title: Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study.
abstract: BACKGROUND
  Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety.
  
  
  OBJECTIVE
  To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines.
  
  
  METHODS
  Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events.
  
  
  RESULTS
  There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event.
  
  
  CONCLUSIONS
  Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.
authors.forename: Christine A
authors.initials: CA
authors.lastname: El-Yahchouchi
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Plastaras
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Maus
authors.forename: Carrie M
authors.initials: CM
authors.lastname: Carr
authors.forename: Zachary L
authors.initials: ZL
authors.lastname: McCormick
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Geske
authors.forename: Matthew
authors.initials: M
authors.lastname: Smuck
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Pingree
authors.forename: David J
authors.initials: DJ
authors.lastname: Kennedy
mesh_terms: D000328:Adult; D000368:Aged; D000767:Anesthesia, Epidural / Q000009:adverse effects* / Q000639:trends*; D015331:Cohort Studies; D005260:Female; D046748:Hematoma, Epidural, Spinal / Q000139:chemically induced; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects / Q000639:trends; D008297:Male; D008875:Middle Aged; D018908:Muscle Weakness / Q000139:chemically induced; D013256:Steroids / Q000008:administration & dosage* / Q000009:adverse effects*
chemical_list: D013256:Steroids