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Manchikanti and Hirsch: In Response to Risks and Pitfalls of Epidural Injections during Management of Lumbar Disc Herniation: Few Comments
Letters to Editor

The Korean Journal of Pain 2015; 28(3): 219-220.

Published online: 1 July 2015

DOI: https://doi.org/10.3344/kjp.2015.28.3.219

In Response to Risks and Pitfalls of Epidural Injections during Management of Lumbar Disc Herniation: Few Comments

Laxmaiah Manchikanti, Joshua A. Hirsch*

Pain Management Center of Paducah, Paducah, and University of Louisville, Louisville, KY, USA.

*Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Correspondence to: Laxmaiah Manchikanti. Pain Management Center of Paducah, Paducah, and University of Louisville, Louisville, KY, 2831, Lone Oak Road, Paducah, Kentucky 42003, USA. Tel: +1-270-554-9412, Fax: +1-270-554-8987, drlm@thepainmd.com

Received 1 April 2015       Accepted 3 April 2015

Copyright © The Korean Pain Society, 2015

(open-access, http://creativecommons.org/licenses/by-nc/3.0/):

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

LETTERS TO EDITORS

We appreciate comments on our manuscript of the Comparison of Efficacy Caudal, Interlaminar, and Transforaminal Epidural Injections in Managing Lumbar Disc Herniation: Is One Method Superior to the Other? [1]. There has been extensive information in reference to the spinal cord infarction due to embolization of particulate steroids, but, also due to needle induced vasospasm, mechanical disruption of radiculomedullary arteries and compression from an epidural abscess or hematoma as probable mechanisms of spinal cord injury in patients undergoing various types of epidural injections [2345678910]. However, no such complications were reported in our manuscript [1]. In fact, we have previously demonstrated a lack of complications in our series [11]. The authors might consider reviewing the manuscript by Atluri et al in reference to lumbar transforaminal epidural injections [9]. All the complications reported with lumbar transforaminal epidural injections have been related to the safe or superior triangle. An infraneural approach appears to be the safest approach. In this trial of transforaminal injections, we have utilized an infraneural approach and occasionally a supraneural approach. Further, the majority of the injections were performed at L5 and S1 with a blunt needle [12]. No post lumbar surgery patients were included. These straightforward precautions assist in avoiding the complications. In addition, we also used a nonparticulate steroid initially until it became unavailable. At present, there is no significant evidence to show the efficacy of nonparticulate steroids available in the present format, so we are unable to recommend nonparticulate steroids; however, there was no significant difference between local anesthetic and steroids [121314151617181920]. In fact, the local anesthetic group fared better than the steroid group [12]. Consequently, we would recommend an infraneural approach and initially utilizing local anesthetic and particulate steroid with appropriate selection criteria for optimal results and to avoid any such complications.

References

1. Manchikanti L, Singh V, Pampati V, Falco FJ, Hirsch JA. Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other? Korean J Pain. 2015; 28:11–21. PMID: 25589942.
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2. Manchikanti L, Falco FJ, Benyamin RM, Gharibo CG, Candido KD, Hirsch JA. Epidural steroid injections safety recommendations by the Multi-Society Pain Workgroup (MPW): more regulations without evidence or clarification. Pain Physician. 2014; 17:E575–E588. PMID: 25247907.
3. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015; 122:974–984. PMID: 25668411.
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4. Manchikanti L, Candido KD, Singh V, Gharibo CG, Boswell MV, Benyamin RM, et al. Epidural steroid warning controversy still dogging FDA. Pain Physician. 2014; 17:E451–E474. PMID: 25054397.
5. Manchikanti L, Falco FJ. Safeguards to prevent neurologic complications after epidural steroid injections: analysis of evidence and lack of applicability of controversial policies. Pain Physician. 2015; 18:E129–E138. PMID: 25794211.
6. Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep. 2015; 19:482. PMID: 25795154.
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7. Engel A, King W, MacVicar J. Standards Division of the International Spine Intervention Society. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014; 15:386–402. PMID: 24308846.
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8. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine (Phila Pa 1976). 2007; 32:1249–1256. PMID: 17495784.
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10. Shah RV. Paraplegia following thoracic and lumbar transforaminal epidural steroid injections: how relevant are particulate steroids? Pain Pract. 2014; 14:297–300. PMID: 24152137.
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11. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012; 15:131–140. PMID: 22430650.
12. Manchikanti L, Cash KA, Pampati V, Falco FJ. Transforaminal epidural injections in chronic lumbar disc herniation: a randomized, double-blind, active-control trial. Pain Physician. 2014; 17:E489–E501. PMID: 25054399.
13. Manchikanti L, Nampiaparampil DE, Manchikanti KN, Falco FJ, Singh V, Benyamin RM, et al. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: a systematic review of randomized controlled trials. Surg Neurol Int. 2015; 6:S194–S235. PMID: 26005584.
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14. Manchikanti L, Benyamin RM, Falco FJ, Kaye AD, Hirsch JA. Do epidural injections provide short- and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res. 2015; 473:1940–1956. PMID: 24515404.
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15. Manchikanti L, Nampiaparampil DE, Candido KD, Bakshi S, Grider JS, Falco FJ, et al. Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review. Pain Physician. 2015; 18:39–60. PMID: 25675059.
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16. Manchikanti L, Kaye AD, Manchikanti K, Boswell M, Pampati V, Hirsch J. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015; 5:e23139. PMID: 25789241.
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17. Bicket MC, Gupta A, Brown CH 4th, Cohen SP. Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the control injections in randomized controlled trials. Anesthesiology. 2013; 119:907–931. PMID: 24195874.
18. Manchikanti L, Falco FJ, Pampati V, Hirsch JA. Lumbar interlaminar epidural injections are superior to caudal epidural injections in managing lumbar central spinal stenosis. Pain Physician. 2014; 17:E691–E702. PMID: 25415784.
19. Manchikanti L, Pampati V, Benyamin RM, Boswell MV. Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: local anesthetic alone vs. local combined with steroids. Int J Med Sci. 2015; 12:214–222. PMID: 25678838.
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20. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013; 16:S49–S283. PMID: 23615883.
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