Epidural Steroid Injections

Table of contents

• Prospective, Controlled Trials
  • Transforaminal
    • vs. saline/local
    • vs. bupivacaine
    • vs. hyaluronidase
• Interlaminar vs. Transforaminal
• Case Series
• In Lumbar Spinal Stenosis
• Reviews
• Technical Corner
  • The Case for Fluoroscopy
  • Contrast flow patterns
  • Vascular uptake
  • Gadolinium use in lieu of iodinated contrast
  • Various
• Relevant anatomy
  • Artery of Adamkiewicz
  • Vertebral artery
  • Radicular arteries
• Morbidity

Prospective, Controlled Trials

• Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R, Parent F, Levesque J, Bergeron V, Montminy P, Blanchette C. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997 Jun 5;336(23):1634-40. This study was an original randomized controlled, double blinded trial in which 158 patients with sciatica secondary to herniated nucleus pulposus (HNP) were randomized to either epidural steroid injections (up to 3) or saline and were followed for 12 months. Although after three and six weeks followup the steroid group had decreased sensory deficits and decreased finger to floor distance (ie increased lumbar flexion), after 12 months, there was no difference between the groups in Oswestry disability scale or probability of undergoing back surgery. They concluded that in the long run, for patients with sciatica secondary to HNP, epidural steroids do not offer any functional improvement or reduce the need for surgery.

Transforaminal

• Karppinen J, Malmivaara A, Kurunlahti M, Kyllonen E, Pienimaki T, Nieminen P, Ohinmaa A, Tervonen O, Vanharanta H. Periradicular infiltration for sciatica: a randomized controlled trial. Spine. 2001 May 1;26(9):1059-67. Karppinen et al. in 2001 conducted a randomized, double-blind trial to test the efficacy of a periradicular corticosteroid injection for the treatment of sciatica. 160 patients with unilateral symptoms of sciatica of at most 6 months duration and never underwent surgery were randomized for double-blind injection with methylprednisolone-bupivacaine combination or saline. Although leg pain, straight leg testing, lumbar flexion, and patient satisfaction were improved at 2 weeks for the steroid group, back and leg pain were significantly lower in the saline group at 3 and 6 months respectively. By 1 year equal numbers (15 vs. 18) in the steroid and saline group underwent surgery. Overall clinical improvement was seen in both the steroid and saline groups. The steroid group has a quicker immediate improvement at 3-6 months, however this improvement equilibrates with the saline group in the long-term.

• Kraemer J, Ludwig J, Bickert U, Owczarek V, Traupe M. Lumbar epidural perineural injection: a new technique. Eur Spine J. 1997;6(5):357-61.

• Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil. 1998 Nov;79(11):1362-6.

• Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine. 2005 Apr 15;30(8):857-62.This is the first randomized controlled trial to determine the efficacy of a single injection of steroids for chronic radicular pain. Forty-three patients with radicular pain were assigned to an injection of bupivicaine and methylprednisone and forty-three patients to bupivicaine only. At three months followup there was no significant difference between the groups with regard to Oswestry disability index, changes in visual analog scale, or walking distance.

• Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine. 2002 Jan 1;27(1):11-6. In 2002, Vad et al. conducted a randomized, prospective study to compare transforaminal epidural steroid injections to saline trigger-point injections for the treatment of lumbosacral radiculopathy due to a herniated disc. Patients randomized by their own personal preference received either a transforaminal epidural steroid injection or a saline trigger-point injection. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris? score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. They found that the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). This study shows that fluoroscopically guided transforaminal epidural steroid injections can provide symptomatic improvement in radicular symptoms as compared to trigger-point injections.

vs. saline/local

• Anderberg L, Annertz M, Persson L, Brandt L, Saveland H. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J. 2006 Jul 12; This was the first prospective double blinded study which randomized forty patients with cervical radiculopathy to a single transforaminal injection of either steroids/local anesthetic or saline/local anesthetic. At three weeks followup, there were no differences in all outcomes of subjective patient improvement in terms of pain or function.

