Letter to the Editor: A report of spinal subdural abscess provides incomplete and inaccurate information

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TO THE EDITOR: The report by Kraeutler et al.5 describing spinal subdural abscess following epidural steroid injection provides incomplete information, leaving the reader with multiple questions (Kraeutler MJ, Bozzay JD, Walker MP, et al: Spinal subdural abscess following epidural steroid injection. J Neurosurg Spine 22:90–93, January 2015). The patient in this case underwent transforaminal steroid injection 24 days prior to his presentation; however, the only information available in this regard is that the procedure was performed under fluoroscopy by an orthopedic spine specialist without complication. No antibiotics were given, and the authors failed to describe sterile precautions, including

TO THE EDITOR: The report by Kraeutler et al.5 describing spinal subdural abscess following epidural steroid injection provides incomplete information, leaving the reader with multiple questions (Kraeutler MJ, Bozzay JD, Walker MP, et al: Spinal subdural abscess following epidural steroid injection. J Neurosurg Spine 22:90–93, January 2015). The patient in this case underwent transforaminal steroid injection 24 days prior to his presentation; however, the only information available in this regard is that the procedure was performed under fluoroscopy by an orthopedic spine specialist without complication. No antibiotics were given, and the authors failed to describe sterile precautions, including the wearing of a mask and sterile gloves, or the type of steroid injected (that is, whether it was methylprednisolone belonging to the contaminated group). Neither did the authors describe the level of the procedure performed or the side. The data showed that the patient had an L5–S1 disc bulge with persistent left neural foraminal narrowing and possible left S-1 nerve root impingement, which was consistent with prior findings. However, clinical examination revealed that strength in his right lower extremity had decreased with intact sensation, whereas it was only mildly decreased in his left lower extremity. Thus, questions arise regarding not only the sterile precautions, but also the side of the procedure, the lack of correlation between MRI findings, and the type of steroid utilized.

In addition, it appears that the MRI study that missed the diagnosis of spinal subdural abscess was performed without administering contrast agent. The authors' Discussion includes the Coumans and Walcott2 report of an epidural abscess following an epidural injection at T-7 that had been administered 11 weeks earlier. In this regard, Kraeutler and colleagues missed that this report specifically stresses the rapid progression of lumbar subdural empyema following an acromial bursal injection, which had been administered 2 days before the patient's presentation. Further, the patient in that report2 also underwent a facet injection at T6–7. The case appears to be an instance of steroid and interventional overuse and again lacks information on sterile precautions. This practice does not correlate with Interventional Pain Management guidelines.6 In addition, multiple cases of spinal subdural abscess, though rare, have secondary causes related to hematogenous spread from remote infection, contiguous spread from decubitus ulcers, and epidural catheterizations, but are mainly attributable to intravenous drug use.4,6

Tan et al.17 have responded to this case report with comments against epidural injections and in favor of surgery. However, they,17 like Kraeutler et al.,5 have relied heavily on a single flawed randomized trial with inappropriate references3,8 and have omitted a multitude of studies performed with what we believe is a more relevant design.9–11,13

Transforaminal epidural injections are associated with significant complications, including paraplegia, especially when they are performed utilizing the safe triangle approach with particulate steroids.1,15,16 These complications can be avoided by using an infraneural approach. Tan et al.17 described only epidural injections performed in central spinal stenosis.3 Further, the case report by Kraeutler et al. described the treatment performed for disc herniation rather than spinal stenosis. Consequently, it may be more appropriate to consider literature related to the effectiveness of epidural injections in disc herniation rather than spinal stenosis only,7,12,14 of alternative approaches for transforaminal epidural injections,1,15,16 of other routes of administration including caudal and lumbar interlaminar routes,13,14 and finally of local anesthetic alone without steroids.12–14

References

  • 1

    Atluri SGlaser SEShah RVSudarshan G: Needle position analysis in cases of paralysis from transforaminal epidurals: Consider alternative approaches to traditional techniques. Pain Physician 16:3213342013

  • 2

    Coumans JVWalcott BP: Rapidly progressive lumbar subdural empyema following acromial bursal injection. J Clin Neurosci 18:156215632011

  • 3

    Friedly JLComstock BATurner JAHeagerty PJDeyo RASullivan SD: A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 371:11212014

  • 4

    Khalil JGNassr ADiehn FECampeau NGAtkinson JLSia IG: Thoracolumbar spinal subdural abscess: Magnetic resonance imaging appearance and limited surgical management. Spine (Phila Pa 1976) 38:E844E8472013

  • 5

    Kraeutler MJBozzay JDWalker MPJohn K: Spinal subdural abscess following epidural steroid injection. J Neurosurg Spine 22:90932015

  • 6

    Manchikanti LAbdi SAtluri SBenyamin RMBoswell MVBuenaventura RM: An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician 16:2 SupplS49S2832013

  • 7

    Manchikanti LBenyamin RMFalco FJKaye ADHirsch JA: Do epidural injections provide short- and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res 473:194019562015

  • 8

    Manchikanti LCandido KDKaye ADBoswell MVBenyamin RMFalco FJE: Randomized trial of epidural injections for spinal stenosis published in the New England Journal of Medicine: Further confusion without clarification. Pain Physician 17:E475E4882014

  • 9

    Manchikanti LCash KAMcManus CDDamron KSPampati VFalco FJE: A randomized, double-blind controlled trial of lumbar interlaminar epidural injections in central spinal stenosis: 2-year follow-up. Pain Physician 18:79922015

  • 10

    Manchikanti LCash KAMcManus CDPampati VFellows B: Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician 15:3713842012

  • 11

    Manchikanti LKaye ADManchikanti KNBoswell MVPampati VHirsch JA: Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med 5:e231392015

