Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections.

BACKGROUND CONTEXT: The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. PURPOSE: To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. STUDY DESIGN/SETTING: A prospective, observational, in vivo, study. PATIENT SAMPLE: Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. OUTCOME MEASURES: Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. METHODS: One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. RESULTS: The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis. CONCLUSIONS: Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.     

Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections

STUDY DESIGN: A prospective, observational, human, in vivo study. OBJECTIVES: To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced, transforaminal lumbar epidural steroid injections (ESIs) and determine whether a "flash" (blood in the needle hub) or aspiration of blood can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA: Incorrectly placed, intravascular lumbosacral spinal injections result in systemic medication flow that misses the desired target. No previous studies evaluate the incidence of vascular injections in transforaminal ESIs, nor the ability of flash to predict a vascular injection. METHODS: The incidence of flash or positive blood aspiration and the incidence of fluoroscopically confirmed vascular spread were prospectively observed in 670 patients treated with lumbosacral fluoroscopically guided transforaminal ESIs. Presence of a flash or positive aspiration was documented. Contrast was injected to determine whether the needle tip was intravascular. RESULTS: Seven hundred sixty-one transforaminal ESIs were included. The overall rate of intravascular injections was 11.2%. There was a statistically significant higher rate of intravascular injections (21.3%) noted with transforaminal ESIs performed at S1 (n = 178), compared with those at the lumbar levels (8.1%, n = 583). Using flash or positive blood aspirate to predict intravascular injections was 97.9% specific, but only 44.7% sensitive. CONCLUSIONS: There is a high incidence of intravascular injections in transforaminal ESIs that is significantly increased at S1. Using a flash or blood aspiration to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in lumbosacral transforaminal ESIs.     

Incidence of intravascular penetration in transforaminal cervical epidural steroid injections

STUDY DESIGN A prospective, observational, human, study was conducted. OBJECTIVES To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced transforaminal cervical epidural steroid injections, and to determine whether the observation of blood in the needle hub can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA Incorrectly placed intravascular cervical spinal injections result in medication flow systemically and not to the desired target. A recently published study demonstrates a high incidence of intravascular injections in transforaminal lumbosacral epidural injections. No studies so far have evaluated the incidence of vascular injections in transforaminal cervical epidural steroid injections, nor have they calculated the ability of observed blood in the needle hub to predict a vascular injection in the cervical spine.METHODS The incidence of fluoroscopically confirmed intravascular uptake of contrast was prospectively observed in 337 patients treated with cervical transforaminal epidural steroid injections. The ability of observed blood in the needle hub to predict intravascular injection was also investigated. For each subject, the injection level was chosen on the basis of the clinical scenario including history, physical examination, and review of imaging studies. Some patients had multilevel injections. Using fluoroscopic guidance, the authors placed a 25-gauge needle into the epidural space using a transforaminal approach according to accepted standard technique. Needle tip location was confirmed with biplanar imaging. The presence or absence of blood in the needle hub spontaneously ("flash") and after attempted aspiration by pulling back on the syringe's plunger was documented. Contrast then was injected under real-time fluoroscopy to determine whether the location of the needle tip was intravascular. The results were recorded in a prospective manner indicating the presence or absence of blood in the needle hub and whether a vascular pattern was noted with contrast injection, and these were correlated. Relevant epidemiologic data also were recorded. RESULTS The study included 504 transforaminal epidural steroid injections. The overall rate of fluoroscopically confirmed intravascular contrast injections was 19.4%. Use of observed blood in the needle hub to predict intravascular injections was 97% specific, but only 45.9% sensitive. There was no significant difference in intravascular rates related to age or gender. CONCLUSIONS As compared with a previous study of lumbosacral epidural steroid injections, there is an overall higher incidence of intravascular injections with cervical transforaminal epidural steroid injections. Use of observed blood in the needle hub to predict an intravascular injection is not sensitive, and therefore the absence of blood in the needle hub despite aspiration is not reliable. The reported sensitivity and specificity rates are similar to lumbar data. Fluoroscopically guided procedures without contrast confirmation instill medications intravascularly, and therefore not in the desired epidural location. This study confirms that there is a need not only for fluoroscopic guidance, but also for contrast instillation in cervical transforaminal epidural steroid injections.     

