Complications of Fluoroscopically Directed Facet Joint Nerve Blocks: A Prospective Evaluation of 7,500 Episodes with 43,000 Nerve Blocks

Abstract

Background: Chronic spinal pain is common along with numerous modalities of diagnostic and therapeutic interventions utilized, creating a health care crisis. Facet joint injections and epidural injections are the 2 most commonly utilized interventions in managing chronic spinal pain. While the literature addressing the effectiveness of facet joint nerve blocks is variable and emerging, there is paucity of literature on adverse effects of facet joint nerve blocks. Study Design: A prospective, non-randomized study of patients undergoing interventional techniques from May 2008 to December 2009. Setting: A private interventional pain management practice, a specialty referral center in the United States. Objectives: Investigation of the incidence in characteristics of adverse effects and complications of facet joint nerve blocks. The study was carried out over a period of 20 months including almost 7,500 episodes of 43,000 facet joint nerve blocks with 3,370 episodes in the cervical region, 3,162 in the lumbar region, and 950 in the thoracic region. All facet joint nerve blocks were performed under fluoroscopic guidance in an ambulatory surgery center by 3 physicians. The complications encountered during the procedure and postoperatively were evaluated prospectively. Methods: This study was carried out over a period of 20 months and included over 7,500 episodes or 43,000 facet joint nerve blocks. All of the interventions were performed under fluoroscopic guidance in an ambulatory surgery center by one of 3 physicians. The complications encountered during the procedure and postoperatively were prospectively evaluated. Outcomes Assessment: Measurable outcomes employed were intravascular entry of the needle, profuse bleeding, local hematoma, dural puncture and headache, nerve root or spinal cord irritation with resultant injury, and infectious complications. Results: There were no major complications. Multiple side effects and complications observed included overall intravascular penetration in 11.4% of episodes with 20% in cervical region, 4% in lumbar region, and 6% in thoracic region; local bleeding in 76.3% of episodes with highest in thoracic region and lowest in cervical region; oozing with 19.6% encounters with highest in cervical region and lowest in lumbar region; with local hematoma seen only in 1.2% of the patients with profuse bleeding, bruising, soreness, nerve root irritation, and all other effects such as vasovagal reactions observed in 1% or less of the episodes. Limitations: Limitations of this study include lack of contrast injection, use of intermittent fluoroscopy and also an observational nature of the study. Conclusion: This study illustrate that major complications are extremely rare and minor side effects are common. Key words: Spinal pain, facet joint nerve blocks, cervical medial branch or facet joint nerve blocks, thoracic medial branch or facet joint nerve blocks, lumbar facet joint nerve blocks, L5 dorsal ramus block complications

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

“…16 A study that reported on complications from 3162 MBBs found superficial bleeding or hematomas in 0.1%-0.4% of the patients. 273 Lumbar MBB and RFA are currently classified as 'low-risk' procedures in the guidelines on spinal procedures in patients on anticoagulant and antiplatelet medications formulated collaboratively by the American Society of Regional Anesthesia and Pain Medicine (ASRA) and other societies. 276 This risk classification was based on a study by Endres et al 277 that reported a 0% complication rate in 1836 patients who continued their anticoagulant therapy.…”

“…These events were more severe and common when anticoagulants were discontinued, while there was no difference in the reported occurrence of bleeding complications stratified by whether or not anticoagulants were continued. 273 Based on the literature, the ASRA anticoagulation guidelines committee placed thoracic and lumbar MBB and RFA in the lowrisk procedure category, especially in patients who are at a high risk of thromboembolic events. This is consistent with guidelines from the SIS, 278 279 and represented a change from the previous version of the ASRA guidelines issued in 2015, in which thoracolumbar procedures were classified as 'intermediate risk'.…”

“…249 Another study that reported on complications from 3162 MBBs found irritation of the nerve roots occurred in 0.1% of the patients, but found no long-term neural deficits. 273 Sensory and motor stimulation to reduce the probability of proximity of the RF cannula tip to the spinal nerve root traversing in the foramen have been advocated for preventing injury to the spinal nerves, but the evidence is inconclusive.…”

Lage rugpijn (aspecifieke)

“…Large, observational studies of epidural and other spinal injections were consistent with randomized trials in reporting rare serious adverse events, though minor adverse events such as local hematoma, bleeding, return of blood, and dural puncture were more common. [157][158][159][160] For example, in a recent study that also evaluated the largest sample, there were no cases of nerve damage, infection, abscess, or epidural hematoma following 2,760 lumbar epidural injections under fluoroscopic guidance. 158 Rates of profuse bleeding ranged from 0.2 to 0.8 percent depending on the approach used.…”

The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery

“…For patients who gain their consciousness, if they tried to sit or stand up again, there may be unconsciousness recurrence. Nausea, sweating and pallor from several minutes to several hours may be in place [7][8][9].…”