Paraspinal abscess complicating facet joint injection

Complications of injections in conservative treatment of degenerative spine disease: a prospective unicentric study

BACKGROUND

Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction.

METHODS

Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated.

RESULTS

Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4-73.5%), radiating pain (9.4-34.7%), and nerve root irritation (2-18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up.

CONCLUSIONS

Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient.

Paraspinal abscess complicated by endocarditis following a facet joint injection⋆

Infectious complications secondary to lumbar facet injections are exceedingly rare, follow an indolent course, and local sequelae include abscess spread or infections of the central nervous system. We present the case of the development of a facet abscess and infective endocarditis, which developed shortly after a lumbar facet injection. With the increase in interventional pain procedures, physicians must be aware of potential infectious complications.

Diagnostic value of lumbar facet joint injection: a prospective triple cross-over study

The diagnosis “lumbar facet syndrome” is common and often indicates severe lumbar spine surgery procedures. It is doubtful whether a painful facet joint (FJ) can be identified by a single FJ block. The aim of this study was to clarify the validity of a single and placebo controlled bilateral FJ blocks using local anesthetics. A prospective single blinded triple cross-over study was performed. 60 patients (31 f, 29 m, mean age 53.2 yrs (22–73)) with chronic low back pain (mean pain persistance 31 months, 6 months of conservative treatment without success) admitted to a local orthopaedic department for surgical or conservative therapy of chronic LBP, were included in the study. Effect on pain reduction (10 point rating scale) was measured. The 60 subjects were divided into six groups with three defined sequences of fluoroscopically guided bilateral monosegmental lumbar FJ test injections in “oblique needle” technique: verum-(local anaesthetic-), placebo-(sodium chloride-) and sham-injection. Carry-over and periodic effects were evaluated and a descriptive and statistical analysis regarding the effectiveness, difference and equality of the FJ injections and the different responses was performed. The results show a high rate of non-response, which documents the lack of reliable and valid predictors for a positive response towards FJ blocks. There was a high rate of placebo reactions noted, including subjects who previously or later reacted positively to verum injections. Equivalence was shown among verum vs. placebo and partly vs. sham also. With regard to test validity criteria, a single intraarticular FJ block with local anesthetics is not useful to detect the pain-responsible FJ and therefore is no valid and reliable diagostic tool to specify indication of lumbar spine surgery. Comparative FJ blocks with local anesthetics and placebo-controls have to be interpretated carefully also, because they solely give no proper diagnosis on FJ being main pain generator.

Pyogenic arthritis of the facet joint with concurrent epidural and paraspinal abscess: a case report

Pyogenic arthritis of lumber spinal facet joints is an extremely rare condition. There are only 40 reported cases worldwide. Most cases were associated with history of paravertebral injection, which was not found in our patient. At the time of hospital admission, he had no abnormal magnetic resonance image findings. Two weeks later, he developed pyogenic facet joint arthritis associated with paravertebral and epidural abscess. This report is the first to describe delayed presentation of pyogenic arthritis associated with paravertebral abscess and epidural infection.

Image-guided lumbar facet joint infiltration in nonradicular low back pain

Objective:

To assess the efficacy of facet joint infiltrations for pain relief in 44 selected patients with chronic nonradicular low back pain (LBP).

Materials and Methods:

Forty-four patients with chronic LBP of more than 3 months' duration were selected for facet joint infiltration. The majority (n = 24) had facetal pain with no evidence of significant facetal arthropathy on imaging. Fifteen patients had radiological evidence of facetal arthropathy, one had a facet joint synovial cyst, three were post–lumbar surgery patients, and two patients had spondylolysis. Facet joint injections were carried out under fluoroscopic guidance in 39 patients and under CT guidance in 5 cases. Pain relief was assessed using the visual analog scale at 1 h post-procedure and, thereafter, at 1, 4, 12, and 24 weeks.

