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SNI Digital Innovations and Learning is pleased to present
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another in the SNI Digital series on Controversies in Spine Surgery, a lecture and discussion given on March 31, 2024
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By Nancy Epstein, who is the Professor of Clinical Neurosurgery at the School of Medicine, the State University of New York at Stonybrook, and the Editor-in-Chief of Surgical Neurology
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International
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The topic of her talk is, Epideral Spinal Injections, Major Risks with No Long-Term Benefits.
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I'm going to be talking about the major risks with no long-term benefits of epidural spinal injections. In Deo's study in 2009, he spoke about lumbar epidural injections. He noted it's one of the
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second most common reasons for physicians going to a doctor's office in the United States, and that actually surprised me.
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Nancy, that surprised me because one of the most common reason for somebody to go to a doctor with pain is back pain.
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And so what you're saying here is obviously with back pain, these people are coming in and either have had or need an epidural or considering an epidural injection. So this is not uncommon. It's
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not only not uncommon, but some of them are being sent for epidural injections without a previous MRI to even determine what the underlying disease or cause may be. And oftentimes they have no
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neurological indications for an epidural, but as I mentioned later in the talk, a lot of them are being rushed especially if they first see it. pain specialists to go get an epidural before they
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spontaneously improve. These people wind up getting even imaging before they get the injection, I would imagine. Not necessarily, not necessarily. Oh, really? Wow. And therefore, some of the
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people have, you know, epidural abscesses,
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infections, fractures, you name it. Well, other kinds of problems are there that they completely miss. What I thought it was interesting is they'll cite it over a 600 increase in Medicare
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spending on epidural injections. And the other thing too is insurance carriers these days, many of them will require that patients have undergone a course of three epidural injections or at least a
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few epidural injections before they will give consent for surgery. That's outrageous, especially because one of the things I'm going to go over is epidural injections are not FDA approved. They're
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improved for injections into joints, but not into the epidural compartment.
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You got to write an editorial about that. Also, what they found is patients who had epidurals versus no epidurals, same results. It didn't really help anybody. And he was discussing the fact that
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you need stronger regulations and surveillance as to who's going for epidurals and how many. I mean, I've known colleagues who are pain management specialists, lots of times it's through anesthesia,
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sometimes neurology, doing like 20 of these a day How can you possibly adequately screen 20 patients a day, five days a week,
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for an epidural injection? I mean, well, of course, if you're an anesthesiologist, typically you have the benefit of total lack of knowledge of how to do a neurological exam and total inability
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to read the MRs and CAT scans. So under those circumstances, I guess ignorance is bliss and you just proceed and you check the patient's insurance. Dale, I think you seem to remember this.
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I don't think he's not a neurosurgeon, isn't he? No, no, no, no, no, but he's written some fantastic articles. Unspine or other things are - Everything, everything. Okay. Everything.
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So I'm gonna be talking about epidural spinal injections and I'm gonna differentiate those from transferaminal epidural injections, but that's gonna be the focus of today. And if anybody who's
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listening to this talk wants to take away a message and is about to turn off this lecture, my message is quick and short. There are too many being done. They're too costly, they're too ineffective
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and they have too many risks and complications associated with them. So actually my husband's a professor at Columbia University and when he would lecture he would always say, if you've fallen
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asleep, rejoin us, get the message. You can go back to sleep again if you want to but take something home with you So here's your real take-home message. And the outline for what I'm going to talk
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about today is, therefore, going to be the following. First of all, I'm going to emphasize these are not approved by the FDA. They're expensive. I'm going to show you briefly what the anatomy is
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for where the epidural injection or transfer aminal injection is placed. I'm going to review briefly some of the contraindications to using these injections, particularly when you have severe canal
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compromise. I'll review the fact that there are only documented minimal to no short-term benefits and no long-term benefits. Most studies will show you exactly that. I'll go over with you briefly
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who performs these. One might certainly care. What's the background of the physician doing these injections? Are they qualified to do this? And what are the major risks associated with these
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injections? And I think people may say, oh, pain, whatever. But if it's paralysis, I think it's worth paying attention to.
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The cartoon says the doctor is ready to maltreat you now. So in terms of getting an epidural injection, they're handed out like water. I would basically say stay away. As I've already mentioned,
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they're not approved by the FDA for the spine, but they are approved for the joints. And how come nobody knows this? I ask patients all the time, did you know when you went for the epidural that
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they're not approved? Did they tell you anything about them or the complications? And to a patient, they say, no, I had absolutely no idea They said here, just show up, do this a few times,
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this will get you better. This is your classic synovium for a hip, a knee, whatever joint you wanna take. This is the synovial fluid. And then here's where the epidural injection is placed in a
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joint. So that's FDA approved, hip, knee, et cetera.
