title: The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature.
abstract: BACKGROUND
  Multiple type of spinal injections, whether epidural/translaminar or transforaminal, facet injections, are offered to patients with/without surgical spinal lesions by pain management specialists (radiologists, physiatrists, and anesthesiologists). Although not approved by the Food and Drug Administration (FDA), injections are being performed with an increased frequency (160%), are typically short-acting and ineffective over the longer-term, while exposing patients to major risks/complications.
  
  
  METHODS
  For many patients with spinal pain alone and no surgical lesions, the "success" of epidural injections may simply reflect the self-limited course of the disease. Alternatively, although those with surgical pathology may experience transient or no pain relief, undergoing these injections (typically administered in a series of three) unnecessarily exposes them to the inherent risks, while also delaying surgery and potentially exposing them to more severe/permanent neurological deficits.
  
  
  RESULTS
  Multiple recent reports cite contaminated epidural steroid injections resulting in meningitis, stroke, paralysis, and death. The Center for Disease Control (CDC) specifically identified 25 deaths (many due to Aspergillosis), 337 patients sickened, and 14,000 exposed to contaminated steroids. Nevertheless, many other patients develop other complications that go unreported/underreported: Other life-threatening infections, spinal fluid leaks (0.4-6%), positional headaches (28%), adhesive arachnoiditis (6-16%), hydrocephalus, air embolism, urinary retention, allergic reactions, intravascular injections (7.9-11.6%), stroke, blindness, neurological deficits/paralysis, hematomas, seizures, and death.
  
  
  CONCLUSIONS
  Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits.
authors: The Albert Einstein College of Medicine, Bronx, 10461, and Chief of Neurosurgical Spine and Education, Department of Neuroscience, Winthrop University Hospital, Mineola, NY, 11501, USA.
authors: Nancy E
authors: NE
authors: Epstein
keywords: Complications; epidural spinal injections; infection; spinal fluid leaks
references: Acta Ortop Mex. 2009 Jul-Aug;23(4):232-6
references: 19960663
references: J Bone Joint Surg Am. 2000 Nov;82(11):1589-93
references: 11097449
references: Pain Physician. 2012 Mar-Apr;15(2):147-52
references: 22430652
references: Spine (Phila Pa 1976). 2005 May 15;30(10):E266-8
references: 15897816
references: Eur Spine J. 2007 Mar;16(3):321-8
references: 16835737
references: PM R. 2009 Jul;1(7):657-68
references: 19627959
references: Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):212-22
references: 19468908
references: Pain Physician. 2012 Mar-Apr;15(2):E143-50
references: 22430660
references: J Bone Joint Surg Br. 2005 Mar;87(3):352-5
references: 15773645
references: Can J Anaesth. 1998 Feb;45(2):110-4
references: 9512843
references: Rheumatology (Oxford). 2005 Nov;44(11):1399-406
references: 16030082
references: Clin Neurol Neurosurg. 2008 Feb;110(2):171-5
references: 17950992
references: MMWR Morb Mortal Wkly Rep. 2012 Oct 19;61(41):839-42
references: 23076093
references: Pain Med. 2004 Jun;5(2):202-5
references: 15209975
references: AJR Am J Roentgenol. 2012 Aug;199(2):419
references: 22826406
references: J Back Musculoskelet Rehabil. 2011;24(2):67-76
references: 21558610
references: Pain Physician. 2006 Oct;9(4):361-6
references: 17066121
references: Reg Anesth. 1989 May-Jun;14(3):149-51
references: 2486595
references: Anesth Analg. 1986 Sep;65(9):938-42
references: 3017152
references: Bull NYU Hosp Jt Dis. 2012;70(1):6-10
references: 22894690
references: Clin J Pain. 2009 Mar-Apr;25(3):206-10
references: 19333170
references: Pain Physician. 2009 Jan-Feb;12(1):163-88
references: 19165302
references: Pain Physician. 2012 Sep-Oct;15(5):371-84
references: 22996849
references: Spine J. 2005 Sep-Oct;5(5):558-63
references: 16153586
references: N Engl J Med. 2012 Dec 6;367(23):2194-203
references: 23131029
references: Ann Rheum Dis. 2003 Jul;62(7):639-43
references: 12810426
references: Spine (Phila Pa 1976). 2007 May 15;32(11):1249-56
references: 17495784
references: Spine (Phila Pa 1976). 2007 Sep 1;32(19):2144-51
references: 17762818
references: Mayo Clin Proc. 2004 May;79(5):682-6
references: 15132414
references: J Clin Anesth. 2009 Aug;21(5):355-9
references: 19700281
references: J Bone Joint Surg Am. 2005 May;87(5):1025-30
references: 15866965
references: Eur Spine J. 2011 Dec;20(12):2228-34
references: 21590496
references: Pain. 1994 Aug;58(2):239-243
references: 7816491
references: Arch Phys Med Rehabil. 2003 May;84(5):627-33
references: 12736872
references: Pain Physician. 2007 Sep;10(5):697-705
references: 17876368
references: Pain Physician. 2012 Mar-Apr;15(2):131-40
references: 22430650
references: N Engl J Med. 1997 Jun 5;336(23):1634-40
references: 9171065
references: Pain Physician. 2010 Sep-Oct;13(5):493-501
references: 20859319
references: Reg Anesth Pain Med. 2011 Nov-Dec;36(6):572-8
references: 22005659
references: Anesth Analg. 2012 Jul;115(1):124-32
references: 22467897