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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 14
| Issue : 2 | Page : 160-162 |
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Intraocular complications after caudal epidural steroid injection for discogenic lumbar pain with radiculopathy
Nazneen Nazm1, Lata Keshkar2, Manju Agrawal3, Mohammad Nasim Akhtar4, Sanjay Keshkar4, Alok C Agrawal5
1 Department of Ophthalmology, ESI-PGIMSR, ESIC Medical College and ESIC Hospital, Joka, Kolkata, The West Bengal University of Health Sciences, Kolkata, India
2 Department of Ophthalmology, Shantiniketan Medical College, Bolpur (West Bengal), India
3 Department of Pharmacology, Pt J N M Medical College, Raipur, Chhattisgarh, India
4 Department of Orthopaedics, ESI-PGIMSR, ESIC Medical College and ESIC Hospital, Joka, Kolkata, The West Bengal University of Health Sciences, Kolkata, India
5 Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
| Date of Submission | 30-Nov-2022 |
| Date of Acceptance | 09-Dec-2022 |
| Date of Web Publication | 30-Dec-2022 |
Correspondence Address:
Dr. Mohammad Nasim Akhtar
Department of Orthopaedics, ESIC Medical College and Hospital, Joka, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jotr.jotr_118_22
Background: Epidural steroid injection is a common intervention for symptomatic lumbar disc herniation. It is safe, but not absolutely free from complications. Visual complications and adverse intraocular events are sparse in the literature. This study is done to determine any intraocular complication after caudal epidural steroid injection for discogenic low back pain and radiculopathy. Materials and Methods: It was a prospective study, conducted from April 2018 to December 2019 by the orthopedics and ophthalmology departments of our institute. A total of 31 patients were recruited based on inclusion/exclusion criteria. All the patients presented to this institute with complaints of low back pain and sciatica were investigated. After proper diagnosis, the decision was made for caudal epidural steroid injection as per the standard principles of orthopedic surgery. Eye evaluations (intraocular pressure [IOP], visual acuity, and ocular examination) were done 1 day before, and 2–4 h, 1 week, and 2 weeks after epidural injection. The differences in eye evaluation values between time points were determined and discussed. Results: A total of 31 patients were recruited for this study, out of which the majority of the patients (27 patients) were between 41 and 60 years of age, and males (22 patients) outnumbered females (nine patients). Most of the patients (17 patients) had prolapsed IV disc of L5-S1. IOP was found to be raised after the intervention of epidural steroid injection which gradually came down to a preinjection level within 2 weeks. There was no change in visual acuity and no other intraocular complications, like hemorrhages. Conclusion: Epidural steroid injection for discogenic low backache (LBA) with radiculopathy did not adversely affect IOP, and neither had any ocular complication (in an ophthalmologically normal set of patients). A prudent approach should always be implemented.
Keywords: Caudal block, discogenic low backache, epidural steroid injection, intraocular complications, intraocular pressure
How to cite this article:
Nazm N, Keshkar L, Agrawal M, Akhtar MN, Keshkar S, Agrawal AC. Intraocular complications after caudal epidural steroid injection for discogenic lumbar pain with radiculopathy. J Orthop Traumatol Rehabil 2022;14:160-2 |
How to cite this URL:
Nazm N, Keshkar L, Agrawal M, Akhtar MN, Keshkar S, Agrawal AC. Intraocular complications after caudal epidural steroid injection for discogenic lumbar pain with radiculopathy. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Apr 1];14:160-2. Available from: https://www.jotr.in/text.asp?2022/14/2/160/365824 |
| Introduction | |  |
Epidural steroid injection is a common intervention for symptomatic lumbar disc herniation.[1] It is safe, but not absolutely free from complications.[2] The sudden rise of intraocular pressure (IOP), transient decreased vision or blindness, and intraocular/retinal hemorrhages have been described.[3],[4],[5],[6] Such complications are medicolegally important but there is poor awareness among orthopedic surgeons. This poor awareness is mainly due to lacunae in knowledge. Visual complications and adverse intraocular events are sparse in the literature. Furthermore, in contemporary orthopedic practice, there is no routine historical or formal screening of patients for potential ophthalmological complications before epidural steroid injection. This study is done to determine any intraocular complication after caudal epidural steroid injection for discogenic low back pain and radiculopathy. The objectives of this study are to evaluate any change in IOP, to document any adverse intraocular events (transient decreased vision, transient blindness, intraocular/retinal hemorrhages, etc.) and to increase awareness among orthopedic surgeons.
| Materials and Methods | | |
It was a prospective cross-sectional descriptive study conducted by the orthopedics and ophthalmology departments. After approval by the ethics committee of the institute, a total of 35 patients were recruited from April 2018 to December 2019 for this study based on inclusion/exclusion criteria, and informed consent was obtained from all patients.
The inclusion criteria for this study were (i) age 20–60 years, (ii) patients who were able to understand study protocol and able to give voluntary consent, (iii) patients with LBA with radiation (radiculopathy) due to lumbar prolapsed IV disc (PIVD) and amenable to caudal epidural steroid injection, and (iv) patients with normal ocular examination and normal IOP (10–21 mmHg).
The exclusion criteria were patients with (i) glaucoma/glaucoma suspects/ocular HTN, (ii) history of (H/O) previous ocular surgery (Sx) (cataract/trabeculectomy/retinal Sx), (iii) H/O retinal disease/retinal hemorrhage, (iv) H/O spine surgery/spinal infection (tuberculosis, etc.), (v) H/O diabetes mellitus/uncontrolled HTN/Cushing disease/on any form of steroid therapy, (vi) H/O allergy to steroids/anesthetics (lignocaine/bupivacaine, etc.), (vii) systemic infection or local infection at the site of a planned injection, (viii) bleeding disorder or fully anticoagulated, (ix) H/O immunosuppression, (x) H/O congestive heart failure, and (xi) patient refusal to proceed with the injection procedure.
