Bradly S. Goodman

Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections

Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging.

A Comparison of Ultrasound and Magnetic Resonance Imaging Findings of a Morel-Lavallée Lesion of the Knee

A Morel‐Lavallée lesion (MLL) is a posttraumatic soft‐tissue injury characterized by an accumulation of blood, lymph, and other physiologic breakdown products between subcutaneous tissue and underlying fascia. It was first described as occurring over the proximal lateral thigh, but it has since been documented at various anatomic locations. Diagnosis is typically made by careful physical examination and a radiographic analysis, most commonly with magnetic resonance imaging (MRI). Recently, musculoskeletal ultrasound (US) has been recognized as a useful adjunct to and potential replacement for MRI in the diagnosis and monitoring of an MLL. We present a case report of a patient with an MLL of the knee. We obtained magenetic resonance (MRI) and US images at the time of diagnosis, and follow‐up US images during convalescence. By doing so, we were able to identify several key sonographic findings of an MLL at this location and compare them with MRI. Although there have been several published reports to date that describe the use of musculoskeletal US in the diagnosis of MLL, this is the first of which we are aware that does so at the knee.

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines

Setting Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk, cessation may precipitate serious thromboembolic events. The Spine Intervention Society (SIS) and American Society of Regional Anesthesia and Pain Medicine (ASRA) put forth guidelines that dissent with regard to management of hemostatically active agents during commonly performed spinal injections. Objective To validate an antiplatelet/anticoagulant management table based on modifications of the SIS 2013 and ASRA 2015 guidelines. Design Prospective descriptive study. Subjects Patients undergoing interventional spine injections from a interventional physiatrists practice. Methods A Modified SIS 2013-ASRA 2015 Antiplatelet & Anticoagulant (MSAAA) guideline table was devised and adopted. Patients undergoing interventional spine procedures were monitored for bleeding events. Results Of 4,253 injection sites, 197 (4.6%) were performed in 74 patients on antiplatelet/anticoagulants. No clinically evident bleeding events were observed in patients on antiplatelet/anticoagulant medications for lumbar transforaminal epidural (N = 90), posterior-approach facet joint (N = 62), lumbar intradiscal (N = 11), lumbar sympathetic (N = 3), and sacroiliac (N = 5) injections or in 26 radiofrequency neurotomy procedures. One in 2,026 (0.05%, 95% confidence interval = 0.00-0.31%) interlaminar epidural injections (cervical, thoracic, lumbar, and caudal) suffered epidural hematoma. This patient was not on an antiplatelet/anticoagulant drug. No patient in 191 cervicothoracic and 723 lumbar transforaminal injections experienced bleeding complications. Conclusions Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.

Prospective and Multicenter Evaluation of Outcomes for Quality of Life and Activities of Daily Living for Balloon Kyphoplasty in the Treatment of Vertebral Compression Fractures: The EVOLVE Trial

Abstract BACKGROUND Osteoporotic and neoplastic vertebral compression fractures (VCF) are common and painful, threatening quality of life and increasing risk of morbidity and mortality. Balloon kyphoplasty is a percutaneous option for treating painful cancer- and osteoporosis-related VCFs, supported by 2 randomized trials demonstrating efficacy benefits of BKP over nonsurgical care. OBJECTIVE To investigate 12-mo disability, quality of life, and safety outcomes specifically in a Medicare-eligible population, representing characteristic patients seen in routine clinical practice. METHODS A total of 354 patients with painful VCFs were enrolled at 24 US sites with 350 undergoing kyphoplasty. Four coprimary endpoints—Numerical Rating Scale (NRS) back pain, Oswestry Disability Index (ODI), Short Form-36 Questionnaire Physical Component Summary (SF-36v2 PCS), EuroQol-5-Domain (EQ-5D)—were evaluated for statistically significant improvement 3 mo after kyphoplasty. Data were collected at baseline, 7 d, and 1, 3, 6, and 12 mo (www.clinicaltrials.gov registration NCT01871519). RESULTS At the 3-mo primary endpoint, NRS improved from 8.7 to 2.7 and ODI improved from 63.4 to 27.1; SF-36 PCS was 24.2 at baseline improving to 36.6, and EQ-5D improved from 0.383 to 0.746 (P < .001 for each). These outcomes were statistically significant at every follow-up time point. Five device-/procedure-related adverse events, intraoperative asymptomatic balloon rupture, rib pain, and aspiration pneumonia, and a new VCF 25 d postprocedure, and myocardial infarction 105 d postprocedure were reported and each resolved with proper treatment. CONCLUSION This large, prospective, clinical study demonstrates that kyphoplasty is a safe, effective, and durable procedure for treating patients with painful VCF due to osteoporosis or cancer.

