This case report details a tragic complication from injecting particulate corticosteroids somewhere in the lumbar spine. The supposition that injection into the lumbar epidural space led to the described complication of paraplegia is not supported by the authors, and this report should not be cited to represent such a complication. The procedure description provides few details, but requires the assumption that the procedure was performed “blind”, in that fluoroscopy guidance with contrast verification was not utilized. The use of a sharp 21-gauge needle is not appropriate for epidural access. The standard of care in placing needles into the epidural space requires the use of larger bore epidural needles (Touhy, Hustead, Crawford), and a loss of resistance technique. In this report, cephalad-caudad location of the injection (spinal level) was unknown in that needle insertion skin entry was guided only by the extent of a previous laminectomy scar. The depth of the injection was guided only by the length of the needle. Judging by the procedure description, the injectionist had no idea of needle tip location prior to injecting the steroid medication.

Interventional pain management is not anesthesia, it is not physical medicine and rehabilitation, nor is it radiology, neurosurgery, or neurology. The medical specialty of Interventional Pain Management draws from many disciplines and has developed a unique set of criteria under which precision guided diagnostic and therapeutic spinal procedures are performed with the intent of minimizing patient risk and maximizing benefit or diagnostic utility. Loss of resistance to the injection of air or saline during the advancement of an 18-gauge epidural needle has been utilized in countless millions of successful epidural anesthetics and in skilled hands, with very low mortality and morbidity. Loss of resistance (LOR) is a critical component of the technique used to safely identify the epidural space. This skill is learned with training in a proctored environment and honed over years of practice. Multiplanar fluoroscopic guidance, with contrast verification of expected injectate flow is required to minimize complications, and is standard of care for all interventional pain procedures in or around the spine.

This article must not be construed as in any way representing a complication of an injection into the epidural space. No documentation is provided that the epidural space was ever identified. The authors present a discussion possibly relating to complications involving a vascular structure within the intervertebral foramen, the medulary artery. In that the foramen is lateral to the epidural space, the discussion has no bearing on actual interlaminer injections. This complication could easily have been prevented by using fluoroscopy with verification of needle placement by contrast injection.