A Prospective Evaluation of Complications of 10,000 Fluoroscopically Directed Epidural Injections

Background: Among the multiple modalities of treatments available in managing chronic spinalpain, including surgery and multiple interventional techniques, epidural injections by various routes,such as interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections,and percutaneous adhesiolysis are common.Even though the complications of fluoroscopically directed epidural injections are fewer than blindepidural injections, and have better effectiveness, multiple complications have been reported inscattered case reports, with only minor complications in randomized or non-randomized studies andsystematic reviews. Thus, prospective studies with large patient series are essential to determine thetypes and incidences of complications.Study Design: A prospective, non-randomized study of patients undergoing interventionaltechniques from May 2008 to December 2009.Setting: A private interventional pain management practice, a specialty referral center in theUnited States.Objectives: To assess the complication rate of fluoroscopically directed epidural injections.Methods: This study was carried out over a period of 20 months and included over 10,000procedures: 39% caudal epidurals, 23% cervical interlaminar epidurals, 14% lumbar interlaminarepidurals, 13% lumbar transforaminal epidurals, 8% percutaneous adhesiolysis, and 3% thoracicinterlaminar epidural procedures. All of the interventions were performed under fluoroscopicguidance in an ambulatory surgery center by one of 3 physicians. The complications encounteredduring the procedure and postoperatively were prospectively evaluated.Outcomes Assessment: Measurable outcomes employed were intravascular entry of the needle,profuse bleeding, local hematoma, bruising, dural puncture and headache, nerve root or spinal cordirritation with resultant injury, infectious complications, vasovagal reactions, and facial flushing.Results: Intravascular entry was higher for adhesiolysis (11.6%) and lumbar transforaminal (7.9%)procedures compared to other epidurals which ranged from 0.5% for lumbar, 3.1% for caudal,4% for thoracic, and 4.1% for cervical epidurals. Dural puncture was observed in a total of 0.5%of the procedures with 1% in the cervical region, 1.3% in the thoracic region, 0.8% with lumbarinterlaminar epidurals, and 1.8% with adhesiolysis.Limitations: Limitations of this study include a single-center study even though it included a largenumber of patients.Conclusion: This study illustrates that major complications are rare and minor side effects arecommon.Key words: Spinal pain, epidural injections, caudal epidural, interlaminar epidural, transforaminalepidural, percutaneous adhesiolysis, complications, and steroids.