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In 2010, a Medicare spent nearly nine million on spinal epidural injections. And by the way, the cost per injection may vary. 600 to1, 500, and some patients are actually forking out the1, 500
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privately because their insurance won't cover it. But these are data that are published by the Center for Medicare and Medicaid Services. And the other thing to note is, it's not just that they do
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one. They typically will prescribe you for three injections. There might be a month in between, it might be a few months in between. Yes, they limit it to three a year, but I've had patients
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come in with lumbar spinal stenosis saying, Well, I've had at least 12 to 16 to 20 injections over the years. And when you get in surgically, there's an incredible amount of scarring they may have
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as he's a retinitis,
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but their spine really looks like a mess. But this is a major cash cow for numbers of specialists.
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Where are these injections supposed to be done? Unfortunately, too many are done in private offices. No fluoroscopy, no CT scans.
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Here's one of the studies saying that yes, it should be done under fluoroscopy. Why? Because you can reduce the risk of nerve, vascular, or dural injuries. Especially, you're doing a cervical
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C7T1 or C6-7 injection. You may get into the vertebral artery, intra-dural injuries. I'll show you later, it's up to even 6 and certainly direct nerve injuries or direct injuries into the cord
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itself. They use a technique for these injections called the loss of syringe resistance so that when you get into the epidural space, it's almost like a vacuum. And that helps tell them where
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they're supposed to be. But then additionally, under fluoro or the CT scan, they can confirm it by injecting dye. So essentially an epiderogram. Here is your typical, you know, C-arm that you
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may be using your fluoro. And then here's an example of your placing a needle. And then here's your intraoperative were intra-fluoro-epidurograms.
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Now, the next article is going to
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tell you basically that you need not only Floro, but you can definitely consider CT scans for these injections. And here's your Floro. Here's your placement transferaminally, 'cause here's the
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foramen at six, seven. On the other hand, here's your CT guided transferaminolepidural injection. So you have these two choices. You have the men ambulatory centers. You have them in hospitals.
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They do not exist in the doctor's offices So all you can do is tell people, do not go and have these in a doctor's office without any kind of imaging whatsoever, because it increases the risks of
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complications. In this study from 2023, epidurals were done under fluoro or CT. Three months later, lumbar injections. No improvement in the patient's disability between those injected versus not.
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No change in the frequency with which surgery was warranted. And in the cervical, all they could say that, limited high quality evidence of benefits. So everybody's really hesitant out there to
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really slam these injections, but it really has to be done. But the hardening comment of this author was, The morbidity with epidurals can be catastrophic. Well, that's nice to say after the
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catastrophe has occurred. The question is, how many physicians can we get a hold of in different specialties to try and steer them away from using epidural injections? So here's the radiological
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anatomy. Yes. Oh, I can't - Can you go back? Can you go back? Yeah, mm-hmm. The slide there around this, using CT Guided shows how difficult that is, and what you're aiming at, which is
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gonna be the root, and to do it without something with that kind of imaging, even the fluoro has gotta be difficult. I mean, it just begins to tell you, anatomically, this is an Asian.
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It's not only not easy, but any of us who've done, you know, far lateral disc surgery, you know you get into that, you go extra for amnole and you find where the nerve root is coming out and it
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can be very variable. And if there's any slip or any significant arthritic change or disc herniation or for aminol spur, the nerve root isn't where you think it's going to be. And in some instances,
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the nerve root could be entirely splayed over that space, increasing the chance that you can directly inject into the nerve root. And certainly that has happened where patients describe, oh my God,
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he injected and I had a lightling-like sensation going down my leg and I've had numbness, tingling and weakness ever since. So that's an excellent point. So radiologically, what is our radiologic
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anatomy for these epidurals? You have the interlaminar injections and here you can see, I've shown you, it goes through the midline. In other words, you have your lamina above, the lamina below,
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and you're going or right there. through the middle and here on the axial study, you're looking at the same thing. Here's your overlying bone. You know, you have, yes, your yellow ligament,
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but most importantly, your dura is sitting here, and hopefully what you're injecting into is the epidural space, but not always, 'cause I'll show you that there's a high risk of CSF leaks with
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these. So a transferaminal injection, you are extending this to the foramen itself, and on the axial image, you're aiming for the foramen, but you're trying to avoid the nerve root, which I said,
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and some instances can be dangerously split across the entire foramen if it's compressed by a significant disc or spur or a slip or whatever the pathology happens to be. Has anybody ever done a study
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going back to that slide, injecting some dye with the various approaches to see just where the liquid would go, and then taking an image of that? You can't imagine that this is not reproducible,
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that's what I'm saying. I don't think that I have not seen a study that deliberately looked at all the epiderograms to see how many are misplaced. I think there are studies, which I'll show you a
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little bit later, telling us how many of these were known CSF leaks that resulted from this. But the problem is, transferamily, you are typically distilled to the dorsal root ganglion, and you no
