• The Korean Journal of Pain
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• v.32 no.1
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• pp.39-46
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• 2019

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.

• The Korean Journal of Pain
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• v.23 no.1
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• pp.18-23
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• 2010

Background: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. Methods: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. Results: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). Conclusions: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

• Journal of Yeungnam Medical Science
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• v.36 no.2
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• pp.109-114
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• 2019

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.

• The Korean Journal of Pain
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• v.20 no.1
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• pp.26-30
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• 2007

Background: Epidural steroid injections (ESI) are a common treatment for spinal disorders. Previous research has shown that aspiration of the syringe is not a sensitive test for placement of an intravascular needle. Serious complications have been reported from injection of steroids and local anesthetics into the vascular space. In addition to safety concerns, the efficacy may decline with partial injection outside the desired epidural location. We hypothesized that incidence of vascular problems is increased in patients who undergo spine surgery compared with the patients who don't undergo spine surgery. We investigated the incidence of vascular problems during lumbosacral transforaminal ESI and we compared the difference of vascular problems between the patients who undergo spinal surgery and those patients who don't undergo spinal surgery. Methods: Two hundreds and three patients were consecutively recruited and they received 299 fluoroscopically guided lumbosacral transforaminal ESIs. Injection of contrast was performed under live dynamic fluoroscopy with using digital substraction analysis. The observed uptake pattern was classified into one of three categories: flashback, aspirated, and positive contrast with negative flashback and aspiration. Results: The vascular incidence rate was 20.4%. Transforaminal ESIs performed at S1 had avascular incidence rate of 27.8% compared with 17.7% for all the other lumbar injection sites. The sensitivity of spontaneous observation of blood in the needle hub or blood aspirate for predicting an intravascular injection in lumbar transforaminal ESIs was 70.4%. Conclusions: There is a high incidence of intravascular problems when performing transforaminal ESIs, and this is significantly increased in patients with previous spine surgery. Using a flash or blood aspiration to predict an intravascular injection is not sensitive therefore; a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are prone to instill medications intravascularly. This finding confirms the need for not only fluoroscopic guidance, but also for contrast injection instillation when performing lumbosacral transforaminal ESIs, and especially for patients with previous spine surgery.

• The Korean Journal of Pain
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• v.22 no.1
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• pp.52-57
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• 2009

Background: Transforaminal epidural injection (TEI) may be useful to treat unilateral pain that has a dermatomal distribution. In this approach, the needle tip can be placed closer to the dorsal root ganglion and ventral aspect of the nerve root. However many studies have reported that serious complications following TEI occurred more frequently when it was conducted at the cervical level. One of the presumptive mechanisms of the complication is intravascular injection. Therefore this study was conducted to identify the incidence of complications in response to intravascular injections at cervical segments. Methods: This study included all patients, who visited our pain clinic and had radicular symptoms or herpes zoster associated pain. All procedures were conducted under fluoroscopic guidance with contrast enhancement by one of the authors. After the ideal needle position was confirmed by biplanar fluoroscopy, the blood aspiration through the needle hub was evaluated, and a 3 ml mixture of nonionic contrast (2 ml) with normal saline (1 ml) was injected at a rate of 0.3-0.5 ml/sec continuously under real time fluoroscopic visualization. We then classified the contrast spreading pattern as neural, simultaneous neural and vascular, or vascular. Results: A total 71 cervical TEIs were performed. In 26 cases (36.6%), the contrast only spread to the nerve sheath. However, 45 cases (63.4%) showed an intravascular spreading pattern, 37 (52.1%) of which showed a neural and vascular pattern and 8 (11.3%) of which showed only a vascular pattern. Conclusions: Approximately two thirds of the cases of cervical TEI were found to lead to intravascular spreading, which is much higher than the incidence reported in previous studies.

