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Complications of Transforaminal Cervical Epidural Steroid Injections

Malhotra, Gautam, MD*; Abbasi, Arjang, DO; Rhee, Michael, MD

doi: 10.1097/BRS.0b013e318194e247
Literature Review

Study Design. A comprehensive literature review.

Objectives. To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with transforaminal cervical epidural steroid injection (TFCESI) and techniques employed to avoid them. The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications and measures that may be undertaken to increase safety.

Summary of Background Data. TFCESI is a component in the diagnosis and management of cervical radicular syndromes in patients who have failed conservative management. There has been much discussion and also controversy in the recent literature. Considerable attention has been paid to reports of catastrophic complications and proposed measures to avoid them.

Methods. Medical databases were searched for studies of TFCESI. The bibliographies of these articles were then searched as well. Thoracic and lumbar articles were discarded as were any nontransforaminal cervical procedures or those that did not involve injection into the epidural space. Particular attention was paid to serious neurologic sequelae after TFCESI and its mechanism, as well as techniques being employed to avoid complications.

Results. There are a limited number of studies looking at complications of TFCESI. One retrospective study reported an overall rate of complications of 1.64%. There are reports of serious neurologic sequelae in the literature including brain and spinal cord infarction due to embolic phenomenon of particulate steroids. Cadaveric dissection revealed ascending and deep cervical arterial branches entering the external opening of the posterior intervertebral foramen, the classic target site for TFCESI. Measures to avoid complications mentioned in the literature include the use of nonparticulate steroids, test dose of local anesthetic before injection of steroids, live fluoroscopy, digital subtraction, no to light sedation, use of true lateral view to supplement frontal and oblique views in fluoroscopy, use of blunt needles, and computed tomography guidance.

Conclusion. The literature reveals a number of rare, potentially catastrophic neurologic sequelae including brain and spinal cord infarction. Most of these are thought to be due to intravascular uptake of particulate steroids. The true overall incidence remains obscure due to the lack of blinded controlled studies. Injectionists, referring physicians, and patients should be aware of the nature and potential consequences of these complications. Additionally, it is imperative for injectionists to standardize techniques to minimize complications, especially by using a test dose of local anesthetic before injection of preferably nonparticulate corticosteroid.

A literature review found reports of rare catastrophic neurologic sequelae after transforaminal cervical epidural steroid injections. The proposed mechanism is intravascular uptake of particulate steroids. Proposed safety measures include use of nonparticulate steroids and test dose of local anesthetic; injectionists must standardize techniques to minimize complications.

From the *Department of Physical Medicine and Rehabilitation, Veterans Affairs, East Orange, NJ; †Department of Physical Medicine and Rehabilitation, Long Island Spine Specialists, Commack, NY; and ‡Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School, Newark, NJ.

Acknowledgment date: July 21, 2008. Revision date: September 6, 2008. Acceptance date: October 9, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Arjang Abbasi, DO, Department of Physical Medicine and Rehabilitation, Long Island Specialists, Commack, NY 11725; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.