Acute lumbosacral hemorrhagic ganglion cyst after transforaminal epidural steroid injection

Epidural steroid injection is one of the most commonly used non-surgical treatments for degenerative lumbar vertebral disease. Its use has increased as degenerative lumbar vertebral disease has increased in frequency. Concomitant complications are being reported more often. In this report, we report a rare case of iatrogenic hemorrhagic cyst following epidural steroid injection. The patient underwent operative treatment with complete resolution of his symptoms     

CT-guided transforaminal cervical and lumbar epidural injections

Transforaminal injections are widely used. Serious complications including strokes and paraplegia have been reported after transforaminal injections of corticosteroids, and the Afssaps (2011) has issued a warning about their use [1]. The needle must be positioned in the posterior aspect of foramen, and its correct placement validated by an injection of contrast product. It is preferable to choose cortivazol (Altim^®) as the corticoid for injection. This procedure is simple, reproducible, and durably effective in 60 to 70% of cases. Complications and adverse effects are rare but potentially serious: allergies, blood pressure surge, vasovagal syncope, transient exacerbation of pain, infection, stroke, and paraplegia. The aim of this course is to stress the need for rigor — in the indication, the technical performance of the procedure, and the overall management of the patient.     

Predicting outcomes of transforaminal epidural injections for sciatica.

BACKGROUND CONTEXT: Previous studies on epidural injections have focused on efficacy and have not evaluated factors predicting outcomes of epidural injections. PURPOSE: To determine which patient factors are associated with transforaminal epidural injection outcomes for sciatica. STUDY DESIGN: Cross-sectional study design at a university spine center. PATIENT SAMPLE: Consecutive patients with sciatica who have had an electromyography study and a transforaminal epidural injection between January 1999 and July 2001. OUTCOME VARIABLE: The outcome variable was a composite score of the patients' pain severity and medication use compared with their initial visit. Independent variables included demographics, previous back surgery, pain severity at initial presentation, pain medication use at initial presentation, litigation, having Social Security Disability Insurance (SSDI) or workers' compensation, electromyography results. METHODS: Medical information was gathered on the variables listed above. RESULTS: Seventy-six patients, mean age 50.4 years and 49% female, participated. At a mean follow-up of 122 days (SD 146.3), 35 (47%) were improved, 21 (28% were unchanged) and 12 (16%) were worse. Initial correlation analysis showed some relationship between outcomes and having SSDI or workers' compensation (R=.43, p<.001), lifting requirements at work (R=.44, p=.002), working status (R=-.31, p=.02), and electromyogram evidence of radiculopathy (R=-.25, p=.04). Regression analysis showed that having SSDI or workers' compensation was the primary factor associated with worse outcomes. CONCLUSIONS: When controlled for SSDI/workers' compensation, lifting requirements at work, but not working status and radiculopathy, also were associated with outcomes but the association was not as strong. This paper brings into question the utility of offering epidural injections to patients who are on SSDI/workers' compensation and require heavy lifting at work.     

Paraplegia following lumbosacral steroid epidural injections

Spinal cord ischemia is a rare but possible neurological complication following routine conservative treatment of lumbosacral radiculopathy. A case of a 46 year old woman with chronic L5 radiculopathy, who developed spinal cord ischemia following epidural steroid injection, is reported. Two months after the epidural injection, she required crutches for walking and had neurogenic bladder and bowel.     

Evaluation of transforaminal epidural steroid injections for discogenic axial lumbosacral back pain utilizing PROMIS as an outcome measure

