Correlation Between Intravascular Injection Rate, Pain Intensity, and Degree of Cervical Neural Foraminal Stenosis During a Cervical Transforaminal Epidural Block

Abstract

Purpose Cervical transforaminal epidural blocks (CTEBs) are useful for the treatment of cervical radicular pain. However, during CTEBs, inadvertent intravascular injection can introduce particulate steroids into the bloodstream, thus leading to serious complications. Moreover, the risk factors associated with intravascular injection during CTEBs have not been identified. Cervical neural foraminal stenosis (CNFS) is a form of neural foraminal narrowing and a common cause of cervical radicular pain. In this study, we aimed to identify whether there is a correlation between the incidence of intravascular injection during CTEB, pain intensity, and the degree of CNFS. Patients and Methods A total of 126 patients were recruited. The patients were classified into two subgroups (group M and group S) based on the routine cervical T2-weighted axial magnetic resonance imaging (MRI) findings. Group M (n = 63) consisted of moderate CNFS patients, while group S (n = 63) consisted of severe CNFS patients. The occurrence of intravascular injection during CTEB was established using real-time fluoroscopy. The intravascular injection was determined by the spreading of the contrast medium through the vascular channel during the injection. Additionally, pain intensity was scored using a Numeric Rating Scale (NRS) before the procedure and 1 month after the procedure. Results There was no significant difference in the incidence of intravascular injection during CTEB between group M and group S (41.3% vs 39.7%, respectively; p = 0.99) and in the NRS scores before and 1 month after CTEB. However, both groups showed a significant decrease in the NRS scores at 1 month after the procedure compared with that before the procedure. Conclusion The degree of CNFS does not affect the incidence of intravascular injection during CTEB. Regardless of whether patients have moderate or severe CNFS, caution should be exercised during CTEB procedures.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study

“…Our results showed no significant difference in the success rates of cervical FJ and TFE steroid injections based on the degree of FS. Kim et al 5 reported that the pain of the participants decreased regardless of the severity of cervical FS, and that there was no difference in the treatment results of TFE steroid injection between the non-severe FS and severe FS groups. Moreover, in 53 patients with cervical FS, there were no significant differences in the effects of TFE steroid injection between patients with non-severe and severe FS.…”

“…A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain. 1 5 6 7 8 However, cervical TFE steroid injections carry a small risk of catastrophic complications, 8 9 and their efficacy has not been demonstrated in randomized controlled trials (RCTs). 10 The most notable risk associated with TFE steroid injection is vascular trespass or unplanned injection into a vein or artery.…”

“…Serious events, such as seizure, infarction of the brainstem or spinal cord, and death, presumably caused by vascular trespass with resultant distal embolization of a particulate steroid, have been reported. 5 6 7 9 11 Accordingly, several researchers have investigated more secure routes of steroid delivery in the vicinity of the involved nerve, including the facet joint (FJ) approach. 7 12 13 …”

Direct Visualization of Cervical Interlaminar Epidural Injections Using Sonography

“…Thus, the safety zone for interlaminar CEDI is very narrow [ 16 ]. In reviews of malpractice claims between 2005 and 2008, 64 cases involved cervical interventions, 20 of which resulted in direct spinal cord injury associated with interlaminar CEDI [ 5 , 9 ].…”

“…Fluoroscopy or computed tomography (CT) guidance aims to reduce the risks of epidural injection, such as dural puncture or spinal cord injury. However, although both guidance approaches improve safety, they cannot completely aid in advancing the tip of the needle into the epidural space, as these approaches cannot visualize the entire intrusion route [ 2 , 3 , 4 , 5 ].…”