No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Subdural empyema following lumbar facet joint injection: An exceeding rare complication
Abstract
Chronic low back pain is extremely common with a life time prevalence estimated at greater than 70% [1]. Facet joint arthrosis is thought to be the causative aetiological substrate in approximately 25% of chronic low back pain cases [2].
Facet joint injection is a routine intervention in the armamentarium for both the diagnostic and therapeutic management of chronic low back pain. In fact, a study by Carrino et al. reported in excess of 94,000 facet joint injection procedures were carried out in the US in 1999 [3].
Although generally considered safe, the procedure is not entirely without risk. Complications including bleeding, infection, exacerbation of pain, dural puncture headache, and pneumothorax have been described.
We report a rare case of a 47-year-old female patient who developed a left L4/5 facet septic arthrosis with an associated subdural empyema and meningitis following facet joint injection. This case is unique, as to the best of our knowledge no other case of subdural empyema following facet joint injection has been reported in the literature.
Furthermore this case serves to highlight the potential serious adverse sequelae of a routine and apparently innocuous intervention. The need for medical practitioners to be alert to and respond rapidly to the infective complications of facet joint injection cannot be understated.
... Facet joint injections (FJI) with steroidal and/or anesthetic injections have been linked to several infectious complications. These include paraspinal muscle abscesses, cellulitis of the psoas muscle and soft tissues, epidural abscesses, meningitis, spondylodiscitis, subdural empyema, septic arthritis, endocarditis, and generalized infection leading to multiorgan failure and death [17][18][19][20]. The most impressive aspect of these reports is the microbial extension from the facet joint to neighboring areas. ...
... The most impressive aspect of these reports is the microbial extension from the facet joint to neighboring areas. In one case, the tracking of the infection along the nerve root was clearly visualized on imaging [17]. S. aureus is the most frequently implicated organism in FJI-related infections in these cases, in addition to S. epidermidis and Pseudomonas aeruginosa [17][18]20]. ...
... In one case, the tracking of the infection along the nerve root was clearly visualized on imaging [17]. S. aureus is the most frequently implicated organism in FJI-related infections in these cases, in addition to S. epidermidis and Pseudomonas aeruginosa [17][18]20]. It is reasonable to believe that like these organisms, infection with S. caprae after FJI also can extend to nearby structures, including the psoas muscle, vertebrae, and disc spaces. ...
Staphylococcus caprae (S. caprae) is a catalase-positive, coagulase-negative organism that was first isolated from goat milk, and was later found to colonize healthy human skin, nails, and nasal mucosa. Rarely, this commensal organism can become pathogenic in humans. S. caprae has been implicated in a variety of human infections, with the highest incidence being in bone and joint infections. We describe a man who, after receiving facet joint injections for back pain, developed native vertebral discitis, vertebral osteomyelitis with phlegmon, and bilateral psoas abscesses, from which S. caprae was isolated.
후관절병증은 퇴행성 추간판 질환 또는 척추관 협착증과 같은 척추 퇴행성 질환과 잘 동반되는 진행성 퇴행성 질환이다. 요추의 후관절병증은 근위부 하지의 통증을 유발할 수 있지만 그 증상과 영상 소견이 비특이적이기 때문에 추간판 탈출증이나 신경근 압박에 의한 통증과 감별이 어렵다. 또한 치료적 요추 후관절 내 스테로이드 주사는 현재까지 그 근거가 낮다고 분류되어 있으나, 다른 여러 연구들에서는 후관절 내 스테로이드 주사의 치료적 효과를 보고하고 있다. 실제 진료 현장에서는 치료적 후관절 내 스테로이드 주사 시술이 증가하고 있는 추세로, 본 종설에서는 후관절 내 주사에 대한 저자들의 경험을 바탕으로 요추 후관절 내 주사의 임상적 유용성 및 시술의 안전성에 대해서 소개하고자 한다.
Purpose:
Chronic pain is a common condition affecting almost one in five Canadians. One of the methods used to treat chronic pain is injection therapies. While they are considered relatively safe procedures, they do carry inherent risk that can result in adverse events. Our goal was to investigate these patient safety events to identify themes that could be used to shape practice guidelines and standards and improve patient safety.
