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Epidural Steroid Injection Complicated by Intrathecal Entry, Pneumocephalus, and Chemical Meningitis
The Journal of Emergency Medicine, Vol. 51, No. 3, pp. 265–268, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.05.040
Selected Topics: Neurological Emergencies
EPIDURAL STEROID INJECTION COMPLICATED BY INTRATHECAL ENTRY, PNEUMOCEPHALUS, AND CHEMICAL MENINGITIS Aakash Kaushik Shah, MD, MBA, MSC,* Andrey Bilko, MD,† and James Kimo Takayesu, MD, MS* *Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts and †Department of Anesthesiology, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania Reprint Address: Aakash Kaushik Shah, MD, MBA, MSC, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, 5 Emerson Place, Boston, MA 02114.
, Abstract—Background: Epidural steroid injections are frequently used to treat back and extremity pain. The procedure is generally safe, with a low rate of adverse events, including intrathecal entry, pneumocephalus, and chemical meningitis. Case Report: We report a case of a 45-year-old woman who presented to the emergency department (ED) with headache, nausea, vomiting, and photophobia after a lumbar epidural steroid injection. She was afebrile and had an elevated white blood cell count. A non-contrast computed tomography scan of the head revealed pneumocephalus within the subarachnoid space and lateral ventricles. The patient was admitted to the ED observation unit for pain control and subsequently developed a marked leukocytosis and worsening meningismus. A lumbar puncture was performed yielding cerebrospinal fluid (CSF) consistent with meningitis (1,000 total nucleated cells, 89% neutrophils, 85 mg/dL total protein, and no red blood cells). Gram stain revealed no bacteria. The patient was admitted on empiric vancomycin and ceftriaxone. Antibiotics were discontinued at 48 h when CSF cultures remained negative and the patient was clinically asymptomatic. Why Should an Emergency Physician Be Aware of This?: Emergency physicians should consider intrathecal entry and pneumocephalus in patients who present with a headache after an epidural intervention. The management of pneumocephalus includes supportive therapies, appropriate positioning, and supplemental oxygen. These symptoms can be accompanied by fever, leukocytosis, and markedly inflammatory CSF findings consistent with bacterial or chemical meningitis. Empiric treatment with broad-spectrum antibiotics should be initiated until
CSF culture results are available. All rights reserved.
Ó 2016 Elsevier Inc.
, Keywords—intrathecal injection; pneumocephalus; chemical meningitis; epidural steroid injection; epidural intervention; headache
INTRODUCTION Epidural steroid injections are frequently used to treat back and extremity pain due to herniated disks, foraminal stenosis, and central canal stenosis (1). These injections are generally well tolerated with a low rate of adverse events (2). Minor complications include pain at the injection site, pre-syncope, vasovagal reactions, facial flushing, and postural headache (3). Case reports of major complications, including intrathecal entry, pneumocephalus, subarachnoid hemorrhage, respiratory depression, and cardiopulmonary arrest, are uncommonly reported (4 7). In this article, we report a case of a lumbar epidural steroid injection complicated by intrathecal entry, pneumocephalus, and chemical meningitis. CASE REPORT A 45-year-old woman with a history of obesity, cervical radiculopathy, and low back pain presented to the emergency department (ED) with headache, nausea, vomiting,
RECEIVED: 12 February 2016; FINAL SUBMISSION RECEIVED: 6 May 2016; ACCEPTED: 17 May 2016 265
266
and photophobia 90 min after receiving a lumbar epidural steroid injection at a local outpatient pain clinic. She had undergone the same procedure 3 months earlier with significant symptomatic relief of her radicular low back pain without complication. During the procedure, the patient was seated, draped in sterile fashion, and given subcutaneous lidocaine for local anesthesia. The needle was advanced toward the desired interspace, with positioning assessed using tactile feedback and confirmed fluoroscopically. Two milliliters of a 0.5% lidocaine solution containing 80 mg methylprednisolone and 12 mg betamethasone were then injected. Residual medication in the tubing was cleared by saline flush and the needle was withdrawn. As she was leaving the clinic, the patient reported dizziness and difficulty ambulating. After arriving home approximately 30 min after the procedure, the patient developed a sudden-onset severe headache accompanied by nausea, emesis, and photophobia. The headache was described as global, constant, throbbing, and positional (worse with sitting up and slightly better with lying down). Given the severity of her symptoms, she was brought to ED by ambulance.
