[quote=paindoc;3134409]Actually, there is no evidence polyethylene or polypropylene glycol cause adhesive arachnoiditis, but there is speculation by those that have no proof of such. If you have proof, please present it here as it would fundamentally change the way we practice pain medicine. There is no absolute method of assuring some medication administered epidural or partially transdural would not cross over into the CSF, therefore all epidural injections containing any PEG would be contraindicated according to such thinking.
Fluoroscopy or not, intrathecal injection is still a very real risk when administering epidural treatments. I'm sure you inform every one of your patients of the slight risk of a wet tap, right?
There is no need to "fundamentally change the way we practice pain medicine." That seems a just a little perponderant, don't you think? Epidural injection can inadvertantly become intravascular or intrathecal. "It seems fluoroscopy guidance may not prevent intrathecal perforation or spinal cord penetration"(Tripathi. Anesth Analg 2005;101:1209-1211).
Injecting an alcohol into the CSF would be deleterious, would you not agree?
So what makes it acceptable to administer a drug via a route not approved by the FDA? Because its common practice...because everyone does it?
Is that how you would respond to an attorney during a trial?
. Arch Neurol.
"Dangers from methylprednisolone acetate therapy by intraspinal injection."
Section of Neurology in Medicine, Medical Center of Delaware, Wilmington.
"Clinical trials first began in 1960 with methylprednisolone acetate (Depo-Medrol) administered intrathecally, in an attempt to treat both disk disease and multiple sclerosis. After a few reports of salubrious results, there began an outpouring of contradictory data, which continues in 1988. During this time span, researchers who cautiously tested the different theses of improvement began to publish serious warnings of many complications. For ten years prior to the intraspinal use of methylprednisolone acetate, basic scientists in anesthesiology and neurochemistry had published the following facts:
(1) Methylprednisolone acetate's content of polyethylene glycol raises the risks of using it near the central nervous system.
(2) Deleterious effects follow the use of glycols when they are placed into or near the neuraxis.
(3) Methylprednisolone acetate contains approximately 30 mg of polyethylene glycol per milliliter.
(4) When that glycol, which is both alcohol and detergent, is injected intraspinally, sterile meningitis, arachnoiditis, or pachymeningitis will occur.
It has also been recognized since the 1960s that the epidural space is not wholly separate from the subdural and/or subarachnoid space. Many thousands of arachnoid villi subtend all the membranes from the intrathecal space, and many of these end in the large epidural veins. Therefore, the various spaces and membranes are not only contiguous, but continuous.
It follows that an injection of methylprednisolone acetate into the epidural space does not guarantee that it will remain isolated there.
Finally, the inadvertency of injections by the epidural route occurs with the following frequency: 40% of injections can be inadvertently made into interspinous ligaments, and 2.5% into the subarachnoid space.