Incidence of intravascular penetration in transforaminal cervical epidural steroid injections

Abstract

Michael B. Furman, MD, Michael T. Giovanniello, MD, York, PA, USA; Erin O'Brien, MD, Philadelphia, PA, USA; Jenna Bridell, York, PA, USACervical epidural steroid injections are an accepted treatment for cervical pain with a radicular component secondary to a cervical disc injury or spinal stenosis. Incorrectly placed, intravascular cervical spinal injections result in medication flow systemically and not to the desired target. Previous studies have evaluated the incidence of inappropriate needle placement and the incidence of vascular penetration with positive aspiration in caudal epidural steroid injections (ESIs). A recently published study demonstrates a high incidence of intravascular injections and a low sensitivity of a “flash” (blood in the needle hub) or blood aspirate to predict an intravascular injection in transforaminal lumbosacral epidural steroid injections. No studies to date have evaluated the incidence of vascular injections in transforaminal cervical ESIs nor have they calculated the ability of flash or blood aspiration to predict a vascular injection. This prospective, observational study evaluated the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced transforaminal cervical ESIs and whether a flash or aspiration of blood can be used to predict a vascular injection.The incidence of a flash or positive blood aspiration and the incidence of fluoroscopically confirmed vascular spread were prospectively observed in 372 patients treated with cervical fluoroscopically guided transforaminal ESIs. Presence of a flash or positive aspiration was documented. Contrast was injected to determine whether the needle tip was intravascular.A total of 392 transforaminal ESIs were included. The overall rate of intravascular injections was 19.6%. Using a flash or positive blood aspirate to predict intravascular injections was 96.5% specific but only 44.2% sensitive.Compared with a previous study of lumbosacral ESIs, there is a higher incidence of intravascular injections with cervical transforaminal ESIs. Using a flash or blood aspirate to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in cervical transforaminal ESIs.