vs. bupivacaine

• Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am. 2000 Nov;82-A(11):1589-93. Riew et al in 2000 conducted a prospective, randomized, controlled, double-blind study to evaluate whether selective nerve-root blocks decrease the need for an operation in patients with lumbar radicular pain who are otherwise operative candidates. 55 LBP patients who had radiographic evidence of nerve-root compression and had been referred for spine surgery were prospectively randomized into the study. All patients had requested operative intervention. They were randomized to a radiologist who performed a selective nerve-root block with either bupivacaine alone or bupivacaine with betamethasone. 29 of 55 patients ultimately did not have surgery after the injections. 9 out of the 27 patients of the patient who had bupivacaine alone elected not to have the operation. 20 of the 28 patients who had received bupivacaine and betamethasone decided not to have the operation. This study shows that selective nerve-root blocks with corticosteroids are significantly more effective than those of bupivacaine alone. Overall the study suggests that patients with lumbar radicular pain at one or two levels should be considered for treatment with selective nerve-root blocks with corticosteroids prior to being considered for operative intervention.

vs. hyaluronidase

• Devulder J, Deene P, De Laat M, Van Bastelaere M, Brusselmans G, Rolly G. Nerve root sleeve injections in patients with failed back surgery syndrome: a comparison of three solutions. Clin J Pain. 1999 Jun;15(2):132-5.

Interlaminar vs. Transforaminal

• Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician. 2006 Oct;9(4):361-6.This retrospective chart review study of forty patients compared the efficacy of interlaminar versus transforaminal epidural injections in terms of pain, surgical rates, and need for repeat injection in patients with lumbar dics herniations. The authors found that the group which received the transforaminal epidural steroid injections had better short-term pain improvement and fewer long-term surgical interventions than the interlaminar injection group. Full text

• Thomas E, Cyteval C, Abiad L, Picot MC, Taourel P, Blotman F. Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia - a prospective, randomised, double-blind study. Clin Rheumatol. 2003 Oct;22(4-5):299-304. In 2002 Thomas et al conducted a prospective, randomised, double-blind study to compare the efficacies of transforaminal and interspinous epidural corticosteroid injections in lumbar radicular pain. 31 patients radicular pain of less than 3 months duration were randomized to have floroscopically guided transforaminal or blind epidural steroid injections. They found that post treatment outcomes at 6 days, 30 days, and 6 months were all significally better in the transforaminal group. Overall this study showed that the transforaminal steriod injections are more efficacious in treating radicular pain the tradiational epidural steriod injections.

Case Series

• Cyteval C, Fescquet N, Thomas E, Decoux E, Blotman F, Taourel P. Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy. AJNR Am J Neuroradiol. 2006 May;27(5):978-82. Cyteval et al in 2006 conducted a study to evaluate the feasibility, tolerance, and efficacy of transforaminal periganglionic steroid infiltration under CT control. 30 patients with cervical radiculopathy underwent percutaneous periradicular foraminal steroid injection under CT guidance. 16 patients had foraminal degenerative stenosis, and 14 patients had disk herniation. No local complications occurred after the procedure. Pain relief was excellent in 11 patients (37%) and good in seven patients (23%). There was no rebound of pain at the 6-month follow-up. They found that intraforaminal steroid cervical injection produced substantial sustained pain relief and under CT guidance the procedure is safe and allows the precise injection of a steroid to the target.

• Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir (Wien). 2005 Oct;147(10):1065-70; discussion 1070. Epub 2005 Jun 9.

• Lin EL, Lieu V, Halevi L, Shamie AN, Wang JC. Cervical epidural steroid injections for symptomatic disc herniations. J Spinal Disord Tech. 2006 May;19(3):183-6.

• Manchikanti L, Singh V, Rivera JJ, Pampati V, Beyer C, Damron K, Barnhill RC. Effectiveness of caudal epidural injections in discogram positive and negative chronic low back pain. Pain Physician. 2002 Jan;5(1):18-29. Full text

• Michel JL, Lemaire S, Bourbon H, Reynier C, Lhoste A, Soubrier S, Dubost JJ, Ristori JM. Fluoroscopy guided L5-S1 transforaminal injection as a treatement for s1 radiculopathy. J Radiol. 2004 Nov;85(11):1937-41. French.

