scholarly journals Vertebral Artery Anatomical Variations as They Relate to Cervical Transforaminal Epidural Steroid Injections

Pain Medicine ◽  
2013 ◽  
Vol 15 (7) ◽  
pp. 1109-1114 ◽  
Author(s):  
Andrew I. Gitkind ◽  
Todd R. Olson ◽  
Sherry A. Downie
Keyword(s):  
Vertebral Artery ◽  
Anatomical Variations ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Neck movement during cervical transforaminal epidural injections and the position of the vertebral artery: an anatomical study

2019 ◽  
Vol 8 (3) ◽  
pp. 205846011983468
Author(s):  
Juan Altafulla ◽  
Emre Yilmaz ◽  
Stefan Lachkar ◽  
Joe Iwanaga ◽  
Jacob Peacock ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Guide Wire ◽  
Anatomical Study ◽  
Epidural Injection ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Intervertebral Foramina ◽  
Digital Subtraction Fluoroscopy

Background Cervical transforaminal epidural steroid injections (CTFESIs) are sometimes performed in patients with cervical radiculopathy secondary to nerve-root compression. Neck movements for patient positioning may include rotation, flexion, and extension. As physicians performing such procedures do not move the neck for fear of injuring the vertebral artery, we performed fluoroscopy and cadaveric dissection to analyze any movement of the vertebral artery during head movement and its relation to the foramina in the setting of CTFESI. Purpose To determine cervical rotational positioning for optimized vertebral artery location in the setting of cervical transforaminal epidural steroid injections. Material and Methods Four sides from two Caucasian whole cadavers (all fresh-frozen) were used. Using a guide wire and digital subtraction fluoroscopy, we evaluated the vertebral artery mimicking a CTFESI, then we removed the transverse processes and evaluated the vertebral artery by direct observation. Results After performing such maneuvers, no displacement of the vertebral artery was seen throughout its course from the C6 to the C2 intervertebral foramina. To our knowledge, this is the first anatomical observation of its kind that evaluates the position of the vertebral artery inside the foramina during movement of the neck. Conclusion Special caution should be given to the medial border of the intervertebral foramina when adjusting the target site and needle penetration for the injection. This is especially true for C6-C4 levels, whereas for the remaining upper vertebrae, the attention should be focused on the anterior aspect of the foramen. Since our study was centered on the vertebral artery, we do not discard the need for contrast injection and real-time digital subtraction fluoroscopy while performing the transforaminal epidural injection in order to prevent other vascular injuries.

Interpreting Reviews and Guidelines: The Case of Lumbar Epidural Steroid Injections

PM&R ◽  
2009 ◽  
Vol 1 (6) ◽  
pp. 576-579 ◽  
Author(s):  
Venu Akuthota ◽  
Charles Argoff ◽  
William C. Watters
Keyword(s):  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Transforaminal Lumbar and Thoracic Interventions and Ischemic Spinal Cord Injury

2016 ◽  
Author(s):  
Scott E. Glaser ◽  
Rinoo Shah
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Spinal Cord Infarction ◽  
Supporting Evidence ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Root Cause ◽  
Cord Injury ◽  
Epidural Steroid ◽  
Ischemic Spinal Cord Injury

Transforaminal epidural steroid injections have been shown to be associated with catastrophic neurologic complications secondary to spinal cord infarction. The reflexive, ad hoc response of practitioners to these injuries has been to recommend risk minimization strategies to prevent embolism of the injected particulate steroids and to use nonparticulate steroids. This focus on distal embolism as the sole or primary cause of catastrophic outcomes lacks conclusive supporting evidence and does not suffice to protect the patient from paraplegia as it fails to address the root cause of the complications. A root cause analysis of the procedure provides evidence that the injection technique itself—the “safe triangle”—creates a risk of arterial damage and sequelae leading to ischemia of the spinal cord. The evidence is strong that the only way to mitigate or eliminate the risk of paraplegia is to use a different technique to perform transforaminal injections: the Kambin triangle approach. This change in technique is the only definitive solution that addresses the root cause of these catastrophic sequelae associated with transforaminal epidural steroid injections. Key Words: Artery of Adamkiewicz, ischemic spinal cord injury, Kambin triangle, safe triangle, transforaminal epidural injection

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