To the Editor

Abstract

The article by Tiso et al. [ [1] Tiso R.L. Cutler T. Catania J.A. Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004; 4: 468-474 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar ] is important for all practitioners of spine diagnostic and therapeutic injections. Recent articles highlight the potential dangers of cervical transforaminal epidural injections [ 2 Brouwers P.J.A.M. Kottnik E.J.B.L. Simon M.A.M. Prevo R.I. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001; 91: 397-399 Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar , 3 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. 2002; 103: 211-215 Abstract Full Text Full Text PDF Scopus (244) Google Scholar , 4 Karasek M. Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med. 2004; 5: 202-205 Crossref PubMed Scopus (127) Google Scholar , 5 Rozin L. Rozin R. Koehler S.A. et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol. 2003; 24: 351-355 Crossref PubMed Scopus (226) Google Scholar , 6 Kloth D.S. Risk of cervical transforaminal epidural injections by anterior approach. Pain Physician. 2003; 6 ([Letter to the editor]): 392-393 PubMed Google Scholar ]. We share our comments pertaining to the case described by Tiso et al. in the following: 1.The patient is 5′2″ tall and 300 lb. It has been our experience that, in patients with this type of body habitus, a C5/6 transforaminal injection is technically difficult and more dangerous. In addition, the authors report “2 mL contrast injected . . . confirming placement by way of a satisfactory lateral epidurogram and extension along the C6 nerve root.” No lateral radiograph is provided at this point. We do not believe a successful lateral epidurogram would be obtained in a patient with this body habitus. 2.The article also states: “Total fluoroscopy time was 7 seconds”. Hopefully this is a misprint. If it isn't, we cannot but question the reliability of statements indicating that the needle was directed to a proper position in the root canal and that a good epidurogram was observed. 3.With respect to the epidurogram, the discussion on page 472 and Fig. 3 on page 473 refer to “the typical fluoroscopic pattern of a right C5/6 selective cervical transforaminal block.” Is the radiograph shown in Fig. 3 the actual film of the patient described in the introduction? The authors do not say that it is. We are shown only a “typical fluoroscopic pattern”. This is misleading if the figure does not represent the film of the actual patient who is the subject of this paper. If the film of this patient is of such poor quality that it could not be published, the above points regarding the danger of the procedure, the compromised visualization, and the very short fluoroscopy time in a patient this size are indeed germane. 4.Also, in regard to Fig. 3, page 474, the cervical spine is shown rotated 90 degrees to the right. We believe it is poor technique to record images in this way. A simple radiology technician's maneuver would right the image relative to the fluoroscopic screen. Moreover, publishing the picture rotated in this fashion might confuse the reader. 5.Some minor points: item 2 on page 473 mentions “non-iodinated contrast material”. We believe the authors mean non-ionic contrast material. Item 7 on the same page suggests use of larger-bore needles. Are there any data that indicate that aspiration with 22-gauge needles will reliably recover blood if the needle is in an intravascular position?