Clinical StudyIncidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections
Introduction
Lumbosacral transforaminal epidural injections of anesthetic and corticosteroids are generally safe procedures, with a reported minor complication rate of 9.6% [1]. There have been reports of rare but serious morbidity associated with lumbosacral epidural injection, including transient paralysis and spinal cord infarction with irreversible neurologic impairment [2], [3], [4]. Adverse outcomes of the same magnitude have also been observed during computed tomography–guided lumbar epidural injections [2], [3]. Many of these adverse outcomes are thought to be secondary to intravascular injection and embolization of corticosteroid particles via the radicular arteries, especially the artery of Adamkiewicz [2], [3], [5], [6]. Direct mechanical injuries to these arteries resulting in thrombosis, spasm, and compression of vascular or neural components have also been proposed as the cause of these sequelae [2], [3], [7].
To help avoid complications from accidental intra-arterial injection of corticosteroids, some practitioners have proposed injecting anesthetic before corticosteroids [5], [6]. However, serious adverse outcomes have been reported as a result of vascular injection of local anesthetic, including, but not limited to, dysgeusia, perioral numbness, tinnitus, vertigo, transient paraplegia, seizure, cardiovascular toxicity, and death [6], [8], [9], [10], [11], [12].
Vascular contrast patterns have been reported in 8.9% to 21.3% of fluoroscopically guided lumbosacral transforaminal epidural steroid injections depending on the level of injection [10], [13], [14]. The commonly employed method of looking for blood return while aspirating on a syringe is only 44.7% sensitive in detecting intravascular needle placement during transforaminal injections [13]. Fortunately, fluoroscopy can detect accidental vascular injection when contrast is used. Because of the fleeting nature of the vascular contrast pattern, intermittent fluoroscopy can miss an accidental vascular injection [5], [9]. Vascular contrast patterns are especially difficult to visualize in the setting of a concurrent epidurogram [5], [10], [15]. The purpose of this study was to determine the incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections using live fluoroscopy during contrast injections.
Section snippets
Methods
The study was Institutional Review Board approved and Health Insurance Portability and Accountability Act compliant. Data were collected by one interventional physiatrist and three fellows under his direct supervision at a university-based spine clinic. Any patient scheduled for a lumbosacral transforaminal epidural injection at the request of the treating physiatrist or spine surgeon was considered a candidate for this study. Patients were excluded from the study for pregnancy, coagulopathy,
Results
Subjects had a mean age of 50.3 years, with a range of 21 to 91 years. Nearly half of the injections were performed on males and the other half on females, 45% and 55% respectively. The greatest number of injections was done at the fifth lumbar nerve root, followed by the fourth lumbar nerve root (Table 1). Three gauges of needles were used: 22-gauge (n=31), 25-gauge (n=81), and 26-gauge (n=79). Of the 103 subjects, diagnoses included stenosis (n=41), radiculopathy (n=77), herniated nucleus
Discussion
The overall incidence of vascular injections reported here, 13.1%, is similar to observations in previous studies. To our knowledge, this is the first time the incidence of simultaneous epidural and vascular injections has been reported. With an incidence of 8.9%, simultaneous epidural and vascular injections account for more than half of all accidental vascular injections.
Serious morbidity has been reported from the accidental intravascular injection of local anesthetics and corticosteroids.
References (15)
- et al.
Complications of fluoroscopically guided transforaminal lumbar epidural injections
Arch Phys Med Rehabil
(2000) - et al.
Paraplegia after lumbosacral nerve root block: report of three cases
Spine J
(2002) - et al.
Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury
Pain
(2003) - et al.
Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids
Spine J
(2004) - et al.
Central nervous system toxicity following the administration of levobupivacaine for lumbar plexus block: a report of two cases
Region Anesth Pain Med
(2003) - et al.
Accuracy of intermittent fluoroscopy to detect intravascular injection during transforaminal epidural injections
Arch Phys Med Rehabil
(2006) - et al.
Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection
Spine
(2005)
Cited by (75)
Comparison Between a Single Subpedicular Transforaminal Epidural Steroid Injection and Lateral Recess Steroid Injection in Reducing Paracentral Disc Herniation–Related Chronic Neuropathic Leg Pain: A Retrospective Study
2021, World NeurosurgeryCitation Excerpt :Ninety-seven percent of the time, radiculomedullary arteries are located in the upper part of the foramen and majority of them are on the left side (88%),38 and never in the lower fifth of the foramen.4 In SP-TFESI, risk of a simultaneous epidural and vascular injection has been estimated to be around 9%, while isolated vascular injections is around 4%.39 An intra-arterial or an intrathecal injection mandates abandoning the procedure, but if intravenous contrast spread is noticed, then needle position may be changed and the procedure can be continued.
Lumbar Epidural Steroid Injections
2018, Physical Medicine and Rehabilitation Clinics of North AmericaMagnetic Resonance Imaging-Guided Spine Interventions
2015, Magnetic Resonance Imaging Clinics of North AmericaEpidural Complications and troubleshooting
2014, Techniques in Regional Anesthesia and Pain ManagementParasagittal Interlaminar and Transforaminal Epidural Steroid Injections for Radicular Low Back Pain; Which is More Comfortable?
2023, Turkish Journal of Anaesthesiology and Reanimation
FDA device/drug status: not applicable.
Nothing of value received from a commercial entity related to this manuscript.