What you do every day is what you do in an emergency
Joe Martin, Battalion Chief, Los Angeles City Fire Department, Retired
A zero complication rate is not attained even in high-reliability organizations, which are considered ultra-safe because they are associated with a 1/10,000,000 complication rate.
We at the APTC take utmost care to prevent complications. We practice only evidence based medicine. We keep informed our patients with all the latest treatment and diagnostic modalities of our specialty. Following are the list of known complications that might result from the interventional procedure. The list is however not exhaustive. Only important ones are discussed for patients general information.
Please fill out the Pain Diary Form and bring it with you on the first follow up appointment. This is mandatory.
Most of the interventional therapeutic procedures are performed under mild sedation. Sedation causes amnesia and reduces anxiety. This in turn improves the patient’s compliance with the treatment protocol. In order to make sure that the effect of sedation does not cause any harm we advise patients:
● Not to operate any motor vehicles, any machinery, or heavy equipment during the first 24 hours after the procedure
● Not to drink alcohol or make important decisions during the first 24 hours after the administration of sedation
● Patients should be accompanied by a competent adult on the day of the procedure so that the patient does not have to drive home
● In elderly patients, the effect of sedation or medicine administered during the procedure might last longer then normal therefore we recommend someone to stay with the patient during the first 24 hours
● After having an interventional procedure, before patients attempt to walk, patients should make sure that someone is available to help should he or she need one. At times, the effects of the local anesthetic become more evident longer than expected. In those situations, to prevent falls, one should make sure that he or she has good strength in the leg muscle and therefore before attempting to stand up, should make sure that help is available to support him or her if that is necessary.
● Elderly patients who normally use canes or walkers, should make sure that those aids are available so that they may use those before they try to walk or try to go to the bathroom. Usually the numbing effect of local anesthesia wears off completely but the duration may be unpredictable.
Profound Weakness in Legs
This is an unintended effect.
● One of the causes of such weakness could be unintended spinal anesthesia. Spinal anesthesia results from administering local anesthetic in to the subarachnoid space which is deep to the epidural space. The subarachnoid space contains spinal cord, its nerves and spinal fluid
● Local anesthesia may cause severe weakness in legs. This condition is reversible as the effect of local anesthesia wears off depending on the type of local anesthetics used
● If the symptoms become evident after discharge, then either the patient should return to the treatment center or should go to the nearest ER. Signs of recovery are manifested by the receding level of the numbness of the skin or gradually improving muscle strength
● If; however, the weakness progresses, then the patient will need to be taken to the ER as soon as possible. Typically an MRI of the spinal cord should be obtained immediately
● One of the known causes is the unintended administration of medication, particularly steroids into the blood vessel supplying the spinal cord. Particulates steroid such as Depo-Medrol, triamcinolone or even Betamethasone might cause this effect
Majority of the causes of headaches after any procedure are benign. They can be: dehydration, withdrawal from caffeine, anxiety, hypoglycemia, high blood pressure, etc. The interventional procedure might exacerbate some chronic headaches. Local anesthetics and even preparation used for cleaning the skin have been blamed. However, some studies have shown that there is only an 18% incidence of benign headaches in patients who had undergone spinal intervention. Benign headaches are usually not bilateral. They get better without intervention.
Post Dural Puncture (PDPH) or Meningeal Puncture Headache (MPH)
If the headache is in the back of skull or in the occipital area (27% cases ), frontal area (25% cases ) and both (47% cases), or behind the eyeball and is worse within 15 minutes of sitting or standing up and gets better after 15 minutes of lying down, it is probably PDPH.
● The physician should be informed about this headache immediately. Usually the headache is always on both sides of the head. The onset is normally after 12 hours of the procedure and may take up to 48 hours to manifest. The headache is described as dull aching, pressure sensation and throbbing type. Occasionally it may be associated with hearing loss, tinnitus or hyperacusis (sound intolerance)
● The headache might also be associated with nausea, vomiting, both shoulder pain and neck pain. In severe cases it may be associated with blurring of vision or double vision (usually the double vision affects only one eye). The name itself describes the cause of headache
● The puncture may be deliberate, as seen in diagnostic or therapeutic spinal taps, or could be unintended while performing an epidural nerve block. The puncture causes acute leakage of cerebrospinal fluid (CSF). The leakage lowers the intracranial pressure (ICP). The sudden lowering of intracranial pressure causes traction on nerves, blood vessels, veins and venous sinuses which causes headache
● In acute cases it might cause the symptoms, which are mild. Conservative treatment such as strict bed rest for 24-48 hours using flat pillow, use of caffeine and plenty of fluid should help
● In case of moderate to severe pain, treatment of choice is “Epidural Blood Patch (EBP) “. In this procedure, the patient’s own blood is administered in to the epidural space. Only an experienced physician should perform this procedure. If 3 EBPs do not do the job then an open repair of the puncture by a Neurosurgeon might be warranted.
Severe Headache Associated with Neck Stiffness, Severe Neck Pain, Fever and General Poor Feeling
This situation may indicate either meningitis or epidural abscess. The headache may be associated with radiating pain to upper extremities or legs. The incidence of meningitis or epidural abscess is extremely low. Scandinavian studies revealed an incidence of meningitis from spinal and epidural blocks to be 1.1:100,000 blocks (Finnish study). Meningitis is more seen in patients who undergo diagnostic spinal tap in the presence of infection. The incidence of epidural abscess is significantly low. The exact incidence is not known. Most of the reported cases are associated with an epidural catheter. The incidence is increased in immunocompromised patients. The commonest organism appears to be staph aureus but gram negative anaerobes have also been implicated. Therefore anytime anybody suffers from severe headache with neck stiffness or pain after an interventional procedure should get in touch with the physician as early as possible. Our treatment center’s policy is to order CBC with differential count, C-reactive protein (CRP), ESR, if possible MRI of spine with gadolinium.
Fever and Sweating
Fever during the first week with or without back pain following any procedure is important and has to be notified to the physician. Any Fever following discography should be reported to the physician immediately.
Incidence of spine infection such infection of the facet joint, sacroiliac joint, paraspinal abscess, epidural abscess, psoas abscess, discitis are extremely rare. Most of the cases are reported in immunocompromised patients and poorly controlled diabetic patients. In many cases the infection had been spontaneous. At our Center, we perform the procedures under strict meticulous sterile technique with meticulous attention to skin preparation. For preventing discitis following discogram we pretreat patients with antibiotics and then discharge them with a course of antibiotics. We avoid interventional treatment in patients with possibility of any infection including sinusitis.
Or inability to pass urine following interventional pain procedure is unusual but can happen in patient undergoing intrathecal trial (morphine pump). The intrathecal medication such as morphine might cause difficulty in emptying bladder. The treatment is to change the medication. Difficulty in emptying the bladder is also a side effect of opioid intake. If this happens after an interventional procedure, bleeding and hematoma formation in the spine compressing the spinal nerve need to be ruled out. This complication is extremely rare. Most of the time the bowel and bladder dysfunction is seen in patients with an acute large disc herniation causing compression of spinal nerve called cauda equina (cauda equina syndrome). This requires emergency neurosurgical treatment.
Antibiotic Induced Diarrhea
Patient who receives antibiotics for preventing infection might suffer diarrhea because of superadded infection of bowel. The infecting agent is Clostridia difficil bacteria. Patient suffers from diarrhea, dehydration and fever and general poorly feeling. The treatment of choice is use of Vancomycin or Metronidazole. Physician need to be informed immediately.