title: Inadvertent disk injection during transforaminal epidural steroid injection: steps for prevention and management.
abstract: OBJECTIVE
  To report two cases of disk injection during transforaminal epidural steroid injection, and to discuss ways to prevent and manage this under-appreciated complication.
  
  
  METHODS
  Case reports and literature reviews.
  
  
  METHODS
  Two patients with radicular symptoms underwent transforaminal epidural steroid injections under fluoroscopic guidance. The needle in both cases was placed in the center of the intervertebral foramen, about 1 cm above the inferior endplate. Injection of contrast in both cases revealed diskographic spread. Repeat magnetic resonance imaging revealed a large foraminal disk herniation in both patients.
  
  
  RESULTS
  A literature search identified three studies whereby the use of a single-needle technique to perform diskography was clearly noted in conjunction with the number of infectious complications. Comparing these data with the incidence of diskitis when a double-needle approach was used found the infectious risk to be considerably higher. There are no data regarding whether imaging studies affect outcomes following epidural steroid injections.
  
  
  CONCLUSIONS
  These cases and similar complications following transforaminal epidural steroid injections provide anecdotal evidence that recent imaging studies, repeated not only for qualitatively new symptoms but after a sustained quantitative increase in pain, may reduce the complication risk. Data extrapolated from studies on diskitis suggest that administering parenteral, and possibly also intradiskal antibiotics, immediately after inadvertent disk injection is appreciated, may reduce the infectious risk.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Pain Management Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. scohen40@jhmi.edu
authors.forename: Steven P
authors.initials: SP
authors.lastname: Cohen
authors.forename: David N
authors.initials: DN
authors.lastname: Maine
authors.forename: Sean M
authors.initials: SM
authors.lastname: Shockey
authors.forename: Sapna
authors.initials: S
authors.lastname: Kudchadkar
authors.forename: Scott
authors.initials: S
authors.lastname: Griffith
mesh_terms: D000368:Aged; D015360:Analgesia, Epidural / Q000009:adverse effects*; D019468:Disease Management; D004824:Epidural Space / Q000000981:diagnostic imaging / Q000187:drug effects; D005539:Foramen Magnum / Q000000981:diagnostic imaging / Q000187:drug effects*; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects; D007403:Intervertebral Disc / Q000000981:diagnostic imaging / Q000187:drug effects*; D017116:Low Back Pain / Q000000981:diagnostic imaging / Q000188:drug therapy; D008297:Male; D011859:Radiography; D013256:Steroids / Q000008:administration & dosage*
chemical_list: D013256:Steroids