accidental discogram - antibiotics?

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powermd

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So what are you guys currently doing if you get an accidental discogram. For example, related to using the retro-discal TF approach.

I've had 2-3 patients who had unexpectedly lateral foraminal disc protrusions that led to injections of the disc with omnipaque.

What I've been doing is explaining the risk to the patient- somewhere between 0-1% that they may get a disc infection, and that prophylactic antibiotics might reduce that risk. If they accept, I put them on cephalexin 500 mg QID x 3 days.

I'm starting to think, wouldn't it make more sense to bust out a cefazolin bottle right there, and put 100 mg in 1 mL right into the disc?

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Pull back and inject steroid after getting epidural flow with contrast. Antibiotics not necessary.

There was an article a few years back saying just put steroids in disc when this happens.
 
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In my former practice, using blunt needles this only very rarely occurred but with sharp needle it was more frequent. Of course the goal with blunt needles is to place the tip medially in the anterior epidural space just beyond the HNP so the injection could be given directly onto the traversing nerve for a paracentral HNP. Sharp needles typically traverse the foraminal ligaments and remain in the canal or may enter as far as the lateral recess, but because of the obtuse angle most people use in placement (45-60 deg to the coronal plane), there is a greater chance of intradiscal injection. This is especially true if there is a broad based disc bulge present laterally. Using a more acute angulation to the coronal plane (20-30 deg) lessens the chance of intradiscal injections. In my prior practice, we used intradiscal cefazolin (kept the powered vials present) if such occurred; in my current practice where I just load the trucks, oral Keflex is given for a few days (high dose). Probably overkill....
 
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Pull back and inject steroid after getting epidural flow with contrast. Antibiotics not necessary.

There was an article a few years back saying just put steroids in disc when this happens.

Huh? If the concern is infection, why on earth would you inject more of anything other than an antibiotic into the disc?
 
Huh? If the concern is infection, why on earth would you inject more of anything other than an antibiotic into the disc?
There was an interesting report of over 10,000 intradiscal steroid injections for DDD performed in Mexico City, presented at a conference I attended about 10 years ago. There is more recent literature giving support to such....
 
Any good reason not to give abx? Iv X1 if in a facility and its available. Po if not. Cya.


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Oops .... do nothing. The risk of steroids,abx, etc not worth it. Just tell patient and follow up
 
Oops .... do nothing. The risk of steroids,abx, etc not worth it. Just tell patient and follow up

This happened once so far with me. I told the patient. Gave precautions. No abx Followed her up in a week. Injected a week later in a better spot. She did very well overall. No infection and became painfree back to running.

I guess also consider if pt is immunocompromised.
 
I wonder what the incidence is using a single needle technique without antibiotics and less skin prep than is typically used for discography?
 
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