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Cervical epidural

Bsb2015

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    Did a cervical epidural on my 38 yo F patient, history of migraines, IV drug abuse now sober. It’s been 2 weeks and she called today to say she has a headache, no relief of her radicular arm pain and that it’s worse. I looked at her images, good needle placement. Didn’t get to talk with her, called back and no answer. Would you suspect the peak Onset of the steroid causing her HA? I would think this would be more of an acute thing. Plan on ruling out PDPH- doubtful about this, and infection vs meningitis. Thoughts?
     

    willabeast

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      Suggest you obtain ESR and CBC and examine patient along with a taking more history. PDPH, meningitis, infection - you should be able to exclude these possibilities with history exam simple blood tests. I like ESR because they are a very reliable test. OTOH you could just tell the patient to go to an E.R. but...the ER might do a Dx spinal tap. If there is any new weakness you are obligated to obtain new imaging. Hope that helps. BTW one thing about IV drug addiction - sometimes they have endocarditis. And that can be tough to diagnose sometimes...
       
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      lobelsteve

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        I would suspect that this in an unrelated headache to your procedure and she’s worse, again not an unusual kind of call. Don’t panic. Reassure her and carry on

        Has nothing to do with your injection. But in this world, you should prove it. If pain worse or different: MRI with and without contrast, ESR/CRP, CBC, blood Cx. MRI brain gets added in too. None of this will be positive. Unless she relapsed and has brain abscess from dirty IVDA.
         
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        Bsb2015

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          I would suspect that this in an unrelated headache to your procedure and she’s worse, again not an unusual kind of call. Don’t panic. Reassure her and carry on
          On another note, I get a lot of calls about the epidurals making pain worse. Maybe stupid question, but I don't understand this. Patient selection? How can it make things worse??
           

          Ronin1

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            Has nothing to do with your injection. But in this world, you should prove it. If pain worse or different: MRI with and without contrast, ESR/CRP, CBC, blood Cx. MRI brain gets added in too. None of this will be positive. Unless she relapsed and has brain abscess from dirty IVDA.

            This reaction is the epitome of defensive medicine.
            Talk to the patient. Document the discussion. Proceed with imaging if any real concerns
             
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            lobelsteve

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              This reaction is the epitome of defensive medicine.
              Talk to the patient. Document the discussion. Proceed with imaging if any real concerns

              Risk is very low of infection or hematoma. Failure to act emergently when getting this exact call could result in death or paralysis. Anyone who has been around for more than years has seen hematomas and discitis.
               
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              Ronin1

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                Risk is very low of infection or hematoma. Failure to act emergently when getting this exact call could result in death or paralysis. Anyone who has been around for more than years has seen hematomas and discitis.
                Thus the point of talking to the patient. We all get this sort of story occasionally. If any real suspicion of a problem certainly proceed with imaging.
                 

                clubdeac

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                  I just had a non english speaking patient call back with significantly worse leg pain following an L4 and L5 TFESI one week earlier. I bring him in. Exam unchanged but he's obviously in severe pain. I decide to get an ESR/CRP and CBC just to be safe. Thankfully they're all normal except for a leukocytosis likely due to the steroid. He then presents another week later with fevers, chills and night sweats. Seen in the ER and found to have marked elevations in his inflammatory markers as well as a WBC of 25k and dirty urine. They diagnose him with urosepsis. I'm internally freaking out as I'm reading the chart thinking he has an unidentified epidural abscess. Thankfully, they get a repeat lumbar MRI which was negative. It was without contrast however. Long story short, I think I'm safe but just glad I at least got the labs when I did showing that I did my due diligence
                   
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                  painfree23

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                    I just had a non english speaking patient call back with significantly worse leg pain following an L4 and L5 TFESI one week earlier. I bring him in. Exam unchanged but he's obviously in severe pain. I decide to get an ESR/CRP and CBC just to be safe. Thankfully they're all normal except for a leukocytosis likely due to the steroid. He then presents another week later with fevers, chills and night sweats. Seen in the ER and found to have marked elevations in his inflammatory markers as well as a WBC of 25k and dirty urine. They diagnose him with urosepsis. I'm internally freaking out as I'm reading the chart thinking he has an unidentified epidural abscess. Thankfully, they get a repeat lumbar MRI which was negative. It was without contrast however. Long story short, I think I'm safe but just glad I at least got the labs when I did showing that I did my due diligence

                    Good to be safe, but to be honest I don’t know if I always freak out (maybe my fault) if a patient says pain is worse after injections, right? I feel like if I always freaked out when that happens I would order so many tests that were normal
                     
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                    bronchospasm

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                      Call her in to examine and document, no new neurological deficits , no local or systemic signs of infection.

                      When any patient calls, always give them the option of coming in same day or go to the ER. Document.

                      If she looks sick or has new symptoms, do a work up.

                      Here is the template
                      Call made by:
                      .Procedure Name and Date:
                      .Patient Name:

                      .Spoke with patient today, Patient was doing well, no new complains, No fever or any other signs of infection, no weakness or any other new neurological complaints.

                      Patient was asked to call back if they had any questions or to go to the closest ER / Call 911 for any new complaints or medical emergency. Patient was also given option to come in to office same day for evaluation. She refuses/ will come in on______
                       
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                      DrSpine

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                        This reaction is the epitome of defensive medicine.
                        Talk to the patient. Document the discussion. Proceed with imaging if any real concerns

                        Don't blame him, I'd do the same. That's the direction they wanted this to go into - with liability/lawsuits - and if one doesn't overreact with defensive medicine, their statement will then be, "why didn't you do this?"
                         
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