Cervical Transforaminal ESIs

[paz5559]

Yet again, an article has been published this month Cerebellar Herniation after Cervical Transforaminal Epidural Injection, Beckman WA, Mendez RJ, Paine GF, Mazziilli MA; Reg Anesth Pain Med. 2006 May-Jun;31(3):282-5 which demonstrates that you can hurt people when you stick needles into them and don't follow the rules. Yet again, what these published versions of scare mongering DON'T do is demonstrate that in competent hands, using ISIS guidelines, tempered with the right amount of respect for the procedure, these are anything other than safe interventions.

In the case of the article in question, the practitioners used Depo-Medrol, rather than either Celestone or Decadron as recommended by Tiso (Spine J. 2004 Jul-Aug;4(4):468-74) and Dreyfuss (Pain Med. 2006 May-Jun;7(3):237-42) respectively. Images are not provided, even though we are assured that "the physician noted good outline of the right C8 nerve root with epidural spread." Neither a test dose of lidocaine nor digital subtraction angiography was utilized.

I always amazes me that an article can be published when all that it demonstrates is that, when a procedure is done in a substandard manner, catastrophic complications can ensue. Makes you wonder what the underlying agenda of the authors or editors of the particular journal really is.

If someone can show me an article that has clear pictures showing good needle position, appropriate contrast flow, use of appropriately small particulate or non-particulate steroid, appropriate test dosing with lidocaine when the patient isn't so snowed with propofol that they can't respond, and catastrophic complications still ensue, then the hue and cry currently being generated about cervical transforaminal ESIs might be reasonable. To date, I am aware of not even one such published case, and Ma et al (J Bone Joint Surg Am. 2005 May;87(5):1025-30) have documented that the procedure can be done safely over an extended time (>1000 C/S TF ESIs) without the catastrophic complications being described elsewhere.


Meanwhile, Dr. Tiso responded to a letter in the Spine Journal recently (Letters to the Editor, Spine J. 2006 Mar-Apr;6(2):219. Epub 2006 Feb 7) which is also relevant to this topic:

To the Editor:
The letter by Drs. Aprill and Dumitrescu [1] in response to our article on adverse central nervous system sequelae after selective transforaminal block [2] brings up several valid observations to those who may be unfamiliar with
the specifics of this case. I would like to address each of these comments:

1. I agree that transforaminal injections in the cervical region are indeed more dangerous. Despite the stated body habitus, a satisfactory epidurogram was in fact obtained. The image was of poor quality but the needle tip position was never in doubt.

2. The total fluoroscopy time was 7 seconds. This is not a misprint. In fact, it is not uncommon in our institution for single-level transforaminal procedures to utilize under 10 seconds of fluoroscopy. The performance of procedures in high volume breeds a certain familiarity with needle directionality and depth so that rapid spot fluoroscopic imaging is all that is necessary. This would include short continuous imaging during injection. Let us be cautious before finding fault with clinicians because they have developed expertise commensurate with 15 years of experience.

3. The readers are shown a typical fluoroscopic pattern for a cervical selective transforaminal block. This in fact does not represent the film of the actual patient who is the subject of the paper. The actual film was, as suggested, of poor quality. However, poor film quality per se does not imply compromised visualization or a disregard of the danger inherent in the performance of these procedures.

4. The cervical spine in Figure 3, page 474, is rotated 90 degrees to the right. It is our convention to orient the spine in the direction of the patient who lies on the table. I appreciate the input about ‘‘technique’’ of recording data but believe the statement in this regard is clinically irrelevant and without merit.

5. It is correct that there is a misprint, in that the contrast is ‘‘non-ionic’’, not ‘‘non-iodinated.’’

6. I am not aware of any data on the reliability of aspiration with 22-gauge needles.

The purpose of this article is to draw attention to a serious complication and to suggest ways for all of us to avoid future misadventure. I welcome the viewpoints of Drs. Aprill and Dumitrescu and agree that this procedure is safe if needle position is precise and well documented with good fluoroscopic dispersal and test dosing. I would also urge the use of nonparticulate steroid preparations. Complications can occur even when the standard of care is met or exceeded. Implications to the contrary serve no benefit and can detract from the issue at hand.

References
[1] Aprill CN, Dumitrescu M. Letters to the Editor. Spine J 2005;5:475.
[2] Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous
system sequelae after selective transforaminal block: the role of corticosteroids. Spine J 2004;4:468–74.