• Narozny M, Zanetti M, Boos N. 'Therapeutic efficacy of selective nerve root blocks in the treatment of lumbar radicular leg pain.' Swiss Med Wkly. 2001 Feb 10;131(5-6):75-80.

• Papagelopoulos PJ, Petrou HG, Triantafyllidis PG, Vlamis JA, Psomas-Pasalis M, Korres DS, Stamos KG. 'Treatment of lumbosacral radicular pain with epidural steroid injections.' Orthopedics. 2001 Feb;24(2):145-9.

• Rosenberg SK, Grabinsky A, Kooser C, Boswell MV. 'Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience.' Pain Physician. 2002 Jul;5(3):266-70. Full text

• Southern D, Lutz GE, Cooper G, Barre L. 'Are fluoroscopic caudal epidural steroid injections effective for managing chronic low back pain?' Pain Physician. 2003 Apr;6(2):167-72. Full text

• Thomas S, Beevi S. 'Epidural dexamethasone reduces postoperative pain and analgesic requirements: (L'administration peridurale de dexamethasone reduit la douleur et la demande d'analgesiques postoperatoires).' Can J Anaesth. 2006 Sep;53(9):899-905.

• Vallee JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, Vallee CA. 'Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection.' Radiology. 2001 Mar;218(3):886-92.

• Yang SC, Fu TS, Lai PL, Niu CC, Chen LH, Chen WJ. 'Transforaminal epidural steroid injection for discectomy candidates: an outcome study with a minimum of two-year follow-up.' Chang Gung Med J. 2006 Jan-Feb;29(1):93-9.

In Lumbar Spinal Stenosis

• Barre L, Lutz GE, Southern D, Cooper G. 'Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a restrospective evaluation of long term efficacy.' Pain Physician. 2004 Apr;7(2):187-93.

• Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, Slaten WK, Rao S. 'Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study.' Am J Phys Med Rehabil. 2002 Dec;81(12):898-905.

• Cooper G, Lutz GE, Boachie-Adjei O, Lin J. 'Effectiveness of transforaminal epidural steroid injections in patients with degenerative lumbar scoliotic stenosis and radiculopathy.' Pain Physician. 2004 Jul;7(3):311-7.

• Delport EG, Cucuzzella AR, Marley JK, Pruitt CM, Fisher JR. 'Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study.' Arch Phys Med Rehabil. 2004 Mar;85(3):479-84.

Reviews

• Abdi S, Datta S, Lucas LF. 'Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications.' Pain Physician. 2005 Jan;8(1):127-43. Full text

• Boswell MV, Hansen HC, Trescot AM, Hirsch JA. 'Epidural steroids in the management of chronic spinal pain and radiculopathy.' Pain Physician. 2003 Jul;6(3):319-34. Full text

• DePalma MJ, Bhargava A, Slipman CW. 'A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy.' Arch Phys Med Rehabil. 2005 Jul;86(7):1477-83. Review.

• Manchikanti L. 'Transforaminal Lumbar Epidural Steroid injections.' Pain Physician. 2000 Oct;3(4):374-98. Full text

• Manchikanti L. 'Role of neuraxial steroids in interventional pain management.' Pain Physician. 2002 Apr;5(2):182-99. Full text

• Singh V, Manchikanti L. 'Role of caudal epidural injections in the management of chronic low back pain.' Pain Physician. 2002 Apr;5(2):133-48. Full text

• Ogoke BA. 'Caudal epidural steroid injections.' Pain Physician. 2000 Jul;3(3):305-12. Full text

Technical Corner

The Case for Fluoroscopy

• Bartynski WS, Grahovac SZ, Rothfus WE. 'Incorrect needle position during lumbar epidural steroid administration: inaccuracy of loss of air pressure resistance and requirement of fluoroscopy and epidurography during needle insertion.' AJNR Am J Neuroradiol. 2005 Mar;26(3):502-5.This study sought to determine the need for imaging assistance during lumbar epidural steroid injections. Physicians who used the loss of air pressure resistance technique to determine the location of the epidural space for a steroid injection, resulted in an incorrect needle-tip position in 25.7% of the cases. The authors concluded that fluoroscopy and epidurogram were essential to identify correct needle-tip location. Full text.

