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Intra-Arterial Injection in the Rat Brain: Evaluation of Steroids Used for Transforaminal Epidurals

Dawley, Joshua D. MD; Moeller-Bertram, Tobias MD; Wallace, Mark S. MD, MAS; Patel, Piyush M. MD

doi: 10.1097/BRS.0b013e3181ac0018
Basic Science

Study Design. Prospective in vivo experimental animal model.

Objectives. To determine the effect of intra-arterial injection of the steroids commonly used for transforaminal epidurals on the central nervous system. And to determine if all of the steroids have the same effect.

Summary of Background Data. Transforaminal epidural steroid injection is commonly employed to treat radicular pain. This approach is associated with complications, including stroke and death. While the mechanism is unknown, the leading hypothesis is that intravascular injection of particulate steroids leads to microembolization.

Methods. To characterize the nature of steroid induced injury, a rodent model was employed. The internal carotid artery was dissected and its branches ligated. The external carotid artery was ligated, mobilized, cannulated, and injectate administered. Five solutions were tested: Depo-Medrol (N = 11), Depo-Medrol carrier (N = 6), Solu-Medrol (N = 6), Decadron (N = 8), and normal saline (N = 7). Drugs, in volume of 50 μL, were injected into the ICA via the ECA cannula at 25 μL/min. The extent of central nervous system injury was evaluated by analysis of coronal sections of the brain.

Results. Cerebral hemorrhage occurred in test subjects with the following frequency: 8 of 11 in the Depo-Medrol group, 7 of 8 in the Solu-Medrol group, and 3 of 6 in the Depo-Medrol carrier group; no lesions were identified in the Decadron or saline groups (P < 0.01). Evan’s blue dye leakage was detected in the Depo-Medrol and Solu-Medrol groups, but not the Decadron or saline groups.

Conclusion. This study presents the first in vivo evaluation of intra-arterial steroid injection. Data demonstrate Depo-Medrol, as well as its nonparticulate carrier, and Solu-Medrol can produce significant injury to the blood-brain barrier when injected intra-arterially. These results demonstrate that injury is produced not only by particulate obstruction of the cerebral microvasculature, but also by toxicity of the carrier or steroid (methylprednisolone).

Transforminal epidural steroid injections can cause stroke and paraplegia from inadvertent arterial injection. The nature of the injury was evaluated using a rodent model in which steroids were injected into the internal carotid artery. Depo-Medrol, Depo-Medrol carrier, and Solu-Medrol produced brain lesions, whereas Decadron and saline did not.

From the Department of Anesthesiology, UCSD, San Diego, CA.

Acknowledgment date: August 12, 2008. Acceptance date: December 15, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Institutional 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 Tobias Moeller-Bertram, MD, MAS, 200 West Arbor Drive, San Diego, CA 92103, MC9125; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.