Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Spine Intervention Preventing Complications Alison Stout, D.O. Fellowship Director Evergreen Health Sports and Spine Care Alison Stout, D.O. Joshua Rittenberg, MD Michael Furman, MD Milton Landers, DO, PhD David Sibell, MD SIS Education Committee Disclosure Statement Epidural steroids are not FDA approved SIS Education Committee Vice Chair NASS Exercise Committee Chair Common Side Effects, Lumbar TFESI Retrospective review , 322 lumbar TFESIs 9.6% incidence of minor self limiting side effects: transient non-positional headache back & leg pain facial flushing vasovagal reaction blood sugar one case of intra-operative hypertension No dural punctures or hospitalizations (Botwin KP: Arch Phys Med Rehabil; 81 (8) : 1045, 2000) Spinal Injection Risks and Complications Patient Factors Medications Procedure/Technique Minimizing Complications Three Procedural Phases Pre-Procedure Peri-Procedure Post- Procedure Care is required During Each Consent The Informed Patient Educate the patient What are we doing? Why are we doing it? Risks and complications Other Treatment Options Document this discussion in your procedure note Procedure Consent Form Risks “SUBSTANTIAL RISKS” New pain Worsening of pain Infection Bleeding/Infarct Permanent skin changes Allergic/unexpected drug reaction with minor/major consequences Nerve injury Dural puncture Headache Paralysis Death Pre-Procedure Interim Patient History Indications for procedure Review images Current Complaint / any recent changes? Response to previous injections Review of systems Active Infections? Pregnant? Pre-Procedure History Allergies Medications Prior Adverse Reactions Allergy history Local anesthetics Contrast Steroids Allergy vs. adverse reaction Any Anaphylaxis Hx Pre-Procedural: Medications Anticoagulants/anti-platelet Diabetes medications Narcotics/benzos WITH ANTICOAGULANTS Risk of Spinal Nature of Spinal Complications Complications CEASING ANTICOAGULANTS Risk of Systemic Thrombotic Complications Nature of Potential Systemic Thrombotic Complications Recommendation Extraspinal very low minor very low severe continue anticoagulants RF Neurotomy unknown minor very low severe continue anticoagulants Lumbar Disc Stimulation unknown, but theoretically low minor low severe continue anticoagulants Cervical or Thoracic Disc Stimulation unknown, but primarily minor theoretically low low severe Lumbar TFESI very low potentially significant very low severe Cervical or Thoracic TFESI unknown potentially serious very low severe 3x greater potentially serious Interlaminar ESI very low severe anticoagulants = relative contraindication* anticoagulants = relative contraindication* anticoagulants = relative contraindication* anticoagulants = relative contraindication* *Relative contraindication means: Physicians should exercise discretion not only on whether or not to cease anticoagulants, but also whether or not the presumed therapeutic benefit of the procedure justifies the risk of ceasing anticoagulants. ASRA Guidelines 2015 Qui c k Ti m e™ and a dec om pres s or are needed to s ee thi s pi c ture. http://links.lww.com/AAP/A142 ASRA Guidelines 2015 Narouze S et at. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2015;40: 182–212 (AKA ASRA 2015) Pre-Procedure Diabetic patient Blood Glucose Monitoring Steroids glucose, mean 136mg/dL x 3d Check glucose pre-procedure Metformin (Glucophage or Glucovance) renal impaired pts may have accumulation of metformin lactic acidosis Stop 48 hours after procedure Consider checking for renal insufficiency a couple days after procedure before restarting metformin Communicate with Managing Physician Minimizing Complications Three Procedural Phases Pre-Procedure Peri-Procedure Post- Procedure Care is required during each Complications Peri-Procedure Vaso-Vagal Response (3.9% overall incidence per RIC practice audit >2500 procedures) Rapid onset Bradycardia Hypotension Pallor Sweating Nausea Faintness Interventional Medications Local Anesthestics Contrast Agents Steroids Allergic Reaction Vasomotor (warmth, flushing) Cutaneous (hives, severe urticaria) Bronchospasm (wheezing) Cardiovascular (hypotension) Vasovagal (bradycardia, hypotension, nausea) Anaphylactoid reaction (angioedema, urticaria, bronchospasm, hypotesion) Local Anesthetics Toxicity Intravascular – Immediate onset Relative overdose – Slow onset with