Yeungnam Univ J Med.  2019 May;36(2):109-114. 10.12701/yujm.2019.00122.

Digital subtraction angiography vs. real-time fluoroscopy for detection of intravascular injection during transforaminal epidural block

• Park K
• Kim S

• KMID: 2449323
• DOI: http://doi.org/10.12701/yujm.2019.00122

Abstract

BACKGROUND
Transforaminal epidural block (TFEB) is an effective treatment option for radicular pain. To reduce complications from intravascular injection during TFEB, use of imaging modalities such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA) has been recommended. In this study, we investigated whether DSA improved the detection of intravascular injection during TFEB at the whole spine level compared to RTF.
METHODS
We prospectively examined 316 patients who underwent TFEB. After confirmation of final needle position using biplanar fluoroscopy, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under RTF; 30 s later, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under DSA.
RESULTS
Thirty-six intravascular injections were detected for an overall rate of 11.4% using RTF, with 45 detected for a rate of 14.2% using DSA. The detection rate using DSA was statistically different from that using RTF (p=0.004). DSA detected a significantly higher proportion of intravascular injections at the cervical level than at the thoracic (p=0.009) and lumbar (p=0.011) levels.
CONCLUSION
During TFEB at the whole spine level, DSA was better than RTF for the detection of intravascular injection. Special attention is advised for cervical TFEB, because of a significantly higher intravascular injection rate at this level than at other levels.

Keyword

Analgesia; Complications; Epidural; Radiculopathy; Spine

MeSH Terms

Analgesia
Angiography, Digital Subtraction*
Fluoroscopy*
Humans
Needles
Prospective Studies
Radiculopathy
Spine

Figure

• 

  Fig. 1. Flow diagram of the study design. DSA, digital subtraction angiography; RTF, real-time fluoroscopy.

Reference

References

1. Manchikanti L, Singh V, Pampati V, Falco FJ, Hirsch JA. Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other? Korean J Pain. 2015; 28:11–21.

2. Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician. 2006; 9:361–6.

3. Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med. 2008; 1:212–22.

4. Waldman SD. Complications of cervical epidural nerve blocks with steroids: a prospective study of 790 consecutive blocks. Reg Anesth. 1989; 14:149–51.

5. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician. 2012; 15:E143–50.

6. Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth. 1998; 45:110–4.

7. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004; 4:468–74.

8. Tofuku K, Koga H, Komiya S. Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report. J Med Case Rep. 2012; 6:142.

9. Chung SG. Convulsion caused by a lidocaine test in cervical transforaminal epidural steroid injection. PM R. 2011; 3:674–7.

10. Lee MH, Yang KS, Kim YH, Jung HD, Lim SJ, Moon DE. Accuracy of live fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections. Korean J Pain. 2010; 23:18–23.

11. Kim YH, Park HJ, Moon DE. Rates of lumbosacral transforaminal injections interpreted as intravascular: fluoroscopy alone or with digital subtraction. Anaesthesia. 2013; 68:1120–3.

12. Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician. 2003; 6:369–72.

13. Maus T, Schueler BA, Leng S, Magnuson D, Magnuson DJ, Diehn FE. Radiation dose incurred in the exclusion of vascular filling in transforaminal epidural steroid injections: fluoroscopy, digital subtraction angiography, and CT/fluoroscopy. Pain Med. 2014; 15:1328–33.

14. Nahm FS, Lee CJ, Lee SH, Kim TH, Sim WS, Cho HS, et al. Risk of intravascular injection in transforaminal epidural injections. Anaesthesia. 2010; 65:917–21.

15. 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. PM R. 2009; 1:636–42.

16. Visnjevac O, Kim P, Farid-Davari S, Johnson P, Nader ND. Digital subtraction angiography versus real-time fluoroscopy for detection of intravascular penetration prior to epidural steroid injections: meta-analysis of prospective studies. Pain Physician. 2015; 18:29–36.

17. Heavner JE, Racz GB, Jenigiri B, Lehman T, Day MR. Sharp versus blunt needle: a comparative study of penetration of internal structures and bleeding in dogs. Pain Pract. 2003; 3:226–31.

18. Akins EW, Hawkins IF Jr, Mladinich C, Tupler R, Siragusa RJ, Pry R. The blunt needle: a new percutaneous access device. AJR Am J Roentgenol. 1989; 152:181–2.

19. Quintero N, Laffont I, Bouhmidi L, Rech C, Schneider AE, Gavardin T, et al. Transforaminal epidural steroid injection and paraplegia: case report and bibliographic review. Ann Readapt Med Phys. 2006; 49:242–7.

20. Özcan U, Şahin Ş, Gurbet A, Türker G, Özgür M, Çelebi S. Comparison of blunt and sharp needles for transforaminal epidural steroid injections. Agri. 2012; 24:85–9.

21. Shin J, Kim YC, Lee SC, Kim JH. A comparison of Quincke and Whitacre needles with respect to risk of intravascular uptake in S1 transforaminal epidural steroid injections: a randomized trial of 1376 cases. Anesth Analg. 2013; 117:1241–7.

22. Hong J, Jung S, Chang H. Whitacre needle reduces the incidence of intravascular uptake in lumbar transforaminal epidural steroid injections. Pain Physician. 2015; 18:325–31.

23. Smuck M, Paulus S, Patel A, Demirjian R, Ith MA, Kennedy DJ. Differential rates of inadvertent intravascular injection during lumbar transforaminal epidural injections using blunt-tip, pencil-point, and catheter-extension needles. Pain Med. 2015; 16:2084–9.

24. Nagpal AS, Chang-Chien GC, Benfield JA, Candido KD, Rana MV, Eckmann M. Digital subtraction angiography use during epidural steroid injections does not reliably distinguish artery from vein. Pain Physician. 2016; 19:255–66.

25. Hong JH, Huh B, Shin HH. Comparison between digital subtraction angiography and real-time fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections. Reg Anesth Pain Med. 2014; 39:329–32.