Transforaminal Epidural Blood Patches for the Treatment of Postsurgical Dural Leaks: Two Case Reports

Unintended dural punctures with leakage of cerebrospinal fluid (CSF) are recognized as a frequent complication of spinal surgery. Although conservative or invasive options may be used to treat postoperative CSF leaks, the existing literature does not define either an algorithmic treatment approach or a universally accepted standard of care. We believe that a transforaminal epidural blood patch (EBP) can serve as a minimally invasive, cost‐effective option to treat postsurgical CSF leaks that do not resolve with conservative management. We have performed an EBP via the transforaminal route to treat postsurgical CSF leaks in both the cervical and lumbar spine. The first case describes a patient who underwent an anterior cervical diskectomy and fusion with a complication of profuse CSF leakage. The application of a cervical transforaminal EBP at the levels of surgical repair was effective in stopping the dural leak. The second case involves a patient who experienced classic positional spinal headaches after a lumbar hemilaminectomy and diskectomy. After utilization of lumbar transforaminal EBPs, his symptoms revolved. This article presents the potential use of an EBP via the transforaminal route to treat postsurgical dural leaks in both the cervical and lumbar region.

Acute Anterior Schmorl's Node/Limbus Vertebrae in a 13 y/o Competitive Cheerleader Treated with an Intradiscal Steroid Injection: A Case Report

a common procedure for decompression treatment of spinal stenosis, the minimally invasive approach of this procedure is not well studied in a large cohort of patients. This study critically analyzes patient characteristics of individuals who underwent minimally invasive laminectomy (MIL). The objective of this study is to review a large retrospective cohort of patients undergoing minimally invasive laminectomy for stenosis and to offer insight into proper patient selection. Setting: 126 consecutive patients (mean age1⁄469, range 20-91) underwent minimally invasive laminectomy from April 2009 to August 2012. Patients presented with stenosis (n1⁄479, 64%), spondylolisthesis with stenosis (n1⁄416, 13%), herniated disc (12, 9%), degenerative disc disease with stenosis (n1⁄44, 3%), scoliosis with stenosis (n1⁄44, 3%), and/or other (n1⁄42, 1%). Results or Clinical Course: 74 males and 52 females were treated. Levels treated included L1-2 (n1⁄48, 6%), L2-3 (n1⁄422, 17%), L3-4 (n1⁄448, 39%), L4-5 (n1⁄446, 37%), and L5-S1 (n1⁄45, 4%). There were 134 total levels treated with 29 one-level, 33 twolevel, 10 three-level, 1 four-level, and 1 five-level laminectomy cases. Estimated blood loss and infection rate were 63 cc and 4%, respectively. Average BMI was 29.48. 4 patients (3%) had a BMI of less than 20, 18 patients (14%) had a BMI of 21-25, 41 patients (33%) had a BMI of 26-30, 32 patients (26%) had a BMI of 31-35, and 16 patients(13%) had a BMI greater than 35. Common comorbidities included hypertension, hypercholesterolemia, diabetes, and cancer. Common medications were NSAIDs, Lisinopril, Hydrocodone, and Simvastatin. Conclusions: This study presents a large retrospective analysis of MIL patient. A systematic approach to patient selection is important to identify those patients who benefit from this procedure.