scholarly journals Anomalous Location of the Vertebral Artery in Relation to the Neural Foramen. Implications for Cervical Transforaminal Epidural Steroid Injections

Pain Medicine ◽  
2013 ◽  
Vol 14 (8) ◽  
pp. 1119-1125 ◽  
Author(s):  
William Jeremy Beckworth ◽  
Rajiv Sood ◽  
Arin Fredrick Katzer ◽  
Baohua Wu
Keyword(s):  
Vertebral Artery ◽  
Neural Foramen ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Needle Position Analysis in Cases of Paralysis From Transforaminal Epidurals: Consider Alternative Approaches to Traditional Technique

2013 ◽  
Vol 4;16 (4;7) ◽  
pp. 321-334
Author(s):  
Sairam Atluri
Keyword(s):  
Anterior Part ◽  
Epidural Injection ◽  
Neural Foramen ◽  
Steroid Injections ◽  
Position Analysis ◽  
Epidural Steroid Injections ◽  
Superior Part ◽  
Traditional Technique ◽  
Needle Position ◽  
Epidural Steroid

Background: Transforaminal technique for epidural steroid injections, unlike other approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis. Objective: To review the literature and analyze the reported cases of paralysis from lumbar transforaminal epidural steroid injections to possibly establish a cause and to prevent this complication. Study Design: Eighteen cases of paralysis from transforaminal epidural injection have been reported. We could analyze the position of the needle within the neural foramen based on the available images and/or description among 10 of these 18 cases. Five cases were performed with computed tomography guidance and 12 cases were performed with fluoroscopic guidance [unknown in one case]. Additionally, other variables associated with the procedure, including the technique, were also examined. Methods: Analysis of the needle position in the neural foramen in cases of paralysis from transforaminal epidural steroid injections. This analysis is based on images and/or description provided in published reports. Results: Paralysis in these cases seems to be associated with a well performed traditional safe triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was in the anterior part of the foramen. This coincides with the location of the radicular artery in the foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone). No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events happened during a left-sided procedure and 8 during a right-sided procedure. No relation to this complication was noted when other variables like type and size of the needles, side of the injection, local anesthetic, contrast, or volume of injectate were taken into consideration. Limitations: Only 18 cases of paralysis from transforaminal epidurals have been reported. Out of these, only 10 cases included images or descriptions which could be evaluated for our study. Conclusion: In light of the anatomical and radiological evidence in the literature that radicular arteries dwell in the superior part of the foramen and along with our needle position analysis, we suggest that the traditional technique of placing the needle in the superior and anterior part of the foramen must be reexamined. Alternative, safer techniques must be considered, one of which is described. Key words: Lumbar epidural injection, lumbar transforaminal, approach, selective nerve root block, paralysis, steroid, particulate, nonparticulate, safe triangle, radicular artery, artery of Adamkiewicz

scholarly journals Neck movement during cervical transforaminal epidural injections and the position of the vertebral artery: an anatomical study

2019 ◽  
Vol 8 (3) ◽  
pp. 205846011983468
Author(s):  
Juan Altafulla ◽  
Emre Yilmaz ◽  
Stefan Lachkar ◽  
Joe Iwanaga ◽  
Jacob Peacock ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Guide Wire ◽  
Anatomical Study ◽  
Epidural Injection ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Intervertebral Foramina ◽  
Digital Subtraction Fluoroscopy