So from what I read, if you do this procedure on a 5'2", 300lb man, using a total of 7 seconds of fluoroscopic time to both precisely place your needle tip AND inject contrast, you don’t save your images (or do save them but they are of such poor quality as to not be publishable), don't use DSA or a test dose, you are still able to claim:

"Complications can occur even when the standard of care is met or exceeded"

I will leave it to you, gentle reader, to judge for yourself.

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[md2k]

Paz,

You mention here that the procedure was substandard. Is there a standard of care for epidural steroid injections? Has a lidocaine test dose been proven? I read the article by Karasek M, Bogduk N and yes it helped them in that case. But I have also read that lidocaine can cause chemical infarcts. How about DSA? How can you be sure that your needle is not in the artery.
So it looks good after you digitally subtract the pic and then you move your hand to replace the syringe with the steroid or local. How do you know the needle tip didn't move. You dont, you just hope it didn't. How about using DSA with a blunt needle??? I think that makes more sense.
I agree with what you are saying. However, is there or should ther be a standard for ESI's????

MD2K

 

[paz5559]

Paz,You mention here that the procedure was substandard. Is there a standard of care for epidural steroid injections? Has a lidocaine test dose been proven? I read the article by Karasek M, Bogduk N and yes it helped them in that case. But I have also read that lidocaine can cause chemical infarcts. How about DSA? How can you be sure that your needle is not in the artery.
So it looks good after you digitally subtract the pic and then you move your hand to replace the syringe with the steroid or local. How do you know the needle tip didn't move. You dont, you just hope it didn't. How about using DSA with a blunt needle??? I think that makes more sense.
I agree with what you are saying. However, is there or should ther be a standard for ESI's????MD2K

Realizing this will bring up the dreaded ISIS vs ASIPP discussion again, yes there are standards, they are called the ISIS Guidelines which is a consensus of the thought leaders in our field.

As for blunt needles, let me defer to the recent article in the ISIS Journal (Vol 5, Number 4, p7-13) entitled Sharp vs Blunt Needles, International Spine Intervention Society White Paper by Professor Bogduk which concluded

Despite the insistence of proponents of blunt needles that they reduce, if not eliminate, the risk of intravascular injection, this has not been the experience of operators who have used them. (An image of a lumbar transforaminal injection in which vascular injection is evident is then provided, despite a blunt needle having been used)

A single case does not establish how often a vascular injection might occur, but it does establish that the risk of vascular injection is not zero. Operators should not believe that blunt needles protect them from intravascular injection.

 

[lobelsteve]

It is easy to gaurantee zer o complications from performing cervical transforaminals: do not perform cervical transforaminals.

The procedure is relatively safe with complication rates 1:10000 (I made up the number- PAZ can post the literature that supports the actual rate).

However, the complication of SCI, seizure, stroke, or death is not one that I can justify against the potential benefit of potential reduction of pain. THis is especially true when the legal staff reviews the case. I am all in favor of not doing these blocks and will happily refer them to somebody else should the patient desire and understand why I will not do them. I can offer a CESI at C7-T1 with a cath towards the affected foramen (unless PAZ can produce a case study with a catheter penetrating a vertebral artery- I can deal with a dural tear if I get that complication).

A CTFESI will not cure cancer, make you taller, or a better lover- I was trained this way and agree with it. Sure I can poke a needle into the neck and make the picture on FLuoro look pretty and demonstrate no obvious contrast in the artery, needle tip not in the root or cord: but if I ever had a catastrophic event- I could rest uncomfortably that my preceptor may testify against me- and I think he would be right.

I have no problem with other people doing CTFESI- just dont do it on me.

 

[paz5559]

However, the complication of SCI, seizure, stroke, or death is not one that I can justify against the potential benefit of potential reduction of pain. THis is especially true when the legal staff reviews the case. I am all in favor of not doing these blocks and will happily refer them to somebody else should the patient desire and understand why I will not do them. I can offer a CESI at C7-T1 with a cath towards the affected foramen (unless PAZ can produce a case study with a catheter penetrating a vertebral artery- I can deal with a dural tear if I get that complication).

Quadriparesis following cervical epidural steroid injections: case report and review of the literature Bose B., Spine J. 2005 Sep-Oct;5(5):558-63.

