Inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle

The safety and efficiency of performing cervical transforaminal epidural steroid injections under fluoroscopic control on an ambulatory/outpatient basis

PURPOSE

Cervical transforaminal epidural steroid injections (CTFESIs) have become an increasingly utilised means of treating radicular pain over recent decades, although a number of reports have brought their safety into question. Much of this has been attributed to the use of particulate steroids and the theoretical risk of embolic complications with inadvertent intra-arterial injection. This study documents the complications encountered at our centre when performing CTFESI over a more than 10-year study period with predominant use of particulate steroid. Our procedural technique is also described. This study aims to highlight the importance of operator technique first and foremost and how, with safe and reproducible technique that confidently avoids intra-arterial injection, CTFESI can be performed safely irrespective of the choice of steroid.

METHODS

All patients undergoing CTFESI between January 2008 and August 2018 at our centre were prospectively recruited to the study, documenting total number of injections/procedures per patient, presence of/description of complications and severity and type of steroid administered.

RESULTS

Five hundred and twenty-seven patients underwent 1047 procedures (1753 individual cervical levels injected) over the study period: 1011 procedures performed with particulate steroid (triamcinolone acetonide) and 36 performed with non-particulate (dexamethasone). Only six complications were encountered, all spontaneously self-resolving without intervention and considered minor (grade 1).

CONCLUSIONS

With fastidious safe technique, CTFESI can be safe, efficacious and cost-effectively administered on an outpatient basis. Predominant use of particulate steroids did not lead to any significant complications. These slides can be retrieved under Electronic Supplementary Material.

Cervical radicular pain: the role of interlaminar and transforaminal epidural injections

Chronic neck pain and cervical radicular pain are relatively common in the adult population. Treatment for chronic radicular pain recalcitrant to conservative management includes surgical management as well as interventional techniques with epidural injections utilizing either an interlaminar approach or transforaminal approach. Although there have been multiple systematic reviews and randomized clinical trials of cervical interlaminar epidural injections, the literature is sparse in reference to cervical transforaminal epidural injections. Overall, there is good evidence for the effectiveness of cervical interlaminar epidural injections in managing cervical disc herniation and fair evidence in managing central spinal stenosis and postsurgery syndrome. The evidence is poor, however, for cervical transforaminal epidural injections. Complications with cervical interlaminar epidural injections are rare, but more commonly occur with transforaminal epidural injections and can be fatal. Emerging concepts in pain include further randomized trials; proper placebo design; focus on control design (either active control or placebo control); and appropriate methodologic quality assessment and evidence synthesis.

The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data

OBJECTIVE

To determine the effectiveness and risks of fluoroscopically guided cervical transforaminal injection of corticosteroids in the treatment of radicular pain.

DESIGN

Systematic review of the literature with comprehensive analysis of the published data.

INTERVENTIONS

Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided cervical transforaminal injection of steroids (CTFIS). Each reviewer independently assessed the methodology of studies found and appraised the quality of the evidence presented.

OUTCOME MEASURES

The primary outcome assessed was relief of radicular pain. Other outcomes such as reduction in surgery rate and complications were noted if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system of evaluating evidence.

RESULTS

The searches yielded 16 primary publications on effectiveness. Available evidence, derived mainly from observational studies, suggests that approximately 50% of patients experience 50% relief of radicular pain for at least 4 weeks after CTFIS, and the intervention may have surgery-sparing effects. The literature also contains 21 articles with primary reports of serious complications, including 13 deaths and many catastrophic neurological injuries. The evidence of pain-relieving effects, of surgery-sparing effects, and of risks of CTFIS were all rated as of very low quality according to the GRADE system.

CONCLUSIONS

In patients with cervical radicular pain, fluoroscopically guided CTFIS may be effective in easing pain and reducing need for surgery. However, the evidence of effectiveness is of very low quality, and the benefits of the procedure are compromised by the risks of serious complications.

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.

Anomalous location of the vertebral artery in relation to the neural foramen. Implications for cervical transforaminal epidural steroid injections

OBJECTIVES

Evaluate the prevalence of an anomalous posterior vertebral artery (VA) in the neural foramen and to see if any factors might correlate with proximity of the VA to needle location in a cervical transforaminal epidural steroid injection (CTFESI).

METHODS

A radiologist with subspecialty training in neuroradiology documented VA location in relation to the neural foramen on axial views of 198 consecutive computed tomography angiograms done for various reasons, 11 were excluded because of poor imaging or occluded VA. The levels of C2-3 through C6-7 were evaluated, where the VA courses within the foramen. The distance was measured from VA to ideal needle location for a CTFESI. Other data were collected including severity of foraminal stenosis, loss of disc height, and medical history. Analysis was done to see if any factor correlated with anomalous VA location.

RESULTS

The VA was in the posterior foramen and within 2 mm of ideal needle location in at least one location in 29% of patients. When looking at the more commonly injected levels of C4-5 through C6-7, the prevalence was 18%. Severity of foraminal stenosis and loss of disc height correlated with VA proximity to typical needle location (both with P < 0.0001).

CONCLUSION

The VA can sometimes be in close proximity to the typical target location of a CTFESI. This proximity correlates with severity of foraminal stenosis and loss of disc height. Physicians should be mindful of this and evaluate the T2 axial magnetic resonance imaging before doing CFTESIs.