  • 12

    Manchikanti LNampiaparampil DECandido KDBakshi SGrider JSFalco FJE: Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review. Pain Physician 18:39602015

  • 13

    Manchikanti LNampiaparampil DEManchikanti KNFalco FJESingh VBenyamin RM: Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: a systematic review of randomized controlled trials. Surg Neurol Int 6:S194S2352015

  • 14

    Manchikanti LSingh VPampati VFalco FJEHirsch JA: Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other?. Korean J Pain 28:11212015

  • 15

    Park JWNam HSCho SKJung HJLee BJPark Y: Kambin's triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med 35:8338432011

  • 16

    Park KDLee JJee HPark Y: Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain. Am J Phys Med Rehabil 91:103910502012

  • 17

    Tan LAKasliwal MKDeutsch H: Complications associated with epidural steroid injection. J Neurosurg Spine 22:5585602015

Disclosures

Dr. Hirsch is a consultant for Medtronic and has taught courses for Carefusion. Dr. Manchikanti is a consultant for Semnur Pharmaceuticals Inc.

Response

We thank Dr. Manchikanti et al. for their response to our case report on a spinal subdural abscess occurring after an epidural steroid injection. We would like to respond by answering some of their questions resulting from our report. Prior to the patient's initial presentation, he underwent a left S-1 transforaminal epidural steroid injection through the first dorsal sacral foramen. Sterile precautions were observed including wearing a mask and sterile gloves and cleaning the skin with ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). Kenalog (triamcinolone acetonide), which does not belong to the methylprednisolone acetate group associated with fungal infections, was the steroid used for this injection.2 However, there have been 2 remote cases of a spinal epidural abscess occurring after epidural steroid injection of triamcinolone.1,3 Both of the patients in these case reports had a history of diabetes mellitus, which was notably absent in our patient.

We appreciate the suggestion by Dr. Manchikanti and colleagues to use a Kambin triangle approach. This technique has shown positive outcomes with no significant complications for patients with lumbar spinal stenosis4 and lumbar radicular pain,5 although it is still unclear whether this approach offers benefits specifically to patients with disc herniation. Future studies should focus on comparing outcomes and complication rates between supraneural and Kambin triangle approaches for patients with disc herniations.

References

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Article Information

INCLUDE WHEN CITING Published online January 1, 2016; DOI: 10.3171/2015.7.SPINE15846.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Atluri SGlaser SEShah RVSudarshan G: Needle position analysis in cases of paralysis from transforaminal epidurals: Consider alternative approaches to traditional techniques. Pain Physician 16:3213342013

2

Coumans JVWalcott BP: Rapidly progressive lumbar subdural empyema following acromial bursal injection. J Clin Neurosci 18:156215632011

3

Friedly JLComstock BATurner JAHeagerty PJDeyo RASullivan SD: A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 371:11212014

4

Khalil JGNassr ADiehn FECampeau NGAtkinson JLSia IG: Thoracolumbar spinal subdural abscess: Magnetic resonance imaging appearance and limited surgical management. Spine (Phila Pa 1976) 38:E844E8472013

5

Kraeutler MJBozzay JDWalker MPJohn K: Spinal subdural abscess following epidural steroid injection. J Neurosurg Spine 22:90932015

6

Manchikanti LAbdi SAtluri SBenyamin RMBoswell MVBuenaventura RM: An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician 16:2 SupplS49S2832013

7

Manchikanti LBenyamin RMFalco FJKaye ADHirsch JA: Do epidural injections provide short- and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res 473:194019562015

8

Manchikanti LCandido KDKaye ADBoswell MVBenyamin RMFalco FJE: Randomized trial of epidural injections for spinal stenosis published in the New England Journal of Medicine: Further confusion without clarification. Pain Physician 17:E475E4882014

9

Manchikanti LCash KAMcManus CDDamron KSPampati VFalco FJE: A randomized, double-blind controlled trial of lumbar interlaminar epidural injections in central spinal stenosis: 2-year follow-up. Pain Physician 18:79922015

10

Manchikanti LCash KAMcManus CDPampati VFellows B: Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician 15:3713842012

11

Manchikanti LKaye ADManchikanti KNBoswell MVPampati VHirsch JA: Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med 5:e231392015

12

Manchikanti LNampiaparampil DECandido KDBakshi SGrider JSFalco FJE: Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review. Pain Physician 18:39602015

13

Manchikanti LNampiaparampil DEManchikanti KNFalco FJESingh VBenyamin RM: Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: a systematic review of randomized controlled trials. Surg Neurol Int 6:S194S2352015

14

Manchikanti LSingh VPampati VFalco FJEHirsch JA: Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other?. Korean J Pain 28:11212015

15

Park JWNam HSCho SKJung HJLee BJPark Y: Kambin's triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med 35:8338432011

16

Park KDLee JJee HPark Y: Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain. Am J Phys Med Rehabil 91:103910502012

17

Tan LAKasliwal MKDeutsch H: Complications associated with epidural steroid injection. J Neurosurg Spine 22:5585602015

1

Chan STLeung S: Spinal epidural abscess following steroid injection for sciatica. Case report. Spine (Phila Pa 1976) 14:1061081989

2

Kuehn BM: CDC probes new outbreak associated with compounded steroids. JAMA 309:25412013

3

Knight JWCordingley JJPalazzo MG: Epidural abscess following epidural steroid and local anaesthetic injection. Anaesthesia 52:5765781997

4

Park JWNam HSCho SKJung HJLee BJPark Y: Kambin's triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med 35:8338432011

5

Park KDLee JJee HPark Y: Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain. Am J Phys Med Rehabil 91:103910502012

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