bs_bs_banner
Green and Drummond
Venous Uptake Despite Negative Aspiration During Fluoroscopically Guided Interlaminar Cervical Epidural Steroid Injections
Dear Editor,
A 61-year-old female presented to our academic pain clinic with a history of chronic neck and upper extremity pain. The patient had previously tried physical therapy and multiple analgesics, but her pain remained 9/10 on a visual analog scale. Magnetic resonance imaging showed multilevel degenerative changes, most severe at C6–C7, with a mild posterior disc bulge, a canal measuring 6 to 7 mm, and extension of the disc into the left intervertebral foramen, causing severe foraminal stenosis. After obtaining informed and written consent for a cervical epidural steroid injection, the patient was placed in the prone position on a fluoroscopy table. The the cervical spine was cleaned and draped in a sterile fashion in preparation for an interlaminar epidural steroid injection. After identifying the C7–T1 interspace using fluoroscopy in the antero-posterior view, the skin was infiltrated with 1% lidocaine; an 18-gauge Tuohy needle was used to locate the epidural space by using the loss of resistance technique with preservative free normal saline. Once loss of resistance was obtained and all aspirations were negative for blood or cerebrospinal fluid, 2 mL of iohexol (240 mg/ mL) contrast agent was injected under live fluoroscopy. The live fluoroscopic image showed venous uptake (Figure 1). The contrast spread was brisk and spread in both a cephalad and caudad direction. The needle was then withdrawn and the procedure was performed uneventfully at the level of T1–T2 using the same technique (there was no evidence of any intravascular uptake at this level). An 80 mg of Depo-Medrol (methylprednisolone acetate, injectable suspension, USP; Pharmacia & Upjohn Co, Division of Pfizer Inc, New York, NY, USA) was injected at the T1–T2 space. The patient tolerated the procedure well without any unintended sequelae. Although others have reported the incidence of vascular uptake despite negative aspiration during the conduct of cervical transforaminal injections [1–3], no comparable studies have been published for cervical interlaminar injections. Our observation of venous uptake despite negative aspiration would not be possible without fluoroscopy and 1814
Figure 1 Vascular uptake of contrast dye prior during placement of needle into epidural space.
the use of contrast dye. It shows that aspiration is an unreliable technique for detecting intravascular injection when performing cervical epidural steroid injection. Although we did not use digital subtraction angiography, its use is associated with a higher detection rate of intravascular injection during cervical transforaminal injections [1]. ADAM W. GREEN, MD and SHAINA DRUMMOND, MD Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA References 1 McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PMR 2009;1(7):636–42. 2 Nahm FS, Lee CJ, Lee SH, et al. Risk of intravascular injection in transforaminal epidural injections. Anaesthesia 2010;65:917–21. 3 Furman MB, Giovanniello MT, O’Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine 2003;28:21–5.
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on March 23, 2016
Cervical epidural injections are one of the more commonly used modalities to treat chronic neck and upper extremity pain after patients have failed medication therapies and physical therapy. Complications related to this intervention are uncommon, but can be caused by direct injury to the spinal cord or by unrecognized intravascular injection of toxic agents. We would like to report our finding of venous uptake despite negative aspiration during an interlaminar cervical epidural steroid injection, which would not have been recognized without fluoroscopy and the use of contrast dye.
Green and Drummond
Venous Uptake Despite Negative Aspiration During Fluoroscopically Guided Interlaminar Cervical Epidural Steroid Injections
Dear Editor,
A 61-year-old female presented to our academic pain clinic with a history of chronic neck and upper extremity pain. The patient had previously tried physical therapy and multiple analgesics, but her pain remained 9/10 on a visual analog scale. Magnetic resonance imaging showed multilevel degenerative changes, most severe at C6–C7, with a mild posterior disc bulge, a canal measuring 6 to 7 mm, and extension of the disc into the left intervertebral foramen, causing severe foraminal stenosis. After obtaining informed and written consent for a cervical epidural steroid injection, the patient was placed in the prone position on a fluoroscopy table. The the cervical spine was cleaned and draped in a sterile fashion in preparation for an interlaminar epidural steroid injection. After identifying the C7–T1 interspace using fluoroscopy in the antero-posterior view, the skin was infiltrated with 1% lidocaine; an 18-gauge Tuohy needle was used to locate the epidural space by using the loss of resistance technique with preservative free normal saline. Once loss of resistance was obtained and all aspirations were negative for blood or cerebrospinal fluid, 2 mL of iohexol (240 mg/ mL) contrast agent was injected under live fluoroscopy. The live fluoroscopic image showed venous uptake (Figure 1). The contrast spread was brisk and spread in both a cephalad and caudad direction. The needle was then withdrawn and the procedure was performed uneventfully at the level of T1–T2 using the same technique (there was no evidence of any intravascular uptake at this level). An 80 mg of Depo-Medrol (methylprednisolone acetate, injectable suspension, USP; Pharmacia & Upjohn Co, Division of Pfizer Inc, New York, NY, USA) was injected at the T1–T2 space. The patient tolerated the procedure well without any unintended sequelae. Although others have reported the incidence of vascular uptake despite negative aspiration during the conduct of cervical transforaminal injections [1–3], no comparable studies have been published for cervical interlaminar injections. Our observation of venous uptake despite negative aspiration would not be possible without fluoroscopy and 1814
Figure 1 Vascular uptake of contrast dye prior during placement of needle into epidural space.
the use of contrast dye. It shows that aspiration is an unreliable technique for detecting intravascular injection when performing cervical epidural steroid injection. Although we did not use digital subtraction angiography, its use is associated with a higher detection rate of intravascular injection during cervical transforaminal injections [1]. ADAM W. GREEN, MD and SHAINA DRUMMOND, MD Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA References 1 McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PMR 2009;1(7):636–42. 2 Nahm FS, Lee CJ, Lee SH, et al. Risk of intravascular injection in transforaminal epidural injections. Anaesthesia 2010;65:917–21. 3 Furman MB, Giovanniello MT, O’Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine 2003;28:21–5.
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on March 23, 2016
Cervical epidural injections are one of the more commonly used modalities to treat chronic neck and upper extremity pain after patients have failed medication therapies and physical therapy. Complications related to this intervention are uncommon, but can be caused by direct injury to the spinal cord or by unrecognized intravascular injection of toxic agents. We would like to report our finding of venous uptake despite negative aspiration during an interlaminar cervical epidural steroid injection, which would not have been recognized without fluoroscopy and the use of contrast dye.
