Major risks and complications of cervical epidural steroid injections: An updated review

Abstract

Background:Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications.Methods:Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.Results:Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature.Conclusions:Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

“…As such, RCTs are not ideal to capture adverse effects related to therapy, 164 and most adverse effects are under-reported. 165 However, steroid injections have a multitude of side-effects, both small and potentially devastating. 25 These adverse effects can be both absolute and dose related.…”

All that glitters is not gold: A spinal epidural empyema following epidural steroid injection

“…[ 1 , 4 , 5 , 13 , 19 , 29 ] Nevertheless, as noted here, there are serious complications of ESIs that include spinal epidural and subdural hematomas, brain/cord infarctions (cervical ESI), and spinal epidural/subdural abscesses. [ 3 , 11 , 24 , 37 , 42 ]…”

Potential risk of impertinent administration of methylprednisolone in lumbar spine surgery: A case report

“…A series of symptoms include generalized weakness, fatigue, anorexia, nausea, vomiting, abdominal pain, fever, and hypotension with refractory blood pressure, which always involve multiple systems or organs [ 6 ]. Thus, spine surgeons should pay more attention to administration of intravenous Methylprednisolone during the perioperative period because of routine usage of glucocorticoid for inhibiting or relieving the edema or inflammation of spinal nerve root [ 1 , 7 ]. Importantly, the detailed examinations and specialist consultation need to be completed before surgery, when a patient has a history of endocrine diseases.…”

“…Several complications of Methylprednisolone infusion have been reported previously, including hyperglycemia, hyperlipidemia, ischemic necrosis of femoral head, and peptic ulcer, possibly leading to gastrointestinal bleeding [ 1 ]. To our knowledge, the complication of Addisonian crisis induced by the routine cessation of intravenous Methylprednisolone has not been reported in open spine surgery for individuals without any adrenal insufficiency.…”