A. K. Shah et al.
On arrival, she was uncomfortable appearing, afebrile, and hemodynamically stable with no focal neurologic deficits on examination. She was given 4 mg intravenous (IV) ondansetron and 10 mg IV metoclopramide, 4 mg IV morphine, and a 1-L bolus of normal saline. Basic laboratory tests were notable for a white count of 12.97 K/uL. Although post-dural puncture headache was the most likely diagnosis, the differential diagnosis included subarachnoid hemorrhage, subdural hematoma, or pneumocephalus. She underwent a STAT non-contrast head CT scan that revealed multiple small foci of air within the subarachnoid space and ventricles with no evidence of herniation or hemorrhage (Figure 1). A diagnosis of pneumocephalus was made and she was transferred to the observation unit for symptomatic treatment and serial neurologic examinations. The following day, the patient reported mild improvement of her symptoms. She remained afebrile and hemodynamically stable with no change on her physical examination. Her morning laboratory tests, however, were notable for a marked increase in her white count from 12.97 K/uL to 24.90 K/uL. A lumbar puncture was performed, given concern for iatrogenic meningitis
Figure 1. Non-contrast computed tomography scan of the head revealed multiple small pockets of air within the subarachnoid space and lateral ventricles (indicated by arrows on bottom row of images).
Complications of Epidural Steroid Injection
and she was empirically started on vancomycin and ceftriaxone. Her cerebrospinal fluid (CSF) results revealed a significant inflammatory response with 1,000 total nucleated cells, 89% neutrophils, 85 mg/dL total protein, and no red blood cells in the fourth tube of CSF fluid. CSF and blood cultures were also sent. The differential diagnosis included both bacterial and chemical meningitis. Magnetic resonance imaging of her spine was performed to assess for epidural or spinal abscesses and was negative. Urinalysis and a chest x-ray studies were negative for any source of occult infection. She was admitted to the general medical service for IV antibiotics, supportive treatment, and monitoring. The next day, 48 h after the onset of her headache, she reported that her symptoms had completely resolved. She remained afebrile and hemodynamically stable with an unremarkable examination. Her white count had decreased from 25.50 K/uL to 12.79 K/uL and her CSF cultures had no growth to date. Given that she was asymptomatic, her white count was down trending, and cultures had no growth for 48 h, a diagnosis of chemical meningitis was made. She was discharged the next day with return precautions. DISCUSSION Several cases of intrathecal entry and pneumocephalus after epidural interventions (e.g., epidural steroid injection, blood patch, catheter placement) have been reported in the literature (8). Nearly all presented with headache, often accompanied by nausea and vomiting, as the chief complaint (8). This complication is most commonly observed in procedures using the loss of resistance to air (LORA) technique, in which clinicians rely on tactile feedback from an air-filled syringe to verify the position of the needle. Multiple studies have linked LORA to higher rates of inadvertent dural puncture and pneumocephalus vs. alternative techniques, such as loss of resistance to saline (LORS) (9 11). A study of 3,730 patients receiving epidural steroid injections for chronic pain found that 94% of pneumocephalus cases involved LORA compared with 0% of cases involving LORS (10). The mainstay of treatment for pneumocephalus includes providing supportive management, positioning the head of the bed moderately below the horizontal, and providing the patient supplementary oxygen (8). The role of supplementary oxygen in treating pneumocephalus is well established and attributed to decreasing the partial pressure of nitrogen, which accelerates the absorption of air collections within the CSF (12). Isolated cases of intrathecal entry, pneumocephalus, and chest discomfort, cardiopulmonary arrest, or respiratory depression after epidural interventions have also been reported. In each of these cases, the symptoms