Methods:
We looked at closed civil legal actions and regulatory college complaints associated with injection therapies for chronic pain in the Canadian Medical Protection Association database from 2015 to 2019. Injury was defined as that arising from, or associated with, plans or actions taken during the provision of health care, rather than an underlying disease or injury.
Results:
Of the 91 cases identified, the most common reported complications were neurologic-related symptoms, injury, and infection. Fifty-eight percent (53/91) of patients experienced health care-related harm that had a negative effect on their health or quality of life. Peer experts were critical of the clinical care provided in 74% (67/91) of the cases. Provider-related (60%, 40/67), team-related (75%, 50/67), and system-related factors (21%, 14/67) were identified as contributing factors in these cases. Common examples of provider-related factors were deficiencies in clinical decision-making (48%, 19/40), failure to follow established procedures (43%, 17/40), and situational awareness (38%, 15/40). Common examples of team-related factors were deficiencies in medical record keeping (80%, 40/50) and communication breakdowns (56%, 28/50). All system-related factors were related to inadequate office procedures.
Conclusion:
We recommend that clinicians conduct appropriate physical examinations, keep up-to-date with clinical standards, and ensure their documentation reflects their assessment, the patient's condition, and the treatment rationale.
Medial branch blockade of the lumbar facet joints is widely performed and generally accepted as a safe intervention. We present a case of neurological damage following a medial branch blockade with local anesthetic and steroid. A patient suffering from chronic low back pain radiating to the buttocks and thighs, underwent 9 medial branch blockades over a few years. Three months after successful back surgery to remove a herniated L2‐3 disc, the pain recurred and left L3‐4, L4‐5 and L5‐S1 medial branch blocks were performed under fluoroscopy. Immediately following the procedure, the patient developed paraparesis to both legs, loss of pinprick but preserved fine touch sensation, proprioception, and sphincter sensory and motor function. MRI showed ischemic lesions of the cauda equina. Direct needle trauma was discounted as a cause, due to the bilateral neurological deficit, plus the lack of pain during the procedure. Particulate steroid preparations can form aggregates, which may embolize and block small terminal arteries, causing neurological damage. Although the patient received 9 sets of injections uneventfully during the previous 36 months, this procedure took place 3 months following spinal surgery. This rare, but catastrophic case of cauda equina syndrome occurred following L3‐4, L4‐5 and L5‐S1 medial branch blockades 3 months after spinal surgery, is believed to be caused by accidental intra‐arterial injection of particulate methylprednisolone, with consequent aggregates causing blockage and ensuing ischemia. Therefore we suggest particulate steroid preparations should not be used in axial spinal injection.
Background:
Interventional spine procedures, such as discography, epidural steroid injections (ESIs), facet joint procedures, and intradiscal therapies, are commonly used to treat pain and improve function in patients with spine conditions. Although infections are known to occur following these procedures, there is a lack of comprehensive studies on this topic in recent years.
Objectives:
To assess and characterize infections following interventional spine procedures.
Study design:
Systematic review.
Methods:
Studies that were published from January 2010 to January 2020 and provided information on infections or infection rates following discography, ESIs, facet joint procedures, and intradiscal therapies were included. PubMed (Medline), EMBASE, and Cochrane Library databases were searched, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Infection data were extracted from included studies, and infection rates were calculated for each procedure type. Case reports and infection-only articles were not included in infection rate calculations.
Results:
Seventy-two studies met the eligibility criteria and were included in the systematic review. The overall incidence of infection across all studies was 0.12% (231/200,588). The majority of studies (n = 51) were linked to ESIs. Infections related to ESIs were more common than those related to discography or facet joint procedures (0.13% [219/174,431] vs. 0% [0/269] or 0.04% [9/25,697], respectively). Intradiscal therapies had the highest calculated rate of infections (1.05%; 2/191). Quality assessments of the included studies ranged widely.
Limitations:
There was an abundance of case reports in comparison to other study designs; to minimize skewing of the analysis, case reports and infection-only articles were not included in the infection rate. Studies that reported combined infection data for multiple procedures could not be included. Many cohort studies and case series were of lower quality because of their retrospective nature. Additionally, the true incidence of infections related to these procedures is unknown because the majority of these infections often go unreported, and information on regions of the spine and procedure details are often lacking.
