Dex and lido lumbar tfesi case report

[oreosandsake]

Safety of dexamethasone in transforaminal epidural steroid injections: A case of temporary paraplegia caused by injection of lidocaine and dexamethasone into a lumbar radiculomedullary artery, with no neurologic sequelae

www.sciencedirect.com

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[vadim1980]

Isn’t it much more likely that there was intrathecal spread of lidocaine to account for this?

 

[lobelsteve]

Interesting. Not sure an ESI is helping that massive honker of extrusion above multilevel fusion.
Endoscopic or open surgery. Especially with cord edema.
Possibilities:
1. Injected rm artery and did not see it on DSA (I didn't on video)
2. Injected IT (never use lidocaine in ESI)
3. Injected into such severe stenosis with existing cord damage with transient increased pressure on cord (liquid- doubt it).

Glad it was temporary. Always DEX. No LIDO. Don't inject where it won't help. We don't save lives. We shouldn't risk catastrophic injury if chance of successful functional improvement outweighs risks.

I would not have offered a TFESI into that spine.

 

[fathead88]

It was “optimistic” to think dexamethasone was going to fix that.

With the preserved sensation in the BLE + motor loss that isn’t an intrathecal injection. More consistent with infarction/local anesthetic injection into rm artery.

 

[Ducttape]

yes the conclusion is that the lidocaine was responsible.

the injection was thought to be in to the artery than intrathecal. intrathecal would have caused both dense paralysis and loss of sensation.

this was discussed in the article...

We present a case of presumed radiculomedullary artery injection, during an L1/2 TFESI, with temporary paraplegia caused by the anesthetic, but no apparent detrimental effect from the co-injected dexamethasone. The aberrant injection was determined to be in a radiculomedullary artery rather than subarachnoid based upon the epidural contrast flow pattern and the patient's ‘normal’ sensation with complete but temporary lower extremity paralysis.

 

[Baron Samedi]

I would think that arterial vasospasm just from needle contact could have been the culprit. That, or the needle itself caused a little fleck of crud to embolize and a cord TIA occurred.

 

[RoloTomassi]

I'd inject that all day if there wasn't signal change. Big cephalad extension but only moderate stenosis centrally and foraminally. T12-L1 ILESI, flow up to herniation, down to adjacent segment stenosis.

 

[clubdeac]

I thought intra-arterial lidocaine typically caused anesthetic toxicity (ringing in the ears, metallic taste in mouth, n/t in hands/feet or perioral, or seizures and LOC) but not motor loss. Always learning something new

 

[MitchLevi]

I'd inject that all day if there wasn't signal change. Big cephalad extension but only moderate stenosis centrally and foraminally. T12-L1 ILESI, flow up to herniation, down to adjacent segment stenosis.

I would certainly inject that

 

[lobelsteve]

I will only inject cord signal change after surgery. And not for that problem.

 

[paindoc007]

Hindsight is 20/20. When a respectable nsgy sends this over with “not ready for surgery yet pls eval for inj”, most pain docs will inject that all day. I probably would have as well. As they say, when you have a complication, pick your patient carefully. Ha

 

[medking]

It was “optimistic” to think dexamethasone was going to fix that.

With the preserved sensation in the BLE + motor loss that isn’t an intrathecal injection. More consistent with infarction/local anesthetic injection into rm artery.

Care to explain the mechanism of action of how local anesthetic injection into the rm artery can cause this?

I’m thinking you’re thinking vasospasm? Is vasospasm unique to local anesthetic?

 

[fathead88]

Care to explain the mechanism of action of how local anesthetic injection into the rm artery can cause this?

I’m thinking you’re thinking vasospasm? Is vasospasm unique to local anesthetic?

Certainly vasospasm. My thought was direct delivery of local anesthetic to nervous tissue fed by the artery causing a temporary anterior cord syndrome (in the same way a few cc’s of local causing seizures if injected into the vert).

 

[MitchLevi]

The moral of this story - Inject this pt and everything will be fine bc this is a freak occurrence. Lose no sleep over this.

Use dex in your TFESI. I will continue using local.

