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Septic and Aseptic Complications of Corticosteroid InjectionsLocal corticosteroid injections can have serious joiint and aseptic complications. From tomedical expert committees and mediation boards reviewed cases of alleged treatment errors sterolds to injections. The injections were intra-articular, alternative to steroids for joint pain, intramuscular, and at other sites. Repeated injections with too little time between them raise the testosterone test high of infection. Physicians should pay more attention to this fact, particularly when deciding on the indication for paravertebral injections. Aseptic technique should be strictly maintained. The indication for the injection should be clearly documented.
Local corticosteroid injections can have serious septic and aseptic complications. From to , medical expert committees and mediation boards reviewed cases of alleged treatment errors relating to injections. The injections were intra-articular, paravertebral, intramuscular, and at other sites.
Repeated injections with too little time between them raise the risk of infection. Physicians should pay more attention to this fact, particularly when deciding on the indication for paravertebral injections.
Aseptic technique should be strictly maintained. The indication for the injection should be clearly documented. When glucocorticosteroids are injected into small joints and tendon spaces, the introduction of crystals into the subcutaneous tissue and adipose tissue should be avoided. The intramuscular administration of depot glucocorticosteroids should be avoided. Parenterally administered corticosteroids are used both for systemic treatment by the intravenous or intramuscular route and for local treatment by infiltration or intra-articular injection.
They are typically obtainable either in aqueous solution or in crystalloid suspension. Ever since the historical beginnings of local treatment by injection, complications have been recognized, including, for example, joint empyema 1 , e1 and abscess formation. Sepsis is a not uncommon sequela of such complications; even death is a possible result. The local administration of steroids in the spine can be complicated by weakness of variable severity, ranging all the way to paraplegia.
Aseptic soft-tissue damage or infection that arises in association with, or in the aftermath of, corticosteroid injections can vary in severity from a small, slightly discolored indentation in the skin over an area of soft-tissue attenuation to extensive necrosis of multiple layers of soft tissue.
In this article, we discuss corticosteroid-related infection and aseptic tissue atrophy but omit any discussion of bony necrosis after intramuscular or intra-articular injection 2 , 3 , e2 , e3. Other types of complication that are beyond the scope of this article include tendon rupture after corticosteroid infiltration 4, e4; a complication that has been recognized for many years , systemic side effects 5 , very rare cases of secondary adrenal insufficiency 6 , and injection-related Tachon syndrome 7.
In these cases, there were instances of infection and 55 of aseptic tissue damage. Even though the selective data contained in MERS cannot be extrapolated to yield an estimate of the total number of injection-related adverse events that occur in Germany every year, they are certainly a good source of information on the cortisone injection—related complications and avoidable treatment errors.
This search also revealed further information about the efficacy of certain therapeutic procedures. Only one physical examination was documented in the entire course of her treatment: All injections included both a local anesthetic and a corticosteroid.
The physicians were later unable to say precisely what quantity was injected probably a total of mg of triamcinolone or whether a fresh needle was used to inject the second side in each treatment. Patient information was documented by a standardized form. Two days after the last injection, the patient was admitted to the hospital via the emergency room and remained hospitalized for four weeks. She underwent three operations for the treatment of abscesses in the paraspinal musculature, in a psoas muscle, and inside the spinal canal.
The causative organism was identified as Staphylococcus aureus. The patient was paraparetic; her weakness resolved slowly during the period of inpatient rehabilitation that followed. The main treatment error was judged to have been that too much corticosteroid was injected at too short intervals, elevating the risk of infection.
About six weeks after the last injection of one of these substances, she required surgery for the removal of g of necrotic skin and subcutaneous fat from the buttock. An infection that arose at the resection site necessitated multiple further hospitalizations. The expert panel determined that there were two treatment errors: According to German law, the burden of proof in cases of alleged treatment error is on the complainant. The complainant bears a lesser burden of proof if the events in the case have followed a typical course, and particularly if causality is supported by prima facie evidence.
This type of evidence also plays an important role in medical malpractice law. It is defined as follows: If, after all the individual circumstances and special features of the case at hand have been duly considered, the course of events is determined in the light of experience to have been a typical one for the fact that was to be established, then this fact can be considered to be established BGHZ , , Such events are so common that tissue damage after injections performed in rapid succession is considered to have been caused by these injections, without the need for any further evidence.
This conclusion is even more certain with respect to gluteal injections at an inadequate depth as in Case 2 , which often cause a typical pattern of necrosis in the skin and subcutaneous fat of the buttock indentation as a result of soft tissue atrophy.
Experience shows, however, that typical courses of events do, in fact, exist and are encountered at high frequency. It is important to realize that the concept of prima facie evidence does not simply remove the burden of proof from the patient and place it on the physician instead. Rather, the physician can bring a valid argument against prima facie evidence by asserting and proving facts that establish a substantial probability that the events in the case actually took a different, atypical course.
In Case 2, for example, the physician might be able to assert and prove that the needle used for injection actually was not too short. If the physician succeeds in establishing this, then the prima facie evidence has been refuted. The distribution of complications infections and aseptic tissue damage by site of application, in both absolute numbers and percentages, is shown in Table 1.
Roughly half of the 55 cases of tissue atrophy after corticosteroid injections involved intramuscular depot injections, mainly for the treatment of allergy. Treatment errors were especially common in this situation. The type and dose of the corticosteroid used could not always be ascertained from the medical record, as they were sometimes not documented. As far as can be determined, the most commonly used corticosteroid was triamcinolone. The most common errors were:.