Conclusions:
Based on our systematic review, the risk of infections following interventional spine procedures appears to be low overall. More studies focusing on infectious complications with larger sample sizes are needed, particularly for intradiscal therapies, in which the microbiome may be an underlying cause of disc infection. To achieve a true incidence of the risk of infections with these procedures, large prospective registries that collect complication rates are necessary.
Objectives
To analyze the incidence and characteristics of intra-articular facet joint injection (FJI)–related adverse events requiring hospitalization and emergency room visits.
Methods
From January 2007 to December 2017, a total of 11,980 FJI procedures in 6066 patients (mean age 66.8 years, range 15–97 years, M:F = 2004:4062) were performed in our department. Of these, we retrospectively reviewed 489 cases in 432 patients who were hospitalized or visited the emergency room within a month of FJI. FJI-related adverse events were classified as procedure-related complications, drug-related systemic events, or uncertain etiology events, on the basis of consensus of two spine radiologists. This is a descriptive study without statistical analysis.
Results
There were 101 FJI-related adverse event cases in 99 patients (mean age 71.8 years, range 39–97 years, M:F = 39:60). The overall incidence of FJI-related adverse events was 0.84% (101/11,980) per case and 1.63% (99/6066) per patient. The incidence of procedure-related complications and drug-related systemic adverse events was 0.07% (8/11,980) and 0.15% (18/11,980), respectively; the rate of uncertain etiology events was 0.63% (75/11,980). All eight procedure-related complication cases involved major complications. There are seven cases of infectious spondylitis and one was progression of systemic aspergillosis to the spine. One patient died of an uncontrolled infection with infective endocarditis, and two patients experienced partial recovery with neurological sequelae.
Conclusions
The overall incidence of FJI-related adverse events is low, and procedure-related major complications are rare without dural puncture or epidural hematoma. Nevertheless, infection can occur, resulting in serious outcomes.
Key Points
• The incidence of FJI-related adverse events requiring hospitalization or ER visit was 0.84%.
• The incidence of major procedure-related complications was 0.07%.
• All major complications were associated with infection and there were no cases of epidural hematoma.
Facet joints have been shown to be a source of chronic low back pain, and it is generally accepted in clinical practice that diagnostic and therapeutic facet joint injections are the most reliable technique for the treatment of facet joint pain, which is considered to be an easy and safe procedure. Serious complications and side effects are uncommon after facet joint injection. However, infectious complications including septic arthritis, epidural abscess, meningitis and endocarditis have been reported following facet joint injections. We report here the first case of death following lumbar facet joint injection due to generalized infection.
Facet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice.
Five hundred consecutive patients with chronic, non-specific spine pain were evaluated. The prevalence of facet joint pain was determined using controlled comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by 0.25% bupivacaine), in accordance with the criteria established by the International Association for the Study of Pain (IASP). The study was performed in the United States in a non-university based ambulatory interventional pain management setting.
The prevalence of facet joint pain in patients with chronic cervical spine pain was 55% 5(95% CI, 49%-61%), with thoracic spine pain was 42% (95% CI, 30%-53%), and in with lumbar spine pain was 31% (95% CI, 27%-36%). The false-positive rate with single blocks with lidocaine was 63% (95% CI, 54%-72%) in the cervical spine, 55% (95% CI, 39%-78%) in the thoracic spine, and 27% (95% CI, 22%-32%) in the lumbar spine.
This study demonstrated that in an interventional pain management setting, facet joints are clinically important spinal pain generators in a significant proportion of patients with chronic spinal pain. Because these patients typically have failed conservative management, including physical therapy, chiropractic treatment and analgesics, they may benefit from specific interventions designed to manage facet joint pain.
Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 x 10(9) per liter, an erythrocyte sedimentation rate of 52 mm/hour, and 10.88 mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.
