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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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Ertilav E, Akyol A, Aydin ON. Posterior Reversible Encephalopathy Syndrome after caudal epidural steroid ınjection: A case report. Pain Pract 2021; 21:974-977. [PMID: 34233073 DOI: 10.1111/papr.13057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Caudal epidural injections are easy, effective, and safe methods and are good options for patients with low back pain and radicular lower extremity pain. Although various complications related to the technique of the procedure or the drugs used in the procedure have been described, Posterior Reversible Encephalopathy Syndrome (PRES) has not yet been defined for this intervention. CASE In this case report, we describe a case of PRES, which we supported with MRI findings in our patient who developed convulsions, changes in consciousness, and vision loss after being administered with caudal epidural steroid, and whose imaging findings regressed with the regression of clinical symptoms during the treatment process. CONCLUSION Although PRES is rarely reported, it should be kept in mind that it is a complication that can develop after caudal epidural steroid injection.
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Affiliation(s)
- Esra Ertilav
- Algology-Neurology Department, Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | - Ali Akyol
- Algology-Neurology Department, Adnan Menderes University Medical Faculty, Aydın, Turkey
| | - Osman Nuri Aydin
- Algology-Anesthesiology Department, Adnan Menderes University Medical Faculty, Aydın, Turkey
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3
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Eisenberg E, Goldman R, Schlag-Eisenberg D, Grinfeld A. Adhesive arachnoiditis following lumbar epidural steroid injections: a report of two cases and review of the literature. J Pain Res 2019; 12:513-518. [PMID: 30774420 PMCID: PMC6357879 DOI: 10.2147/jpr.s192706] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Lumbar epidural steroid injections (LESIs) are commonly used for managing lower back pain (LBP) and radicular pain. LESIs are generally considered safe with only rare serious complication. One very rare complication that is frequently cited in the literature is adhesive arachnoiditis. However, a literature search failed to detect even one published manuscript, clearly documenting LESI induced arachnoiditis. This article presents two patients who received a transforaminal L5–S1 and two L3–L4 interlaminar LESIs. Although the presented patients developed clear radiological (MRI) findings of arachnoiditis, they were not accompanied by any improvement or deterioration in their clinical condition. The article also reviews the literature on the prevalence, pathogenesis, diagnosis, and clinical features of adhesive arachnoiditis. Literature suggests that adhesive arachnoiditis following LESIs is a rare entity, which – as seen in our patients – has clear radiological characteristics but uncertain pathogenesis. It has a large spectrum of clinical presentation, ranging from an incidental finding to a serious neurological sequela. In at least some patients with adhesive arachnoiditis following LESI, the radiological and clinical findings may fail to correlate with each other. In light of the fact that LESI is one of the most commonly performed procedures for managing LBP, clinicians should be aware of this rare yet existing entity.
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Affiliation(s)
- Elon Eisenberg
- Pain Research Unit, Institute of Pain Medicine, Rambam Health Care Campus, Haifa, Israel, .,B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel,
| | | | | | - Anat Grinfeld
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
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Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, van Kleef M, Rathmell JP, Van Zundert J. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. Pain Pract 2018; 19:61-92. [PMID: 29756333 PMCID: PMC7379698 DOI: 10.1111/papr.12709] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review. METHODS A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. RESULTS Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected. CONCLUSION Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Jasper de Jong
- Department of Pain Management, Westfriesgasthuis, Hoorn, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - James P Rathmell
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium.,Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
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5
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Stretching of roots contributes to the pathophysiology of radiculopathies. Joint Bone Spine 2018; 85:41-45. [DOI: 10.1016/j.jbspin.2017.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/05/2017] [Indexed: 12/26/2022]
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Seo YT, Kong HH, Lee GJ, Bang HJ. Persistent cauda equina syndrome after caudal epidural injection under severe spinal stenosis: a case report. J Pain Res 2017; 10:1425-1429. [PMID: 28652808 PMCID: PMC5476633 DOI: 10.2147/jpr.s134636] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Caudal epidural injection (CEI) is one of the most common treatments for low-back pain with sciatica. CEI rarely leads to neurologic complications. We report a case of persistent cauda equina syndrome after CEI. A 44-year-old male patient with severe L4 and L5 spinal ste-nosis underwent CEI for low-back pain and sciatica. The CEI solution consisted of bupivacaine, hyaluronidase, triamcinolone acetonide, and normal saline. He experienced motor weakness and sensory loss in both lower extremities and neurogenic bladder for more than 1 year after the procedure. His ankle dorsiflexors, big-toe extensors, and ankle plantar flexors on both sides were checked and categorized as motor-power Medical Research Council grade 0. His bilateral ankle-jerk reflection was absent. An electrophysiological study showed lumbosacral polyradiculopathy affecting both sides of the L5 and S1 nerve roots. A urodynamic study revealed hypoactive neurogenic bladder affecting both sacral roots.
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Affiliation(s)
- Young Tak Seo
- Department of Rehabilitation Medicine, Chungbuk National University Hospital
| | - Hyun Ho Kong
- Department of Rehabilitation Medicine, Chungbuk National University Hospital
| | - Goo Joo Lee
- Department of Rehabilitation Medicine, Chungbuk National University Hospital
| | - Heui Je Bang
- Department of Rehabilitation Medicine, Chungbuk National University Hospital.,Department of Rehabilitation Medicine, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
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Singla A, Yang S, Werner BC, Cancienne JM, Nourbakhsh A, Shimer AL, Hassanzadeh H, Shen FH. The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery. J Neurosurg Spine 2017; 26:645-649. [DOI: 10.3171/2016.9.spine16484] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVELumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion.METHODSA nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI.RESULTSThe overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1–3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI.CONCLUSIONSLumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.
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Affiliation(s)
- Anuj Singla
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Scott Yang
- 2Children's Orthopaedic Center, Children's Hospital Los Angeles, California
| | - Brian C. Werner
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jourdan M. Cancienne
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ali Nourbakhsh
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Adam L. Shimer
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Hamid Hassanzadeh
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Francis H. Shen
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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Lee Y, Kim JS, Kim JY. Cervical Meningomyelitis After Lumbar Epidural Steroid Injection. Ann Rehabil Med 2015; 39:504-7. [PMID: 26161360 PMCID: PMC4496525 DOI: 10.5535/arm.2015.39.3.504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 09/05/2014] [Indexed: 11/05/2022] Open
Abstract
Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement.
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Affiliation(s)
- Yujin Lee
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Joon-Sung Kim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Ji Yeon Kim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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9
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Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015; 5:129-46. [DOI: 10.2217/pmt.14.53] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
SUMMARY Epidural steroid injections (ESIs), which can provide significant but temporary pain relief in well-selected patients, are the most commonly performed procedure in pain management. The anatomy of the epidural space provides a framework for understanding risks associated with ESIs, a topic relevant to both patients and physicians in interventional pain, surgery and primary care. Safety considerations of epidural steroids include drug preparation and myriad physiological effects stemming from steroid exposure. Although major complications associated with ESI occur rarely, potentially catastrophic events resulting from infectious, hematologic and neurologic morbidity may lead to permanent injury. The safety profile of ESIs may improve with development and dissemination of sound injection technique, safer compounds manufactured in a sterile manner and deficient of thromboembolic potential and the application of existing technology.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology, Critical Care & Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - David Chang
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - Steven P Cohen
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, 707 North Broadway, Baltimore, MD 21205, USA
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