Cerebellar herniation after cervical transforaminal epidural injection.

OBJECTIVE: The purpose of this study is to inform readers of potential catastrophic complications associated with performing cervical transforaminal epidural steroid injections. CASE REPORT: A 31-year-old man presented to the pain clinic with a history of cervical radicular pain and right upper-extremity radicular symptoms. He was referred from the orthopedic spine clinic for evaluation for epidural steroid injection, having failed conservative treatment consisting of nonsteroidal anti-inflammatory drugs, muscle relaxants, oral steroids, and physical therapy. After undergoing a transforaminal epidural steroid injection at the right C8 nerve root, he developed a cerebellar infarct and brainstem herniation. He survived but has residual deficits of persistent diplopia on right lateral gaze and difficulties with short-term memory loss and concentration. CONCLUSIONS: Although transforaminal epidural steroid injections are an efficacious treatment for radicular syndromes, there can be catastrophic complications. In light of the growing body of similar case reports, further investigation is warranted to establish a safe protocol for the use of this modality.

Anesthesia services aboard USNS COMFORT (T-AH-20) during Operation Iraqi Freedom.

USNS COMFORT (T-AH-20), the only U.S. hospital ship to be deployed in support of combat operations during Operation Iraqi Freedom, sailed from Baltimore, Maryland, on January 6, 2003, and returned on June 12, 2003. During the course of her deployment, 648 anesthetic procedures were performed. We describe the anesthesia services provided, lessons learned, and recommendations for future concepts of employment.

Evaluation of the L2 spinal nerve root infiltration as a diagnostic tool for discogenic low back pain.

BACKGROUND: To assess whether unilateral L2 infiltration with local anesthetic can be used to identify patients who will have negative discograms and thus eliminate the need for the discogram. Discogenic low-back pain is considered to have afferent pathways in the sinuvertebral nerves, mainly originating from the ventral rami of the spinal nerves. There is evidence that pain arising from the lower lumbar intervertebral discs may be transmitted through the sympathetic afferent fibers contained in the L2 spinal nerve root. Provocative discography, within the context of other clinical data, is the current "gold standard" by which to diagnose discogenic low-back pain, but a far more invasive procedure than L2 infiltration. OBJECTIVE: To evaluate the correlation between unilateral second lumbar (L2) spinal nerve root infiltration with local anesthetic and provocative discography in patients with chronic low back pain. STUDY DESIGN: A prospective, observational study. METHODS: All patients scheduled for discography were asked to participate in having local anesthetic infiltration of the L2 spinal nerve root at least two weeks prior to discography, until forty subjects were enrolled. Discography was performed after the patient's pain level returned to baseline. RESULTS: Local anesthetic infiltration of the L2 spinal nerve root was predictive of provocative discography results in only 46.5% of the subjects (26% true positives, and 20.5% true negatives). In 53.5% of the subjects, L2 infiltration was not predictive of discography results (20.5% false positives, and 33% false negatives). CONCLUSIONS: The results showed that unilateral L2 infiltration is not predictive of discogenic low-back pain when compared to discography, the current "gold-standard" for diagnosis.