BACKGROUND CONTEXT: Cervical epidural steroid injections are frequently used in the conservative management of neck pain, cervical radiculitis, and cervical radiculopathy. Between 64-76% of patients who receive injections report subjective pain improvement. Injections are usually well-tolerated with only mild, transient side effects, although a few case reports of patients with adverse effects do appear in the literature. Some clinicians have expressed concerns about epidural injections above the C7-T1 level, and in the use of methylprednisolone epidurally; as yet, neither is a consensus viewpoint. PURPOSE: This case report describes severe adverse effects (quadriplegia and respiratory arrest) associated with an epidural injection into the C6-C7 space. Although the patient's symptoms improved somewhat with supportive care, quadriparesis appears irreversible. No reports of quadriparesis after cervical epidural injection were found in the literature, although other adverse effects have been reported. STUDY DESIGN/SETTING: The patient was injected by a fellowship-trained pain management specialist in an outpatient surgicenter using C-arm fluoroscopic guidance. Immediately he experienced respiratory arrest with quadriplegia. He was intubated and transferred to the hospital, then transferred again to Christiana Health Care Services. METHODS: The patient was hospitalized, treated with steroid protocol within 8 hours, and followed clinically for 6 months. RESULTS: Magnetic resonance imaging within 6 hours of the injury and 6 months later showed no significant findings aside from lordosis (40 degrees angle) of the cervical spine at the C6-C7 level. CONCLUSION: Although evidence is not conclusive, this patient may have suffered a vascular event from a cervical epidural injection.

A CTFESI will not cure cancer, make you taller, or a better lover- I was trained this way and agree with it. Sure I can poke a needle into the neck and make the picture on FLuoro look pretty and demonstrate no obvious contrast in the artery, needle tip not in the root or cord: but if I ever had a catastrophic event- I could rest uncomfortably that my preceptor may testify against me

Here Steve brings up one of my pet peeves about our field

The preceptor Steve refers to actually performs these procedures, albeit rarely, but he, like most of the luminaries in our field, will be all too glad to testify against another practitioner when the case goes badly. I would argue that, if you act according to generally accepted practices and principles, and you get an adverse outcome, what you have is an unfortunate complication, rather than having committed malpractice.

The Orthopaedic community has gone so far as to have members of the Academy sign a pledge that they will live up to the following tenants:

1. An orthopaedic expert witness shall not knowingly provide testimony that is false.

2. An orthopaedic expert witness shall provide opinions and/or factual testimony in a fair and impartial manner.

3. An orthopaedic expert witness shall evaluate the medical condition and care provided in light of generally accepted standards at the time, place and in the context of care delivered.

4. An orthopaedic expert witness shall neither condemn performance that falls within generally accepted practice standards nor endorse or condone performance that falls outside these standards.

5. An orthopaedic expert witness shall state how and why his or her opinion varies from generally accepted standards.

6. An orthopaedic expert witness shall seek and review all pertinent medical records related to a particular patient prior to rendering an opinion on the medical or surgical management of the patient.

7. An orthopaedic expert witness shall have knowledge and experience about the standard of care and the available scientific evidence for the condition in question during the relevant time, place and in the context of medical care provided and shall respond accurately to questions about the standard of care and the available scientific evidence.

8. An orthopaedic expert witness shall provide evidence or testify only in matters in which he or she has relevant clinical experience and knowledge in the areas of medicine that are the subject of the proceeding.

9. An orthopaedic expert witness shall be prepared to state the basis of the testimony presented and whether it is based on personal experience, specific clinical or scientific evidence.

10. An orthopaedic expert witness shall have a current, valid, and unrestricted license to practice medicine in any state or U.S. territory.10. An orthopaedic expert witness shall have a current, valid, and unrestricted license to practice medicine in any state or U.S. territory.

11. An orthopaedic expert witness shall maintain a current certificate from the American Board of Orthopaedic Surgery (ABOS), the American Osteopathic Board of Orthopaedic Surgery, or the certifying body, if any, in the country in which the orthopaedic surgeon took his or her training.

12. An orthopaedic expert witness shall be engaged in the active practice of orthopaedic surgery or demonstrate enough familiarity with present practices to warrant designation as an expert.

13. An orthopaedic expert witness shall not misrepresent his or her credentials, qualifications, experience or background.

14. An orthopaedic expert witness shall not agree to or accept an expert witness fee that is contingent upon the outcome of a case.

15. Compensation for an orthopaedic expert witness shall be reasonable and commensurate with expertise and the time and effort necessary to evaluate and testify on the facts of the case.

I would hope that someday soon a similar set of principles are contingent for membership in ISIS, ASIPP, AAPM, or similar organizations.