267
were most likely due to complications other than pneumocephalus. In one case, chest discomfort reported after a lumbar epidural steroid injection was also complicated by thoracic pneumorrhachis at the level of pain (6). Cardiopulmonary arrest occurring during a cervical lumbar epidural steroid injection was believed to be secondary to a blockade of the cardio-acceleratory fibers at the site of injection (4). The case of marked respiratory depression observed after epidural catheter placement in another case was likely due to the introduction of morphine directly into the CSF (7). Cases of chemical meningitis after intrathecal spinal anesthesia, as opposed to epidural interventions, have also been observed. These cases presented with headache, photophobia, and fever shortly after the procedure (13 15). Subsequent CSF findings in these cases were also initially concerning for bacteria with elevated nucleated cell counts with a neutrophilic predominance, but no bacterial organisms were seen on staining or subsequent culture. These findings suggest that the mechanism of chemical meningitis was most likely unintended intrathecal entry of the injected solution. It is unclear, however, which component of the injected solution induced the chemical meningitis and if the patient was now at increased risk for chemical meningitis during subsequent epidural interventions. Fortunately, the prognosis of chemical meningitis is extremely favorable, with most cases resolving within 10 days without significant intervention (14,15). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? In summary, emergency physicians should consider intrathecal entry and pneumocephalus in patients who present with a headache within hours to days of an epidural intervention. Treatment includes supportive therapies, appropriate positioning, and supplemental oxygen. Subsequent development of fever, leukocytosis, and markedly inflammatory CSF findings may indicate bacterial or chemical meningitis. Physicians should initiate empiric treatment with broad-spectrum antibiotics until CSF culture results are available. REFERENCES 1. Wilkinson IM, Cohen SP. Epidural steroid injections. Curr Pain Headache Rep 2012;16:50–9. 2. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med 2011;12:726–31. 3. Huston CW, Slipman CW, Garvin C, et al. Complications and side effects of cervi- cal and lumbosacral selective nerve root injections. Arch Phys Med Med Rehabil 2005;86:277–83. 4. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical epidural injection. Pain Physician 2012;15:147–52.
268 5. Gu¨zel M, Salt O, Erenler AK, et al. Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia. Am J Emerg Med 2014;32:945. 6. Ergenoglu P, Bali C, Akin S, et al. Pneumorrhachis and pneumocephalus with severe chest pain symptom: a rare complication of epidural steroid injection. Pain Med 2014;15:1239–40. 7. Lin H, Wu H, Peng T, et al. Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia: a case report. Acta Anaesthesiol Sin 1997;35:119–23. 8. Verdun AV, Cohen SP, Williams BS, et al. Pneumocephalus after lumbar epidural steroid injection: a case report and review of the literature. Anesth Analg Case Rep 2014;3:9–13. 9. Schier R, Guerra D, Aguilar J, et al. Epidural space identification: a meta-analysis of complications after air versus liquid as the medium for loss of resistance. Anesth Analg 2009;109:2012–21.
A. K. Shah et al. 10. Aida S, Taga K, Yamakura T, et al. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998; 88:76–81. 11. Yentis SM. Time to abandon loss of resistance to air. Anaesthesia 1997;52:184. 12. Dexter F, Reasoner DK. Theoretical assessment of normobaric oxygen therapy to treat pneumocephalus. Anesthesiology 1996;84: 442–7. 13. Bert A, Laasberg L. Aseptic meningitis following spinal anesthesia—a complication of the past? Anesthesiology 1985;62: 674–7. 14. Nishimura C, Tsubokawa K, Kasama S, et al. Two cases of chemical meningitis following spinal anesthesia. J Anesth 2001;15:111–3. 15. Tateno F, Sakakibara R, Kishi M, et al. Bupivacaine-induced chemical meningitis. J Neurol 2010;257:1327–9.
