hold dose below which the side-effect profile is significantly diminished. Practitioners need to understand and educate their patients regarding the full scope of potential side effects that can occur when receiving epidural steroids. Practitioners should also consider limiting the dose and frequency of epidural corticosteroid injections and using nonparticulate corticosteroids for transforaminal epidural injections. Finally, because the efficacy of adding corticosteroids to epidural injections is not clear, practitioners should consider the option of epidural injections with only local anesthetics—leaving out the corticosteroids altogether. 27
Rare but life-threatening complications from epidural analgesia include the following: (1) maternal convulsions or cardiovascular collapse after unintentional direct intravenous injection of a local anesthetic and (2) total spinal anesthesia following unintentional subarachnoid injection of local anesthetic. Slow, incremental administration of the local anesthetic with appropriate maternal and fetal monitoring will produce signs and symptoms of subarachnoid or intravenous injection before serious consequences occur. Many physicians administer an epidural “test dose” (., 3 mL of percent lidocaine [Xylocaine] with epinephrine 1:200,000) to detect subarachnoid or intravenous placement of the catheter.
This is a rare complication that may occur if a small hole is made in the fibrous sac and does not close up after the needle puncture. These small holes are only made in less than 1% of epidural injections and usually heal on their own. The spinal fluid inside can leak out, and when severe, the brain loses the cushioning effect of the fluid, which causes a severe headache when you sit or stand. These types of headaches occur typically about 2-3 days after the procedure and are positional - they come on when you sit or stand and go away when you lie down. If you do develop a spinal headache, it is OK to treat yourself. As long as you do not feel ill and have no fever and the headache goes away when you lay down, you may treat yourself with 24 hours of bed rest with bathroom privileges while drinking plenty of fluids. This almost always works. If it does not, contact the radiologist who performed the procedure or your referring physician. A procedure (called an epidural blood patch) can be performed in the hospital that has a very high success rate in treating spinal headaches.