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Incidence of Simultaneous Epidural and Vascular Injection During Cervical Transforaminal Epidural Injections

Smuck, Matthew MD*; Tang, Chi-Tsai MD; Fuller, Brian J. MD

doi: 10.1097/BRS.0b013e3181b043d1
Cervical Spine

Study Design. Prospective, observational in vivo study.

Objective. The aim of this study was to determine the incidence of simultaneous epidural and vascular contrast injection during cervical transforaminal epidural injections.

Summary of Background Data. In the lumbar spine, vascular contrast patterns are more than twice as likely to appear simultaneous to the anticipated epidural pattern, than they are to occur alone. This is important because practitioners are more likely to miss a vascular pattern when it appears simultaneous to the expected epidural flow. The incidence of intravascular penetration in cervical transforaminal epidural injections is known to exceed than that of lumbar injections, however, no study has determined the incidence of simultaneous epidural and vascular injection in the cervical spine.

Methods. Contrast patterns were observed with live fluoroscopy during 121 injections performed on 82 patients and categorized as one of the following: epidural only, vascular only, or simultaneous epidural and vascular.

Results. The incidence of simultaneous epidural and vascular injection during cervical transforaminal epidural injections was 18.9%. The incidence of vascular only injection was 13.9%, for a total vascular injection incidence of 32.8%. There was no correlation between the observed contrast pattern with patients’ age, sex, side of injection, needle gauge, or diagnosis. There was a significant correlation between the level of injection and the risk of vascular injection. The higher the injection level, the higher the probability of a vascular injection. Fluoroscopy time was significantly increased when a vascular injection was identified.

Conclusion. Simultaneous epidural and vascular injection accounts for over half of all vascular injections during cervical transforaminal epidural injections. With the risk of severe complications and high incidence of vascular injections in the cervical spine, live fluoroscopy is recommended during contrast injection with specific attention to simultaneous epidural and vascular flow.

In this prospective study, 121 cervical transforaminal injections were performed on 82 patients. The incidence of simultaneous epidural and vascular injection was 18.9%; adding 13.9% incidence of vascular only injection results in an overall 32.8% incidence of vascular injection. Risk of vascular injection is greater at higher cervical levels.

From the *Department of Orthopaedic Surgery, Stanford University, Stanford, CA; and †Department of Physical Medicine and Rehabilitation, The Spine Program, University of Michigan, Ann Arbor, MI.

Acknowledgment date: November 6, 2008. Revision date: February 4, 2009. Acceptance date: March 12, 2009.

The device(s)/drug(s) i/are FDA-approved or approved by corresponding national agency for this indication.

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 manuscript.

Address correspondence and reprint requests to Matthew Smuck, MD, Department of Orthopaedic Surgery, Stanford University, Stanford, CA; E-mail: msmuck@stanford.edu

© 2009 Lippincott Williams & Wilkins, Inc.