Background Cervical transforaminal epidural steroid injections (CTFESIs) are sometimes performed in patients with cervical radiculopathy secondary to nerve-root compression. Neck movements for patient positioning may include rotation, flexion, and extension. As physicians performing such procedures do not move the neck for fear of injuring the vertebral artery, we performed fluoroscopy and cadaveric dissection to analyze any movement of the vertebral artery during head movement and its relation to the foramina in the setting of CTFESI. Purpose To determine cervical rotational positioning for optimized vertebral artery location in the setting of cervical transforaminal epidural steroid injections. Material and Methods Four sides from two Caucasian whole cadavers (all fresh-frozen) were used. Using a guide wire and digital subtraction fluoroscopy, we evaluated the vertebral artery mimicking a CTFESI, then we removed the transverse processes and evaluated the vertebral artery by direct observation. Results After performing such maneuvers, no displacement of the vertebral artery was seen throughout its course from the C6 to the C2 intervertebral foramina. To our knowledge, this is the first anatomical observation of its kind that evaluates the position of the vertebral artery inside the foramina during movement of the neck. Conclusion Special caution should be given to the medial border of the intervertebral foramina when adjusting the target site and needle penetration for the injection. This is especially true for C6-C4 levels, whereas for the remaining upper vertebrae, the attention should be focused on the anterior aspect of the foramen. Since our study was centered on the vertebral artery, we do not discard the need for contrast injection and real-time digital subtraction fluoroscopy while performing the transforaminal epidural injection in order to prevent other vascular injuries.

scholarly journals Vertebral Artery Anatomical Variations as They Relate to Cervical Transforaminal Epidural Steroid Injections

Pain Medicine ◽  
2013 ◽  
Vol 15 (7) ◽  
pp. 1109-1114 ◽  
Author(s):  
Andrew I. Gitkind ◽  
Todd R. Olson ◽  
Sherry A. Downie
Keyword(s):  
Vertebral Artery ◽  
Anatomical Variations ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

The retroneural approach: an alternative technique for lumbar transforaminal epidural steroid injections

2018 ◽  
Vol 59 (12) ◽  
pp. 1508-1516
Author(s):  
Stefan Ignjatovic ◽  
Reza Omidi ◽  
Rahel A Kubik-Huch ◽  
Suzanne Anderson ◽  
Frank J Ahlhelm
Keyword(s):  
Pain Relief ◽  
Nerve Root ◽  
Spinal Cord Infarction ◽  
Short Term ◽  
Neural Foramen ◽  
Ct Guided ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Tip Position ◽  
Epidural Steroid

Background Compared with other available injection techniques for lumbar transforaminal epidural steroid injections (LTFESIs), the traditionally performed subpedicular approach is associated with a higher risk of spinal cord infarction, a rare but catastrophic complication. Purpose To assess the short-term efficacy of the retroneural approach for computed tomography (CT)-guided LTFESIs with respect to different needle-tip positions. Material and Methods This retrospective analysis included 238 patients receiving 286 CT-guided LTFESIs from January 2013 to January 2016. Short-term outcomes in terms of pain relief were assessed using the visual analogue scale (VAS) at baseline and 30 min after. The needle-tip location was categorized as extraforaminal, junctional, or foraminal relative to the neural foramen. Additionally, the distance from the needle tip to the nerve root was measured. Results A mean pain reduction of 3.22 points (±2.17 points) on the VAS was achieved. The needle-tip location was extraforaminal in 48% (136/286), junctional in 42% (120/286), and foraminal in 10% (28/286) of the cases. The mean distance from the needle tip to the nerve root was 3.83 mm (±3.37 mm). There was no significant correlation between pain relief and needle-tip position in relation to the neural foramen. Therapy success was not dependent on the distance between the needle tip and the nerve root. No major complications were observed. Conclusion In our population treated with LTFESIs, the retroneural approach was shown to be an effective technique, with no significant differences in pain relief following different needle-tip positions.

Incidence of Intravascular Penetration in Transforaminal Cervical Epidural Steroid Injections

Spine ◽  
2003 ◽  
Vol 28 (1) ◽  
pp. 21-25 ◽  
Author(s):  
Michael B. Furman ◽  
Michael T. Giovanniello ◽  
Erin M. O’Brien
Keyword(s):  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Cervical Epidural Steroid Injections ◽  
Epidural Steroid

Interpreting Reviews and Guidelines: The Case of Lumbar Epidural Steroid Injections

PM&R ◽  
2009 ◽  
Vol 1 (6) ◽  
pp. 576-579 ◽  
Author(s):  
Venu Akuthota ◽  
Charles Argoff ◽  
William C. Watters
Keyword(s):  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid
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