• Steven P Cohen, David N Maine, Sean M Shockey, Sapna Kudchadkar, and Scott Griffith.
• Department of Anesthesiology and Critical Care Medicine, Pain Management Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. scohen40@jhmi.edu
• Pain Med. 2008 Sep 1;9(6):688-94.

ObjectivesTo report two cases of disk injection during transforaminal epidural steroid injection, and to discuss ways to prevent and manage this under-appreciated complication.DesignCase reports and literature reviews.PatientsTwo patients with radicular symptoms underwent transforaminal epidural steroid injections under fluoroscopic guidance. The needle in both cases was placed in the center of the intervertebral foramen, about 1 cm above the inferior endplate. Injection of contrast in both cases revealed diskographic spread. Repeat magnetic resonance imaging revealed a large foraminal disk herniation in both patients.ResultsA literature search identified three studies whereby the use of a single-needle technique to perform diskography was clearly noted in conjunction with the number of infectious complications. Comparing these data with the incidence of diskitis when a double-needle approach was used found the infectious risk to be considerably higher. There are no data regarding whether imaging studies affect outcomes following epidural steroid injections.ConclusionsThese cases and similar complications following transforaminal epidural steroid injections provide anecdotal evidence that recent imaging studies, repeated not only for qualitatively new symptoms but after a sustained quantitative increase in pain, may reduce the complication risk. Data extrapolated from studies on diskitis suggest that administering parenteral, and possibly also intradiskal antibiotics, immediately after inadvertent disk injection is appreciated, may reduce the infectious risk.

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