• Fredman B, Nun MB, Zohar E, Iraqi G, Shapiro M, Gepstein R, Jedeikin R. 'Epidural steroids for treating "failed back surgery syndrome": is fluoroscopy really necessary?' Anesth Analg. 1999 Feb;88(2):367-72. Full text.

• Liu SS, Melmed AP, Klos JW, Innis CA. 'Prospective experience with a 20-gauge Tuohy needle for lumbar epidural steroid injections: Is confirmation with fluoroscopy necessary?' Reg Anesth Pain Med. 2001 Mar-Apr;26(2):143-6.

• Mehta M, Salmon N. 'Extradural block. Confirmation of the injection site by X-ray monitoring.' Anaesthesia. 1985 Oct;40(10):1009-12.

• Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. 'Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration.' AJNR Am J Neuroradiol. 1991 Sep-Oct;12(5):1003-7.

• Stewart HD, Quinnell RC, Dann N. 'Epidurography in the management of sciatica.' Br J Rheumatol. 1987 Dec;26(6):424-9.

• Stitz MY, Sommer HM. 'Accuracy of blind versus fluoroscopically guided caudal epidural injection.' Spine. 1999 Jul 1;24(13):1371-6.

• Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. 'The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns.' Spine. 2002 Mar 1;27(5):509-14.

• White AH, Derby R, Wynne G. 'Epidural injections for the diagnosis and treatment of low-back pain.' Spine. 1980 Jan-Feb;5(1):78-86.

Contrast flow patterns

• Botwin KP, Natalicchio J, Hanna A. 'Fluoroscopic Guided Lumbar Interlaminar Epidural injections: A Prospective Evaluation of Epidurography Contrast Patterns and Anatomical Review of the Epidural Space.' Pain Physician. 2004 Jan;7(1):77-80. Full text

• Goel A, Pollan JJ. 'Contrast flow characteristics in the cervical epidural space: an analysis of cervical epidurograms.' Spine. 2006 Jun 15;31(14):1576-9.

• Manchikanti L, Cash KA, Pampati V, Damron KS, McManus CD. 'Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report.' Pain Physician. 2004 Apr;7(2):217-23. Full text.

Vascular uptake

• Furman MB, O'Brien EM, Zgleszewski TM. 'Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections.' Spine. 2000 Oct 15;25(20):2628-32.

• Furman MB, Giovanniello MT, O'Brien EM. 'Incidence of intravascular penetration in transforaminal cervical epidural steroid injections.' Spine. 2003 Jan 1;28(1):21-5.

• Ho KY. 'Vascular uptake of contrast despite negative aspiration in interlaminar cervical epidural injection.' Pain Physician. 2006 Jul;9(3):267-8. Full text.

• Smuck M, Fuller BJ, Yoder B, Huerta J. 'Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections.' Spine J. 2007 Jan-Feb;7(1):79-82. Epub 2006 Nov 28.

• Stretanski MF, Chopko B. 'Unintentional vascular uptake in fluoroscopically guided, contrast-confirmed spinal injections: a 1-yr clinical experience and discussion of findings.' Am J Phys Med Rehabil. 2005 Jan;84(1):30-5.

• Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, Prather H, Press JM. 'Incidence of intravascular uptake in lumbar spinal injection procedures.' Spine. 2000 Feb 15;25(4):481-6.

Gadolinium use in lieu of iodinated contrast

• Falco FJ, Rubbani M. 'Visualization of spinal injection procedures using gadolinium contrast.' Spine. 2003 Dec 1;28(23):E496-8.

• Safriel Y, Ali M, Hayt M, Ang R. 'Gadolinium use in spine procedures for patients with allergy to iodinated contrast--experience of 127 procedures.' AJNR Am J Neuroradiol. 2006 Jun-Jul;27(6):1194-7.

• Shetty SK, Nelson EN, Lawrimore TM, Palmer WE. 'Use of gadolinium chelate to confirm epidural needle placement in patients with an iodinated contrast reaction.' Skeletal Radiol. 2006 Dec 23

Various

• Dunbar SA, Manikantan P, Philip J. 'Epidural infusion pressure in degenerative spinal disease before and after epidural steroid therapy.' Anesth Analg. 2002 Feb;94(2):417-20, table of contents. Full text.

