Disclosures: Kenneth K. Leong, MD: No financial relationships or conflicts of interest  

Objective: Cervical transforaminal epidural steroid injections (CTESI) for treating cervical radicular pain have been associated with rare but catastrophic complications. These complications are likely due to distal vessel infarct following needle penetration or injection of particulate steroids into vertebral or radicular arteries, which supply the spinal cord and the brain. This study aims to evaluate if the addition of digital subtraction angiography (DSA) can improve detection of vascular uptake during CTESI procedures as compared to real-time fluoroscopy alone in the same subject.

Design: One injector at our outpatient office from October 2009 to June 2014 performed 220 CTFESIs on 107 patients. The data of venous and arterial penetration using fluoroscopic guided and contrast enhanced injection with and without DSA was collected during the procedure as part of an Institutional Review Board-approved protocol.

Setting: Outpatient office.

Participants: 107 patients.

Interventions: Cervical transforaminal epidural steroid injection.

Main Outcome Measures: Venous and arterial penetration using fluoroscopic guided and contrast enhanced injection with and without DSA was then collected.

Results: Of the 220 injections, fluoroscopy/contrast identified intravascular uptake in 55 cases (25%), including 30 with intravenous uptake (14%) and 25 with intra-arterial uptake (11%). The addition of DSA improved the sensitivity of detection, demonstrating intravascular uptake in 78 cases (35%), including 43 with intravenous uptake (20%) and 35 with intra-arterial uptake (16%). Thus, the addition of DSA detected an additional 23 cases of intravascular uptake, including 13 intravenous and 10 intra-arterial. Thus, fluoroscopy/contrast without DSA failed to identify intravenous uptake in 6% of injections and failed to identify intra-arterial uptake in 5% of injections.

Conclusions: This study demonstrates that the addition of DSA to real-time fluoroscopy with contrast injection can improve the detection rate of arterial and venous vascular penetration during CTESI in the same subject group. The significant improvement in intravascular injection detection may decrease the risk of catastrophic side effects associated with CTESI.

Level of Evidence: Level III

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/comparison-of-intravascular-injection-rates-during-cervical-transforaminal-epidural-steroid-injections-with-the-use-of-digital-subtraction-angiography/