progression of irritability Local Anesthetics CNS Toxicity Numbness of tongue (initial) Foreign taste (initial) Headache Tinnitus Blurred vision Seizure – muscle twitching Local Anesthetics Cardiovascular System Toxicity Dysrythmias Hypertension ~2X blood level compared with seizure dose Except with Bupivacaine Contrast must be used for all Spinal Injections = Contrast Assure Validity of Procedure Reduce Risk Inject with “live” fluoroscopy Shellfish Allergy irrelevant Non-ionic contrast <1% had reaction = same as population non-ionic less allergenic NO “crossover” with shellfish allergy Iodine Not an allergen Contrast allergy Anaphylactoid reaction Gadolinium Option for spinal procedures in patient with contraindications to iodinated contrast Lower opacity - Consider use of digital subtraction to improve visualization of flow Iohexol 240 Gadolinium (gadodiamide) AVOID Intrathecal Space (Safriel, AJNR 2006) Corticosteroid Contraindications Absolute Local or systemic bacterial or fungal infection Relative Pregnancy (check w OBGYN usually okay) Diabetes (poorly controlled) Osteoporosis History of steroid psychosis Pending surgery Corticosteroid Systemic Effects • Postinjection flare of pain (2-5%) • Headache (3%) • Facial flushing (1-28%) • Insomnia • Fluid retention, HTN, CHF • Gastric/peptic ulcer • Skin atrophy/depigmentati on (<1%) • • • • • • • Adrenal suppression Bone demineralization Lymphocyte function Cartilage attrition Epidural lipomatosis Hyperglycemia Anxiety/psychosis Corticosteroids Use Judiciously Not necessary for diagnostic blocks Dose in patients at risk Consider 6 month ≤ 5mg/Kg body weight (example 80kg pt=max 400 mg) Critically evaluate patient response after EACH injection ACR 2010 Guidelines All cases of systemic GC: Education & evaluation modifiable risk factors Ca++ & Vit D # Exposures to ESI does overall risk of fragility fx Corticosteroids Transforaminal Injection Particulate Matters! 12 cases (reported in literature) Spinal cord infarction subsequent to Lumbar or Sacral Transforaminal injection of particulate steroids Single most serious risk = Injection of particulate matter into a reinforcing medullary artery ISIS Practice Guidelines 2nd Edition Edited by N Bogduk 2013 Steroid Particle Size Compared to RBC (10 µm) Methylprednisolone (Depo-Medrol), Triamcinolone Acetate (Kenalog), Betamethasoneacetate/sodium phosphate (CelestoneSoluspan) All with particles > size of RBC Dexamethasone sodium phosphate Pure liquid without particles (Benzon) 0.5 µm particles, 5-10 x smaller than RBC (Derby) (Derby 2006, Benzon 2007) Particulate vs. Non-particulate Pig vertebral arteries injected with methylprednisolone vs. dexamethasone Methylprednisolone: All required ventilatory support and did not recover Histologic evidence of hypoxic/ischemic brain damage MRI with diffuse edema in upper cord and brainstem Dexamethasone: None ventilated, no neuro changes evident Okubadejo JBJS 2008 Minimize Risk Use Non-particulate Steroids for Upper Lumbar or All Transforaminal Injections Particulate Steroid is accepted for Interlaminar ESIs and Intraarticular injections Spinal Injection Complications Needle malposition Any needle stick can cause problems Bleeding Infection Optimal to Personally Review Imaging Anatomic Barriers? Post Surgical? Perineural Cysts? Procedural Risks Needle Malposition Dependent on Specific Procedure Structures to Avoid Piercing: •Nerve Roots •Dura •Spinal Cord •Arteries •Peripheral Nerves Spinal Injections Needle Placement To prevent problems: “It’s not only knowing where to put your needle, It’s knowing where not to put it” Know the Anatomy Minimizing Complications Peri-Procedure • Maintain verbal contact with patient • Heavy sedation should be avoided! • Patient will be unable to report warning signs of needle to neuraxis contact Neal et al. ASRA Practice Advisory, Reg Anes Pain Med 2008 Procedural Risks Intravascular Injection Immediate onset Headache Tachycardia Anesthetic toxicity Vasovagal reaction Flushing Steroid side effects Spinal cord block/infarct Intravascular Injection Venous plexus Radicular artery Radiculomedullary artery Artery of Adamkiewicz Is the Safe Triangle really safe? Artery of Adamkiewicz • note characteristic “hairpin turn” • usually on left side, but side and level may vary • located in superior, anterior foramen • consider alternate approach at L3 and above, targeting the more inferior