Background contextDiscogenic lumbosacral back pain continues to present a challenging clinical entity with limited, controversial therapeutic options. No study to date has evaluated the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESI) in a homogenous patient population with axial lumbosacral back pain from discogenic pathology utilizing strict, explicitly clinical and radiographic criteria. Additionally, there is a paucity of published data utilizing Patient Reported Outcome Measurement Information System (PROMIS) scores as an outcome measure for interventional spine procedures.PurposeEvaluate the therapeutic effect of TFESIs in a specific subset of patients with discogenic axial lumbosacral back pain. Investigate PROMIS as an outcome measure for interventional spine procedures targeting focal degenerative spinal pathology.Study design/settingRetrospective review of patients presenting to a multidisciplinary, tertiary academic spine center.Patient sampleThree thousand eight hundred eighty-one patients were screened for inclusion. A total of 26 patients with discogenic axial low back, based on strict clinical and radiographic criteria, underwent TFESIs. All patients had axial low back pain without radicular pain, ≥3 clinical features of discogenic pain, corroborative radiographic features of active discogenic pathology on lumbar spine magnetic resonance imaging without confounding spinal pathology.Outcome measuresPROMIS Pain Interference (PI) v1.1, PROMIS Physical Function (PF) v1.2/v2.0, and PROMIS Depression (D) v1.0 outcome scores were collected at baseline and postprocedure follow-up.MethodsQuery of an institutional, patient reported outcome database and subsequent retrospective review of electronic medical records was performed. Statistical analysis comparing baseline and postprocedural PROMIS outcome scores and correlation between these instruments was performed. Additionally, an exploratory investigation of minimal clinically important difference achievement rates was performed.ResultsAnalysis determined a statistically significant improvement in PROMIS PI (p=.017, 95% CI=?8.02 to ?1.82) and PROMIS PF (p=.003, 95% CI=0.91–8.72) scores after treatment with TFESIs. At post treatment time points, TFESI had medium effect size on pain (d=0.55) and function (d=0.59). Change in PROMIS D scores (p=.488, 95% CI ?1.74–3.54; d=.08) did not demonstrate statistical significance. Pearson correlation demonstrated a moderate negative correlation (r=?0.544, p=.004) between PROMIS PF with PROMIS PI. Correlation between PROMIS PF (r=?0.239, p=.24) and PROMIS PI (r=0.198, p=.33) with PROMIS D was not significant. Fourteen (53.8%) and 9 (34.6%) subjects achieved minimum clinically important difference (MCID) for PROMIS PI and PROMIS PF, respectively. Nine subjects (34.6%) achieved MCID for PROMIS D despite not otherwise reaching statistical significance otherwise.ConclusionsUtilizing PROMIS as an outcome measure, discogenic axial lumbosacral back pain patients appear to benefit from TFESI in terms of pain and physical function. This study contributes to the growing body of literature utilizing PROMIS scores in patients with clinical sequelae of degenerative spinal pathology; however, prospective studies are needed.     

Cerebellar herniation after cervical transforaminal epidural injection

OBJECTIVE: The purpose of this study is to inform readers of potential catastrophic complications associated with performing cervical transforaminal epidural steroid injections. CASE REPORT: A 31-year-old man presented to the pain clinic with a history of cervical radicular pain and right upper-extremity radicular symptoms. He was referred from the orthopedic spine clinic for evaluation for epidural steroid injection, having failed conservative treatment consisting of nonsteroidal anti-inflammatory drugs, muscle relaxants, oral steroids, and physical therapy. After undergoing a transforaminal epidural steroid injection at the right C8 nerve root, he developed a cerebellar infarct and brainstem herniation. He survived but has residual deficits of persistent diplopia on right lateral gaze and difficulties with short-term memory loss and concentration. CONCLUSIONS: Although transforaminal epidural steroid injections are an efficacious treatment for radicular syndromes, there can be catastrophic complications. In light of the growing body of similar case reports, further investigation is warranted to establish a safe protocol for the use of this modality.     

Treatment of lumbosacral radicular pain with epidural steroid injections

Fifty patients with an average age of 47 years received epidural steroid injections for lumbosacral radicular pain due to disk herniation or spinal stenosis. All patients had failed previous conservative treatment. Mean follow-up was 24 months (range: 12-36 months). Immediately after injection, all 50 patients reported various degrees of relief from leg and back pain. At the last follow-up examination, 68% of patients were asymptomatic, 20% had no change in preinjection radicular symptoms, and 12% had various degrees of relief. No significant correlation was found between pain relief, age, or number of injections. Early pain relief may be anticipated after epidural steroid injections in 80% of patients with radicular symptoms due to disk herniation or spinal stenosis.     

