Tülin ARICI, Mustafa KURÇALOĞLU, CAN EYİGÖR, Meltem UYAR

Transforaminal epidural steroid injection and infraneural approach

Transforaminal epidural steroid injections are a common intervention in the treatment of radicular pain. Complications are rare, but can be catastrophic. One of the potentially devastating complications is occlusion of the artery of Adamkiewicz (AKA). This report is a description of an approach to avoid the complication of injury to the AKA related to transforaminal epidural injection. A 71-year-old male patient presented at the clinic with radiculopathy secondary to lumbar disc hernia. A transforaminal epidural steroid injection was planned. After a radiocontrast injection, vascular filling was detected. The needle was repositioned and an inferior entrance to the epidural space was used. No vascularity was seen and dexamethasone was administered to the patient. A transforaminal epidural steroid injection is an effective interventional treatment for radicular pain, but it requires careful attention due to the possible complications. The AKA was located in the upper half of the foramen. Keeping the wide variation in the anatomy of the AKA in mind is very important in order to prevent spinal cord ischemia.

Transforaminal epidural steroid enjeksiyonu ve infranöral yaklaşım

Transforaminal epidural steroid enjeksiyonu radiküler ağrı tedavisi için kullanılan yaygın bir girişimdir. Komplikasyonları nadir fakat katastrofiktir. En nadir katastrofik komplikasyonlarından biri Adamkiewicz arter (AKA) oklüzyonu ile ilgilidir. Bu sunumda transforaminal epidural steroid enjeksiyonu ile ilişkili AKA injurisinden kaçınmak için uyguladığımız yaklaşımı sunduk. 71 yaşında erkek hasta kliniğimize lomber disk hernisine bağlı radikülopati ile başvurdu. Hastaya transforaminal steroid enjeksiyonu planlandı. Radyokontrast enjeksiyonu sonrasında vasküler dolum görüldü. Bunun üzerine iğneye yeniden pozisyon verilerek epidural alana ulaşmak için inferior giriş uygulandı. Vasküler yayılım görülmedi ve dexametazon enjekte edildi. Transforaminal epidural enjeksiyon radiküler ağrı için efektif bir girişimsel ağrı tedavisidir. Fakat muhtemel katastrofik komplikasyonlar nedeniyle dikkatli olmayı gerektirir. AKA büyük oranda foramenin üst yarısında lokalizedir. Spinal kord iskemisini önlemek için AKA’nın çok geniş bir anatomik varyasyona sahip olduğunu akılda bulundurmak çok önemlidir.

PDF

___

Murthy NS, Maus TP, Behrns CL. Intraforaminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz): a retrospective review. Pain Med 2010;11(12):1756–64. [CrossRef]

AbdeleRahman KT, Rakocevic G. Paraplegia following lumbosacral steroid epidural injections. J Clin Anesth 2014;26(6):497–9. [CrossRef]

Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J 2002;2(1):70–5.

Abdi S, Datta S, Lucas LF. Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician 2005;8(1):127–43.

Huntoon MA. Cervical Spine: Case Presentation, Complications, and Their Prevention. Pain Medicine 2008;S35–40.

Bredow J, Oppermann J, Keller K, Beyer F, Boese CK, Zarghooni K, et al. Anterior spinal artery syndrome: reversible paraplegia after minimally invasive spine surgery. Case Rep Orthop 2014;2014:205732. [CrossRef]

Melissano G, Chiesa R. Advances in imaging of the spinal cord vascular supply and its relationship with paraplegia after aortic interventions. A review. Eur J Vasc Endovasc Surg 2009;38(5):567–77. [CrossRef]

Tatsuya Nishii, Atsushi K. Kono, Noriyuki Negi,H Hashimura, K Uotani, Y Okita, K Sugimura. The Feasibility of a 64-slice MDCT for detection of the Adamkiewicz artery: comparison of the detection rate of intravenous injection CT angiography using a 64-slice MDCT versus intra-arterial and intravenous injection CT angiography using a 16-slice MDCT. Int J Cardiovasc Imaging (2013) 29:127–133. [CrossRef]

Melissano G, Bertoglio L, Civelli V, Amato AC, Coppi G, Civilini E, et al. Demonstration of the Adamkiewicz artery by multidetector computed tomography angiography analysed with the open-source software OsiriX. Eur J Vasc Endovasc Surg 2009;37(4):395-400. [CrossRef]

Lo D. Vallee JN, Spelle K, Cormier E, Saillant G, Rancurel G, et al. Unusual origin of the artery of Adamkiewicz from the fourth lumbar artery. Neuroradiology 2002;44(2):153–7.

Furman MB, O’Brien EM, Zgleszewski TM. Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections. Spine (Phila Pa 1976) 2000;25(20):2628–32. [CrossRef]