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Incidence of Intravascular Penetration in Transforaminal Cervical Epidural Steroid Injections

Furman, Michael B. MD, MS*; Giovanniello, Michael T. MD; O’Brien, Erin M. MD

Cervical Spine

Study Design. A prospective, observational, human, in vivo 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.

From the *The Center for Pain Management and Rehabilitation, KDV Orthopaedics and Rehabilitation, York, Pennsylvania, the

†Center for Physical Medicine and Pain Management, Salt Lake City, Utah, and the

‡Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Acknowledgment date: November 19, 2001.

First revision date: April 17, 2002. Second revision date: May 14, 2002.

Acceptance date: May 20, 2002.

Device status/drug statement: The devices and drugs are approved by the FDA or by corresponding national agency for this indication.

Conflict of interest: No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.

Address reprint requests to Michael B. Furman, MD, MS, The Center for Pain Management and Rehabilitation, KDV Orthopaedics and Rehabilitation, 908 South George Street, York, PA 17403. E-mail: MFurman@KDVOrtho.com.

© 2003 Lippincott Williams & Wilkins, Inc.