Incidence Of Vascular Injection Research Articles

Intravascular Flow Patterns in Transforaminal Epidural Injections: A Comparative Study of the Cervical and Lumbar Vertebral Segments

Transforaminal epidural injection (TEI) is commonly used in the treatment of radicular pain. However, there have been many published cases of serious complications after a TEI, occurring most often in cervical levels. One of the presumptive reasons for this complication is inadvertent intravascular injection. We sought to identify the incidence of intravascular injections in cervical and lumbar spinal segments during TEI. All patients with radicular symptoms or herpes zoster-associated pain underwent cervical and lumbar TEIs (LTEIs) prospectively by one of the authors. After an ideal needle position was confirmed by biplanar fluoroscopy, 3 mL of a mixture containing nonionic contrast and normal saline was continuously injected at the rate of 0.3-0.5 mL/s with real-time fluoroscopic visualization. One hundred eighty-two TEIs were performed. Fifty-six cases (30.8%) showed intravascular spreading patterns, 45 cases occurring during a cervical TEI (CTEI) and 11 during a LTEI. The incidences of simultaneous perineural and vascular injection in cervical and LTEIs were 52.1% and 9%, respectively, and pure vascular flow pattern rates in cervical and LTEIs were 11.3% and 0.9%, respectively. The incidence of vascular injection in CTEIs is significantly higher than in LTEIs, suggesting that CTEIs should be performed more cautiously. Furthermore, the vascular injection rate of CTEIs is much higher than that previously reported. This finding suggests the need for a proper volume of contrast injection (3 mL) to detect vascular flow, especially in simultaneous perineural and vascular injections.

Poster 244: Influence of Needle Type on the Incidence of Intravascular Injection During Lumbosacral Transforaminal Epidural Injections: A Comparison of Short Bevel and Long Bevel Needles

Objective: To determine if the incidence of intravascular injection differs between short bevel and long bevel needles during lumbosacral transforaminal epidural injections. Design: Prospective, observational comparison study. Setting: University spine center. Participants: 77 consecutive consenting patients scheduled to receive lumbar transforaminal epidural injections. Subjects had a mean age of 49.7 years (range, 21–91y), 43% were men and 57% women. Interventions: One physician performed 157 fluoroscopically-guided lumbosacral transforaminal epidural injections on the 77 study participants. For each injection the dynamic flow of contrast was observed under live fluoroscopy and the presence or absence of vascular patterns was recorded. Main Outcome Measures: The Fisher exact test was used to determine the significance of variance in the incidence of vascular contrast patterns observed in the injections performed with short bevel needles compared with long bevel needles. Results: Of the 157 injections, 58 were performed using short bevel (chiba point) needles and 99 using long bevel (quincke point) needles. Vascular injections were observed in 22 of the 157 injections for an overall incidence of 14.0%. The incidence of vascular injections with short bevel needles was 17.2% (10 out of 58) and with long bevel needles was 12.1% (12 out of 99). This difference was not statistically significant at P=0.364. Conclusions: Potential complications related to accidental intravascular penetration during transforaminal epidural injections has piqued interest in the relative safety of sharp versus blunt needles. This is the first study to report on the incidence of inadvertent intravascular injection with short bevel needles in comparison with long bevel needles, finding no difference in the incidence between these 2 needle types.

Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections

The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. A prospective, observational, in vivo, study. Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis. Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.