Cervical epidural injection complicated by syrinx formation: a case report

Radiation exposure to the eyes and thyroid during C-arm fluoroscopy-guided cervical epidural injections is far below the safety limit

Background

The aim of this study was to evaluate radiation exposure to the eye and thyroid in pain physicians during the fluoroscopy-guided cervical epidural block (CEB).

Methods

Two pain physicians (a fellow and a professor) who regularly performed C-arm fluoroscopy-guided CEBs were included. Seven dosimeters were used to measure radiation exposure, five of which were placed on the physician (forehead, inside and outside of the thyroid protector, and inside and outside of the lead apron) and two were used as controls. Patient age, sex, height, and weight were noted, as were radiation exposure time, absorbed radiation dose, and distance from the X-ray field center to the physician.

Results

One hundred CEB procedures using C-arm fluoroscopy were performed on comparable patients. Only the distance from the X-ray field center to the physician was significantly different between the two physicians (fellow: 37.5 ± 2.1 cm, professor: 41.2 ± 3.6 cm, P = 0.03). The use of lead-based protection effectively decreased the absorbed radiation dose by up to 35%.

Conclusions

Although there was no difference in radiation exposure between the professor and the fellow, there was a difference in the distance from the X-ray field during the CEBs. Further, radiation exposure can be minimized if proper protection (thyroid protector, leaded apron, and eyewear) is used, even if the distance between the X-ray beam and the pain physician is small. Damage from frequent, low-dose radiation exposure is not yet fully understood. Therefore, safety measures, including lead-based protection, should always be enforced.

Reliability and Accuracy of MRI Laminar Angle Measurements to Determine Intra-Procedural Contralateral Oblique View Angle for Cervical or Thoracic Interlaminar Epidural Steroid Injections

BACKGROUND AND OBJECTIVE

Contralateral oblique (CLO) angle view has been a useful addition to standard views in fluoroscopically guided interlaminar epidural injections. Determination of the appropriate CLO angle is paramount in the usefulness of this technique. Using MRI laminar angle measurements as a pre-procedural guide for the intra-procedural fluoroscopic CLO angle has been proposed. The purpose of this study was to help determine if using axial MRI laminar measurements prior to a cervical or thoracic epidural steroid injection would be useful in predicting the appropriate fluoroscopic CLO angle.

STUDY DESIGN

A retrospective review was performed for patients who underwent cervical or thoracic interlaminar injections. In the performance of interlaminar injections, the authors had routinely determined the true fluoroscopic contra-lateral oblique angle after epidural access was confirmed, for use during any potential future injections. The fluoroscopic CLO angle measurements were obtained from a chart review and compared blindly to each patient's MRI axial laminar angle measurements.

RESULTS

34 injections were included. Inter-rater reliability comparing the two authors' MRI angle measurements was considered fair, ICC = 0.395. Accuracy was only 57% comparing MRI laminar angle measurements to within five degrees of the true fluoroscopic CLO angle as determined during the injection procedure. Accuracy by ICC showed only fair agreement, 0.47 and 0.22, for the two authors.

CONCLUSIONS

The findings of this study indicate fair inter-rater reliability in manual measurements of laminar angle on axial MRI images. MRI laminar angle measurements do not appear to be highly accurate in determining the appropriate fluoroscopic CLO angle.

Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials

BACKGROUND

The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups.

METHODS

Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV).

RESULTS

A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone.

CONCLUSION

This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone.

Cervical epidural steroid injections for the treatment of cervical spinal (neck) pain

Cervical epidural steroid injections (CESI) are an accepted treatment for neck pain with a radicular component, and may be accomplished by using either transforaminal (CTFESI) or interlaminar (CILESI) approaches. CESIs are routinely performed using real-time fluoroscopic-guidance in conjunction with the injection of water soluble, iodine-based contrast media to enhance visualization of intravascular injections. Digital subtraction angiography (DSA) imaging is an adjuvant to fluoroscopic methods for visualizing blood vessels while performing spinal injections. However, as with any neuraxial procedure, various complications associated with CESIs have been reported. Complications are directly associated with the technical procedures of CESIs. Particulate steroids may have a prolonged duration of action but non-particulate steroids are safer for CESIs. Blunt-beveled needles are less likely than sharp-beveled needles to penetrate blood vessels to cause bleeding complications during CTFESI procedures. Small doses of local anesthetics appear to be safe and assist in identifying intravascular injections previously overlooked by conventional techniques.

CT-guided transforaminal cervical and lumbar epidural injections

Transforaminal injections are widely used. Serious complications including strokes and paraplegia have been reported after transforaminal injections of corticosteroids, and the Afssaps (2011) has issued a warning about their use [1]. The needle must be positioned in the posterior aspect of foramen, and its correct placement validated by an injection of contrast product. It is preferable to choose cortivazol (Altim(®)) as the corticoid for injection. This procedure is simple, reproducible, and durably effective in 60 to 70% of cases. Complications and adverse effects are rare but potentially serious: allergies, blood pressure surge, vasovagal syncope, transient exacerbation of pain, infection, stroke, and paraplegia. The aim of this course is to stress the need for rigor - in the indication, the technical performance of the procedure, and the overall management of the patient.