Background: Epidural steroid injections (ESIs) are among the most common procedures
performed in an interventional pain management practice. It is well known that tragic
complications may arise from ESIs, most commonly those performed using a transforaminal
approach. Digital subtraction angiography (DSA) has been hailed as a fluoroscopic technique
that can be used to detect arterial placement of the injection needle, and therefore as a safety
measure that can decrease the incidence of catastrophic sequelae of these procedures.
Objective: The objective of this article was to review existing scientific pain literature to
determine if DSA can distinguish arterial vs. venous uptake.
Study Design: Narrative review.
Methods: The current narrative review of DSA in interventional spine was completed with
a PUBMED search using the key words: digital subtraction angiography, epidural, fluoroscopy,
intravascular injection, paraplegia, and quadriplegia in accordance with Preferred Reporting
Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines.
Results: After identification of duplicate articles, 383 articles were screened by title, abstract,
and/or full article review. Ten of these articles were deemed appropriate, after applying inclusion
and exclusion criteria, as they specifically looked at the use of digital subtraction angiography in
interventional spine epidural injections. This included 4 case reports, 3 prospective studies, one
retrospective analysis, one prospective cohort study, and one meta-analysis.
All of the available studies claiming that DSA was capable of detecting vascular spread are
likely accurate, but no significant detection of specifically arterial spread has been reported. The
known catastrophic complications related to ESIs are purported to be due to arterial injection
of insoluble steroids or local anesthetic and detection of arterial spread of contrast during
fluoroscopy would be of obvious benefit to the interventionalist.
Limitations: Small study size, non-randomized studies between DSA and real time
fluoroscopy.
Conclusion: Existing studies do not support that DSA can predict arterial spread. In fact, DSA
exposes the practitioner and the patient to higher levels of radiation without objective evidence
of any safety parameters.
Key words: Digital subtraction angiography, real-time fluoroscopy, transforaminal epidural
injection, particulate steroids, cervical radicular artery, lumbar radicular artery, spinal cord injury
Digital Subtraction Angiography Use During
Epidural Steroid Injections Does Not Reliably
Distinguish Artery from Vein