Authors: Osman Hakan Gu¨ndu¨z, MD Uzma Akhlaque, MD Savas Sencan, MD Alp Eren Celenlioglu, MD Askin Seker, MD
Spine
Affiliations:
CLINICAL NOTE
From the Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, School of Medicine, Marmara University, Istanbul, Turkey (OHG, UA, SS); Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan (UA); and Department of Physical Medicine and Rehabilitation (AEC) and Department of Neurosurgery (AS), School of Medicine, Marmara University, Istanbul, Turkey.
Contralateral Lumbar Radicular Pain Shortly After a Transforaminal Epidural Steroid Injection
Correspondence:
ABSTRACT
All correspondence and requests for reprints should be addressed to: Osman Hakan Gu¨ndu¨z, MD, Marmara Universitesi Tip Fakultesi, Fiziksel Tip ve Rehabilitasyon Anabilim Dali, Pendik Egitim ve Arastirma Hastanesi, Fevzi Cakmak Mahallesi, Tepe Sokak No 41, Oda no 1628, Pendik 34899 Istanbul, Turkey.
Gu¨ndu¨z OH, Akhlaque U, Sencan S, Celenlioglu AE, Seker A: Contralateral
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9309-0834 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000150
834
An Unusual Sequel
lumbar radicular pain shortly after a transforaminal epidural steroid injection: an unusual sequel. Am J Phys Med Rehabil 2014;93:834Y835.
L
umbar transforaminal epidural steroid injections (TFESIs) are valuable techniques used in the treatment of lumbar radicular pain and other lumbosacral pain syndromes.1 Complications from these procedures may arise from improper or unsafe needle placement, injection of contrast, or the administration of the final injectate including corticosteroids and anesthetic. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disk entry, urinary retention, radiation exposure, and hypersensitivity reactions, to mention a few.2 In addition, selecting the correct nerve root(s) is of prime importance during a diagnostic TFESI.3 The purpose of this case report was to highlight the importance of considering bilateral transforaminal injections in the treatment of large-sized central lumbar disk herniations. A 43-yr-old man who presented with a history of left radicular low back pain for a 6-mo duration that did not significantly improve after physical therapy and medical treatment. On examination, there was reduced flexion of the lumbosacral spine, pain with flexion, and associated significant paraspinal muscle spasm. The result of the straight leg raise test was positive bilaterally. The left ankle jerk reflex was diminished. Manual motor testing demonstrated 4 of 5 strength in bilateral extensor hallucis longus with decreased sensations in the left L5 and S1 dermatomes. Magnetic resonance imaging of the lumbosacral spine demonstrated a central disk protrusion (Fig. 1) with central spinal stenosis at the L5/S1 level (Fig. 2). He was subsequently scheduled for a left S1 TFESI. The subject was placed in the prone position. After positioning the C-arm with 13-degree oblique tilt to optimally visualize the left S1 foramen, a 22-gauge spinal needle was introduced under fluoroscopic guidance under coaxial/trajectory view into the left S1 foramen. The placement of the needle was considered satisfactory. After negative aspiration for cerebrospinal fluid or blood, approximately 1 ml of contrast medium (iohexol) was injected. There was optimal contrast flow along the Am. J. Phys. Med. Rehabil. & Vol. 93, No. 9, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
left S1 nerve root observed. Next, a mixture containing 80 mg of depot steroid (methylprednisolone), 1 ml of 0.5% bupivacaine, and 1 ml of normal saline was injected without any apparent immediate complications. Within 15 mins after the procedure, the subject complained of shooting radicular pain that shifted from the left to the right lower limb. Meanwhile, the initial left-sided pain had subsided as expected. The subject was observed by staff, and analgesic medications were administered. The patient responded well and had reduction of pain after approximately 24Y36 hrs. Despite extensive review of the available literature, this complication was unique without a satisfactory explanation.3,4 It seemed to the authors that the large central disk protrusion at L5YS1 resulted in bilateral nerve compression, which was initially masked on the right side because of significant muscle spasm. The authors speculate that this muscle spasm before the TFESI helped reduce the compression of the exiting nerve root on the right side, but there was insufficient muscle spasm on the left side to achieve this goal. The authors surmise that the resultant decrease in paraspinal muscle tone after administration of the injectate TFESI (especially the bupivacaine) might be the reason for unmasking of nerve root compression and its symptomatic presentation on the right side.
FIGURE 2 Lumbosacral spine magnetic resonance imaging, axial view, at L5/S1, demonstrating central disk herniation.
Another possibility is that the increased fluid injected along with the spinal stenosis created increased compression of the right-sided nerve root. In conclusion, bilateral transforaminal injections may be necessary in the setting of large central disk herniations, especially with findings of the crossed straight leg raise test, to avoid the complication of contralateral radicular nerve root pain. This will ensure a more effective and efficient interventional pain management. REFERENCES 1. Gharibo C, Koo C, Chung J, et al: Epidural steroid injections: An update on mechanisms of injury and safety. Tech Reg Anesth Pain Manag 2009;13:266Y71 2. Abdi S, Datta S, Lucas LF: Role of epidural steroids in the management of chronic spinal pain: A systematic review of effectiveness and complications. Pain Physician 2005;8:127Y44 3. Boswell MV, Shah RV, Everett CR, et al: Interventional techniques in the management of chronic spinal pain: Evidence-based practice guidelines. Pain Physician 2005;8:1Y48
FIGURE 1 Lumbosacral spine magnetic resonance imaging, sagittal view, demonstrating an L5/S1 disk herniation.
www.ajpmr.com
4. Goodman BS, Posecion LWF, Mallempati S, et al: Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212Y22
Lumbar Pain After TFESIs Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
835
Spine
Affiliations:
CLINICAL NOTE
From the Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, School of Medicine, Marmara University, Istanbul, Turkey (OHG, UA, SS); Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan (UA); and Department of Physical Medicine and Rehabilitation (AEC) and Department of Neurosurgery (AS), School of Medicine, Marmara University, Istanbul, Turkey.
