Differential Rates of Inadvertent Intravascular Injection during Lumbar Transforaminal Epidural Injections Using Blunt-Tip, Pencil-Point, and Catheter-Extension Needles

Comparison of Touhy and Quincke needles on intravascular injection rate in lumbar transforaminal epidural block: a randomized prospective trial

BACKGROUND

Transforaminal epidural steroid injection is widely used in clinical practice to effectively deliver injectate into the ventral epidural space. Complications associated with intravascular injection such as spinal cord infarction and paraplegia can occur during transforaminal epidural steroid injection. To improve the safety of the procedure, avoidance of intravascular injection is crucial, for which appropriate needle selection is important. The primary aim of this study was to compare intravascular injection rates during transforaminal epidural steroid injection between commonly used Quincke and Tuohy needles.

METHOD

Two hundred and four transforaminal epidural steroid injection cases were randomly assigned to one of two needle groups (22-gage Quincke needle or 22-gage Tuohy needle). Intravascular injection was evaluated using digital subtraction angiography. Spread of contrast medium to the ventral and medial epidural spaces was evaluated. Procedure time was compared between the two needle types.

RESULTS

The overall incidence of intravascular injection was 7.8%. The rate of intravascular injection was significantly lower in the Tuohy needle group than the Quincke needle group (2.9% vs 12.7%, p=0.009). The ventral and medial epidural spread rates of the Tuohy needle group were 92.2% and 95.1%, respectively, significantly higher than those of the Quincke needle group. The procedure time was shorter in the Tuohy needle group than in the Quincke needle group (97.4 (19.3) seconds vs 117.8 (31.9) s; mean difference -20.40 (95% CI -34.35 to -6.45), p=0.005).

CONCLUSIONS

In conclusion, Tuohy needles had a lower intravascular injection rate and higher medial and ventral epidural spreading rates than Quincke needles.

TRIAL REGISTRATION NUMBER

KCT0002095.

Intravenous Catheter Employed in Peritrochlear Injection of Triamcinolone in the Treatment of Trochleitis

PURPOSE

Injection of corticosteroid into the peritrochlear region is a widely practiced and highly successful treatment option for trochleitis, conventionally using a 25- or 27-gauge needle for the steroid injection. Injection into the vascular-rich peritrochlear region poses a risk, albeit rare, of central retinal artery occlusion or orbital hemorrhage. We describe a potentially safer method of delivering triamcinolone to the peritrochlear region using a 24-gauge intravenous catheter.

METHODS

Interventional retrospective case series including all patients who received peritrochlear injections of triamcinolone via intravenous catheter for trochleitis by a single surgeon (BJW). Surgical technique: After a subcutaneous wheel of local anesthetic was delivered to the medial upper eyelid skin nearest to the trochlea, a 24-gauge intravenous catheter was used to penetrate the skin and orbital septum. Once past the septum, the needle was removed and the blunt catheter was advanced into the peritrochlear region. A 1-ml syringe filled with 40 mg/ml triamcinolone was attached to the catheter. After pulling back to ensure that the catheter was not intravascular, triamcinolone was delivered to the orbit. The catheter was then removed.

RESULTS

Ten catheter injections were performed on 3 patients over an 8-year period. There were no complications.

CONCLUSION

Injection of corticosteroid into the peritrochlear region using the commonly available 24-gauge intravenous catheter is an effective and theoretically safer alternative to typical injection using a 25-gauge needle for treatment of trochleitis. Use of nonparticulate steroid solutions may further decrease the risk of adverse events.

Comparison of Whitacre needle and Chiba needle on the incidence of intravascular injection during caudal epidural injections: A single-blind, randomized clinical consort study

Caudal epidural injection (CEI) is effective for lumbar spinal pain. However, accidental intravascular injection reduces therapeutic efficacy of CEI and leads to fatal complications such as hematoma, and neurologic deficit. Whitacre needle has been reported to be effective for reducing intravascular injection during transforaminal epidural injection, compared with Quincke needle. The bevel of Chiba needle is shorter than that of Quincke needle. In this study we compared Whitacre needle and Chiba needle on incidence of intravascular injection during CEI.This was a single-blind, randomized clinical consort study. After institutional Review Board approval, a total of 164 patients underwent CEI were randomly allocated to one of 2 group (Whitacre needle or Chiba needle group). Intravascular injection was assessed with real-time fluoroscopy. In addition, total procedure time was measured. Data were compared between groups, and P < .05 was consideredstatistically significant.There were no differences between groups in terms of patient demographic and clinical characteristics. There was no significant difference on incidence of intravascular injection between Whitacre and Chiba needle group (11% vs 19.5%, P = .192). However, the procedure time is significantly longer in the Whitacre than Chiba needle group (172.8 ± 53.8 sec vs 147.1 ± 61.1 sec, P = .005).Based on current study, our results indicated that Whitacre needle was not effective to decrease the incidence of intravascular injection during CEI, compared to Chiba needle.

Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin's Triangle Approach

Purpose

Dispersion of contrast media into the anterior epidural space is correlated with better outcomes after transforaminal epidural injection (TFEI). Needle tip position is an important factor affecting the pattern of contrast media dispersion. It is difficult to advance the needle medially to the interpedicle line with a conventional approach, especially in a severe spinal stenosis. But, with Kambin’s triangle approach, the needle can be advanced more medially even in the severe stenosis. We aimed to compare contrast media dispersion patterns according to the needle tip position in TFEI with Kambin’s triangle approach.

