The Korean Journal of Pain

The Korean Pain Society (대한통증학회)
권호 표지
DOI QR코드

DOI QR Code

Analysis of Intravascular Flow Patterns following Cervical Transforaminal Epidural Injection

경부 경추간공 경막외 차단술 시 혈관 내 조영에 대한 분석

  • Hwang, Su Jin (Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University) ;
  • Han, Kyung Ream (Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University) ;
  • Kim, Sae Young (Pain Clinic, CHA General Hospital, College of Medicine, Pochon CHA University) ;
  • Kim, Nan Seol (Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University) ;
  • Kim, Chan (Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University)
  • 황수진 (아주대학교 의과대학 부속병원 마취통증의학과 신경통증클리닉) ;
  • 한경림 (아주대학교 의과대학 부속병원 마취통증의학과 신경통증클리닉) ;
  • 김세영 (포천중문의과대학교 분당차병원 통증클리닉) ;
  • 김난설 (아주대학교 의과대학 부속병원 마취통증의학과 신경통증클리닉) ;
  • 김찬 (아주대학교 의과대학 부속병원 마취통증의학과 신경통증클리닉)
  • Received : 2008.10.28
  • Accepted : 2009.01.08
  • Published : 2009.04.01
Download PDF
⟨ Previous Next ⟩

Abstract

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.

Keywords

References

  1. Boswell MV, Hansen HC, Trescot AM, Hirsch JA: Epidural steroids in the management of chronic spinal pain and radiculopathy. Pain Physician 2003; 6: 319-34
  2. Manchikanti L: Transforaminal lumbar epidural steroid injections. Pain Physician 2000; 3: 374-98
  3. Rosenberg SK, Grabinsky A, Kooser C, Boswell MV: Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience. Pain Physician 2002; 5:266-70
  4. Vad VB, Bhat AL, Lutz GE, Cammisa F: Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine 2002; 27: 11-6 https://doi.org/10.1097/00007632-200201010-00005
  5. Hayashi N, Weinstein JN, Meller ST, Lee HM, Spratt KF, Gebhart GF: The effect of epidural injection of betamethasone or bupivacaine in a rat model of lumbar radiculopathy. Spine 1998; 23: 877-85 https://doi.org/10.1097/00007632-199804150-00008
  6. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, et al: The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am 2000; 82: 1589-93 https://doi.org/10.2106/00004623-200011000-00012
  7. Houten JK, Errico TJ: Paraplegia after lumbosacral nerve root block: report of three cases. Spine J 2002; 2: 70-5
  8. McLain RF, Fry M, Hecht ST: Transient paralysis associated with epidural steroid injection. J Spinal Disord 1997; 10:441-4
  9. Muro K, O'Shaughnessy B, Ganju A: Infarction of the cervical spinal cord following multilevel transforaminal epidural steroid injection: case report and review of the literature. J Spinal Cord Med 2007; 30: 385-8 https://doi.org/10.1080/10790268.2007.11753957
  10. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS: Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician 2004; 7: 445-9
  11. Baker R, Dreyfuss P, Mercer S, Bogduk N: Cervical transforaminal injection of corticosteroids into a radicular artery:a possible mechanism for spinal cord injury. Pain 2003; 103:211-5 https://doi.org/10.1016/S0304-3959(02)00343-3
  12. Lee JH, Lee JK, Seo BR, Moon SJ, Kim JH, Kim SH: Spinal cord injury produced by direct damage during cervical transforaminal epidural injection. Reg Anesth Pain Med 2008; 33: 377-9 https://doi.org/10.1097/00115550-200807000-00016
  13. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS: Cervical transforaminal epidural steroid injections:more dangerous than we think? Spine 2007; 32: 1249-56 https://doi.org/10.1097/BRS.0b013e318053ec50
  14. Furman MB, Giovanniello MT, O'Brien EM: Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine 2003; 28: 21-5 https://doi.org/10.1097/00007632-200301010-00007
  15. Furman MB, O'Brien EM, Zgleszewski TM: Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections. Spine 2000; 25: 2628-32 https://doi.org/10.1097/00007632-200010150-00014
  16. Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, et al: Incidence of intravascular uptake in lumbar spinal injection procedures. Spine 2000;25: 481-6 https://doi.org/10.1097/00007632-200002150-00015
  17. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, et al: Fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil 2002; 81: 898-905 https://doi.org/10.1097/00002060-200212000-00003
  18. Lutz GE, Vad VB, Wisneski RJ: Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil 1998; 79: 1362-6 https://doi.org/10.1016/S0003-9993(98)90228-3
  19. Thomas E, Cyteval C, Abiad L, Picot MC, Taourel P, Blotman F: Efficacy of transforaminal versus interspinous corticosteroid injection discal radiculalgia-a prospective, randomized, double-blind study. Clin Rheumatol 2003; 22: 299-304 https://doi.org/10.1007/s10067-003-0736-z
  20. Kloth DS: Risk of cervical transforaminal epidural injections by anterior approach. Pain Physician 2003; 6: 392-3
  21. el-Khoury GY, Ehara S, Weinstein JN, Montgomery WJ, Kathol MH: Epidural steroid injection: a procedure ideally performed with fluoroscopic control. Radiology 1988; 168:554-7 https://doi.org/10.1148/radiology.168.2.2969118
  22. Groen RJ, Groenewegen HJ, van Alphen HA, Hoogland PV: Morphology of the human internal vertebral venous plexus:a cadaver study after intravenous Araldite CY 221 injection. Anat Rec 1997; 249: 285-94 https://doi.org/10.1002/(SICI)1097-0185(199710)249:2<285::AID-AR16>3.0.CO;2-K
  23. Batson OV: The function of the vertebral veins and their role in the spread of metastases. Ann Surg 1940; 112: 138-49 https://doi.org/10.1097/00000658-194007000-00016
  24. Batson OV: The vertebral vein system. Caldwell lecture, 1956. Am J Roentgenol Radium Ther Nucl Med 1957; 78: 195-212
  25. van der Kuip M, Hoogland PV, Groen RJ: Human radicular veins: regulation of venous reflux in the absence of valves. Anat Rec 1999; 254: 173-80 https://doi.org/10.1002/(SICI)1097-0185(19990201)254:2<173::AID-AR3>3.0.CO;2-B
  26. Hoeft MA, Rathmell JP, Monsey RD, Fonda BJ: Cervical transforaminal injection and the radicular artery: variation in anatomical location within the cervical intervertebral foramina. Reg Anesth Pain Med 2006; 31: 270-4
  27. Manchikanti L, Singh V: Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections. Spine J 2007; 7: 629-30 https://doi.org/10.1016/j.spinee.2006.06.380
  28. 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 https://doi.org/10.1046/j.1533-2500.2003.03027.x
  29. Kim DW, Shim JC: Incidence of intravascular penetration during transforaminal lumbosacral epidural steroid injection. Korean J Pain 2007; 20: 26-30 https://doi.org/10.3344/kjp.2007.20.1.26

Cited by

  1. Transient quadriplegia after fluoroscopic-guided selective cervical nerve root block in a patient who received cervical interbody fusion -A case report- vol.59, pp.Suppl, 2010, https://doi.org/10.4097/kjae.2010.59.S.S95