Influence of needle type on the incidence of intravascular injection during transforaminal epidural injections: a comparison of short-bevel and long-bevel needles

Background contextVascular penetration and injection of corticosteroids into a vessel during lumbosacral transforaminal epidural injection is a suspected cause of myelopathy. Blunt needles have been suggested to avoid vascular penetration, but they are difficult to navigate. Another alternative to the standard long-bevel sharp needles is the short-bevel needles. Some have postulated that short-bevel needles are the best option for high-risk spine injections because they maintain navigation characteristics while potentially reducing the risk of complications. To date, no studies have been performed to either confirm or refute this.PurposeThe purpose of this study was to determine if there is a difference in the incidence of vascular penetration during lumbosacral transforaminal epidural injections between short-bevel and long-bevel needles.Study design/settingThis is a prospective, observational, in vivo study.Patient sampleThe sample comprises patients receiving lumbosacral transforaminal epidural injections at a university-based outpatient spine center.Outcome measureThe outcome measure was the incidence of vascular contrast patterns observed under live fluoroscopy.MethodsOne interventional spine physician recorded contrast patterns observed during 158 fluoroscopically guided lumbosacral transforaminal epidural injections under live fluoroscopy using two different types of needle tips.ResultsVascular injections were observed in 22 of the 158 injections, for an overall incidence of 13.9%. The incidence of vascular injections in the short-bevel group was 15.6% (10/64) and in the long-bevel group was 12.8% (12/94). This difference was not statistically significant (p=.6447). A secondary analysis was performed to determine if the needle gauge influenced the incidence of vascular injections, and again, there were no statistical differences in the overall rates of vascular injection.ConclusionsIn comparison with long-bevel needles, short-bevel needles do not reduce the risk of inadvertent vascular injection in lumbosacral transforaminal epidural injections.     

Incidence of intravascular injection and the spread of contrast media during S1 transforaminal epidural steroid injection by two approaches: anteroposterior vs oblique

The aim of this randomised study was to compare the incidence of intravascular injections during S1 transforaminal epidural steroid injection performed in the anteroposterior and oblique views. We also compared epidural spread patterns of contrast media, which included 201 injections at the S1 level. The overall incidence of intravascular injection during S1 transforaminal epidural steroid injection in the anteroposterior view was 29% (29/99), significantly higher than in the oblique view (11%, 11/102, p = 0.001). There were no significant differences between the two groups for epidural spread of contrast media in cases where intravascular injections did not occur (p = 0.77). Performing S1 transforaminal epidural steroid injection in the oblique view rather than the anteroposterior view reduces the risk of intravascular injections.     

Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections

Background context

Reports of serious complications from cervical transforaminal epidural corticosteroid injections often consider accidental intra-arterial injection the most likely mechanism of injury. As a result, many physicians have instituted methods to prevent intravascular injections. Routine use of the anesthetic test dose is one such method. The utility of the anesthetic test dose in this function has not been characterized in the current literature.

Purpose

The aim of this study was to determine the utility of injecting an anesthetic test dose before cervical transforaminal epidural corticosteroid injection and estimate the rate of false-negative intravascular contrast injection using live fluoroscopy and digital subtraction angiography (DSA).

Study design

Two-center retrospective study.

Patient sample

A consecutive cohort of men and women, ages of 23 to 83, who underwent cervical transforaminal epidural injection and received the anesthetic test dose after contrast injection was negative for vascular uptake, observed using live fluoroscopy or DSA.

Outcome measures

Response to the anesthetic test dose was documented in each procedure note and recorded as either positive or negative.

Methods

Records of three physiatrists at two academic spine centers (Center A and Center B) were reviewed to identify all patients who received a cervical transforaminal epidural injection during the preceding 5 years, resulting in a cohort of consecutively treated patients at each center. Each patient record was reviewed for demographics, indication for injection, procedure level and side, needle gauge, use of DSA, volume and type of anesthetic test dose used, and result of test dose injection. The test dose was considered positive if the following occurred: agitation or other sudden central nervous system change; gross motor deficits and/or paresthesias in the trunk, legs, or contralateral arm; systemic symptoms of anesthetic toxicity including cardiac arrhythmia, perioral numbness, metallic taste, dizziness, and/or ringing in the ear. For analysis, injections were separated into groups to compare results at Center A to Center B and to compare injections that used DSA to those that did not. The incidence of a positive response was calculated as a percentage from the total number of injections in the group. Differences between groups were analyzed for statistical significance using the Fisher exact test.