Patients were found to have been inadequately informed of the risks of treatment in 20 cases; in nine of these cases, the treatment was judged to have been properly conducted in other respects. The injection of corticosteroids into inflamed joints is a method of treatment that has been used with good effect for decades e5 — e7. Unfortunately, it can also be complicated by intra-articular infection, sometimes leading to severe sepsis.
Another complication that has been known and feared for decades is abscess formation after intramuscular injection; necrotizing fasciitis is a severe variant of this problem 8 , e8. The reported frequencies of joint infection after intra-articular injection range from 1 in to 1 in 9 , e2 , e6 , e9 — e Faulty aseptic technique at the time of injection is thought to be the main cause. Expert panels generally consider infection to be no more than the random expression of a small risk inherent to the procedure if it is found to have occurred despite proper aseptic precautions.
In such cases, infection is thought to be due to pathogenic organisms that were present in deeper-lying parts of the skin not accessible to aseptic disinfection 9 , e1 , e It has likewise been known for at least 50 years that locally injected corticosteroids can damage the skin 10 — 12 , e14 — e Moreover, corticosteroid-related soft-tissue damage has been reported in the eye e19 , the hairy scalp e20 , the mandible, and the sole of the foot e Soft-tissue damage can also be a complication of injections into tendon spaces 12 and of injections that were intended to be intra-articular e Most of these individual case reports involved mild, primarily cosmetic complications.
Some involved more extensive ones taking the form of embolia cutis medicamentosa e23 or even very extensive and severe tissue necrosis in Nicolau syndrome 13 , e24 — e The locally injected drug is usually a combination of a local anesthetic with a corticosteroid; intramuscular injections are usually of a corticosteroid alone, or else of a corticosteroid combined with an analgesic by intragluteal injection, as described in Case 2, above.
Intra-articular corticosteroid injections are usually performed without any other admixed drugs, or else after local anesthetization of the needle trajectory. Sometimes the corticosteroid is given in combination with a so-called cartilage-production promoter. Paravertebral infiltrations and injections are very common as well.
They are generally performed in the vicinity of nerve roots. Facet infiltration is also a type of nerve-root infiltration, as it is intended to block the posterior branch that emerges directly from the spinal nerve 14 , 15 , e29 — e Injections performed without image guidance are often soft-tissue infiltrations rather than nerve-root infiltrations.
Infection after paravertebral injections is a less widely known complication than infections at other sites, even though it can have very severe consequences.
Superficial atrophy of skin and adipose tissue, with central discoloration of the skin, is attributed to a combination of the following factors:. In about half of all cases as far as can be determined from an overview of case reports , the affected area returns to normal over a few months to years. The duration of this process seems to be a function of the cortisone dose.
It has been pointed out time and again—and rightly so! Nicolau syndrome is a rare entity that has been observed as a complication of the types of treatments that we have been discussing. It is caused by acute arterial thrombosis or spasm upon the intravascular injection of an insoluble drug, leading to ischemic soft-tissue damage in the distribution of the vessel in question. Severe pain and livid discoloration of the skin usually arise right after the injection.
Nicolau syndrome can cause small central or more extensive necrosis, nerve damage, compartment syndrome, and gangrene. Corticosteroid injections without any other precipitating cause account for only a small minority of the reported cases. Superficial infiltration can cause more extensive damage embolia cutis medicamentosa.
A thorough discussion of the pharmacological properties of the various types of glucocorticosteroid would be beyond the scope of this article. For more information on the half-life, crystal size, parenteral effects, and threshold doses of each type of corticosteroid, as well as the recommended temporal intervals between repeated injections at a single site, the reader is referred to the specialized literature 16 and to manufacturer-supplied information.
Overtreatment is certainly a problem in German medicine in general, particularly with respect to invasive treatments 17 , e Many such treatments have turned out not to meet the high expectations originally placed on them when their effects were later subjected to careful study, e.
Clearly, some patients are being endangered where there is no justification for doing so. Infection after corticosteroid injections is relatively common; there would be far fewer severe complications and complications overall if injections were performed only when strictly indicated. The following conclusions can be drawn from the material provided by the expert panels:.
Moreover, repeated injections should be performed only after an adequate interval, and the total quantity injected in one year should not exceed the allowable limit. Intraartikuläre Punktion und Injektionen [Intra-Articular Punctures and Injections] [ 24 , e37 — e39 ] state that aseptic technique should be used. This implies, among other things, that the physician must invariably have an assistant when performing joint punctures and injections or paravertebral infiltrations e Furthermore, expert panels generally cannot assess the methods that physicians claim to have employed to ensure asepsis, because the panels are not judicial bodies and cannot examine witnesses.
Thus, panels must proceed from the assumption that the injection was performed in adherence to the specifications for standard aseptic technique, without any violation. In any case, there should be standardized specifications for aseptic technique and instructions for treatment personnel in any institution or practice where such treatments are performed. Missed infections e41 , e42 were judged several times to have been treatment errors Table 2.
On the slightest suspicion of infection after an injection, the appropriate diagnostic tests should be ordered at once laboratory tests, ultrasonography, magnetic resonance imaging and the patient should be followed up at short intervals, or, if necessary, hospitalized. Joint fluid obtained by puncture should be sent for bacteriological testing on the slightest suspicion of an intra-articular infection. The indication for treatment should always be documented in the medical record in such a way that it can be critically evaluated by others.
Corticosteroids should be used for facet injections only when a prior test injection of local anesthetic has led to clear improvement.
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