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http://dx.doi.org/10.12701/yujm.2019.00122

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

Park, Kibeom (Department of Anesthesiology and Pain Medicine, Keimyung University School of Medicine)
Kim, Saeyoung (Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine)
Publication Information
Journal of Yeungnam Medical Science / v.36, no.2, 2019 , pp. 109-114 More about this Journal
Abstract
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.
Keywords
Analgesia; Complications; Epidural; Radiculopathy; Spine;
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1 Manchikanti L, Singh V, Pampati V, Falco FJ, Hirsch JA. Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other? Korean J Pain 2015;28:11-21.   DOI
2 Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician 2006;9:361-6.
3 Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212-22.   DOI
4 Waldman SD. Complications of cervical epidural nerve blocks with steroids: a prospective study of 790 consecutive blocks. Reg Anesth 1989;14:149-51.
5 Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician 2012;15:E143-50.
6 Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth 1998;45:110-4.   DOI
7 Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J 2004;4:468-74.   DOI
8 Tofuku K, Koga H, Komiya S. Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report. J Med Case Rep 2012;6:142.   DOI
9 Chung SG. Convulsion caused by a lidocaine test in cervical transforaminal epidural steroid injection. PM R 2011;3:674-7.   DOI
10 Lee MH, Yang KS, Kim YH, Jung HD, Lim SJ, Moon DE. Accuracy of live fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections. Korean J Pain 2010;23:18-23.   DOI
11 Kim YH, Park HJ, Moon DE. Rates of lumbosacral transforaminal injections interpreted as intravascular: fluoroscopy alone or with digital subtraction. Anaesthesia 2013;68:1120-3.   DOI
12 Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician 2003;6:369-72.   DOI
13 Maus T, Schueler BA, Leng S, Magnuson D, Magnuson DJ, Diehn FE. Radiation dose incurred in the exclusion of vascular filling in transforaminal epidural steroid injections: fluoroscopy, digital subtraction angiography, and CT/fluoroscopy. Pain Med 2014;15:1328-33.   DOI
14 Heavner JE, Racz GB, Jenigiri B, Lehman T, Day MR. Sharp versus blunt needle: a comparative study of penetration of internal structures and bleeding in dogs. Pain Pract 2003;3:226-31.   DOI
15 Nahm FS, Lee CJ, Lee SH, Kim TH, Sim WS, Cho HS, et al. Risk of intravascular injection in transforaminal epidural injections. Anaesthesia 2010;65:917-21.   DOI
16 McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PM R 2009;1:636-42.   DOI
17 Visnjevac O, Kim P, Farid-Davari S, Johnson P, Nader ND. Digital subtraction angiography versus real-time fluoroscopy for detection of intravascular penetration prior to epidural steroid injections: meta-analysis of prospective studies. Pain Physician 2015;18:29-36.
18 Akins EW, Hawkins IF Jr, Mladinich C, Tupler R, Siragusa RJ, Pry R. The blunt needle: a new percutaneous access device. AJR Am J Roentgenol 1989;152:181-2.   DOI
19 Quintero N, Laffont I, Bouhmidi L, Rech C, Schneider AE, Gavardin T, et al. Transforaminal epidural steroid injection and paraplegia: case report and bibliographic review. Ann Readapt Med Phys 2006;49:242-7.   DOI
20 Ozcan U, Sahin S, Gurbet A, Turker G, Ozgur M, Celebi S. Comparison of blunt and sharp needles for transforaminal epidural steroid injections. Agri 2012;24:85-9.   DOI
21 Shin J, Kim YC, Lee SC, Kim JH. A comparison of Quincke and Whitacre needles with respect to risk of intravascular uptake in S1 transforaminal epidural steroid injections: a randomized trial of 1376 cases. Anesth Analg 2013;117:1241-7.   DOI
22 Hong JH, Huh B, Shin HH. Comparison between digital subtraction angiography and real-time fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections. Reg Anesth Pain Med 2014;39:329-32.   DOI
23 Hong J, Jung S, Chang H. Whitacre needle reduces the incidence of intravascular uptake in lumbar transforaminal epidural steroid injections. Pain Physician 2015;18:325-31.   DOI
24 Smuck M, Paulus S, Patel A, Demirjian R, Ith MA, Kennedy DJ. Differential rates of inadvertent intravascular injection during lumbar transforaminal epidural injections using blunt-tip, pencil-point, and catheter-extension needles. Pain Med 2015;16:2084-9.   DOI
25 Nagpal AS, Chang-Chien GC, Benfield JA, Candido KD, Rana MV, Eckmann M. Digital subtraction angiography use during epidural steroid injections does not reliably distinguish artery from vein. Pain Physician 2016;19:255-66.