Korean J Pain.  2010 Mar;23(1):18-23.

Accuracy of Live Fluoroscopy to Detect Intravascular Injection During Lumbar Transforaminal Epidural Injections

• Lee MH
• Yang KS
• Kim YH
• Jung HD
• Lim SJ
• Moon DE

Abstract

BACKGROUND
Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy.
METHODS
During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images.
RESULTS
Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%).
CONCLUSION
This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

Keyword

digital subtraction image; epidural injection; fluoroscopy; intravascular injection

MeSH Terms

Adrenal Cortex Hormones
Fluoroscopy
Incidence
Injections, Epidural
Adrenal Cortex Hormones

Figure

• 

  Fig. 1 (A) An anteroposterior live fluoroscopic image taken during contrast injection for right L5-S1 transforaminal steroid injection. It shows the epidural contrast pattern without vascular injection. (B) An anteroposterior digital subtraction image taken during same injection. It shows a simultaneous epidural and vascular contrast pattern.

Reference

1. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, et al. Interventional techniques: evidence based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007; 10:7–111. PMID: 17256025.

2. Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician. 2009; 12:233–251. PMID: 19165306.

3. Marshall LL, Trethewie ER, Curtain CC. Chemical radiculitis: a clinical, physiological and immunological study. Clin Orthop Relat Res. 1977; 129:61–67. PMID: 608297.

4. Wheeler AH, Murrey DB. Chronic lumbar spine and radicular pain: pathophysiology and treatment. Curr Pain Headache Rep. 2002; 6:97–105. PMID: 11872180.

5. Hadjipavlou AG, Tzermiadianos MN, Bogduk N, Zindrick MR. The pathophysiology of disc degeneration: a critical review. J Bone Joint Surg Br. 2008; 90:1261–1270. PMID: 18827232.

6. Yamashita M, Ohtori S, Koshi T, Inoue G, Yamauchi K, Suzuki M, et al. Tumor necrosis factor-alpha in the nucleus pulposus mediates radicular pain, but not increase of inflammatory peptide, associated with nerve damage in mice. Spine. 2008; 33:1836–1842. PMID: 18670336.

7. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil. 2000; 81:1045–1050. PMID: 10943753.

8. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009; 10:1389–1394. PMID: 19863744.

9. Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, et al. Complications of spinal diagnostic and treatment procedures. Pain Med. 2008; 9:S11–S34.

10. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J. 2002; 2:70–75. PMID: 14588291.

11. McLain RF, Fry M, Hecht ST. Transient paralysis associated with epidural steroid injection. J Spinal Disord. 1997; 10:441–444. PMID: 9355063.

12. Reitman CA, Watters W 3rd. Subdural hematoma after cervical epidural steroid injection. Spine. 2002; 27:E174–E176. PMID: 11884923.

13. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003; 103:211–215. PMID: 12749976.

14. Smuck M, Fuller BJ, Chiodo A, Benny B, Singaracharlu B, Tong H, et al. Accuracy of intermittent fluoroscopy to detect intravascular injection during transforaminal epidural injections. Spine. 2008; 33:E205–E210. PMID: 18379390.

15. Furman MB, Giovanniello MT, O'Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine. 2003; 28:21–25. PMID: 12544950.

16. Smuck M, Fuller BJ, Yoder B, Huerta J. Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections. Spine J. 2007; 7:79–82. PMID: 17197337.

17. Jasper JF. Is digital subtraction fluoroscopy a useful tool for the interventional pain physician? Pain Physician. 2002; 5:36–39. PMID: 16896356.

18. Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician. 2003; 6:369–372. PMID: 16880884.

19. Batson OV. The vertebral vein system. Caldwell lecture, 1956. Am J Roentgenol Radium Ther Nucl Med. 1957; 78:195–212.

20. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004; 4:468–474. PMID: 15246308.

21. Breslin DS, Martin G, Macleod DB, D'ercole F, Grant SA. Central nervous system toxicity following the administration of levobupivacaine for lumbar plexus block: a report of two cases. Reg Anesth Pain Med. 2003; 28:144–147. PMID: 12677626.

22. Kim DW, Shim JC. Incidence of intravascular penetration during transforaminal lumbosacral epidural steroid injection. Korean J Pain. 2007; 20:26–30.

23. Karasek M, Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med. 2004; 5:202–205. PMID: 15209975.

24. Stretanski MF, Chopko B. Unintentional vascular uptake in fluoroscopically guided, contrast confirmed spinal injections: a 1-yr clinical experience and discussion of findings. Am J Phys Med Rehabil. 2005; 84:30–35. PMID: 15632486.

25. Barbey MM, Farber A, Marienhoff N, Gmelin E. Digital subtraction angiography with carbon dioxide-basic principles, technique and clinical application. Vasa. 1999; 28:243–249. PMID: 10611841.