Srinivas Mallempati

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.

Optimizing patient positioning and fluoroscopic imaging for the performance of cervical interlaminar epidural steroid injections.

ervical interlaminar epidural steroid injection (CILESI) has been widely used for the anagement of neck pain and cervical radiculopathy [1,2]. The risks of CILESI are often elated to the injectate or inappropriate needle placement [3]. Knowing the needle depth is rucial, not only in the proper performance of the procedure but also to prevent potential rauma to the spinal cord. Furthermore, the interventionalist cannot always rely on loss of esistance or hanging drop methods because the ligamentum flavum can sometimes be iscontinuous [4,5]. The key to procedural safety is a good lateral image to view the pinolaminar line (which corresponds to the posterior edge of the epidural space) and to etermine the depth of the needle. An equally essential aspect in the safe performance of ILESI is proper identification of contrast pattern [6]. Optimizing needle imaging is critical o prevent inappropriately deep insertion of the needle and potential spinal cord trauma. hen positioning patients, cervical flexion is optimized to allow a wider interlaminarnterspinous space for the needle. Spine interventionalists use imaging and positioning echniques to aid in fluoroscopic visualization with needle depth and placement as well as ontrast enhancement. This is especially the case when it is difficult to obtain adequate ateral fluoroscopic images. Rather than using a higher interspace where the shoulders re less of an obstruction, the C7-T1 interspace is commonly used because of its relatively arge epidural space [5]. The different recommended positions for the performance of ILESIs are sitting, lateral, and prone [7].

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.

Measurement of plantarflexor spasticity in traumatic brain injury: correlational study of resistance torque compared with the modified Ashworth scale.

Annaswamy T, Mallempati S, Allison SC, Abraham LD: Measurement of plantarflexor spasticity in traumatic brain injury: correlational study of resistance torque compared with the modified Ashworth scale. Am J Phys Med Rehabil 2007;86:404–411. Objectives:To examine the usefulness of a biomechanical measure, resistance torque (RT), in quantifying spasticity by comparing its use with a clinical scale, the modified Ashworth scale (MAS), and quantitative electrophysiological measures. Design:This is a correlational study of spasticity measurements in 34 adults with traumatic brain injury and plantarflexor spasticity. Plantarflexor spasticity was measured in the seated position before and after cryotherapy using the MAS and also by strapping each subject’s foot and ankle to an apparatus that provided a ramp and hold stretch. The quantitative measures were (1) reflex threshold angle (RTA) calculated through electromyographic signals and joint angle traces, (2) Hdorsiflexion (Hdf)/Hcontrol (Hctrl) amplitude ratio obtained through reciprocal inhibition of the soleus H-reflex, (3) Hvibration (Hvib)/Hctrl ratio obtained through vibratory inhibition of the soleus H-reflex, and (4) RT calculated as the time integral of the torque graph between the starting and ending pulses of the stretch. Results:Correlation coefficients between RT and MAS scores in both pre-ice (0.41) and post-ice trials (0.42) were fair (P = 0.001). The correlation coefficients between RT scores and RTA scores in both the pre-ice (0.66) and post-ice trials (0.75) were moderate (P ≤ 0.001). Conclusion:RT is a measure of the cumulative torque during an imposed stretch. The MAS is a subjective measure of the cumulative resistance perceived by the clinician during an imposed stretch. RT seems to be a fair quantitative correlate of the MAS in assessing spasticity.

Intradiskal Steroids: A Viable Treatment for Low Back Pain?

E. J. is an otherwise healthy 34-year-old graphic designer at a technology company. He first developed low back pain approximately 1 year ago while helping a friend move a couch. At that time, he had an abrupt onset of severe and debilitating low back pain without any radiation into the lower limbs. This severe pain spontaneously resolved within 2 weeks, but he has continued to experience a dull aching low back pain that he rates a 4-6/10. His pain is worse with sitting and better with standing. He notes that the pain interferes with his ability to sit at a computer and work. Results of his physical examination demonstrate no neurologic deficits in the lower limbs, with intact and symmetric reflexes and strength throughout. He has no focal tenderness to palpation. He has a negative seated slump and straight leg raise bilaterally. He has no pain with flexion abduction and external rotation (FABER) or any movement of the hips bilaterally. The only maneuver that aggravates his pain is forward flexion of the lumbar spine, but he still has full range of motion. Recent magnetic resonance imaging was grossly normal except for the L5/S1 disk, which has a broad-based posterior protrusion and a high-intensity zone, without any neuroforaminal narrowing. There were no Modic end plate changes demonstrated at any level. The patient does not have any depression but does note that the pain is substantial and interferes with his job and recreational activities. Bradly S. Goodman, MD, Matthew R. Willey, MD, Matthew T. Smith, MD, and Srinivas Mallempati, MD, will argue that intradiskal steroids are a viable option for this patient, and Gwendolyn A. Sowa, MD, PhD, and Marzena Buzanowska, MD, will argue that intradiskal steroids are not an ideal treatment for this patient.

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.