• The Korean Journal of Pain
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• v.28 no.2
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• pp.122-128
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• 2015

Background: Caudal epidural injections have been commonly performed in patients with low back pain and radiculopathy. Although caudal injection has generally been accepted as a safe procedure, serious complications such as inadvertent intravascular injection and dural puncture can occur. The present prospective study was designed to investigate the influence of the depth of the inserted needle on the success rate of caudal epidural blocks. Methods: A total of 49 adults scheduled to receive caudal epidural injections were randomly divided into 2 groups: Group 1 to receive the caudal injection through a conventional method, i.e., caudal injection after advancement of the needle 1 cm into the sacral canal (n = 25), and Group 2 to receive the injection through a new method, i.e., injection right after penetrating the sacrococcygeal ligament (n = 24). Ultrasound was used to identify the sacral hiatus and to achieve accurate needle placement according to the allocated groups. Contrast dyed fluoroscopy was obtained to evaluate the epidural spread of injected materials and to monitor the possible complications. Results: The success rates of the caudal injections were 68.0% in Group 1 and 95.8% in Group 2 (P = 0.023). The incidences of intravascular injections were 24.0% in Group 1 and 0% in Group 2 (P = 0.022). No intrathecal injection was found in either of the two groups. Conclusions: The new caudal epidural injection technique tested in this study is a reliable alternative, with a higher success rate and lower risk of accidental intravascular injection than the conventional technique.

• 대한임상약리학회:학술대회논문집
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• 1998.12a
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• pp.34-34
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• 1998

• The Korean Journal of Pain
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• v.14 no.2
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• pp.186-192
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• 2001

Background: Epidural test doses containing epinephrine are an incomplete marker for the detection of inadvertent intravascular injection. Therefore, many investigators have attempted to find a more reliable marker as an alternative to epinephrine in adult patients anesthetized with enflurane. The present study was designed to test whether two different simulated intravenous test doses of isoproterenol could be used as a reliable marker for the detection of inadvertent intravascular injection in adult patients anesthetized with $O_2-N_2O$-enflurane. Methods: Forty healthy adult patients were anesthetized with 1% end-tidal enflurane and nitrous oxide after endotracheal intubation and were randomized to one of two groups according to the dose of isoproterenol. Group 1 and 2 (n = 20 each) received 3 ml of 1.5% lidocaine with 3 and 5 g isoproterenol intravenously, respectively, to simulate an intravascularly administered test dose. Heart rate (HR) and systolic blood pressure (SBP) were measured at 20-second intervals for 4 min after injection. Results: Mean maximal HR increases were $24{\pm}17$, $35{\pm}11$ bpm (P < 0.05), mean maximal SBP increases were $14{\pm}8$, $13{\pm}9$ mmHg and mean maximal SBP decreases $20{\pm}11$, $22{\pm}9$ mmHg following the IV injection of 3, $5{\mu}g$ isoproterenol, respectively. The incidence of hypotension was similar in both groups. Isoproterenol 3 and $5{\mu}g$ produced 75%, 100% sensitivity in the HR criteria ($\geq$ 20 bpm increase) and 60%, 70% sensitivity in the SBP criteria ($\geq$ 15 mmHg), respectively. Conclusions: These results indicate that based on the HR response, the epidural test dose containing $5{\mu}g$ isoproterenol to simulate an intravascular administration is a more reliable marker than $3{\mu}g$ isoproterenol in adult healthy patients during enflurane anesthesia.

• Archives of Pharmacal Research
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• v.10 no.1
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• pp.42-49
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• 1987

This study is to evaluate the potential use of aclarubicin-loaded gelatin microspheres as an intravascular biodegradable drug delivery system for the regional cancer therapy. The diameter of the microspheres prepared by water in oil emulsion polymerization could be controlled by adjusting the stirring rate in the range of 10-50 $\mu$m : D(in $\mu$m) = -73.8 log (rpm) + 262.7. The addition of proteolytic enzyme increased the in vitro aclarubicin release but it did not change the amount of the initial burst release which reached about 45%. Microspheres injected intravenously into the mouse tail vein embolized only to the lung when observed by fluorescence microscopy. From histological examination following injection of gelatin microspheres into mouse femoral muscle, mild inflammation was observed from the appearance of neutrophils after 2 days and rapid repair process was confirmed thereafter. Biodegradation process of gelatin microspheres lodged on the pulmonary capillary bed was followed up by microscopic observation; degradation was taking place by about 36 hrs, followed by severe damage on the spheerical shape and microspheres was no longer found 10 days after injection.

• Archives of Plastic Surgery
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• v.44 no.4
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• pp.340-343
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• 2017

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient's clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.