Many theories have been presented regarding the pathologic changes that underlie low back pain. The subject is still far from settled, although year by year knowledge of the condition improves. To any one who studies the skeleton, the vertebrae particularly, and their anatomy, the importance of the articular facets in the function of the spinal column must be obvious. Further study of a series of spinal columns will reveal that in many of them are changes around the articular facets which must produce symptoms.The articular facets must be regarded as the only true joints in the spinal column.1 As true joints, hyaline cartilage covers their surfaces and synovial membrane lines their articular capsules. This articular capsule is more redundant and loose in the cervical region than in the lower portion of the spinal column. It has seemed to me that many of the aches and pains which are
Injection of irritant fluid precisely into the facet joint causes referred pain patterns indistinguishable from the pain complaints frequently associated with the "disk syndrome." Even straight leg raising and diminished reflex signs can be obliterated by precise local anesthetic injection into the facet joint. The use of radiographically localized injection of steroids and local anesthetic into the facet joint has been presented as a diagnostic-therapeutic procedure. Clinical experience with a group of 100 consecutive patients suggests that this treatment alone can achieve long-term relief in one-fifth of the patients with lumbago and sciatica and partial relief in another one-third of these patients. This information suggests that the structures related to the facet joint can be a persistent contributor to the chronic pain complaints of individuals with low back and leg pain.
Epidural abscess is a serious complication of epidural block. Because of its low incidence, the risk factors and the symptoms and cause of epidural abscess related to epidural anesthesia and analgesia are not well known by anesthesiologists.
A computer-assisted search of the literature on epidural catheter-related abscess was performed to describe the clinical course and bacteriology of this complication, to determine possible risk factors, and to assess the index of suspicion among physicians.
Forty-two patients with a catheter-related epidural abscess were identified. Only in 15 patients was the correct diagnosis considered initially. The time from insertion of the epidural catheter to symptoms varied between 1 and 60 d. Initial symptoms included back pain, fever, and leukocytosis. The time from symptoms to treatment was a few hours to 108 d. Interval from first symptoms to treatment was significantly longer in patients with persistent neurologic deficits compared with patients who completely recovered. Staphylococcus aureus was the most common etiologic agent. Outcome was reported in 39 patients, but only 19 made a full recovery.
The index of suspicion among anesthesiologists, other physicians and nurses taking care of patients with epidural catheters must be increased for this complication; this should shorten the interval from symptoms to treatment and lower the incidence of neurological sequelae.
Injection to the zygapophysial joint is a procedure which is performed frequently for diagnostic or therapeutic reasons in the management of back pain. It is generally considered to be free of significant complications. We report a patient who developed a paraspinal abscess following a lumbar facet joint injection.
Retrospective.
To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections.
There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases.
This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment.
A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37).
Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.
To evaluate spinal injection procedures for trends in volume, reimbursement, and physician specialty participation.
By using the 1993, 1996, 1998, and 1999 Medicare Part B claims database, we studied Current Procedural Terminology revision 4 codes used for percutaneous spinal injection procedures, including cervical and lumbar discography, disk aspiration and/or injection, facet and/or perifacet joint injection, and epidural steroid injection. For each of these procedures, volume, reimbursement, and physician specialty participation (categorized as radiology, anesthesiology, surgery, physiatry, and other specialties) for each year were recorded.
Despite an overall increase in spinal injection procedure volume and reimbursement from 1993 to 1999, nonradiologists performed most of these procedures. Epidural steroid and facet joint injections had the highest volume and reimbursement during this time period and were performed almost exclusively by nonradiologists (predominantly anesthesiologists). Radiologists performed more discography procedures than did other specialists in 1993, but participation decreased each year, while anesthesiologist participation increased; as of 1999, anesthesiologists performed more discography procedures than did radiologists. Although radiologists performed more disk aspiration procedures than did other specialists, procedure volume remained low during the period studied.
Spinal injection volume and reimbursement have increased substantially in the Medicare population from 1993 to 1999. During this interval, radiologist participation has decreased. Nonradiologists perform most spinal injection procedures.