 

[Greenbayslacker]

Lidocaine causing arterial vasospasm?? It’s a vasodilator! If spasm is suspected it could be from direct needle contact, steroid, or contrast.

 

[Greenbayslacker]

Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis - PubMed

Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing spinal pain secondary to disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results...

pubmed.ncbi.nlm.nih.gov

 

[medking]

Lidocaine causing arterial vasospasm?? It’s a vasodilator! If spasm is suspected it could be from direct needle contact, steroid, or contrast.

Which is the scary part in all this. Even if dexamethasone is used, given arteries can’t be visualized under fluoroscopy until contrast is given, (and even then, may not show up), if vasospasm occurs from direct needle contact or contrast administration, then I guess we can only do our best in trying to minimize these things happening with digital subtraction and choice of steroid.

I agree with a previous poster that the likelihood of these things happening is relatively low, but it is a scary thought because one of these types of events is too many given the potential severity of outcomes.

 

[Orin]

I agree with a previous poster that the likelihood of these things happening is relatively low, but it is a scary thought because one of these types of events is too many given the potential severity of outcomes.

Oddly enough the literature suggests ~5-10% incidence of vascular injection during epidurals, with some studies going up to 30% like this one with CT guidance

Incidence of Inadvertent Intravascular Injection during CT Fluoroscopy–Guided Epidural Steroid Injections

BACKGROUND AND PURPOSE: Inadvertent intravascular injection during epidural steroid injection can result in complications and has been investigated previously with conventional fluoroscopy, but not CT fluoroscopy. The purpose of this study was to determine the incidence of intravascular...

www.ajnr.org

It's a rare event with the symptomatic issues described and I don't know if it's needle, injectate, volume, or something else in this scenario. The kinetics of it don't make sense to me for any of the things described.

 

[MD87]

It’s also possible that this was all psych. Just saying.
My colleague had a patient admitted to hospital for paralysis after ESI years ago. Eventual diagnosis was conversion disorder. Not saying that’s what this is, but we don’t always have good explanations for what patients feel/experience after these procedures.

 

[Ferrismonk]

Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis - PubMed

Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing spinal pain secondary to disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results...

pubmed.ncbi.nlm.nih.gov

This article always stumped me. So "ESI" is equally effective if I use steroids or not, as long as I use local. Other studies show that the ESI is equally effective if I use local or not, as long as I use steroids. Studies show similar results between particulate and non-particulate steroids as well.

I would like to see a study comparing the effect of an "ESI" just using saline. Maybe the whole point of these injections are just to wash away chemical irritants and put some fluid between an angry disc and a nerve.

 

[PinchandBurn]

This article always stumped me. So "ESI" is equally effective if I use steroids or not, as long as I use local. Other studies show that the ESI is equally effective if I use local or not, as long as I use steroids. Studies show similar results between particulate and non-particulate steroids as well.

I would like to see a study comparing the effect of an "ESI" just using saline. Maybe the whole point of these injections are just to wash away chemical irritants and put some fluid between an angry disc and a nerve.

So true potentially .

 

[Greenbayslacker]

I would like to see a study comparing the effect of an "ESI" just using saline. Maybe the whole point of these injections are just to wash away chemical irritants and put some fluid between an angry disc and a nerve.

“Just injecting liquid into the epidural space appears to work,” says Cohen, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. “This shows us that most of the relief may not be from the steroid, which everyone worries about.”

I cannot find the actual article in Anesthesiology however. Not sure if it was ever published.

Need Steroids? Maybe Not for Lower Back Pain - 09/18/2013

New research from Johns Hopkins suggests that it may not be the steroids in spinal shots that provide relief from lower back pain, but the mere introduction of any of a number of fluids, such as anesthetics and saline, to the space around the spinal cord.

www.hopkinsmedicine.org

 

[MitchLevi]

Maybe the whole point of these injections are just to wash away chemical irritants and put some fluid between an angry disc and a nerve.

"Rinsing it off" is part of why these work IMO. At least, that's what I tell myself.

 

[PinchandBurn]

"Rinsing it off" is part of why these work IMO. At least, that's what I tell myself.