• Lee JW, Kim SH, Choi JY, Yeom JS, Kim KJ, Chung SK, Kim HJ, Kim C, Kwack KS, Kwon JW, Moon SG, Jun WS, Kang HS. 'Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach.' Korean J Radiol. 2006 Apr-Jun;7(2):139-44. Full text

• Shah RV, Merritt W, Collins D, Racz GB. 'Targeting the Spinal Nerve via A Double-Needle,Transforaminal Approach in Failed Back Surgery Syndrome: Demonstration of A Technique.' Pain Physician. 2004 Jan;7(1):93-7. Full text

Relevant anatomy

Artery of Adamkiewicz

• Biglioli P, Roberto M, Cannata A, Parolari A, Fumero A, Grillo F, Maggioni M, Coggi G, Spirito R. 'Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries.' J Thorac Cardiovasc Surg. 2004 Apr;127(4):1188-92. The arteria radicularis magna level was variable, ranging from T9 to L5. The arteria radicularis magna arose from a lumbar artery in 36 cases (70.5%) and it was left-sided in 32 cases (62.7%).

• Koshino T, Murakami G, Morishita K, Mawatari T, Abe T. Does the Adamkiewicz artery originate from the larger segmental arteries? J Thorac Cardiovasc Surg 1999;117 : 898-905 Full text. Cadaveric study. Range T5 - L2, left sided origin 72%, 2 or more arteries of Adamkiewicz in 26%.

• Kudo K, Terae S, Asano T, Oka M, Kaneko K, Ushikoshi S, Miyasaka K. 'Anterior spinal artery and artery of Adamkiewicz detected by using multi-detector row CT.' AJNR Am J Neuroradiol. 2003 Jan;24(1):13-7. Full text.

• Lo D, Vallee JN, Spelle L, Cormier E, Saillant G, Rancurel G, Chiras J. 'Unusual origin of the artery of Adamkiewicz from the fourth lumbar artery.' Neuroradiology. 2002 Feb;44(2):153-7.

• Nojiri J, Matsumoto K, Kato A, Miho T, Furukawa K, Ohtsubo S, Itoh T, Kudo S. 'The Adamkiewicz artery: demonstration by intra-arterial computed tomographic angiography.' Eur J Cardiothorac Surg. 2007 Feb;31(2):249-55. Epub 2006 Dec 19. Range T8 - L3, left sided origin 63%.

• Ou P, Schmit P, Layouss W, Sidi D, Bonnet D, Brunelle F. 'CT Angiography of the Artery of Adamkiewicz with 64-Section Technology: First Experience in Children.' AJNR Am J Neuroradiol. 2007 Feb;28(2):216-9.

• Takase K, Sawamura Y, Igarashi K, Chiba Y, Haga K, Saito H, Takahashi S. 'Demonstration of the artery of Adamkiewicz at multi- detector row helical CT.' Radiology. 2002 Apr;223(1):39-45. Full text. Two arteries of Adamkiewicz were identified in 24% patients. Left-sided origin 69% with range of T7 - L2.

Vertebral artery

• de Bray JM, Penisson-Besnier I, Giroud M, Klein J, Tanguy JY, Pasco A, Dubas F. 'Cervical deficit radiculopathy in 3 cases of vertebral artery dissection' Rev Neurol (Paris). 1998 Nov;154(11):762-6. Review. French.

• Duthel R, Tudor C, Motuo-Fotso MJ, Brunon J. 'Cervical root compression by a loop of the vertebral artery: case report.' Neurosurgery. 1994 Jul;35(1):140-2.

• Epstein NE, Silvergleid R. 'Magnetic resonance angiographic diagnosis of ectatic vertebral artery.' J Spinal Disord. 1995 Aug;8(4):308-10.

• Hetzel A, Berger W, Schumacher M, Lucking CH. 'Dissection of the vertebral artery with cervical nerve root lesions.' J Neurol. 1996 Feb;243(2):121-5.