Patients and Methods

This single-center retrospective study analyzed fluoroscopic data of patients who underwent TFEI from March 2019 to July 2019. Data on the history of lumbar spinal fusion surgery and MRI findings were collected. The needle tip position was evaluated in three positions on fluoroscopic images (final anteroposterior [AP] view): extraforaminal (EF), lateral foramen (LF), and medial foramen (MF). Contrast media dispersion into the epidural space (epidural pattern) in the AP view was evaluated as a dependent variable. The relationship between the contrast media dispersion pattern and needle tip position was analyzed, and other factors affecting the contrast media dispersion pattern were identified.

Results

Ninety-eight TFEI cases were analyzed (51 LF, 35 MF, and 12 EF). An epidural pattern of dispersion was observed more frequently in the LF and MF groups than in the EF group. The LF and MF groups showed no significant difference in epidural pattern frequency. On logistic regression analysis, needle tip position emerged as a major factor influencing epidural pattern, while other factors including spine conditions had no significant effect.

Conclusion

Positioning the needle tip medial to the pedicle helps in the spread of the contrast media into the epidural space during TFEI with Kambin’s approach. Factors other than the needle tip position did not significantly affect the contrast media dispersion pattern.

Differential rates of intravascular uptake and pain perception during lumbosacral epidural injection among adults using a 22-gauge needle versus 25-gauge needle: a randomized clinical trial

Background

Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception.

Methods

This was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study – 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale.

Results

Fisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375].

Conclusions

The study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections.

Trial registration

ClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered).

Digital subtraction angiography vs. real-time fluoroscopy for detection of intravascular injection during transforaminal epidural block

Background

Transforaminal epidural block (TFEB) is an effective treatment option for radicular pain. To reduce complications from intravascular injection during TFEB, use of imaging modalities such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA) has been recommended. In this study, we investigated whether DSA improved the detection of intravascular injection during TFEB at the whole spine level compared to RTF.

Methods

We prospectively examined 316 patients who underwent TFEB. After confirmation of final needle position using biplanar fluoroscopy, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under RTF; 30 s later, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under DSA.

Results

Thirty-six intravascular injections were detected for an overall rate of 11.4% using RTF, with 45 detected for a rate of 14.2% using DSA. The detection rate using DSA was statistically different from that using RTF (p=0.004). DSA detected a significantly higher proportion of intravascular injections at the cervical level than at the thoracic (p=0.009) and lumbar (p=0.011) levels.

Conclusion

During TFEB at the whole spine level, DSA was better than RTF for the detection of intravascular injection. Special attention is advised for cervical TFEB, because of a significantly higher intravascular injection rate at this level than at other levels.

Effect of needle type on intravascular injection in transforaminal epidural injection: a meta-analysis

Background

Lumbosacral transforaminal epidural injection (TFEI) is an effective treatment for spinal disease. However, TFEI may have several types of complications, some of which can be attributed to intravascular injection. We reviewed studies to compare the intravascular injection rate among different needle types.

Methods

We searched the literature for articles on the intravascular injection rate among different needle types used in TFEI. The search was performed using PubMed, MEDLINE, the Cochrane Library, EMBASE, and Web of Science.

Results

A total of six studies comprising 2359 patients were identified. Compared with the Quincke needle, the Whitacre needle reduced the intravascular injection rate (OR = 0.57, 95% CI = [0.44-0.73], P < 0.001). However, compared with the Quincke needle, the Chiba needle did not reduce the intravascular injection rate (OR = 0.80, 95% CI = [0.44-1.45], P = 0.46). In one study, the intravascular injection rate using a blunt-tip needle was lower than that using a sharp needle. In another study, the Whitacre and the blunt-tip needle have similar intravascular injection rates, while, the catheter-extension needle showed a reduced intravascular injection rate.

Conclusions

This meta-analysis showed that the Whitacre needle reduced the intravascular injection rate as compared with the Quincke needle, but failed to establish that the Chiba needle can decrease the intravascular injection rate in TFEI. Moreover, the blunt-tip needle can reduce the intravascular injection rate compared with the Quincke needle, and the catheter-extension needle can reduce the intravascular injection rate compared with the Whitacre and the blunt-tip needle.

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

Tip Design for Safety of Steerable Needles for Robot-Controlled Brain Insertion

Background

Current practice in neurosurgical needle insertion is limited by the straight trajectories inherent with rigid probes. One technique allowing curvilinear trajectories involves flexible bevel-tipped needles, which bend during insertion due to their asymmetry. In the brain, safety will require avoidance of the sharp tips often used in laboratory studies, in favor of a more rounded profile. Steering performance, on the other hand, requires maximal asymmetry. Design of safe bevel-tipped brain needles thus involves management of this tradeoff by adjusting needle gauge, bevel angle, and fillet (or tip) radius to arrive at a design that is suitably asymmetrical while producing strain, strain rate, and stress below the levels that would damage brain tissue.

Methods

Designs with a variety of values of needle radius, bevel angle, and fillet radius were evaluated in finite-element simulations of simultaneous insertion and rotation. Brain tissue was modeled as a hyperelastic, linear viscoelastic material. Based on the literature available, safety thresholds of 0.19 strain, 10 s^-1 strain rate, and 120 kPa stress were used. Safe values of needle radius, bevel angle, and fillet radius were selected, along with an appropriate velocity envelope for safe operation. The resulting needle was fabricated and compared with a Sedan side-cutting brain biopsy needle in a study in the porcine model in vivo (N=3).

Results

The prototype needle selected was 1.66 mm in diameter, with bevel angle of 10° and fillet radius of 0.25 mm. Upon examination of postoperative CT and histological images, no differences in tissue trauma or hemorrhage were noted between the prototype needle and the Sedan needle.

Conclusions

The study indicates a general design technique for safe bevel-tipped brain needles based on comparison with relevant damage thresholds for strain, strain rate, and stress. The full potential of the technique awaits the determination of more exact safety thresholds.