We report the case of a 46-year-old, otherwise healthy, man with chronic lower back pain and no evidence of nerve root compression who underwent diagnostic facet joint injections to assist in establishing where his pain sources were located and to try to help his spinal rehabilitation program. He presented with a facet joint infection 2 months after injection, in a manner that was indistinguishable from an acute intervertebral disc herniation. The diagnosis was confirmed on magnetic resonance imaging, and he was successfully treated with surgical debridement and antibiotics. Septic arthritis of a lumbar facet joint with an associated paraspinal abscess is a rare complication of facet joint infiltration with only two similar cases reported in the literature. We propose that this diagnosis be considered in patients who have undergone diagnostic facet joint injection who subsequently deteriorate with back and leg pain without another apparent cause.
Low back pain is often treated with paraspinal injections of analgesics and steroids. Infectious complications of these techniques are rare but they can potentially hold high risks for the patients. History and clinical data of all patients admitted to a neurological unit suffering from community acquired purulent meningitis were prospectively analyzed during an 8 year interval (1992 and 2000) with special regard to the previous medical history. One hundred and twenty eight patients were included in the study. Eight out of 128 patients (6.25%) had a history of single or repeated paravertebral (4/8), facet-joint (2/8), peridural (1/8) or spinal (1/8) injections 2-21 days before admission to the hospital. In six out of eight patients either Staphylococcus aureus (4/8) or coagulase-negative staphylococci (2/8) were found in the cerebro spinal fluid (CSF), in two patients no causative organism was detected. One patient died, three survived with sequel. Repeated paraspinal, peridural or spinal injections with analgesic drugs in combination with corticosteroids hold a risk for parameningeal inoculation of bacteria resulting in paraspinal, spinal, and epidural abscesses or meningitis. The absolute frequency of these complications may be rare but they are responsible for a considerable proportion of community acquired purulent CNS infections.
Lumbar facet joint injections are commonly employed in the treatment of low back pain and are considered to be relatively safe with few known complications. We report the case of septic facet arthritis following a periarticular facet injection in a patient with recurrent urinary tract infections. The literature is reviewed to identify epidemiological and clinical features of patients in whom septic facet arthritis developed after lumbar facet injection. The diagnosis of iatrogenic septic facet arthritis is often delayed because neurologic and constitutional signs and symptoms develop slowly. Serologic nonspecific markers of infection and appropriate imaging studies may be more sensitive for the early diagnosis of septic facet arthritis. Recalcitrant or worsening back pain after facet injections should prompt an investigation to rule out infectious causes.
Infectious complications secondary to lumbar facet injections are exceedingly rare, follow an indolent course, and local sequelae include abscess spread or infections of the central nervous system. We present the case of the development of a facet abscess and infective endocarditis, which developed shortly after a lumbar facet injection. With the increase in interventional pain procedures, physicians must be aware of potential infectious complications. © 2007 European Federation of Chapters of the International Association for the Study of Pain.
Systematic literature review.
To explore the available research literature, and provide an up-to-date synthesis of the epidemiology of idiopathic adolescent spinal pain (IASP).
IASP and its potential causes have been a concern to researchers for over 2 decades. Because it has been suggested that IASP is related to the incidence of adult spinal pain, it appears important to synthesize what is currently known about IASP.
A systematic meta-synthesis approach was used to identify secondary review articles and primary epidemiological studies regarding any type of IASP (neck, upper back, or low back).
A total of 56 primary epidemiological (cross-sectional or longitudinal) studies were identified. Spinal or back pain was the most commonly reported measure, with the lifetime prevalence figures ranging from 4.7% to 74.4%. The lifetime prevalence of low back pain had a similar range, 7% to 72%. The prevalence of pain in other areas of the spine (i.e., thoracic spine and neck) was variably reported, as were incidence rates for all areas of the adolescent spine. IASP is thus a significant problem, and the prevalence figures approach those of adults. There is some evidence that IASP is a risk factor for spinal pain in adulthood. However, there was considerable variation in how back pain was defined, the areas of the spine that were reported on, the manner in which data were collected and reported, thus preventing any significant comparisons of prevalence or incidence rates across studies.
Although there is wide discrepancy in the manner in which adolescent spinal pain is reported, it is evident that lifetime prevalence rates increase steadily with age and approximate adult levels by around the age of 18 years. There is an opportunity for further longitudinal research, with standardized methodology, to be undertaken that builds on the findings from this large group of studies.