• Korinth MC, Mull M. 'Vertebral artery loop causing cervical radiculopathy.' Surg Neurol. 2007 Feb;67(2):172-3. Epub 2006 Oct 4.

• Maiuri F, Iaconetta G, Gallicchio B, Briganti F. 'Coiling of the vertebral artery presenting with neuralgic pain.' Clin Neurol Neurosurg. 1997 Feb;99(1):56-9.

Radicular arteries

• Hoeft MA, Rathmell JP, Monsey RD, Fonda BJ. 'Cervical transforaminal injection and the radicular artery: variation in anatomical location within the cervical intervertebral foramina.' Reg Anesth Pain Med. 2006 May-Jun;31(3):270-4.

Morbidity

• Beckman WA, Mendez RJ, Paine GF, Mazzilli MA. 'Cerebellar herniation after cervical transforaminal epidural injection.' Reg Anesth Pain Med. 2006 May-Jun;31(3):282-5

• Bilir A, Gulec S. 'Cauda equina syndrome after epidural steroid injection: a case report.' J Manipulative Physiol Ther. 2006 Jul-Aug;29(6):492.e1-3.

• Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. 'Complications following cervical epidural steroid injections by expert interventionalists in 2003.' Pain Physician. 2004 Oct;7(4):445-9. Full text

• Everett CR, Baskin MN, Speech D, Novoseletsky D, Patel R. 'Flushing as a side effect following lumbar transforaminal epidural steroid injection.' Pain Physician. 2004 Oct;7(4):427-9. Full text

• Finn KP, Case JL. 'Disk entry: a complication of transforaminal epidural injection--a case report.' Arch Phys Med Rehabil. 2005 Jul;86(7):1489-91. Review.

• Furman MB, Giovanniello MT, O'Brien EM. 'Incidence of intravascular penetration in transforaminal cervical epidural steroid injections.' Spine. 2003 Jan 1;28(1):21-5.

• Glaser SE, Falco F. 'Paraplegia following a thoracolumbar transforaminal epidural steroid injection.' Pain Physician. 2005 Jul;8(3):309-14. Full text

• Guarino AH, Wright NM. '''Pneumocephalus after a lumbar epidural steroid injection. Pain Physician. 2005 Apr;8(2):239-41.

• Ho KY. 'Vascular uptake of contrast despite negative aspiration in interlaminar cervical epidural injection.' Pain Physician. 2006 Jul;9(3):267-8. Full text

• Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. 'Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports.' Spine. 1998 Oct 1;23(19):2137-42; discussion 2141-2.

• Houten JK, Errico TJ. 'Paraplegia after lumbosacral nerve root block: report of three cases.' Spine J. 2002 Jan-Feb;2(1):70-5.

• Huntoon MA, Martin DP. 'Paralysis after transforaminal epidural injection and previous spinal surgery.' Reg Anesth Pain Med. 2004 Sep-Oct;29(5):494-5.

• Kabbara A, Rosenberg SK, Untal C. 'Methicillin-resistant Staphylococcus aureus epidural abscess after transforaminal epidural steroid injection.' Pain Physician. 2004 Apr;7(2):269-72. Full text

• Ludwig MA, Burns SP. 'Spinal cord infarction following cervical transforaminal epidural injection: a case report.' Spine. 2005 May 15;30(10):E266-8.

• Quintero N, Laffont I, Bouhmidi L, Rech C, Schneider AE, Gavardin T, Dizien O. 'Transforaminal epidural steroid injection and paraplegia: case report and bibliographic review' Ann Readapt Med Phys. 2006 Jun;49(5):242-7. Epub 2006 Apr 7. French.

• Tiso RL, Cutler T, Catania JA, Whalen K. 'Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids.' Spine J. 2004 Jul-Aug;4(4):468-74. Review.

• Somayaji HS, Saifuddin A, Casey AT, Briggs TW. 'Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection.' Spine. 2005 Feb 15;30(4):E106-8.

• Ziai WC, Ardelt AA, Llinas RH. 'Brainstem stroke following uncomplicated cervical epidural steroid injection.' Arch Neurol. 2006 Nov;63(11):1643-6.

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