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longer have a subarachnoid space there. So you're just going directly into the nerve. You know, when you're more medial or, you know, you're proximal, you're in the midline, you're doing the
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interlaminar. Yes, you get a CSF leak, you're going to know that most of the time. And you can do your epiderogram and then the dye is going to go everywhere. But that's one of the maneuvers that
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they have to try and hopefully have you safely perform these injections and not do an interdural injection We're not to do an intranurve routine check. or intramedular injection like into the
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cervical cord so that you know that you're in the right place at the right time but it's very difficult to really document that especially when you have pathology that's changing your anatomy. Oh
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true. So here's your anatomy again for the epidural here at midline approach for a lumbar epidural injection and here my anatomical diagram here dorsally is your lamina, here is your dura, your
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thicosac with the nerve root sitting in it and here is they show you a very generous potential epidural space. Of course there may be hypertrophy ligament in this space, there may be synovial cysts
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in this space. You know look they're going to be doing this based on an MR but if you did a CAT scan sometimes you're going to have calcified ossified yellow ligament and ossified synovial cysts and
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other things that may be obstructing your view and lots of times the pathology Dorsally is very adherent to the Dura or Dura. calcified into the Dura. So this potential space, as it is shown here,
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often is not the real case.
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But hope spring is eternal. Here again, this is what you're supposed to be doing. You go between the Spanish processes, perhaps, you know, Paramedian, you are injecting in the epidural
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compartment. Here's your Dura being compressed actually by your injectate There are injectates, usually several CCs. It's a combination of lidocaine and your epidural steroid is the, you know,
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the Kenalog or whichever variant they're going to use. But that's a few CCs. And if you look at this, you know, look, that spinal canal here, lots of room. But what I'm going to show you
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shortly with some other slides is if that level is extremely compromised and stenotic, but the disks, stenosis, a synovial system.
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OPLL, whatever it happens to be, if there's no room at that level and you're performing this injection, you are further narrowing down that spinal canal and you can make that patient precipitously
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worse or paraporetic. If you look at your picture on top, which is great with the needle going interlaminar there, you see that? Right. And you see the green halo around the dura? Yes. And if
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that was the steroid and the lidocaine mixture, that's probably what it's gonna do is diffuse into that area and you just kind of ask yourself is that, what is that treating? Well, that's why
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there have been studies that have shown, I mean, I'll show you some studies that I specifically cite, epidural steroids versus epidural saline, but there are lots of studies where epidural
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steroids versus oral steroids, same effect, epidural steroids versus intramuscular steroids, same effect So the answer is you don't have to do an epidural into the body, choose another root, it's
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gonna be equally effective, plus the fact that it can cause a breakdown of the dura, especially in older patients, and result in a CSF leak, or you can end up getting what's called adhesive
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arachnoiditis. Some of this may go trans-dural, and some may go directly inter-dural-y as part of your inadvertent injection, and that can cause tremendous scarring. Terrific points
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Contraindications for cervical or lumbar epidurals, as I said, severe compression of the spinal canal. If there's severe stenosis, disc, cyst, ossified
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or calcified yellow ligament, there's a problem. I mean, here is your perfect diagram. Here's your epidural needle, catheter, whatever, your lumbar, space, everything. Everybody has lots of
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room, looks perfect. But add to that, look, look at this patient with a massive disc herniation at L5S1 You do an epidural injection here. you're adding between three to five plus CCs here, you
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can make that patient decompensate and they can end up with a paraparasis, paraplegia, acute foot drop, loss of bladder or bowel function. So it's being used in instances where nothing should be
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placed, actually surgeries should be done. Here's for a transferaminal epidurals in the cervical. Here's the foramen for the cervical and here's a foramenal injection for the lumbar This is what I
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was talking about, by the way. If you have a far lateral disc in your lumbar spinal canal, okay? Your nerve root may be not just, you know, skirting it on one side or the other, but splayed
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right across the entire disc, in which case your injection is being performed right into the nerve root itself and you can cause major permanent deficit with that. Contraindications for a
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transferaminal injection, same as for the epidurals. This is a case of cervical where you've got stenosis ossification of the poached to your longitudinal ligament. You do an injection in this case,
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and you can make the patient quadriplegic, and I've seen cases like that. So here is your axial study. C3 to 5 is where you have your severe OPLL
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and stenosis. This, see this chunk? Yeah. That is OPLL of mass your extending into the canal, almost to the back of the lamina here. Okay, so let's corroborate that with a sagittal image This
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is a parasagittal image. Here's C2, here's C3, here's C4. And basically that is mass of OPLL. And that's just showing you, you try and do an epidural injection into that canal. You're gonna
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render that patient quadriplegic. Oh, and by the way, you know, they also did get an MRI scan. And you see all this calcification here. Okay, on an MR it all appears black And I can't tell you
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how many spinal surgeons. can't even read their own MRI scans to realize this is not a disc herniation. They'll come in and they'll try and do multiple discectomies, anterior discectomy infusion,
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three, four, four, five, five, six. And then the patient wakes up quadriplegic because they've left all of this OPLL behind. So you see this massive OPLL and you see the high signal in the cord.