Results:

A total of 141 facet joints were infiltrated in 44 patients over a 2-year period. There was significant pain relief in 81.8% patients 1 h after the procedure, in 86.3% after 1 week, in 93.3% after 4 weeks, in 85.7% after 12 weeks, and in 62.5% after 24 weeks. No major complications were encountered.

Conclusions:

Facet nerve block was found to be a simple, minimally invasive, and safe procedure. With meticulous patient selection, we achieved long-term success rates of over 60%. We conclude that this method represents an important alternative treatment for nonradicular back pain.

Prosthetic valve endocarditis: a complication of spinal epidural abscess

Epidural injections for chronic low back pain are controversial, and their effectiveness is debated. Although epidural injections are considered a minor procedure with low morbidity, catastrophic complications may occur. We describe a case of prosthetic valve endocarditis secondary to an epidural abscess after epidural injection to alert clinicians to this unusual association.

Spondylodiscitis after facet joint steroid injection: A case report and review of the literature

Spondylodiscitis is a rare complication after facet joint steroid injection. This article presents a 78-y-old male with chronic back pain and facet joint arthritis who developed Pseudomonas aeruginosa L2-L3 and L3-L4 spondylodiscitis after computed tomography-guided facet joint steroid injection. Magnetic resonance imaging, fine needle aspiration and cultures confirmed the diagnosis. The patient was treated with intravenous administration of amikacin, and imipenem plus cilastatin for 4 weeks, followed by oral administration of ciprofloxacin for another 10 weeks. Sterile preparation prior to facet joint steroid injection should be stressed. To the best of our knowledge, this is the only reported case of iatrogenic spondylodiscitis after facet joint steroid injection. This iatrogenic complication should be considered in the risk-benefit analysis of facet joint diagnostic or therapeutic injections.

Lumbar radiculopathy after zygapophyseal joint injection

We report a case of lumbar radiculopathy after zygapophyseal joint injections for chronic low back pain. The management of the patient and potential causes for the radiculopathy are discussed. The case acts as a reminder that the spinal nerve roots should be considered when performing intra-articular facet joint injections and demonstrates the importance of including nerve injury in the patient consent process as a rare, but significant complication.

Paraspinal abscess communicated with epidural abscess after extra-articular facet joint injection

Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 x 10(9) per liter, an erythrocyte sedimentation rate of 52 mm/hour, and 10.88 mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.

Septic Arthritis of Lumbar Facet Joints Without Predisposing Infection

Septic arthritis of a lumbar facet joint is a rare clinical entity and most articles have reported a single case. There have been few studies that have evaluated the clinical and imaging features of septic arthritis of lumbar facet joints. The clinical data of 5 patients diagnosed with septic arthritis of lumbar facet joints were retrospectively studied. The average age of 5 patients was 73.6 years. All patients had elevated temperature at admission (37.7 degrees C). Leukocyte count was tested in all 5 patients and was elevated in only 2 patients. Erythrocyte sedimentation rate and C-reactive protein were examined and were elevated in all 5 cases. Magnetic resonance imaging was accurate in identifying the septic joint and associated abscess formation. All patients were treated with bed rest and received intravenous antibiotics for an average of 33.3 days. Four of 5 patients had positive outcomes with full recoveries and no evidence of recurrent infections. One patient exhibited evidence of recurrent infection and required open facet arthrotomy and paraspinal muscle debridement after intravenous administration of antibiotics. Septic arthritis of the lumbar facet joint is a rare cause of low back pain. It is important to ascertain the diagnosis at the earliest possible stage and to start intravenous antibiotics therapy as soon as possible. Magnetic resonance imaging is quite a sensitive modality for identifying infection of the lumbar facet joint. Familiarity with its clinical symptoms and radiographic features is necessary to avoid misdiagnosis of this condition.

Spontaneous pyogenic facet joint infection

OBJECTIVE

To analyze the clinical features, approaches to management, and outcome of spontaneous pyogenic facet joint infection (PFJI) in adults.

