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      Comparison of incidence of intravascular injections during transforaminal epidural steroid injection using different needle types

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          Abstract

          Background

          Infrequent but serious complications of transforaminal epidural steroid injection (TFESI) occur due to inadvertent intravascular injections. A few studies reported that the different needle types can influence on the occurrences of intravascular incidence in TFESI. This study prospectively evaluated whether short-bevel needle can reduce the incidences of intravascular injection of TFESI compared to long-bevel needles.

          Methods

          From March 2013 to December 2013, 239 consecutive patients were enrolled and received 249 fluoroscopically guided TFESI using the classic technique. Confirmation of intravascular spread was done initially with real time fluoroscopy and then with digital subtraction angiography method in a same patient. Injection technique for TFESI was the same for both short-bevel and long-bevel needle types.

          Results

          The incidences of intravascular injections with the long-bevel and short-bevel needles were 15.0% (21/140) and 9.2% (4/140), respectively. More than half of intravascular injections occurred simultaneously with epidural injections (8.0%, 20/249). There were no statistically significant differences between the long-bevel and the short-bevel needles in the rates of intravascular injections (P = 0.17).

          Conclusions

          Short-bevel needles did not demonstrate any benefits in reducing the incidence of intravascular injection.

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          Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports.

          Charles Aprill, Paul Dreyfuss, Adam D. Kennedy … (2009)
          To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases. Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe. An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma. These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.
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            Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury.

            Vicki S. Mercer, Paul Dreyfuss, Nikolai Bogduk … (2003)
            Spinal cord injury has been recognized as a complication of cervical transforaminal injections, but the mechanism of injury is uncertain. In the course of a transforaminal injection, an observation was made after the initial injection of contrast medium. The contrast medium filled a radicular artery that passed to the spinal cord. The procedure was summarily abandoned, and the patient suffered no ill effects. This case demonstrates that despite using careful and accurate technique, it is possible for material to be injected into a radicular artery. Consequently, inadvertent injection of corticosteroids into a radicular artery may be the mechanism for spinal cord injury following transforaminal injections. This observation warns operators to always perform a test injection of contrast medium, and carefully check for arterial filling using real-time fluoroscopy with digital subtraction.
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              Paraplegia after lumbosacral nerve root block: report of three cases.

              John K. Houten, Thomas J Errico (2015)
              Lumbar nerve root blocks and epidural steroid injections are frequently employed in the management of degenerative conditions of the lumbar spine, but relatively few papers have been published that address the complications associated with these interventions. Serious complications include epidural abscess, arachnoiditis, epidural hematoma, cerebrospinal fluid fistula and hypersensitivity reaction to injectate. Although transient paraparesis has been described after inadvertent intrathecal injection, an immediate and lasting deficit has not been previously described as sequelae of a nerve root block. We present three cases in which either persisting paraplegia or paraparesis occurred immediately after administration of a lumbar nerve root block and propose a mechanism for this devastating but previously unreported complication. Case reports of three patients. Three patients, two women and one man ranging in age from 42 to 64 years, underwent three procedures performed at three different facilities, in the hands of two different injectionists. In each instance, penetration of the dura was not thought to have occurred. In two procedures the needles were placed transforamenally, one at L3-4 on the left and one at L3-4 on the right, and in the third the needle tip was placed immediately lateral to the S1 nerve root. Patient follow-up data from medical office records. In each case, needle placement was verified with injection of a contrast media in conjunction with either computerized tomography or biplanar fluoroscopy. No backbleeding or cerebrospinal fluid was encountered upon aspiration in any of the procedures. Magnetic resonance imaging (MRI) was performed within 48 hours of injury in all patients. In each patient, paraplegia suddenly ensued after instillation of the steroid solution and, in each instance, postprocedure MRI revealed increased signal in the low thoracic spinal cord on T2-weighted imaging consistent with edema. The sudden onset of neurological deficit and the imaging changes noted in the spinal cord point to a vascular explanation for these injuries. We postulate that in these patients the spinal needle either penetrated or caused injury to an abnormally low dominant radiculomedullary artery, a recognized anatomical variant. This vessel, also known as the artery of Adamkiewicz, in 85% of individuals arises between T9 and L2, usually from the left, but in a minority of people may arise from the lower lumbar spine and rarely even from as low as S1. The artery of Adamkiewicz travels with the nerve root through the neural foramen and irrigates the anterior spinal artery. Injury of it or injection of particulate matter into it, as what may happen with the commonly used epidural steroid injectates, may result in infarction of the lower thoracic spinal cord, producing the clinical and imaging findings seen in these three patients. We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the artery of Adamkiewicz and an undetected intraarterial penetration of the procedure needle.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Anesthesiol
                Journal ID (iso-abbrev): Korean J Anesthesiol
                Journal ID (publisher-id): KJAE
                Title: Korean Journal of Anesthesiology
                Publisher: The Korean Society of Anesthesiologists
                ISSN (Print): 2005-6419
                ISSN (Electronic): 2005-7563
                Publication date (Print): September 2014
                Publication date (Electronic): 24 September 2014
                Volume: 67
                Issue: 3
                Pages: 193-197
                Affiliations
                Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea.
                Author notes
                Corresponding author: Ji Hee Hong, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, 56, Dalsung-ro, Jung-gu, Daegu 700-712, Korea. Tel: 82-53-250-7288, Fax: 82-53-250-7240, pain1004@ 123456dsmc.or.kr
                Article
                DOI: 10.4097/kjae.2014.67.3.193
                PMC ID: 4188765
                SO-VID: a1bc2cca-1a32-4726-8928-61d09e5a3bfe
                Copyright © Copyright © the Korean Society of Anesthesiologists, 2014
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 21 February 2014
                Date revision received : 18 March 2014
                Date accepted : 18 March 2014
                Categories
                Subject: Clinical Research Article

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: intravascular,long-bevel,short-bevel,transforaminal epidural steroid injection
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: intravascular, long-bevel, short-bevel, transforaminal epidural steroid injection

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