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So patients with severe stenosis, OPLL, severe disease could be a huge disc herniation, could be cervical, could be lumbar Don't do epidurals in these patients. Plus patients like this really
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need an operation.
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The sooner, the better. Minimal to no short-term and certainly no long-term benefits for epidurals versus epidural saline injections. I'm gonna show you multiple studies that are basically
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corroborating this. And we know that we're interested in the surgical extruded and sequestrated disc. Extruded disc is still in continuity with the disc space, sequestrated, the fragment is
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migrated inferiorly. And here's sort of your classic extruded disc at the L45 level. It's not filling the entire canal. Okay, but again, why do an epidural in this patient? Why risk getting a
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CSF leak? By the way, if you do an epidural within three months of doing an operation, you increase the risk of infection and you're not gonna have any short or long-term benefits for that
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treatment. So here are just some references that you'll, you can see at the end of the discussion today to look them up that are basically saying, as I said above here, no shorter long-term
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benefits for epidural injections versus a placebo, which is what epidural steroids are. So here is a distinct study, epidural steroids versus placebos, followed for like up to a year, minimal to
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no short-term benefits. One year later, there was the same risk of surgery needed in each of these groups, epidural injection versus placebo, which was again, saline, okay So the conclusion is
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there's no efficacy of lower epidurals. or sciatica, yet these are being done on a very consistent basis. As I said, many of the interventionalists are doing up to 20 of these a day, not
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well-screened patients, obviously. Here's the same result for epidural transfer amylin injections versus epidural saline injections. And again, here's your epidural compartment. Again, why are
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these being done?
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Same results Again, for epidurals in the lumbar spine versus a placebo, which is
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saline. And here you can see, sagittal view, superior anterior anterior posterior. L3, 4, L4, 5, L5, S1. You've got stenosis at multiple levels.
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And nothing is basically going to be done other than your epidural. That's not the way to treat this patient. If they're decompensating, especially at four or five, there's no room whatsoever This
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is not the way to treat these patients.
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Some pain management specialists, by the way, rush to do epidurals before patients can get better on their own.
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One thing on that, you mentioned on the patients who got the placebo injections of three previous studies. Did the placebo group have a higher incidence of complications or are people gonna say,
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Well, it didn't hurt 'em anyway? Did they have, in other words, were there complications from just doing the technical epidural? Yeah, I would say that they sort of evened out for that, that
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there wasn't, they so rarely acknowledged that there are any complications of an epidural period, but at least they were just acknowledging that the addition of steroids to the epidural injection
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did not make them significantly worse. Okay, yeah. So here's a classic example. Patient has a normal neurological exam, they may have pain, and they do an MRI, MRI is completely normal. I've
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been to especially neurology conferences that can drive you crazy because they're saying, well, maybe there's some foraminal disease and this correlates with that and look at the study. There's
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nothing there. So again, what do you find? They're sent for epidurals, often three. So the patient has no opportunity to improve on their own before the injections are being made. And then any
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improvements the patient comes in with the next time or all attributed to the epidural steroid, which has actually nothing to do with the injections whatsoever. I mean, I have a colleague who's a
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fantastic neurologist and he'll sometimes put these patients on two weeks of oral steroids. And so often that's gonna knock out whatever the problem happens to be. They'll get an MRI scan,
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obviously during that period of time to make sure that they don't have an epidural abscess. But the pathology will be documented and if something more aggressive surgically has to be done, it'll be
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done But there's no reason to really do the epidurals in these patients. So then the next question becomes, who gives or who administers these epidurals? Well, pain management specialists, but
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who are they? Well they can come from radiology. Radiologists are trained to read MRs and CAT scans, so they can read the diagnostic studies. Are they trained to do a neurological exam? If they
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ever were trained to do that, it was way back in medical school and they probably haven't done one since.