http://dx.doi.org/10.1016/j.jemermed.2016.05.040
Selected Topics: Neurological Emergencies
EPIDURAL STEROID INJECTION COMPLICATED BY INTRATHECAL ENTRY, PNEUMOCEPHALUS, AND CHEMICAL MENINGITIS Aakash Kaushik Shah, MD, MBA, MSC,* Andrey Bilko, MD,† and James Kimo Takayesu, MD, MS* *Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts and †Department of Anesthesiology, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania Reprint Address: Aakash Kaushik Shah, MD, MBA, MSC, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, 5 Emerson Place, Boston, MA 02114.
, Abstract—Background: Epidural steroid injections are frequently used to treat back and extremity pain. The procedure is generally safe, with a low rate of adverse events, including intrathecal entry, pneumocephalus, and chemical meningitis. Case Report: We report a case of a 45-year-old woman who presented to the emergency department (ED) with headache, nausea, vomiting, and photophobia after a lumbar epidural steroid injection. She was afebrile and had an elevated white blood cell count. A non-contrast computed tomography scan of the head revealed pneumocephalus within the subarachnoid space and lateral ventricles. The patient was admitted to the ED observation unit for pain control and subsequently developed a marked leukocytosis and worsening meningismus. A lumbar puncture was performed yielding cerebrospinal fluid (CSF) consistent with meningitis (1,000 total nucleated cells, 89% neutrophils, 85 mg/dL total protein, and no red blood cells). Gram stain revealed no bacteria. The patient was admitted on empiric vancomycin and ceftriaxone. Antibiotics were discontinued at 48 h when CSF cultures remained negative and the patient was clinically asymptomatic. Why Should an Emergency Physician Be Aware of This?: Emergency physicians should consider intrathecal entry and pneumocephalus in patients who present with a headache after an epidural intervention. The management of pneumocephalus includes supportive therapies, appropriate positioning, and supplemental oxygen. These symptoms can be accompanied by fever, leukocytosis, and markedly inflammatory CSF findings consistent with bacterial or chemical meningitis. Empiric treatment with broad-spectrum antibiotics should be initiated until
CSF culture results are available. All rights reserved.
Ó 2016 Elsevier Inc.
, Keywords—intrathecal injection; pneumocephalus; chemical meningitis; epidural steroid injection; epidural intervention; headache
INTRODUCTION Epidural steroid injections are frequently used to treat back and extremity pain due to herniated disks, foraminal stenosis, and central canal stenosis (1). These injections are generally well tolerated with a low rate of adverse events (2). Minor complications include pain at the injection site, pre-syncope, vasovagal reactions, facial flushing, and postural headache (3). Case reports of major complications, including intrathecal entry, pneumocephalus, subarachnoid hemorrhage, respiratory depression, and cardiopulmonary arrest, are uncommonly reported (4 7). In this article, we report a case of a lumbar epidural steroid injection complicated by intrathecal entry, pneumocephalus, and chemical meningitis. CASE REPORT A 45-year-old woman with a history of obesity, cervical radiculopathy, and low back pain presented to the emergency department (ED) with headache, nausea, vomiting,
RECEIVED: 12 February 2016; FINAL SUBMISSION RECEIVED: 6 May 2016; ACCEPTED: 17 May 2016 265
266
and photophobia 90 min after receiving a lumbar epidural steroid injection at a local outpatient pain clinic. She had undergone the same procedure 3 months earlier with significant symptomatic relief of her radicular low back pain without complication. During the procedure, the patient was seated, draped in sterile fashion, and given subcutaneous lidocaine for local anesthesia. The needle was advanced toward the desired interspace, with positioning assessed using tactile feedback and confirmed fluoroscopically. Two milliliters of a 0.5% lidocaine solution containing 80 mg methylprednisolone and 12 mg betamethasone were then injected. Residual medication in the tubing was cleared by saline flush and the needle was withdrawn. As she was leaving the clinic, the patient reported dizziness and difficulty ambulating. After arriving home approximately 30 min after the procedure, the patient developed a sudden-onset severe headache accompanied by nausea, emesis, and photophobia. The headache was described as global, constant, throbbing, and positional (worse with sitting up and slightly better with lying down). Given the severity of her symptoms, she was brought to ED by ambulance.
