Alison Stout, D.O . Joshua Rittenberg, MD Michael Furman, MD Milton Landers, DO, PhD

1. 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

2. Disclosure Statement Epidural steroids are not FDA approved SIS Education Committee Vice Chair NASS Exercise Committee Chair

3. 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)

6. Spinal InjectionRisks and Complications Patient Factors Medications Procedure/Technique

7. Minimizing Complications Three Procedural Phases Pre-Procedure Peri-Procedure Post- Procedure Care is required During Each

8. ConsentThe 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

9. 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

10. 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?

11. Pre-ProcedureHistory Allergies Medications Prior Adverse Reactions

12. Allergy history Local anesthetics Contrast Steroids Allergy vs. adverse reaction Any Anaphylaxis Hx

13. Pre-Procedural: Medications Anticoagulants/anti-platelet Diabetes medications Narcotics/benzos

15. ASRA Guidelines 2015 http://links.lww.com/AAP/A142

16. 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)

17. 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

18. Minimizing Complications Three Procedural Phases Pre-Procedure Peri-Procedure Post- Procedure Care is required during each

19. Complications Peri-Procedure Vaso-Vagal Response (3.9% overall incidence per RIC practice audit >2500 procedures) Rapid onset Bradycardia Hypotension Pallor Sweating Nausea Faintness

21. Interventional Medications Local Anesthestics Contrast Agents Steroids

22. Allergic Reaction Vasomotor (warmth, flushing) Cutaneous (hives, severe urticaria) Bronchospasm (wheezing) Cardiovascular (hypotension) Vasovagal (bradycardia, hypotension, nausea) Anaphylactoid reaction (angioedema, urticaria, bronchospasm, hypotesion)

23. Local Anesthetics Toxicity Intravascular – Immediate onset Relative overdose – Slow onset with progression of irritability

24. Local Anesthetics CNS Toxicity Numbness of tongue (initial) Foreign taste (initial) Headache Tinnitus Blurred vision Seizure – muscle twitching

25. Local Anesthetics Cardiovascular System Toxicity Dysrythmias Hypertension ~2X blood level compared with seizure dose Except with Bupivacaine

26. Contrast must be used for all Spinal Injections = Contrast Assure Validity of Procedure Reduce Risk Inject with “live” fluoroscopy

27. 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

28. Gadolinium • Option for spinal procedures in patient with contraindications to iodinated contrast • Lower opacity - Consider use of digital subtraction to improve visualization of flow • AVOID Intrathecal Space Gadolinium (gadodiamide) Iohexol 240 (Safriel, AJNR 2006)

29. 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

30. Corticosteroid Systemic Effects • Adrenal suppression • Bone demineralization •  Lymphocyte function • Cartilage attrition • Epidural lipomatosis • Hyperglycemia • Anxiety/psychosis • Postinjection flare of pain (2-5%) • Headache (3%) • Facial flushing (1-28%) • Insomnia • Fluid retention, HTN, CHF • Gastric/peptic ulcer • Skin atrophy/depigmentation (<1%)

31. 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

32. 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

33. Corticosteroids Transforaminal Injection Particulate Matters!

34. 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

35. 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)

36. 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

38. Minimize Risk Use Non-particulate Steroids for Upper Lumbar or All Transforaminal Injections Particulate Steroid is accepted for Interlaminar ESIs and Intraarticular injections

40. Spinal Injection Complications Needle malposition Any needle stick can cause problems Bleeding Infection

41. Optimal to Personally Review Imaging Anatomic Barriers? Post Surgical? Perineural Cysts?

42. Procedural Risks Needle Malposition • Dependent on Specific Procedure • Structures to Avoid Piercing: • Nerve Roots • Dura • Spinal Cord • Arteries • Peripheral Nerves

43. 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

44. Maintain verbal contact with patient Heavy sedation should be avoided! Patient will be unable to report warning signs of needle to neuraxis contact Minimizing ComplicationsPeri-Procedure Neal et al. ASRA Practice Advisory, RegAnes Pain Med 2008

45. Procedural RisksIntravascular Injection Immediate onset Headache Tachycardia Anesthetic toxicity Vasovagal reaction Flushing Steroid side effects Spinal cord block/infarct

46. Intravascular Injection Venous plexus Radicular artery Radiculomedullary artery Artery of Adamkiewicz

47. 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

48. Why Use Fluoroscopy Confirm needle-contrast-medication is in, and is covering, the desired target-area Avoid placing needle / medication in unintended location

49. Intravascular Injection Simultaneous epidural and vascular uptake occurs ≈ 75% of vascular injections (Smuck 2006) Minimum of live fluoro contrast injection

50. Is DSA necessary? Cervical TFESI with venous flow • 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)