Relative Conspicuity of Gadolinium-Based Contrast Agents in Interventional Pain Procedures

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Hidden risk of gadolinium-based contrast agents during interventional pain medicine procedures: a retrospective chart review

INTRODUCTION

Epidural steroid injections and epidural blood patches commonly involve the injection of a small amount of radiocontrast media under fluoroscopy to properly identify the target tissue or anatomic space and prevent off-target or intravascular delivery of therapeutic or diagnostic drugs. Iodinated low osmolar non-ionic contrast media is the standard preparation used as it is considered safe and cost-effective, but gadolinium-based preparations have been used as an alternative for patients with an 'iodine'-related or radiocontrast media allergy label to prevent hypersensitivity reactions. The risk of neurotoxic events when gadolinium is inadvertently injected into the intrathecal space has been reported in recent years, raising concerns when gadolinium-based contrast media is used in lieu of iodinated low osmolar non-ionic contrast media.

METHODS

A retrospective review was conducted of patients who received gadolinium-based contrast media for procedures with risk of inadvertent intrathecal access from January 1, 2019 to May 1, 2022. Information on patient demographics, allergy label information, and procedure description was documented for all patients who received gadolinium-based contrast media for axial spine procedures (including epidural steroid injections, epidural blood patch procedures, and selective nerve root blocks), and all side effects reported within 1 month of the procedure were recorded. Saved fluoroscopy images of all procedures for which there was concern for possible gadolinium-based contrast media-related side effect were reviewed for evidence of inadvertent intrathecal gadolinium-based contrast media administration. Descriptive statistical analysis was performed using REDCap and IBM SPSS Statistics V.28.

RESULTS

We identified 508 patients who received gadolinium-based contrast media during a fluoroscopically guided axial spine procedure. These patients underwent 697 epidural procedures and 23 patients were identified as experiencing an adverse event that could be consistent with possible, probable, or clear signs of exposure to intrathecal gadolinium. Our calculated adverse event rate was 3.3%. Ten patients required additional medical evaluation or treatment.

DISCUSSION

Almost all patients in our cohort had an allergy label on their chart that guided the provider to switch to gadolinium-based contrast media, but most were incomplete, ill-defined, or related to allergy to iodine but not iodinated contrast media. Such practice is not recommended based on current guidelines. The current study raises concern regarding the use of gadolinium-based contrast media in axial spine procedures, with the risk of potential severe adverse events, without evidence-based need for avoiding iodinated contrast media.

American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement

The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.

Best practices for interventional pain procedures in the setting of an iodinated contrast media shortage: A multisociety practice advisory

Representatives from the Spine Intervention Society (SIS) and American Academy of Pain Medicine (AAPM) have developed the following best practice recommendations for the performance of interventional pain procedures in the setting of an iodinated contrast media shortage. The practice advisory has been endorsed by SIS, AAPM, American Academy of Physical Medicine and Rehabilitation (AAPMR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), North American Neuromodulation Society (NANS), North American Spine Society (NASS), and Society of Interventional Radiology (SIR).

Encephalopathy after unintentional intrathecal gadolinium: A letter to the editor

Objective

Raise awareness of gadolinium encephalopathy, a rare cause of neurological symptoms.

Setting

An L5-S1 interlaminar epidural steroid injection (IL-ESI) was performed with a gadolinium-based contrast agent (GBCA) due to the patient's history of allergic reaction to iodine-based contrast agents.

Discussion

Several hours after administration of GBCA, the patient had nausea and vomiting with altered mental status. Patient was treated with dexamethasone IV, and was discharged on day 2. Patient had no residual deficits at follow-up two weeks later. Current literature shows that caution should be used to prevent inadvertent intrathecal GBCA, and doses >2.0 mmols are associated with serious adverse effects, including death.

Conclusions

Intrathecal administration of GBCAs should be limited to less than 0.5 mmol. If adverse effects are experienced, IV steroids should be administered as soon as possible, and a CSF drain should be considered.

Practice Management Strategies for Imaging Facilities Facing an Acute Iodinated Contrast Media Shortage

An unanticipated but severe shortage in iodinated contrast media (ICM) is currently affecting imaging practices across the globe and is expected to persist through at least the end of June 2022. This supply shock may lead to healthcare systems experiencing an acute imaging crisis, as many affected facilities have contrast agent supplies that are anticipated to last only a week or two under normal operating conditions. To maximize the opportunity to continue to provide optimal care for patients with emergent or life-threatening imaging indications and thereby minimize the overall impact on patient care, practice leaders will need to quickly assess their contrast material inventories, prioritize examination indications, and reduce their expected short-term usage of ICM. This Clinical Perspective reviews ICM conservation techniques that we have deployed, or are considering deploying, depending on the severity and length of the supply shortage.

The Use of Contrast Agents in Interventional Pain Procedures: A Multispecialty and Multisociety Practice Advisory on Nephrogenic Systemic Fibrosis, Gadolinium Deposition in the Brain, Encephalopathy After Unintentional Intrathecal Gadolinium Injection, and Hypersensitivity Reactions

This Practice Advisory presents a comprehensive and evidence-based set of position statements and recommendations for the use of contrast media in interventional pain procedures. The advisory was established by an international panel of experts under the auspices of 11 multinational and multispecialty organizations based on a comprehensive review of the literature up to December 31, 2019. The advisory discusses the risks of using gadolinium-based contrast agents. These include nephrogenic systemic fibrosis, gadolinium brain deposition/retention, and encephalopathy and death after an unintentional intrathecal gadolinium injection. The advisory provides recommendations on the selection of a specific gadolinium-based contrast agent in patients with renal insufficiency, those who had multiple gadolinium-enhanced magnetic resonance imaging examinations, and in cases of paraspinal injections. Additionally, recommendations are made for patients who have a history of mild, moderate, or severe hypersensitivity reactions to contrast medium.

Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review

Gadolinium-based contrast agents (GBCAs) have been suggested as off-label alternatives to iodine-based contrast agents for fluoroscopic imaging during interventional pain procedures. We report a case of accidental intrathecal administration of a GBCA during a neuraxial interventional pain procedure leading to acute gadolinium neurotoxicity, which resulted in encephalopathy and ultimately death. To our knowledge, it is the first published case of fatal intrathecal gadolinium-induced encephalopathy and the first published case of intrathecal gadoteridol causing serious neurologic complications. In addition, the case presented here is placed in context with an associated comprehensive, evidence-based review of the use of gadolinium in interventional pain procedures, addressing gadolinium chemistry and pharmacologic properties, neurotoxicity and radiology. Physicians must be aware that gadolinium poses a significant risk of acute neurotoxicity even in small doses. Until further safety research is performed, GBCAs should not be considered a safe alternative for use in neuraxial interventional spine procedures when there is a risk of inadvertent intrathecal administration.