A. K. Shah et al.
On arrival, she was uncomfortable appearing, afebrile, and hemodynamically stable with no focal neurologic deficits on examination. She was given 4 mg intravenous (IV) ondansetron and 10 mg IV metoclopramide, 4 mg IV morphine, and a 1-L bolus of normal saline. Basic laboratory tests were notable for a white count of 12.97 K/uL. Although post-dural puncture headache was the most likely diagnosis, the differential diagnosis included subarachnoid hemorrhage, subdural hematoma, or pneumocephalus. She underwent a STAT non-contrast head CT scan that revealed multiple small foci of air within the subarachnoid space and ventricles with no evidence of herniation or hemorrhage (Figure 1). A diagnosis of pneumocephalus was made and she was transferred to the observation unit for symptomatic treatment and serial neurologic examinations. The following day, the patient reported mild improvement of her symptoms. She remained afebrile and hemodynamically stable with no change on her physical examination. Her morning laboratory tests, however, were notable for a marked increase in her white count from 12.97 K/uL to 24.90 K/uL. A lumbar puncture was performed, given concern for iatrogenic meningitis
Figure 1. Non-contrast computed tomography scan of the head revealed multiple small pockets of air within the subarachnoid space and lateral ventricles (indicated by arrows on bottom row of images).
Complications of Epidural Steroid Injection
and she was empirically started on vancomycin and ceftriaxone. Her cerebrospinal fluid (CSF) results revealed a significant inflammatory response with 1,000 total nucleated cells, 89% neutrophils, 85 mg/dL total protein, and no red blood cells in the fourth tube of CSF fluid. CSF and blood cultures were also sent. The differential diagnosis included both bacterial and chemical meningitis. Magnetic resonance imaging of her spine was performed to assess for epidural or spinal abscesses and was negative. Urinalysis and a chest x-ray studies were negative for any source of occult infection. She was admitted to the general medical service for IV antibiotics, supportive treatment, and monitoring. The next day, 48 h after the onset of her headache, she reported that her symptoms had completely resolved. She remained afebrile and hemodynamically stable with an unremarkable examination. Her white count had decreased from 25.50 K/uL to 12.79 K/uL and her CSF cultures had no growth to date. Given that she was asymptomatic, her white count was down trending, and cultures had no growth for 48 h, a diagnosis of chemical meningitis was made. She was discharged the next day with return precautions. DISCUSSION Several cases of intrathecal entry and pneumocephalus after epidural interventions (e.g., epidural steroid injection, blood patch, catheter placement) have been reported in the literature (8). Nearly all presented with headache, often accompanied by nausea and vomiting, as the chief complaint (8). This complication is most commonly observed in procedures using the loss of resistance to air (LORA) technique, in which clinicians rely on tactile feedback from an air-filled syringe to verify the position of the needle. Multiple studies have linked LORA to higher rates of inadvertent dural puncture and pneumocephalus vs. alternative techniques, such as loss of resistance to saline (LORS) (9 11). A study of 3,730 patients receiving epidural steroid injections for chronic pain found that 94% of pneumocephalus cases involved LORA compared with 0% of cases involving LORS (10). The mainstay of treatment for pneumocephalus includes providing supportive management, positioning the head of the bed moderately below the horizontal, and providing the patient supplementary oxygen (8). The role of supplementary oxygen in treating pneumocephalus is well established and attributed to decreasing the partial pressure of nitrogen, which accelerates the absorption of air collections within the CSF (12). Isolated cases of intrathecal entry, pneumocephalus, and chest discomfort, cardiopulmonary arrest, or respiratory depression after epidural interventions have also been reported. In each of these cases, the symptoms
