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Not a single spinal cord injury due to direct needle trauma in over 1.3 million epidural steroid injections

To the Editor We commend Eworuke et al on their study of serious spinal adverse events (SSAEs) associated with epidural steroid injections (ESIs) in the Medicare population. ESIs are a commonly performed procedure, so improving our knowledge of the rate of SSAEs following these injections is an important undertaking. The study authors used feeforservice Medicare enrollment and claims databases to identify 1 355 957 eligible patients. Next, they identified 110 potential cases of SSAE among those patients and selected 43 for medical record retrieval and case classification, leading to successful location of records for 41 potential cases. Of those 41 potential cases, 17 were determined to be spinal surgeries rather than outpatient ESIs, 11 were adjudicated as probable SSAEs following ESIs, 5 as possible and 8 as unrelated. Of the 11 probable cases, 10 were found to be epidural hematomas and 1 was described as an intradural hematoma. The authors did not identify a single case of spinal cord injury associated either with particulate steroid use or with direct needle trauma to the cord. Two prior analyses that used the American Society of Anesthesiologists’ closed claims database and the Controlled Risk Insurance Company Comparative (CRICO) Benchmarking System database both identified a significant number of spinal cord injuries from direct needle trauma and from potential embolism related to the use of particulate steroid for transforaminal ESIs. 3 The closed claims analysis identified 20 cases of needle trauma to the spinal cord or spinal nerves and 9 cases of spinal cord infarction or stroke following intraarterial injection. The CRICO analysis identified 11 cases of needle spinal cord trauma and 16 cases of spinal cord infarct. It is hard to reconcile the discrepancy between these two earlier analyses that showed that catastrophic neurologic injuries other than epidural hematoma are rare events that do occur, and Eworuke et al’s study which found none of these catastrophic neurologic events and is likely to lull practitioners into a false sense of security. Why then were none of these events seen in the current series? Eworuke et al used a wide range of International Classification of Diseases codes to capture potential SSAEs. Perhaps it would be fruitful to identify specific cases of spinal cord injury that occurred in this population during the study period and work backwards to understand why they were not identified or to use a more sensitive search algorithm to capture potential SSAEs? For now, we warn practitioners to continue to follow expert guidelines aimed at reducing these catastrophic neurologic injuries.