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Physiatrists, physical therapy doctors, in theory they're supposed to be able to read both the diagnostic studies and do a neurological exam. Too often I find they can't do either. But they're
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also doing these injections because it's a big money maker. Anesthesiologists, they're trained to put patients to sleep, wake them up. They can do neither. They're not trained to read the
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radiology studies and they're not trained to do a neurological exam. So this is who you're choosing, oh by the way, occasionally neurologists and neurosurgeons will do epidural injections but
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that's pretty rare these days. So the answer is But can they do a neurological exam and read your MRI studies? Just think about that if you're seeing these people. Why are they screening you? Why
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are they giving you 10 minutes in their office before they send you down the hall to go ahead and schedule your epidural in jail? Lots of times they haven't even done a neurological exam. I can't
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tell you how many times patients come to the office saying, Thank you for doing an exam. And you say, As opposed to what? Because lots of times there's no neurological correlate at all So this is
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just a warning. A lot of unqualified physicians are doing epidurals and they may be causing paralysis. And I couldn't resist that. It says the physician or so-called, the guy in the white coat is
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saying, Actually, I'm not a doctor. I'm the healthcare administrator. And the guy on the exam table is saying, Well, actually I'm not the patient. I'm his lawyer. They're
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great Okay, so there are multiple risks associated with these injections. Here is a study looking at transferaminal adverse events. And they identified 30 in this instance, 16 vertebrae basilar
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problems, 12 cervical cord injections, two brain stem and cord infarox. 13 of these were fatal, 13 out of 30 of these
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injections. I mean, this is just, well, they were obviously screening for this. Brain infarric, brain spinal cord, seizure anesthesia, not stated strokes The strokes can be into the
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interspinal artery, a radicular artery. What are the strokes from? It's really from the particulate matter of the epidural material that's injected, okay? Also, if you inject into the vertebral
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artery, you can get a perforation, a dissection, a thrombosis of that vessel, much less lack of flow through that vessel, causing that patient to have an infarric. And here is a midline,
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sagittal
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image and more here's C2. C2. C3, C4, C5, C6, et cetera, C2, 3, 4, 5, intramagilary injection, seen right there. Servical epidural injections risk strokes, another study 2015, you'll
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see that I ordered them in terms of becoming, you know, more recent as we go, again, documenting no benefit of a cervical epidural versus epidurals using saline and versus other injections using
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no steroids whatsoever. Patients ended up with neurological deficits, including quadriplegia, intravascular injections, embolization of these stroke particles. And here is an example of a
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cerebellar and brainstem stroke. And look at this, you can see a total whiteout of the left cerebellar hemisphere in this case.
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Servical epidurals, what are the other adverse events that you may see with these? Again, They offer no long-term benefits.
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What are the risks associated with these? Hematomas, infection, abscess, meningitis, strokes, cord injections with paralysis, and may delay critical surgery.
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Or not so critical surgery in that case, right? Servical epidurals can presuec's cord strokes. 18 cervical randomized controlled studies with transferaminal epidural injections, looking what
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happens after three to six months? What are the major adverse events? Again, vascular injections, particular steroid embolization, cord strokes, and here's an example, an MR of a cervical cord
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stroke, where you're seeing here is the C2 level, and here is the stroke, three, four, five, six, so it goes all the way down to the C56 level, an anterior spinal artery injection.
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Devastating and permanent. Here's a cervical epidural that resulted in acute epidural hematoma.
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You know, reviewing medical legal cases, I've actually not gonna give you any identifiers here other than the fact that the patient never needed an epidural, by the way, in the cervical spine, or
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the cervical MR was negative. The cervical epidural was done in an ambulatory care center. Took three minutes, by the way, and if you look at the data for how long these epidural takes, almost
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always just three minutes. On a table, injection off the table. The patient in the recovery room started complaining of severe pain and weakness in an arm and then it rapidly spread to both legs
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and then the other arm. The patient was not seen by a physician for at least two hours, just sitting in the ambulatory care center. And it wasn't the physician who had done the study because he was
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running to another facility. The patient was ultimately transferred to a real hospital. The emergency room physician dropped the ball. She sat there for 12 hours She happened to have gotten an MRI
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scan about eight hours it'll stay. And it shows something that looked like this. These were not her actual images, but you can see here is a cervical MRI. Here's the vertebral body. Here's your
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spinal cord compressed anteriorly. This back here, these are your lamina, and here is your epidural hematoma. And that's on your axial study. And in the same patient, which is not directly this
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patient, you can see the cervical cord coming down. See 2, 3, 4, 5, 6, 7, T1. So it's starting up here, and then it's just taking over the entire canal. A huge epidural hematoma, and again,
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these were not the direct images of this patient, but a facsimile there of indicating
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that where these patients are done is important. Ambulatory care centers, lots of times, good luck to you if it's after seven o'clock at night, lots of times when all the doctors are going home,
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you're lucky if you get it. anybody to see you, nurse practitioners and the PAs may make some really bad mistakes and not recognize what's going on, but in this case, it took too long to recognize
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it. The patient sat in the hospital, had a delayed MRI scan and very delayed surgery 12 hours. She regained partial function, but it's still partially quadriperetic.
