditis (6-16%), hydrocephalus, air embolism, urinary retention, allergic reactions, intravascular injections (7.9-11.6%), stroke, blindness, neurological deficits/paralysis, hematomas, seizures, and death. Conclusions: Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits. Keywords: Complications, epidural spinal injections, infection, spinal fluid leaks How to cite this article: Epstein NE. The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surg Neurol Int 2013;4, Suppl S2:74-93 How to cite this URL: Epstein NE. The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surg Neurol Int [serial online] 2013 [cited 2014 Jan 19];4:74-93. Available from: http://www.surgicalneurologyint.com/text.asp?2013/4/3/74/109446