scholarly journals Radiation Dose Incurred in the Exclusion of Vascular Filling in Transforaminal Epidural Steroid Injections: Fluoroscopy, Digital Subtraction Angiography, and CT/Fluoroscopy

Pain Medicine ◽  
2014 ◽  
Vol 15 (8) ◽  
pp. 1328-1333 ◽  
Author(s):  
Timothy Maus ◽  
Beth A. Schueler ◽  
Shuai Leng ◽  
Dayne Magnuson ◽  
Dixon J. Magnuson ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Digital Subtraction Angiography ◽  
Digital Subtraction ◽  
Ct Fluoroscopy ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Digital Subtraction Angiography Use During Epidural Steroid Injections Does Not Reliably Distinguish Artery from Vein

2016 ◽  
Vol 4;19 (4;5) ◽  
pp. 255-266
Author(s):  
Jonathan A. Benfield
Keyword(s):  
Key Words ◽  
Digital Subtraction Angiography ◽  
Real Time ◽  
Narrative Review ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Objective Evidence ◽  
Cord Injury ◽  
Epidural Steroid

Background: Epidural steroid injections (ESIs) are among the most common procedures performed in an interventional pain management practice. It is well known that tragic complications may arise from ESIs, most commonly those performed using a transforaminal approach. Digital subtraction angiography (DSA) has been hailed as a fluoroscopic technique that can be used to detect arterial placement of the injection needle, and therefore as a safety measure that can decrease the incidence of catastrophic sequelae of these procedures. Objective: The objective of this article was to review existing scientific pain literature to determine if DSA can distinguish arterial vs. venous uptake. Study Design: Narrative review. Methods: The current narrative review of DSA in interventional spine was completed with a PUBMED search using the key words: digital subtraction angiography, epidural, fluoroscopy, intravascular injection, paraplegia, and quadriplegia in accordance with Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines. Results: After identification of duplicate articles, 383 articles were screened by title, abstract, and/or full article review. Ten of these articles were deemed appropriate, after applying inclusion and exclusion criteria, as they specifically looked at the use of digital subtraction angiography in interventional spine epidural injections. This included 4 case reports, 3 prospective studies, one retrospective analysis, one prospective cohort study, and one meta-analysis. All of the available studies claiming that DSA was capable of detecting vascular spread are likely accurate, but no significant detection of specifically arterial spread has been reported. The known catastrophic complications related to ESIs are purported to be due to arterial injection of insoluble steroids or local anesthetic and detection of arterial spread of contrast during fluoroscopy would be of obvious benefit to the interventionalist. Limitations: Small study size, non-randomized studies between DSA and real time fluoroscopy. Conclusion: Existing studies do not support that DSA can predict arterial spread. In fact, DSA exposes the practitioner and the patient to higher levels of radiation without objective evidence of any safety parameters. Key words: Digital subtraction angiography, real-time fluoroscopy, transforaminal epidural injection, particulate steroids, cervical radicular artery, lumbar radicular artery, spinal cord injury

Radiation Dose Exposure for Lumbar Spine Epidural Steroid Injections: A Comparison of Conventional Fluoroscopy Data and CT Fluoroscopy Techniques

2011 ◽  
Vol 197 (4) ◽  
pp. 778-782 ◽  
Author(s):  
Jenny K. Hoang ◽  
Terry T. Yoshizumi ◽  
Greta Toncheva ◽  
Linda Gray ◽  
Andreia R. Gafton ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Radiation Dose ◽  
Ct Fluoroscopy ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Radiation Dose Exposure ◽  
Epidural Steroid

scholarly journals Digital Subtraction Angiography Versus RealTime Fluoroscopy for Detection of Intravascular Penetration Prior to Epidural Steroid Injections: Meta-Analysis of Prospective Studies

2015 ◽  
Vol 18;1 (1;1) ◽  
pp. 29-36
Author(s):  
Nader Djalal Nader
Keyword(s):  
Digital Subtraction Angiography ◽  
Real Time ◽  
Prospective Studies ◽  
Meta Analysis ◽  
Secondary Outcome ◽  
Digital Subtraction ◽  
Vascular Events ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Background: Neurological injury is a rare but devastating complication of epidural steroid injections (ESIs) generally thought to arise from neurovascular compromise. The use of real-time fluoroscopy (RTF) with contrast media is the most common preventative measure taken to avoid intravascular penetration. In 2002, it was proposed that digital subtraction angiography (DSA) might be more useful than RTF. Since then, several prospective studies have advocated for its use. Objectives: As DSA is not currently a “gold standard,” a meta-analysis was performed to compare the efficacy of DSA versus RTF for detection of intravascular penetration during ESI. Study Design: Meta-analysis of prospective observational studies. Methods: A targeted Pubmed search was conducted, yielding 49 reports and 4 manuscripts, which were analyzed using Review Manager Software (Rev Man 5.2). Inclusion/exclusion criteria: peer-reviewed prospective reports comparing the sensitivity of DSA to RTF in the same individuals without change in needle position between comparative imaging. Pooled estimate of odds ratios with 95% confidence interval using a random effect model was applied. Results: There were a total of 188 intravascular events from 1,290 ESIs performed. RTF was able to detect 148 events with DSA detecting an additional 40 events missed by RTF. No major neurological complications were reported. DSA had a statistically significant favorable odds ratio over RTF for detection of intravascular penetration during ESI (OR = 1.32 [1.05 – 1.67]; P = 0.02). Limitations: Although the major methodological aspects of each study assessed in this metaanalysis were quite similar, there were small differences in needle gauge and the selection of secondary outcome measures. Despite attempts to minimize it, concern for operator bias also exists. Conclusions: DSA had a 32% improvement (OR = 1.32) for detection of intravascular penetration with ESI when compared to RTF. Although this supports advocacy for use of DSA, it also suggests that there is a greater than 30% “missed-events” rate for detection of vascular penetration when using RTF for ESI, which does not correlate with the generally reported cumulative rates of complications (1%). This discrepancy suggests that factors other than vascular events also play a role in complications. Nonetheless, given the evidence, we advocate for the increased use of DSA over RTF for transformational ESIs. Key words: Digital subtraction angiography, real-time fluoroscopy, epidural steroid injection, complications, outcomes, pain imaging, chronic pain, intravascular injection, meta-analysis