The problem is the LCD calls for steroid technically.

If steroid isn't required would be immersing to see what the downside is to be doing more than 2 to 3 a year. I recall them working on non steroid substances to inject into epidural but non to my knowledge has come to fruition..

 

[fathead88]

Lidocaine causing arterial vasospasm?? It’s a vasodilator! If spasm is suspected it could be from direct needle contact, steroid, or contrast.

Spinal Wada test - PubMed

Various doses of pentobarbital (1.25-20 mg) and lidocaine (2.5-20 mg) were injected selectively into the artery of Adamkiewicz and anterior spinal artery of 11 monkeys. Pentobarbital produced an acute paraplegia; lidocaine caused a transient paraplegia followed by hyper-reflexia and muscular...

pubmed.ncbi.nlm.nih.gov

No, the needle causes vasospasm.
Lidocaine injected into arteries like rm or AoA will deliver lidocaine to the end organ (in this case anterior cord) and exert its effects, then be metabolized. Thus a transient paralysis.

 

[MitchLevi]

Spinal Wada test - PubMed

Various doses of pentobarbital (1.25-20 mg) and lidocaine (2.5-20 mg) were injected selectively into the artery of Adamkiewicz and anterior spinal artery of 11 monkeys. Pentobarbital produced an acute paraplegia; lidocaine caused a transient paraplegia followed by hyper-reflexia and muscular...

pubmed.ncbi.nlm.nih.gov

No, the needle causes vasospasm.
Lidocaine injected into arteries like rm or AoA will deliver lidocaine to the end organ (in this case anterior cord) and exert its effects, then be metabolized. Thus a transient paralysis.

"The needle spasm thing...Probably isn't real."

DJ Kennedy to me and 5 other fellows.

He went on to briefly discuss the fact CEA pts aren't dying regularly. I do recall our infusing thrombolytics during those surgeries.

 

[Orin]

"The needle spasm thing...Probably isn't real."

DJ Kennedy to me and 5 other fellows.

He went on to briefly discuss the fact CEA pts aren't dying regularly. I do recall our infusing thrombolytics during those surgeries.

There's a major difference based on the size of the vessel/needle. It's a common thing you've probably seen when you're cannulating a radial artery and you ding it once. Blood may flow but it doesn't pulsate. IR docs do all kinds of mumbo-jumbo to work around it, so I am pretty confident it can happen around our stuff.

This is an example from femoral artery caths in babies:

https://www.ajronline.org/doi/10.2214/ajr.138.2.295

"the most important factor in spasm is the relative size of catheter to artery."

I suspect a 25g would cause minimal vasospasm relative to the size of a radicular vessel

 

[Orin]

Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis - PubMed

Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing spinal pain secondary to disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results...

pubmed.ncbi.nlm.nih.gov

Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials
What confuses me more is the earlier work from the group which showed that steroids were useful specifically in disc herniations

"This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone"

 

[epidural man]

Really interesting case.

I think a pressure phenomenon is more likely than the authors. The patient already had cord edema which means vascular supply was already compromised.

 

[cameroncarter]

Interesting. Not sure an ESI is helping that massive honker of extrusion above multilevel fusion.
Endoscopic or open surgery. Especially with cord edema.
Possibilities:
1. Injected rm artery and did not see it on DSA (I didn't on video)
2. Injected IT (never use lidocaine in ESI)
3. Injected into such severe stenosis with existing cord damage with transient increased pressure on cord (liquid- doubt it).

Glad it was temporary. Always DEX. No LIDO. Don't inject where it won't help. We don't save lives. We shouldn't risk catastrophic injury if chance of successful functional improvement outweighs risks.

I would not have offered a TFESI into that spine.

What about L4-L5? Or lower? Still Dex only?

 

[lobelsteve]

What about L4-L5? Or lower? Still Dex only?

Dex only.
Dex only.
Dex only.

Occasionally I will break out Celestone for a knee or hip IA.

 

[BobBarker]

Triamcinolone for knees and hips is cheaper and probably better than celestone. Ortho’s favorite steroid.