Results

Six hundred seventy-eight injections were included. Of these, 349 were performed at Center A with test doses given after contrast injection under live fluoroscopy. The remaining 329 were performed at Center B, 183 also using live fluoroscopy, and 146 using DSA. The overall incidence of a positive anesthetic test dose was 0.59% (4/678). There was no significant difference between the incidence at each of the two centers (0.86% [3/349] vs. 0.30% [1/329]; p=.63). The overall incidence after live fluoroscopy was 0.75% (4/532) and after DSA was 0% (0/146), but this difference was not statistically significant (p=.58). Positive symptoms elicited by test dose administration included midneck and contralateral arm pain, metallic taste, dizziness, tachycardia, full body paresthesias, auditory changes, slurred speech, and motor ataxia. In all four cases with a positive response, the procedure was immediately terminated, symptoms resolved, and no lasting complications were observed.

Conclusions

The routine use of an anesthetic test dose appears to be safe and capable of detecting potentially dangerous intravascular injections undetected by conventional techniques. Positive responses occur in a small portion of those who receive the test dose injection. Further studies are required to determine the optimal dose and concentration of anesthetic to be used and the time required for observation after test dose administration.     

Paralysis after transforaminal epidural injection and previous spinal surgery

OBJECTIVE: This case discusses a rare but devastating complication of transforaminal epidural injection. Elements in the patient's history that may be risk factors are discussed. CASE REPORT: A 64-year-old man was evaluated for chronic low-back pain after multiple spine surgeries. After the most recent surgery, he suffered transient cauda equina symptoms. Because conservative therapy was not helpful for spinal stenosis and neuroclaudication, a left L2 transforaminal epidural injection was attempted, but a posterolateral fusion mass made this procedure impossible. A left L1 transforaminal approach was successful, and 1 mL of iopamidol (Isovue) contrast was injected, followed by 5 mL of a solution of 0.125% bupivacaine and 40 mg of triamcinolone. Approximately 1 to 2 minutes after injection, the patient described discomfort in the lower abdomen, and 1 minute later, he was unable to move his lower extremities. An MRI showed T2 signal change in the conus medullaris gray matter at T11-12, consistent with an acute vascular infarct. Spinal shock protocol with high-dose methylprednisolone was begun without change. More than 4 years later, the patient continues to be troubled by persistent paraparesis and chronic pain. CONCLUSIONS: This case report is part of a new and growing body of literature that demonstrates the potential risk of transforaminal injection. Further study is necessary to ensure that spinal vascular injuries can be kept to an acceptably rare level.     

经椎间孔硬膜外注药与经椎板硬膜外注药治疗腰骶根性疼痛疗效对比的Meta分析

目的:系统评价经椎间孔硬膜外注药(TFESI)与经椎板硬膜外注药(ILESI)治疗腰骶神经根性疼痛疗效的差异。方法:计算机检索1990年1月~2014年7月Pubmed、Medline、Embase以及Ovid电子数据库,搜集关于比较TFESI和ILESI治疗腰骶神经根性疼痛的随机对照试验(RCT)研究,制定严格的纳入和排除标准,由两位研究人员独立筛选出符合标准的文献,根据Cochrane手册的改良Jadad量表进行方法学质量评价,并利用Revman 5.3进行Meta分析。结果:初筛共378篇文献,最后纳入5篇文献、199例患者,其中行TFESI 102例,行ILESI 97例。文献质量1篇为5分,2篇为6分,2篇为7分;4篇语种为英文,1篇为法文。Meta分析结果显示:在缓解腰骶神经根性疼痛上,TFESI在术后2周[MD=-1.77,95%CI(-2.95,-0.59),P0.01]、1~3个月[MD=18.77,95%CI(4.54,33.0),P=0.01]及6个月[MD=-1.08,95%CI(-1.53,-0.64),P0.05]时的疗效优于ILESI,在术后1个月脊柱柔软度改善无明显差异[腰椎活动度(schober index):MD=0.07,95%CI(-0.42,0.57),P0.05;指-地距离(finger-to-floor):MD=1.21,95%CI(-6.41,8.82),P0.05)]。结论:在缓解腰骶神经根性疼痛上,TFESI在术后6个月内疗效均优于ILESI,但在改善脊柱柔软度上两种方法无明显差异。     

Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis

BACKGROUND CONTEXT

Epidural steroid injection has been used to treat back or radicular pain from lumbar and lumbosacral disc herniation (LDH). However, the superiority of transforaminal injection (TFESI) to caudal injection (CESI) remains controversial.