aspect of the foramen Murthy 2010 Pain Medicine Why Use Fluoroscopy Confirm needle-contrast-medication is in, and is covering, the desired target-area Avoid placing needle / medication in unintended location Intravascular Injection Simultaneous epidural and vascular uptake occurs ≈ 75% of vascular injections (Smuck 2006) Minimum of live fluoro contrast injection Is DSA necessary? Digital subtraction angiography (DSA) superior to live fluoro for detecting vascular flow during lumbar transforaminals Only 60% of cases of vascular flow detected with DSA were seen with live fluoro (Lee MH. Korean J Pain. 2010 Mar;23(1):18-23.) DSA rate of detection also better with cervical TFESI (McLean 2009) QuickTime™ and a decompressor are needed to see thi s picture. Cervical TFESI with venous flow Lidocaine Test Dose • Inject 0.5-1 ml of lidocaine after confirming contrast flow • Wait > 1.5 min • Monitor any neurologic changes, dizziness, weakness, tinnitus, headache… • Ask patient to move fingers and toes • If everything okay, then proceed with injecting steroid Risks of Intrathecal Injection Increase in pain Spinal block Prolonged anesthesia Hypotension Vasovagal reaction Headache Meningitis Arachnoiditis Intrathecal Intrathecal Dural Puncture < 0.5% incidence (experienced injectionists) Spinal headache Not all dural punctures = spinal headache Headache is positional Onset several hours to 48 hours Most resolve spontaneously Rarely, uncal herniation and death Dural Puncture Prevention Interlaminar ESI Smaller gauge epidural needle (Lambert) 17 gauge: 75% required blood patch 25-27 gauge: 13-39% require blood patch Use AP and Lateral/contralateral views! Don’t use interspace with prior laminectomy Avoid stenotic level (review the MR) Keep bevel parallel to longitudinal dural fibers Higher incidence with multiple attempts Transforaminal ESI Lumbar: Do not advance beyond 6 o’clock position of Pedicle (AP view) Dural Puncture Spinal anesthesia From local anesthetics Subdural injection produces similar result Loss of consciousness, hypotension, apnea, cardiac arrest, death Prevention Don’t inject local anesthetics if unsure Procedural Risks Subdural Injection “Slow” spinal Increase in pain Prolonged anesthesia Hypotension Vasovagal reaction Headache Meningitis (Arachnoiditis) Subdural Injection between Dura and Arachnoid Layers Small Volume of Local Anesthetic can Cause neurologic impairment Subdural injection Note “Railroad tracks” Subdural injection Note “Railroad tracks” No space between vertebral body and thecal sac From Levy, D. Pain Medicine Volume 11, Issue 5, pages 716–718, May 2010 Minimizing Complications Three Procedural Phases Pre-Procedure Peri-Procedure Post- Procedure Post Procedure Recover patient Assess pain and provocative maneuvers Good documentation Written instructions Will save you from after hours calls about routine or minor complaints! Schedule follow-up for evaluating procedure Post Procedure Complaints If problem evaluate and treat without delay Pain – Assess if increased Fever/Chills – CBC/ESR/CRP Weakness/Numbness, Bowel/Bladder Secondary to LA? – reassure patient Other cause suspected? - evaluate ASAP! Make sure the patient knows how to contact you after regular hours! Epidural hematoma Neck or back pain Neurological deficits ↑Risk Coagulopathy Epidural vascular malformations Recent surgery/injection Time is critical! Guffey PJ. Anesth Analg. 2010 Oct;111(4):992-5. Lawton MT. J Neurosurg. 1995 Jul;83(1):1-7 Epidural Abscess Fever, tenderness Radiculitis → myelopathy/cauda equina syndrome ↑ WBC, ESR, CRP MRI very sensitive, CT not Gram + cocci in ~80% ↑Risk Immunocompromised/Diabetes Skin disruption/colonization Time is critical! Tompkins M. J Emerg Med. 2010 Sep;39(3):384-90. Kumar K. Neurocrit Care. 2005;2(3):245-51. Facet Infection 50 year old male,, worsening LBP, admitted to hospital 10 days following lumbar facet joint injection Kim, SY Korean J Anesthesiol. 2010 April; 58(4): 401–404. Case Report 64 yo PMH multiple pulmonary infections L5-S1 interlaminar ESI fluoro guided 6 wks later => 4 weeks of worsening low back pain, hospitalized with severe LBP, fever ESR 82 and CRP 17.4 mg/L Hooten, et al. Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the Case Report Literature. Pain Medicine 2006 Hooten, et al. Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the Case Report Literature. Pain Medicine 2006 Thank You!