Contralateral Lumbar Radicular Pain Shortly After a Transforaminal Epidural Steroid Injection
Correspondence:
ABSTRACT
All correspondence and requests for reprints should be addressed to: Osman Hakan Gu¨ndu¨z, MD, Marmara Universitesi Tip Fakultesi, Fiziksel Tip ve Rehabilitasyon Anabilim Dali, Pendik Egitim ve Arastirma Hastanesi, Fevzi Cakmak Mahallesi, Tepe Sokak No 41, Oda no 1628, Pendik 34899 Istanbul, Turkey.
Gu¨ndu¨z OH, Akhlaque U, Sencan S, Celenlioglu AE, Seker A: Contralateral
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9309-0834 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000150
834
An Unusual Sequel
lumbar radicular pain shortly after a transforaminal epidural steroid injection: an unusual sequel. Am J Phys Med Rehabil 2014;93:834Y835.
L
umbar transforaminal epidural steroid injections (TFESIs) are valuable techniques used in the treatment of lumbar radicular pain and other lumbosacral pain syndromes.1 Complications from these procedures may arise from improper or unsafe needle placement, injection of contrast, or the administration of the final injectate including corticosteroids and anesthetic. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disk entry, urinary retention, radiation exposure, and hypersensitivity reactions, to mention a few.2 In addition, selecting the correct nerve root(s) is of prime importance during a diagnostic TFESI.3 The purpose of this case report was to highlight the importance of considering bilateral transforaminal injections in the treatment of large-sized central lumbar disk herniations. A 43-yr-old man who presented with a history of left radicular low back pain for a 6-mo duration that did not significantly improve after physical therapy and medical treatment. On examination, there was reduced flexion of the lumbosacral spine, pain with flexion, and associated significant paraspinal muscle spasm. The result of the straight leg raise test was positive bilaterally. The left ankle jerk reflex was diminished. Manual motor testing demonstrated 4 of 5 strength in bilateral extensor hallucis longus with decreased sensations in the left L5 and S1 dermatomes. Magnetic resonance imaging of the lumbosacral spine demonstrated a central disk protrusion (Fig. 1) with central spinal stenosis at the L5/S1 level (Fig. 2). He was subsequently scheduled for a left S1 TFESI. The subject was placed in the prone position. After positioning the C-arm with 13-degree oblique tilt to optimally visualize the left S1 foramen, a 22-gauge spinal needle was introduced under fluoroscopic guidance under coaxial/trajectory view into the left S1 foramen. The placement of the needle was considered satisfactory. After negative aspiration for cerebrospinal fluid or blood, approximately 1 ml of contrast medium (iohexol) was injected. There was optimal contrast flow along the Am. J. Phys. Med. Rehabil. & Vol. 93, No. 9, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
left S1 nerve root observed. Next, a mixture containing 80 mg of depot steroid (methylprednisolone), 1 ml of 0.5% bupivacaine, and 1 ml of normal saline was injected without any apparent immediate complications. Within 15 mins after the procedure, the subject complained of shooting radicular pain that shifted from the left to the right lower limb. Meanwhile, the initial left-sided pain had subsided as expected. The subject was observed by staff, and analgesic medications were administered. The patient responded well and had reduction of pain after approximately 24Y36 hrs. Despite extensive review of the available literature, this complication was unique without a satisfactory explanation.3,4 It seemed to the authors that the large central disk protrusion at L5YS1 resulted in bilateral nerve compression, which was initially masked on the right side because of significant muscle spasm. The authors speculate that this muscle spasm before the TFESI helped reduce the compression of the exiting nerve root on the right side, but there was insufficient muscle spasm on the left side to achieve this goal. The authors surmise that the resultant decrease in paraspinal muscle tone after administration of the injectate TFESI (especially the bupivacaine) might be the reason for unmasking of nerve root compression and its symptomatic presentation on the right side.
FIGURE 2 Lumbosacral spine magnetic resonance imaging, axial view, at L5/S1, demonstrating central disk herniation.
Another possibility is that the increased fluid injected along with the spinal stenosis created increased compression of the right-sided nerve root. In conclusion, bilateral transforaminal injections may be necessary in the setting of large central disk herniations, especially with findings of the crossed straight leg raise test, to avoid the complication of contralateral radicular nerve root pain. This will ensure a more effective and efficient interventional pain management. REFERENCES 1. Gharibo C, Koo C, Chung J, et al: Epidural steroid injections: An update on mechanisms of injury and safety. Tech Reg Anesth Pain Manag 2009;13:266Y71 2. Abdi S, Datta S, Lucas LF: Role of epidural steroids in the management of chronic spinal pain: A systematic review of effectiveness and complications. Pain Physician 2005;8:127Y44 3. Boswell MV, Shah RV, Everett CR, et al: Interventional techniques in the management of chronic spinal pain: Evidence-based practice guidelines. Pain Physician 2005;8:1Y48
FIGURE 1 Lumbosacral spine magnetic resonance imaging, sagittal view, demonstrating an L5/S1 disk herniation.
www.ajpmr.com
4. Goodman BS, Posecion LWF, Mallempati S, et al: Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212Y22
Lumbar Pain After TFESIs Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
835