Methodology
It was a prospective cross-sectional descriptive study. All the patients presented to this institute with complaints of low back pain and sciatica were investigated. The diagnostic algorithm consisted of proper history, clinical examination, and lumbosacral anteroposterior and lateral radiographs followed by magnetic resonance imaging of the lumbosacral spine. Blood investigation included a complete hemogram, blood sugar, urea, creatinine, uric acid, and liver function test (LFT). After proper diagnosis, the decision was made for caudal epidural steroid injection as per the standard principles of orthopedic surgery. Eye evaluation was done 1 day before, 2-4 h, 1 week, and 2 weeks after the epidural injection. IOP was measured by a Goldmann applanation tonometer. Visual acuity was measured by a Snellen eye chart. The ocular examination is done by slit-lamp biomicroscopy. All caudal injections were given by a single orthopedic surgeon (experienced in spinal intervention/surgery) and all ocular examinations/glaucoma workups were performed by a single ophthalmic surgeon (experienced in glaucoma postfellowship).
The differences in IOP values between time points were determined with the Kruskal–Wallis nonparametric analysis of variance. Statistical significance was accepted at P values below 0.05.
Caudal epidural steroid injection procedure
We used a cocktail of 80 mg (2 ml) of methylprednisolone acetate and 50 mg of 1% preservative-free lignocaine (5 ml) and the volume was made to 20 ml with normal saline. The epidural injection was given in the operating room in a lateral decubitus position through sacral hiatus.
| Results | | |
A total of 35 patients were recruited for this study from April 2018 to December 2019, out of which one patient refused consent for caudal epidural injection, one refused consent for eye examination and two patients lost to follow-up. Hence, a total of 31 patients were included in this study for evaluation. As per general demographics [Figure 1], the majority of the patients (27 patients) were between 41–60 years of age, and males (22 patients) outnumbered females (nine patients). Most of the patients (17 patients) had PIVD of L5-S1. | Figure 1: General demographics of patients in tabular forms showing the number of patients according to age group (Table 1a), sex (Table 1b), and level of PIVD (Table 1c). PIVD: Prolapsed IV disc
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IOP was found to be raised after the intervention of epidural steroid injection which gradually came down to a preinjection level within 2 weeks. It is evident in a graphical representation of IOP observed for both eyes [Figure 2]. Mean IOP, standard deviation, and significance level were calculated [Figure 3]. There was no change in visual acuity and no intraocular complications, like hemorrhages. | Figure 2: Graphical representation of IOP observed for both eyes. IOP: Intraocular pressure
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 | Figure 3: Values of mean IOP, standard deviation, and significance level. IOP: Intraocular pressure
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| Discussion | | |
A significant increase in IOP is one of the most common ocular complications of epidural steroid injection.[1] Other reported complications are sudden blurred vision and glaucoma (after the third lumbar epidural injection)[7] and transient visual loss and retinal hemorrhages.[4] The normal value of IOP ranges from 10 to 21 mmHg. In this study, four patients had high normal values [Figure 4]. | Figure 4: High normal value of IOP in four patients (normal value of IOP ranges from 10 to 21 mmHg). IOP: Intraocular pressure
Click here to view |
Pre- and postinjection eye examination with IOP charting is not only essential for patient safety but also for medicolegal support. While planning for an epidural steroid injection, one must aware of the possibility of ocular complications and its discussion, especially if risk factors (family history, preexisting ophthalmic conditions) are present.
Recent (2012–2016) Cochrane systematic reviews have disclosed controversial results and have questioned the effectiveness of ESIs. The conclusion of the review is “Nil to possible” efficacy in chronic discogenic LBA with radiculopathy for short-to-midterm benefit. The prudent approach to the intervention of such injection is another problem.
The merits of our study are a novel idea, original research work, prospective study with a good sample size (N = 31), reduced scope of interobserver bias, and use of Goldmann applanation tonometer, which is the gold standard.
There are some limitations, for example, nonrandomized, power of the study and sample size not considered, ocular hypertension/glaucoma suspects, glaucoma patients not studied, and risk of developing ocular complications in “normal/diseased” population not known.
| Conclusion | | |
Epidural steroid injection for discogenic LBA with radiculopathy did not adversely affect IOP, and neither had any ocular complication (in an ophthalmologically normal set of patients). A prudent approach should always be implemented.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Deepti S, Ingrid S, Callahan C, Malayil JP, Gillon J, Eckert J. Association of epidural steroid injections(s) with intraocular pressure elevation. Invest Ophthalmol Vis Sci 2013;54:5621.  |
| 2. | Kang SS, Kim IS, Park JH, Hong SJ, Shin HK, Song CG, et al. Short-term changes of intraocular pressure after cervical interlaminar epidural injection: A pilot study. Br J Anaesth 2014;113:865-8. |
| 3. | Clark CJ, Whitwell J. Intraocular haemorrhage after epidural injection. Br Med J 1961;2:1612-3. |
| 4. | Kushner FH, Olson JC. Retinal hemorrhage as a consequence of epidural steroid injection. Arch Ophthalmol 1995;113:309-13. |
| 5. | Purdy EP, Ajimal GS. Vision loss after lumbar epidural steroid injection. Anesth Analg 1998;86:119-22. |
| 6. | Young WF. Transient blindness after lumbar epidural steroid injection: A case report and literature review. Spine (Phila Pa 1976) 2002;27:E476-7. |
| 7. | Manjiani D, Said S, Kaye AD. Transient glaucoma after an epidural steroid injection: A case report. Ochsner J 2015;15:79-82. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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