Elsevier

The Spine Journal

Volume 7, Issue 1, January–February 2007, Pages 79-82
The Spine Journal

Clinical Study
Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections

https://doi.org/10.1016/j.spinee.2006.06.380Get rights and content

Abstract

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.

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)

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