Pain Management Procedure Causes Stroke

Case Overview

This case involves a sixty-two-year-old male who underwent a pain management procedure for chronic lumbar radiculopathy with associated lumbar disc herniation. The procedure was a fluoroscopically guided, contrast controlled left L5 and S1 transforaminal epidural steroid injection with epidurogram done under local anesthesia plus IV sedation. The pre-operative notes reflect that the patient had a blood pressure over 200 on several readings, but the physician still chose to conduct the procedure. The procedure was performed uneventfully and the operative notes make no mention of any difficulty. Shortly after, however, the patient displayed stroke-like symptoms in the recovery room. A CAT scan performed after surgery showed a right internal capsule lacunar infarct with a subtle area of low attenuation.

Questions to the Anesthesiology expert and their responses

Should the patient’s high blood pressure been given more attention before the surgical procedure?

Operating while the patient has such high blood pressure is certainly not within the standard of care. If a patient has high blood pressure, and 200 is certainly high, then the blood pressure needs to be controlled before a procedure like this is done. Whenever I have a patient with 200+ blood pressure, I promptly administer currently accepted medical therapy for hypertension, and only push for surgery when it is a medical emergency.

About the expert

This actively practicing, board-certified anesthesiologist specializes in pain medicine, and currently holds high-ranking administrative and clinical positions at a major New York healthcare institution. He also is fellowship trained in pediatric anesthesiology, making him especially capable of reviewing the case at hand.