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Here is a case that I had seen years ago as a 54-year-old. He had been previously in great shape and he was bicycling out one area of Long Island and he started to get back pain. He said three
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months ago I presented to a
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physiatrist and he had an MRI scan done and for three months he just said I just got worse and worse and worse and when he came into the office he was like Quasimodo. He was walking at almost
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parallel to the floor, 90 degrees over. So here is the original MR, these two. This is the actual images, five one, four, five, three, four. This is his
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L23 sagittal image of that disc herniation and if you're not convinced with the sagittal image this was his axial image and yes this was his massive disc herniation and look at his quarter coin and it
32:59
is squashed This was his original MR. this patient should have gone emergently to surgery. This patient's surgery was delayed by three months. Three months later, the MR was repeated. Guess what?
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The disc herniation was certainly no better, questionably worse. He had surgery, he did get a fair degree of improvement, but there's no excuse for the fact that originally this patient, who was
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being followed also by his internist in addition to the pain management specialist, should have gone immediately to surgery three months ago, and would therefore have been left with no deficit
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whatsoever. So this is the kind of inexcusable management that's going on at this point. And this is just emphasizing to you the severe damage and the severe compromise to our patients that can
33:49
occur when people are seeing them who are not really adequately trained to treat and diagnose them. Other major problems that we see are one to 2 risk of infection, And here, to the right, it says,
34:01
wait, this one's a lawyer. We better wash our hands.
34:05
That's often not done adequately. Here is a postmortem example of an epidural discitis dash abscess infection. 50 of the organisms that are identified, by the way, staph aureus. So it was
34:17
introduced at the time of the injection. Typically, it's staph aureus that's methsilin sensitive. It could occasionally be resistant But here are all the other infectious etiologies, meningitis,
34:31
discitis, epidural abscess,
34:34
osteomyelitis, erectinoditis, paralysis, and death. All of these are possibilities in terms of infection that can be introduced with an epidural injection. None of these typically are discussed
34:43
with the patient whatsoever. This is a huge frequency. Look, 04 to more like 6 risk of CSF leaks or dural tears from epidural steroid injections. I did one study of multilevel, where I did a
34:55
multi-level lumberlaminectomy.
34:59
And I found that six of the 24 CSF weeks in like 336 cases were due to dural tears that have been produced by the
35:12
epidural steroid injections. And sometimes they're punctate and sometimes they've ripped through the door for a few levels. Okay, these are often unreported and ignored. And typically, you know,
35:27
your pain medicine specialists don't know how to deal with it. They say, well, you know, handed off to the neurologist or somebody else, et cetera. They're typically inadequately treated bed
35:36
rest, epidural blood patches, injections, fiber and sealant. These things don't work. Basically, if you have an injection, you really need to do a primary open repair. These other efforts are
35:47
often not going to work. They're tried, but they don't usually work. Here's an example of a patient had a laminectomy This was actually a Florida medical legal case. It was treated with five
35:59
epidural steroid injections, resulting in a massive CSF leak in pseudomoningocele. They tried epidural blood patches after that. Finally, the patient was seen at a real hospital because by the way,
36:12
the patient with all these leaks and actually was leaking outward as well was just sent across the street to stay in a motel rather than being transferred to a hospital down the street. But this is
36:24
what a pseudomoningocele that can end up, what it looks like, it can be huge with communication and it has to be open surgery, do yourself a favor, identify the leak site and treat it with your
36:38
muscle, dural, patch graft, derogen, fiber and sealant, et cetera. Up to 16 of patients undergoing epidurals can end up with adhesumarachnoditis. Adhesumarachnoditis doesn't even have to have a
36:53
correlate the radiographic studies. The symptoms are signs. pain, motor, sensory, sphincter deficit, sexual dysfunction. It's a whole syndrome that's very complicated. And oftentimes, you
37:05
know, just missed. This is what a normal quarter coinage should look like on an axial MR. And here is what it can look like when you have what's called the empty canal sign. What can happen is
37:18
because of the clumping, all the nerve roots are kind of plastered to the perimeter of the dura So it looks like one big hole in the middle. And this may help clarify that point even better. Okay,
37:32
this is what happens. You end up originally with very swollen nerve roots. But later on, what can happen is they become plastered to the perimeter of the dura. So you can actually go in surgically.