PATIENTS AND METHODS

Case series of 10 adults with microbiologically proven PFJI diagnosed during a 10-year period in a teaching hospital, plus a review of 32 additional cases previously reported (PubMed 1972 to 2003). Patients with prior spinal instrumentation or surgery and injection drug users were excluded. Only cases that were sufficiently detailed to be individually analyzed were included. These 32 cases, together with our 10 patients, form the basis of the present analysis.

RESULTS

PFJI represented nearly 20% of all spontaneous pyogenic spinal infection diagnosed in our hospital during a 10-year period. This data suggest that PFJI is more common than was previously thought. Of the 42 patients with PFJI, 26 (62%) were men and 16 (38%) were women, with ages ranging from 20 to 86 years (mean age, 59+/-15 years); 55% of patients were older than 60 years. The most common location of infections was the lumbosacral region (86%). All patients presented with severe back pain; fever was noted in 83% of the cases and neurological impairment in nearly 48%. In 38% of patients a systemic predisposing factor for infection was present; the most common conditions were diabetes mellitus, malignancies, and alcoholism. In almost 36% of cases, one or more concomitant infectious processes due to the same microorganism was found, mainly arthritis, skin and soft-tissue infections, endocarditis, and urinary tract infections. Staphylococcus aureus was the most common etiologic microorganism (86% of cases). Bacteremia was documented in 81% of the cases. The diagnosis of PFJI was based mainly on imaging study findings. Paraspinal and/or epidural extension was frequent (81% of cases), but its presence did not indicate a worse prognosis. Medical treatment alone was usually successful. The overall prognosis of PFJI was good, with a mortality rate of only 2%. The great majority of patients were cured without functional sequelae.

CONCLUSION

Incidence data from our institution reveal that PFJI is not a rare condition, representing approximately 20% of all pyogenic spinal infections. This entity should be considered in the differential diagnosis of patients with low back pain, especially in the presence of fever, whatever the patient's immunological status.

Septic Facet Joint Arthritis after a Corticosteroid Facet Injection

Lumbar facet joint injections are commonly employed in the treatment of low back pain and are considered to be relatively safe with few known complications. We report the case of septic facet arthritis following a periarticular facet injection in a patient with recurrent urinary tract infections. The literature is reviewed to identify epidemiological and clinical features of patients in whom septic facet arthritis developed after lumbar facet injection. The diagnosis of iatrogenic septic facet arthritis is often delayed because neurologic and constitutional signs and symptoms develop slowly. Serologic nonspecific markers of infection and appropriate imaging studies may be more sensitive for the early diagnosis of septic facet arthritis. Recalcitrant or worsening back pain after facet injections should prompt an investigation to rule out infectious causes.

Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the Case Report Literature

OBJECTIVE

The primary objective is to document the first case report of discitis after a lumbar epidural corticosteroid injection. The second objective is to analyze the case report literature to identify clinical features and trends of patients with infectious complications after spinal injections.

DESIGN

Single case report. A MEDLINE and EMBASE literature search was conducted using key words from the names of commonly performed spinal procedures, including epidural corticosteroid, selective nerve root, transforaminal epidural, facet joint, and sacroiliac joint injections.

SETTING

Pain medicine clinic at a tertiary medical center.

PATIENT

A 64-year-old man with an 8-year history of left lower extremity radicular pain and recurrent pulmonary infections was referred for a lumbar epidural corticosteroid injection. Six weeks following the injection, the patient returned with a 4-week history of worsening right-sided paraspinous pain without associated recurrent pneumonia. Magnetic resonance imaging revealed a right-sided L5-S1 disc extrusion with discitis and a right L5-S1 discectomy was performed. Cultures of disc material and blood showed growth of coagulase-negative Staphylococcus, and a transesophageal echocardiogram showed no evidence of endocarditis. The patient received 6 weeks of intravenous antibiotics and he had symptomatic recovery at 3-month follow-up.

RESULTS

Including our patient, the literature search identified 27 case reports of infectious complications. Similar clinical features and significant trends were evident in five categories including predisposing factors, symptom presentation, diagnostic evaluation, etiological organisms, and treatment outcomes.

