Sinem SARI GÖKAY, Saliha Yeter AMASYALI, Mehmet Emre YILMAZ, YASEMİN TURAN, Ali YILMAZ, Ali AKYOL, Ömer Faruk Kutsi KÖSEOĞLU, Osman Nuri AYDIN

Intravascular escape during lumbar transforaminal anterior epidural steroid injection: A retrospective study

Objectives: Demonstrate of accidental intravascular injection during lumbar transforaminal anterior epidural steroid injection (TAESI) performed with three-dimensional imaging angiography (3DIA) and fluoroscopy.Methods: We assessed 20 (9 males and 11 females) patients (with a total of 40 levels) whose images were received with simultaneously 3DIA and fluoroscopy-guided TAESI between January 2016 and September 2016 as retrospective. Injections werecarried out in the lumbar fourth intervertebral space bilaterally and performed in the same way all of the cases.Results: The mean age and body mass index of the patients were 47.9±2.72 years and 26.95±1.21, respectively. There were 10patients with disc herniation, seven patients with spinal stenosis, and three patients with failed back surgery syndrome. In 3Dimaging, vascular escape was detected in the 7 levels (17.5%) which were thought to be no escape in the fluoroscopy imaging.Conclusion: In chronic lumbar radiculopathy patients, intravascular escapes may occur during the fluoroscopic TAESI procedure. To avoid intravascular injections during TAESI procedure, it may be appropriate to use different imaging methods thatcan give more detailed results such as 3D angiography.

Lomber transforaminal anterior epidural steroid enjeksiyonu sırasında intravaskuler kaçak: Retrospektif çalışma

Amaç: Üç boyutlu anjiyografi (3BA) ve floroskopi ile yapılan lomber transforaminal anterior epidural steroid enjeksiyonu (TAESI) sırasında istenmeyen intravasküler enjeksiyonun gösterilmesi. Gereç ve Yöntem: Ocak 2016 ile Eylül 2016 tarihleri arasında 20 (9 erkek, 11 kadın) hastaya (toplam 40 seviye) lomber dördüncü intervertebral seviyeden bilateral transforaminal anterior epidural steroid enjeksiyonu (TAESI) işlemi yapıldı. TAESI işlemi sırasında eş zamanlı olarak çekilen, 3BA ve fluroskopi görüntüleri retrospektif olarak değerlendirildi. Bulgular: Hastaların ortalama yaş ve vücut kitle indeksi sırasıyla 47.9±2.72 yıl ve 26.95±1.21 idi. Hastaların onunda lomber disk hernisi, yedisinde spinal dar kanal,ve üçünde başarısız bel cerrahisi sendromuna bağlı şikayetleri vardı. Yedi seviyede (%17.5), floroskopik görüntülemede vasküler kaçış görülmemesine rağmen, 3BA görüntülemede vasküler kaçış saptandı. Sonuç: Kronik lomber radikulopati hastalarinda floroskopi eşliginde uygulanan TAESI işlemi sirasinda farkedilemeyebilen intravaskuler kaçışlar olabilmektedir. TAESI işlemi sırasında intravasküler enjeksiyonlardan kaçinmak icin 3BA gibi daha ayrıntılı sonuçlar verebilen farklı görüntüleme yöntemlerinin kullanılması uygun olabilir.

PDF

___

1. Çetin MF, Karaman H, Kavak GO, Tüfek A, Yildirim ZB. Efficacy of transforaminal lumbar epidural steroid injections in patients with lumbar radiculopathy. Agri 2012;24(2):77– 84.

2. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: Two case reports. Pain Med 2009;10(8):1389–94.

3. Windsor RE, Storm S, Sugar R, Nagula D. Cervical transforaminal injection: Review of the literature, complications and a suggested technique. Pain Physician 2003;6(4):457– 65.

4. Smuck M, Fuller BJ, Chiodo A, Benny B, Singaracharlu B, Tong H, et al. Accuracy of intermittent fluoroscopy to detect intravascular injection during transforaminal epidural injections. Spine (Phila Pa 1976) 2008;33(7):E205–10.

5. Kranz PG, Abbott M, Abbott D, Hoang JK. Optimal contrast concentration for CT-guided epidural steroid injections. AJNR Am J Neuroradiol 2014;35(1):191–5.

6. Zhang T, Wang Y, Ye P, Liu J, Cheng Y, Wang S, et al. Threedimensional computed tomography reconstructive diagnosis of snakebite-induced cerebral infarction. J Xray Sci Technol 2018;26(1):165–9.

7. Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: An outcome study. Arch Phys Med Rehabil 1998;79(11):1362–6.

8. Seemann MD, Englmeier K, Schuhmann DR, Minx C, Fürst H, Heuck A, et al. Evaluation of the carotid and vertebral arteries: Comparison of 3D SCTA and IA-DSA-work in progress. Eur Radiol 1999;9(1):105–12.

9. Zhao L, Zhou S, Fan T, Li B, Liang W, Dong H. Three-dimensional printing enhances preparation for repair of double outlet right ventricular surgery. J Card Surg 2018;33:24–7.

10. Lee DG, Ahn SH, Lee J. Comparative effectiveness of pulsed radiofrequency and transforaminal steroid injection for radicular pain due to disc herniation: A prospective randomized trial. J Korean Med Sci 2016;31(8):1324–30.

11. Johansson A, Hao J, Sjölund B. Local corticosteroid application blocks transmission in normal nociceptive C-fibres. Acta Anaesthesiol Scand 1990;34(5):335–8.

12. Rosenberg SK, Grabinsky A, Kooser C, Boswell MV. Effectiveness of transforaminal epidural steroid injections in low back pain: A one year experience. Pain Physician 2002;5(3):266–70.

13. Arici T, Kurçaloğlu M, Eyıgor C, Uyar M. Transforaminal epidural steroid injection and infraneural approach. Agri 2019;31(2):104–6.

14. Epstein NE. Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections. Surg Neurol Int 2017;8:60.

15. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: More dangerous than we think? Spine (Phila Pa 1976) 2007;32(11):1249–56.

16. Chien GC, Candido KD, Knezevic NN. Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminal epidural steroid injection. Pain Physician 2012;15(6):515–23.

17. Jeon Y, Kim S. Detection of ıntravascular ınjection during cervical transforaminal epidural ınjection: A comparison of digital subtraction angiography and real-time fluoroscopy. Pain Physician 2018;21(2):E181–6.

18. Fenster AJ, Fernandes K, Brook AL, Miller T. The safety of CT-guided epidural steroid ınjections in an older patient cohort. Pain Physician 2016;19(8):E1139–46.

19. 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(8):1328–33.