37:46
I mean, this is not a surgical entity. With surgery, these patients actually typically get much worse. And you can end up making an incision right through some of the nerves themselves. but
37:55
that's what's called the empty canal syndrome. And this is what you see in an MR, as you just see, that looks like there's nothing there, no nerve root tissue, but it is there and it's plastered
38:06
to the sides and it's untreatable other than, you know, pain, you know, with oral medication and things like that. There's up to a six to
38:16
26 risk with epidurals or spinal anesthesia of post-procedural spinal headaches or postural headaches patients stand up Severe headaches, they have to lie down. It's like a vices on their head.
38:29
Conservative treatment, bed rest, caffeine, moderate severe problems. They'll do epidural blood patches till they come out of your ears. By the way, epidural blood patch, what is it? They take
38:39
10 cc's of blood out of you and then they inject them into the spinal epidural space, hopefully, although sometimes they're actually creating an epidural hematoma and sometimes they're injecting it
38:49
into a durali, which is really going to make the adhesive retinitis work.
38:53
So again, here, lots of times, the best treatment is a primary repair. You use seven-o-gortex sutures interrupted, just like as I've shown here. And then you may need to supplement it with patch
39:05
grafts, derogen, and to seal. Intravascular injections, up to 116, particulate steroids, producing an embolism. So here's your cervical injection that's done, maybe right into the vertebral
39:18
artery, and here's your particulate steroid embolus that may be causing that patient a problem. Here is a study that said, this patient had a transferamel injection, but the patient developed the
39:32
deficit immediately after doing the local injection, so they stopped, okay? It was done at C6-7. The patient was quadriplegic for 20 minutes, but because they did not follow with the steroid
39:44
injection itself, the
39:48
lidocaine resorbed and the patient was okay. Here's an example anatomically, the anterior nerve root, the posterior nerve root, and most importantly, here is an example of where your vertebral
39:60
artery is, but also the radicular arteries that are anterior, as well as posteriorly located. So that's what you have to be aware of. And you can't directly see them.
40:13
Here is an irreversible problem where the patient had an intramagillary injection for an intravascular injection leading to cardiorespiratory arrest. Here's a lateral view of the cervical spine.
40:25
Here's your cord. You may have diffuse multilevel stenosis. And here
40:30
is the result of your, this is a stroke to the cord after a transferaminal injection, C2 to T1, and direct injection into the cord going down to C2 to T1. So under C-armed fluoro, which is the
40:47
optimal condition other than perhaps using CT. injected it into the anterior spinal artery, and it resulted in permanent paralysis in this case.
40:58
Here is another example of the same kind of case, a sagittal MR of the cord, showing you an infarct going from C2, and it goes all the way down to the C5 level. It was a 53-year-old, had an
41:11
injection. 10 to 15 minutes developed left upper extremity, and then bilateral lower extremity weakness. And in 24 hours, this is what the MRI showed, and the patient never improved.
41:23
Other adverse events that you may see with these injections, and this was a total of 19, 000 epidurals. Here are some studies that you can look up, looking at these, allergic reactions,
41:34
hypertension, vasovagal episodes, the
41:38
blindness, especially if it goes into the posterior cerebral. Seizures, hematomas, and here's an example of a hematoma that may occur in your epidural compartment. in the thoracic spine.
41:56
So in conclusion, there are major risks of these injections without significant benefits. No shirt, no shoes, no evolution. Why do them?
42:07
Okay, they are not FDA approved. If patients knew that, I bet many of them would not be, you know, in flocks going to have these done 20 a day up to 100 a week by some physicians They post
42:21
significant risks to the health of these patients. They're too many being done. They're too costly. They're too ineffective and they're too risky. And here's a mouse saying to the other mouse,
42:32
well, come on, you only never once, looking at the cheese that's there. But in this case, there's no, you know, they're promising a benefit that actually doesn't exist. They could benefit from
42:42
oral steroids. They could benefit from an IM injection of steroids. They can benefit
42:49
from Gavapentin, Narontin, muscle relaxants, All kinds of other things that are - up the neurologist's sleeves. It's like, do you really want to take the chance to either have an epidural
42:57
yourself or if you're a physician to give an epidural? And in conclusion, I would avoid these epidural injections and I think certainly your patients are going to thank you.
43:16
I think it's an outstanding summary. I mean, once you look at that, it's very difficult to justify doing that. And my contact with people is mostly lumbar, but you mentioned cervical, I can't
43:28
imagine 'cause there's probably less canal space available than the lumbar region and you've got the cord in there and you've got vessels coming in for you. And
43:41
it just seems to me that's just fraught with danger Yeah. And they are much more dangerous. Absolutely. So I'm doing it the longest enough problem of doing it serverically, just I don't know why
43:52
you'd do that. But a tremendous example, so I had some questions while we can, we can, and I'm here at the end.
