37. Complication of fluoroscopically guided extraforaminal cervical nerve blocks an analysis of 1036 injections

Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S for epidural steroid injection over simple steroid injection or placebo injection, there is no study which tells us whether there is any long term advantage for the patients. PURPOSE: To assess whether epidural steroid injection (ESI) is effective in the treatment of nerve root pathology caused by compression in the lumbar spine secondary to either spinal stenosis or disc prolapse. STUDY DESIGN/SETTING: Design The trial was a prospective randomised controlled trial, patients were randomised either to ESI or intramuscular steroid injection, with minimum two year follow-up. Setting National Health Service Hospital Orthopaedic and Anaesthetic departments. PATIENT SAMPLE: Participants Ninety two patients with symptoms, signs and radiological findings consistent with lumbar nerve root compression suitable for surgical decompression. OUTCOME MEASURES: Main outcome measures The main outcome measures were the Oxford Pain Chart over the first month, Oswestry Disability Index, and the need for surgery. METHODS: Patients completed the Oxford Pain Questionnaire over a thirty five day period to assess the level of apin and the use of pain relieving medications. The patients were followed over a two year period and the main outcome measure was the need for surgical treament of the nerve root compressio during the two year period of the study. RESULTS: There was a significant reduction in pain early on after ESI compared with controls (p⫽⬍0.004) between 10 and 35 days. There was no difference in the long term between the two groups, and the rate of surgery in the two groups was not significantly different. Indeed the rate of surgery was higher in the ESI group than the control group (41% vs. 31%), but this was not significant. A second ESI did not change the likelihood that surgery would be required. CONCLUSIONS: ESI is effective for early pain relief for lumbar nerve root compression. However it does not change the natural history of the condition and does not reduce the ultimate need for surgery. It is probably effect to “buy time” in acute sciatica until improvement occurs naturally. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.037 4:42 37. Complication of fluoroscopically guided extraforaminal cervical nerve blocks an analysis of 1036 injections Daniel Ma, BS, Louis Gilula, MD, K. Daniel Riew, MD; Washington University in St. Louis, St. Louis, MO, USA

BACKGROUND CONTEXT: Despite the popularity of cervical nerve root blocks for therapeutic/diagnostic purposes, complications are not wellestablished. There have been recent case reports of fatal spinal cord infarction, injection into an anterior radicular artery and puncture of the epidural sac of the nerve root sleeve. In a review of English language literature, we were unable to identify any papers devoted to the complications associated with the procedure. PURPOSE: We investigated our experience with cervical nerve root blocks to determine the incidence of complications. STUDY DESIGN/SETTING: Patient films. PATIENT SAMPLE: Patients who had a fluoroscopically guided extraforaminal cervical nerve block at our institution from October 1999 to June 2003. OUTCOME MEASURES: Serious complications (Deaths, paralyses, strokes, spinal cord injuries, and vertebral artery injuries). Minor complications (Dizziness, numbness, transient weakness, some pain, memory loss). METHODS: For the procedure patients were placed in a lateral decubitus position with the side of interest elevated. Sterile precautions with alcohol and betadine solutions were used. Superficial local anesthetic was used prior to placing a 25-gauge 2 or 3-1/2 inch needle into the extraforaminal area under fluoroscopic control to slide along the anterior surface of the articular pillar. Needle was kept as posterior as possible to avoid the veretebral artery. To ascertain that the needle tip was not in a vascular

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structure, contrast material was injected prior to injecting anesthetic/medication mixture. Plain-film radiographs documenting the procedure were taken as part of the standard QA protocol. An independent observer uninvolved with the procedures reviewed a prospectively kept database of all patient films. We subsequently reviewed the records of these patients to identify instances of complications and correlated complications to needle tip position. RESULTS: From October 1999 to June 2003, we performed 1036 fluoroscopically-guided extraforaminal cervical nerve blocks at varying levels of needle tip depth and anterior-posterior placement. There were no instances of the deaths, paralyses, strokes, spinal cord injuries, or vertebral artery injuries described as case reports within the literature. Overall, 17 incidences of minor complications (dizziness, numbness, transient weakness, some pain, and one case of transient global amnesia) were associated with the procedure (1.64%). Furthermore, we did not find any statistically significant difference between a deep injection (n⫽798) and a shallow injection (n⫽238) (2.15%, 0.84%, p⫽0.31.) A statistically significant difference did exist between the incidence of complications associated with a near-perfect posterior placement of the needle tip (n⫽904) and a more anterior placement (n⫽33) (1.44%,6.06%, p⫽0.04.) CONCLUSIONS: As with any invasive procedure, cervical nerve root blocks are associated with potential complications. Case reports can be unnecessarily alarming in that they most often do not provide the incidence of such complications. In this large series of fluoroscopically-guided extraforaminal cervical nerve blocks, we found no instances of catastrophic complications and a small incidence (1.64%) of minor complications. The medial/ lateral needle depth in the frontal view during the procedure does not seem to correlate with complications, though improper needle tip positioning in the lateral view does seem to contribute towards minor complications. A true lateral view is necessary to determine needle tip position in the antero-posterior plane. DISCLOSURES: Device or drug: Corticosteroids. Status: Approved for this indication. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.038 4:49 38. Bone scintigraphy in predicting the outcome of facet joint injection in patients with lower back pain Spiros Pneumaticos, Sofia Chatziioannou, John Hipp, Warren Moore, Stephen Esses; Baylor College of Medicine, Houston, TX, USA BACKGROUND CONTEXT: Facet joint injections are widely used for pain management of low back pain. However, the response of the patients is variable. PURPOSE: The purpose of the present study is to evaluate the utility of bone SPECT in the identification of patients who would benefit from lumbar facet joint injections. STUDY DESIGN/SETTING: The study represents a prospective randomized trial. The protocol was reviewed and approved by the Institutional Review Board at our institution. PATIENT SAMPLE: We prospectively enrolled 47 adult patients with lower back pain who had been diagnosed with facet joint syndrome by the referring physician and were scheduled for facet joint injections. All patients read and signed a consent form. Patients met the following inclusion criteria: a) lower back pain without leg pain; b) been symptomatic for ⬎6 months; c) lower back pain with extension of the lumbar spine, d) imaging evidence (excluding bone scan evidence) of facet joint abnormalities. Patients were excluded from enrollment, if they a) had prior spine surgery or prior facet joint injections; b) had other spine abnormalities (benign or malignant tumors, congenital defects, spondylolysis, spondylolisthesis); c) were unable to tolerate SPECT imaging; d) were pregnant. OUTCOME MEASURES: Outcomes data were analyzed by analysis of variance with post-hoc multiple comparison tests between groups (Stata, College Station, TX). A oneway analysis of variance with Bonferroni