267
were most likely due to complications other than pneumocephalus. In one case, chest discomfort reported after a lumbar epidural steroid injection was also complicated by thoracic pneumorrhachis at the level of pain (6). Cardiopulmonary arrest occurring during a cervical lumbar epidural steroid injection was believed to be secondary to a blockade of the cardio-acceleratory fibers at the site of injection (4). The case of marked respiratory depression observed after epidural catheter placement in another case was likely due to the introduction of morphine directly into the CSF (7). Cases of chemical meningitis after intrathecal spinal anesthesia, as opposed to epidural interventions, have also been observed. These cases presented with headache, photophobia, and fever shortly after the procedure (13 15). Subsequent CSF findings in these cases were also initially concerning for bacteria with elevated nucleated cell counts with a neutrophilic predominance, but no bacterial organisms were seen on staining or subsequent culture. These findings suggest that the mechanism of chemical meningitis was most likely unintended intrathecal entry of the injected solution. It is unclear, however, which component of the injected solution induced the chemical meningitis and if the patient was now at increased risk for chemical meningitis during subsequent epidural interventions. Fortunately, the prognosis of chemical meningitis is extremely favorable, with most cases resolving within 10 days without significant intervention (14,15). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? In summary, emergency physicians should consider intrathecal entry and pneumocephalus in patients who present with a headache within hours to days of an epidural intervention. Treatment includes supportive therapies, appropriate positioning, and supplemental oxygen. Subsequent development of fever, leukocytosis, and markedly inflammatory CSF findings may indicate bacterial or chemical meningitis. Physicians should initiate empiric treatment with broad-spectrum antibiotics until CSF culture results are available. REFERENCES 1. Wilkinson IM, Cohen SP. Epidural steroid injections. Curr Pain Headache Rep 2012;16:50–9. 2. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med 2011;12:726–31. 3. Huston CW, Slipman CW, Garvin C, et al. Complications and side effects of cervi- cal and lumbosacral selective nerve root injections. Arch Phys Med Med Rehabil 2005;86:277–83. 4. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical epidural injection. Pain Physician 2012;15:147–52.
268 5. Gu¨zel M, Salt O, Erenler AK, et al. Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia. Am J Emerg Med 2014;32:945. 6. Ergenoglu P, Bali C, Akin S, et al. Pneumorrhachis and pneumocephalus with severe chest pain symptom: a rare complication of epidural steroid injection. Pain Med 2014;15:1239–40. 7. Lin H, Wu H, Peng T, et al. Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia: a case report. Acta Anaesthesiol Sin 1997;35:119–23. 8. Verdun AV, Cohen SP, Williams BS, et al. Pneumocephalus after lumbar epidural steroid injection: a case report and review of the literature. Anesth Analg Case Rep 2014;3:9–13. 9. Schier R, Guerra D, Aguilar J, et al. Epidural space identification: a meta-analysis of complications after air versus liquid as the medium for loss of resistance. Anesth Analg 2009;109:2012–21.
A. K. Shah et al. 10. Aida S, Taga K, Yamakura T, et al. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998; 88:76–81. 11. Yentis SM. Time to abandon loss of resistance to air. Anaesthesia 1997;52:184. 12. Dexter F, Reasoner DK. Theoretical assessment of normobaric oxygen therapy to treat pneumocephalus. Anesthesiology 1996;84: 442–7. 13. Bert A, Laasberg L. Aseptic meningitis following spinal anesthesia—a complication of the past? Anesthesiology 1985;62: 674–7. 14. Nishimura C, Tsubokawa K, Kasama S, et al. Two cases of chemical meningitis following spinal anesthesia. J Anesth 2001;15:111–3. 15. Tateno F, Sakakibara R, Kishi M, et al. Bupivacaine-induced chemical meningitis. J Neurol 2010;257:1327–9.