CONCLUSIONS

The identified clinical features and trends could prove useful to the practitioner when an infectious complication is suspected or has occurred.

Delayed presentation of septic arthritis of a lumbar facet joint after diagnostic facet joint injection

We report the case of a 46-year-old, otherwise healthy, man with chronic lower back pain and no evidence of nerve root compression who underwent diagnostic facet joint injections to assist in establishing where his pain sources were located and to try to help his spinal rehabilitation program. He presented with a facet joint infection 2 months after injection, in a manner that was indistinguishable from an acute intervertebral disc herniation. The diagnosis was confirmed on magnetic resonance imaging, and he was successfully treated with surgical debridement and antibiotics. Septic arthritis of a lumbar facet joint with an associated paraspinal abscess is a rare complication of facet joint infiltration with only two similar cases reported in the literature. We propose that this diagnosis be considered in patients who have undergone diagnostic facet joint injection who subsequently deteriorate with back and leg pain without another apparent cause.

Chronic inflammatory granuloma mimics clinical manifestations of lumbar spinal stenosis after acupuncture: a case report

STUDY DESIGN

A case report and review of the literature.

OBJECTIVES

To present a case of chronic inflammatory epidural granuloma formed after acupuncture.

SUMMARY OF THE BACKGROUND DATA

A number of cases of complications resulting from acupuncture have been reported, including acute infection, hemorrhage, and direct injury to internal organs or neural tissues. However, to the best of our knowledge, there has been no report of epidural granuloma formed following acupuncture and mimicking clinical manifestations of lumbar stenosis.

METHODS

A 68-year-old woman suffered from low back pain and sciatica aggravated by acupuncture. We reviewed her medical record, imaging studies, microscopic findings of the mass, and related literature.

RESULTS

Microscopic examination revealed the mass as a chronic inflammatory granuloma. From her previous history and imaging study, the mass, which compressed the lumbar forth nerve and dural sac,was highly suspected to have been formed after acupuncture. Surgical decompression and excision of the epidural mass relieved her symptoms.

CONCLUSION

Chronic inflammatory granuloma may be formed as a complication of acupuncture. Under such circumstances, surgical excision of the mass may be an effective way of relieving the symptoms.

Septic arthritis of bilateral lumbar facet joints: report of a case with MRI findings in the early stage

STUDY DESIGN

A case is reported.

OBJECTIVE

To report and discuss a case of septic arthritis of bilateral lumbar facet joints with contiguous extension into the paraspinal musculature without infection of the vertebral body or disc space.

SUMMARY OF BACKGROUND DATA

Septic arthritis of a lumbar facet joint is a rare cause of low back pain, and only a few cases have been described. If the condition is not associated with epidural or paraspinal abscess formation and self-limiting, the correct diagnosis may be overlooked. To the author's knowledge, septic arthritis of bilateral facet joints has not been previously described in the literature.

METHODS

A 72-year-old woman without any systemic illness was hospitalized because of acute severe back pain and high fever. Examination showed local tenderness over the lower lumbar region. Magnetic resonance imaging showed widened facet joints, abscess in the joints, and paraspinal involvement, which aided diagnosis and preoperative planning.

RESULTS

The infection did not respond to intravenous antibiotics therapy, so a thorough debridement of the bilateral facet joints was performed. At the latest follow-up assessment, the patient remained afebrile and had a marked reduction of low back pain.

CONCLUSIONS

Septic arthritis of the lumbar facet joint is a rare cause of low back pain. It is important to ascertain the diagnosis at the earliest possible stage and to start intravenous antibiotics therapy as soon as possible. Magnetic resonance imaging is a quite sensitive method for identifying infection of the lumbar facet joint. Surgical debridement may be necessary if antibiotic therapy fails.

Hematogenous pyogenic facet joint infection

STUDY DESIGN

Retrospective.

OBJECTIVES

To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections.

SUMMARY OF BACKGROUND DATA

There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases.

METHODS

This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment.

RESULTS

A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37).

CONCLUSIONS

Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.