scholarly journals Digital Subtraction Angiography Does Not Reliably Prevent Paraplegia Associated with Lumbar Transforaminal Epidural Steroid Injection

2012 ◽  
Vol 6;15 (6;12) ◽  
pp. 515-523
Author(s):  
Kenneth D. Candido
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Lower Extremity ◽  
Digital Subtraction Angiography ◽  
Test Dose ◽  
Spinal Cord Infarction ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epidural steroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately following the completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids. Key words: Digital subtraction angiography, transforaminal epidural steroid injections, paraplegia, chronic low back pain.

The Rate of Detection of Intravascular Injection in Cervical Transforaminal Epidural Steroid Injections With and Without Digital Subtraction Angiography

PM&R ◽  
2009 ◽  
Vol 1 (7) ◽  
pp. 636-642 ◽  
Author(s):  
James P. McLean ◽  
James D. Sigler ◽  
Christopher T. Plastaras ◽  
Cynthia Wilson Garvan ◽  
Joshua D. Rittenberg
Keyword(s):  
Digital Subtraction Angiography ◽  
Digital Subtraction ◽  
Intravascular Injection ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Intravascular Flow Detection During Transforaminal Epidural Injections: A Prospective Assessment

2014 ◽  
Vol 17;1 (1;17) ◽  
pp. 21-27
Author(s):  
Omar El Abd
Keyword(s):  
Digital Subtraction Angiography ◽  
Control Group ◽  
Safe Procedure ◽  
Digital Subtraction ◽  
Traditional Methods ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Number Of Patients ◽  
Epidural Steroid ◽  
The Impact

Background: Transforaminal epidural steroid injections (TFESI) are a mainstay in the treatment of spine pain. Though this commonly performed procedure is generally felt to be safe, devastating complications following inadvertent intra-arterial injections of particulate steroid have been reported. The use of digital subtraction angiography (DSA) has been suggested as a means of detecting intra-arterial needle placements prior to medication injection. Objective: To examine the efficacy of DSA in detecting intra-arterial needle placements during TFESI. Study Design: Prospective cohort study evaluating the impact of DSA on detecting intra-arterial needle placements during TFESI. Methods: We enrolled 150 consecutive patients presenting to a university-affiliated spine center with discogenic and/or radicular symptoms affecting the cervical, lumbar, and sacral regions. For each injection, prior to imaging with DSA, traditional methods for vascular penetration detection were employed, including the identification of blood in the needle hub (flash), negative aspiration of blood prior to injection, and live fluoroscopic injection of contrast. Once these tests were performed and negative for signs of intra-arterial needle placement, DSA imaging was utilized prior to medication administration for identification of vascular flow. Results: A total number of 222 TFESI were performed, 41 injections at the cervical levels (18.47%), 113 at the lumbar levels (50.9%), and 68 at the sacral levels (30.36%). Flash was observed in 13 injections performed (5.85% of the total number of injections): one (0.45%) in the cervical, 2 (0.9%) in the lumbar, and 10 (4.5%) in the sacral levels. In 11 TFESI blood aspiration was obtained (4.95% of all injections): 3 (1.3%) in cervical, 4 (1.8%) in lumbar, and 4 (1.8%) in sacral injections. Live fluoroscopy during contrast injection detected 46 (20.72%) intravascular flow patterns: 7 (3.1%) cervical, 17 (7.6%) lumbar, and 22 (9.9%) sacral. DSA identified an additional 5 intravascular injections after all previous steps had resulted in negative vascular penetration signs, which accounted for 2.25% of all injections. Limitations: This is a prospective, single-center study with a relatively small number of patients and no control group. Conclusion: DSA detected additional 5.26% intravascular needle placements following traditional methods. Our findings also support other studies that conclude TFESI are generally a safe procedure. We recommend that special attention should be paid to the sacral injections as vascular penetration was statistically higher than at other levels. Key words: Digital subtraction angiography, transforaminal epidural steroid injections

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