Epidural steroid injections, both translaminar and transforaminal, are a common therapeutic provided by many pain management practitioners.  While this procedure is generally considered safe, there have been reported cases of neurological injuries including spinal cord injury, respiratory arrest, spinal cord infarction, paralysis, and death. The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, reports “an alarming incidence of major claims relating to cervical epidural steroid blocks.” The FDA facilitated a group meeting of leading pain management organizations with the goal of reducing the risk of these severe neurological complications.

The actual incidence of severe complications cannot be accurately calculated due to limited and incomplete data available.  The cervical region has many more devastating complications than the other regions of the spine. In fact, the number of medical malpractice claims for these blocks exceeds the combined total of claims for steroid blocks at all other levels.[1]

Here are a few examples of how a spinal injection expert witness was used in medical malpractice claims:

Example: Transforaminal Steroid Injection
I was retained by the defense in a case where the physician was accused of causing a neurological injury. What I was able to help show was that the neurologic injury that the woman had was present before the injection and the manner in which the procedure was performed as well as the steroid agent that was injected met the standard of care.

Example: Translaminar Epidural
I was retained by the defense in which a University physician was alleged to have caused neurological injuries which occurred in a man while he was recovering from a trauma.  I was able to demonstrate the translaminar epidural was performed in a standard manner and that the actual etiology for the man’s problem was epidural lipomatosis.

Example: Spinal Cord Injury
I was retained by the plaintiff in a case of spinal cord injury. I was able to show how the epidural steroid injection caused the spinal cord injury in the plaintiff.

Example: Spinal Cord Infection – Quadriplegic
I was retained as an expert witness in a case where a patient received substandard care during the performance of an epidural steroid injection resulting in a spinal infection that ultimately lead to her becoming quadriplegic.

The working group of physicians created a list of issues that they felt needed to be considered in order to minimize the risk of neurological injuries from epidural steroid injections.

Total consensus was reached on the following:

  1. Cervical translaminar epidural steroids are associated with a rare risk of catastrophic neurologic injury.
  2. Spinal transforaminal injections using particulate steroids are associated with a rare risk of catastrophic neurovascular complications.
  3. All cervical translaminar epidural steroid injections should be performed with image guidance and a test dose of contrast medium.
  4. Cervical translaminar epidural steroid injections should not be performed above the C6-7 level.
  5. One must perform a review of imaging to assure there is adequate space for a needle placement before proceeding with a cervical translaminar epidural steroid injection.
  6. Do not use particulate steroids when performing a cervical transforaminal epidural steroid injection.
  7. All lumbar translaminar epidural steroid injections should be performed with imaging and a test dose of contrast medium.
  8. Particulate steroids can be injected in lumbar transforaminal epidural steroid injections.
  9. A face mask and sterile gloves must be worn during the procedure.
  10. The decision to do a translaminar versus a transforaminal epidural steroid injection should be based on the decision of the health care practitioner performing the injection.
  11. When doing a transforaminal epidural steroid injection in a patient with a contrast allergy, you must use a preservative free, particulate-free steroid.
  12. Moderate to heavy sedation for epidural injections is not recommended. If sedation is necessary, use light sedation so that the patient can clearly communicate with the treating physician.

A near consensus was reached on the following:

  1. Cervical and lumbar transforaminal epidural steroid injections should be performed by injecting contrast medium during real-time fluoroscopy or digital subtraction imaging first before consideration to injection of the actual steroid.
  2. A nonparticulate steroid should be used for the initial lumbar transforaminal epidural injections.
  3. Extension tubing should be used during transforaminal epidural injections.
  4. Cervical and lumbar translaminar epidural injections can be performed without contrast in patients with documented contraindication to the use of contrast.

Standard of Care
the new consensus opinion on Safeguards to Prevent Neurological Complications After Epidural Injections[2] will influence medical malpractice claims and the standard of care in the cases.

Common to all of the recommendations is the need for image guidance for all cervical tranlaminar epidural steroid injections in order to avoid damage to the spinal cord.  Relying on loss of resistance and anterior-posterior imaging does not provide adequate protection against a spinal cord injection in the cervical region or intrathecally in the lumbar region.

Cervical translaminar epidural injections should only be considered after review of imaging that can show adequate space for needle placement.

Heavily sedated patients increase the risk for spinal cord injuries.  If sedation is used, the patient needs to be able to clearly communicate their sensations at all times during the procedure.

The main risk in transforaminal epidural steroid injections is an injection into the arterial supply to the neural structures in the area intended to treat.  An injection of dye before the steroid needs to occur to help assure that this does not happen.  Dexamethasone, a nonparticulate steroid is the recommended steroid for these injections because particulate steroids were noted in all the case reports of adverse sequelae from transforaminals.  There are questions about whether dexamethasone is an adequate steroid for effecting relief but the generally thought is that safety preempts the slight fewer efficacies noted in studies.

These recommendations are reasonable and logical.  I believe that complying with them will lead to less adverse neurological complications during the performance of spinal translaminar and transforaminal epidural injections.

It is the author’s hope that following the consensus opinions noted above will result in a decrease in the number and severity of neurological complications after epidural steroid injections.

About the Author
Dr. Anthony Guarino is a nationally recognized pain management expert and a celebrated clinician, teacher, author, expert witness, and researcher. His interest in pain management began during his undergraduate work at Yale University, and developed further during graduate studies in religion at Yale Divinity School. He completed a medical degree at the University of Maryland, an internship in medicine at Sinai Hospital in Baltimore and an anesthesiology residency and formal training in pain management at the Johns Hopkins Hospital. Dr. Guarino serves as director of pain management services for Washington University at Barnes Jewish West County Hospital where he evaluates and treats not only the area of pain but the whole person. Dr. Guarino regularly is called upon to consult and testify in cases including complications from epidural steroid injections. He can be reached at (314) 580-4609, aguarino@msn.com, www.painstrategy.com.

[1] Complications of Cervical Epidural Steroid Injections; The Doctors Company (2015)

[2] Rathmel JP, Benzon HT, Dreyfuss P, et. Al. Safeguards to prevent neurologic complications after epidural steroid injections. Anesthesiology V XXX X(1-11), 2015.