44:03
I'm a physician, I'm in the community. And I'm saying, well, I've sent them for referral and nobody's really ever had a complaint for it. I don't know what Nancy's talking about. I don't see it.
44:15
What's your answer to that?
44:19
Well, that they mean it. Somebody in the community saw a physician and that physician told them to go get an epidural. In the patient, he sends a
44:28
patient to the person that does the epidural. The epidural is not a complaint. Patient goes home, he says he's better, so forth and so on. That's probably the regular story. Right. Well,
44:40
that's a lot of the stories.
44:43
The issue there is the steroid was given. These are relatively high dose steroids, actually. Some people can actually end up with immunosuppression of their adrenal gland if they get three of these.
44:55
But the question is, if they had had just the oral steroid, would the oral steroid have been as effective without the risk of the epidural injection? And the answer to that typically is yes. I
45:08
mean, that's the, to me, that's a key take-home here It obviously doesn't give money to your referral doctor but what it says is that you can put them on oral steroids and still get a similar
45:20
effect and not
45:23
have all these risks. Plus the fact that, you know, Jim, that the neurologist also, you know, your diabetics, they're not gonna wanna put them on steroids necessarily. So you put them on, or
45:33
you start them on gabapentin, you know, progressive doses, or they're placed on a muscle relaxant And the combinations of those can be very effective regular anti-inflammatory medications that are
45:45
just largely ignored in favor of just jumping to the epidurals. Yeah, I think that's true. Do you have any idea how many, because this gets to the comment I first made about what I don't see it,
45:58
how many epidural steroid injections in the United States are done a year? It's got to be. Oh, it's like, I think I had had a slide that showed that it was like at least 250, 000. I mean, huge
46:11
numbers, actually.
46:14
Probably more than that. I think I had that. Well, no, I had the 89 million a year that was being spent on it in 2010. So, if that was 2010 and it was nearly nine times 10 to the six, then each
46:29
of those, each of those injections, you say, is maybe a thousand. So, you know, you've got hundreds of thousands of these that are being done. I would think that that's probably the reason.
46:40
And so, I can just give you an example. experience I had I didn't it was a patient who went to a physician sent him for an epidural ejection and when I saw him in the evening I knew he was going out
46:52
for dinner he was using a walker oh he said what happened he said an epidural injection he couldn't walk and obviously he got better he got better the next day he was lucky but so so I think the other
47:04
reason that people say well I don't hear about it is people people don't report it they don't report it uh they don't they don't know any better in other words they think well maybe this is what it's
47:16
supposed to be like and then their physician says oh give a few days and maybe in a few days go by but maybe that patient by then has lost has developed a corticorna syndrome they've lost bowel
47:28
bladder or they've developed a foot drop or some of the permanent deficits simply because the inject date created a mass what is the corticorna what is the Dr. Duke, 'cause I.
47:41
where the FDA or the government of the insurance company says requires them to have epidural steroid injections. How does the practicing doctor avoid that?
47:53
I think a lot of them, at least what I've done in the past is I had neurology see them, put them on, you know, Narontin, Gavapentin, loss of relaxants, whatever it happened to be. I did not
48:05
let them go for epidural injections. If neurology wanted to give them a trial of steroids to see if they could get better, I would do that, but I would not go through epidural injections. You just
48:16
skip
48:17
it. But again, if you think that patient's really going to need an operation, you know, they've got a big disc or whatever happens to me. And you have them go through that epidural. There's a
48:26
good chance when you get in there operatively you're gonna be chasing after at least back, about six to 10 of the time, you're gonna look for that hole that that epidural created in the door,
48:37
especially in that patient with severe stenosis. where there's no demarcation between, there's just no epidural space any longer, andor you're gonna be trying to repair that leak and it might not
48:50
be simple to repair it. Yeah, I think we've covered all the bases here. They're easier alternatives versus also the better alternatives is don't do it, or don't do that. This storage gonna help?
49:04
Well, maybe it'll help, you don't know Well, oral steroids, a short course a few days of that with that help, maybe, but you don't wanna get into habituation with that. So. Also with the oral
49:20
steroids, I've seen malpractice cases where they put them on oral steroids, but they didn't do an MR to make sure the patient didn't have an epidural abscess or a discitis or some kind of a brewing
49:33
infection And the patient exacerbated that. Excellent point, excellent point.
49:40
I think a terrific job. I think I hope people learn a lot from this. And I think there was just a lot of very good practical information.
49:50
These are the references for Nancy's talk.
49:56
You can take a screenshot
49:59
of this page and use that as your CFET in pursuing these references. There are three pages of these references.
50:33
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