Radiation Dose Incurred in the Exclusion of Vascular Filling in Transforaminal Epidural Steroid Injections: Fluoroscopy, Digital Subtraction Angiography, and CT/Fluoroscopy

Maus, Timothy P.; Schueler, Beth A.; Leng, Shuai; Magnuson, Dayne; Magnuson, Dixon J.; Diehn, Felix E.

doi:10.1111/pme.12455

Cited by 21 publications

(13 citation statements)

References 16 publications

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“…In addition, DSA has disadvantages, such as additional radiation exposure to physicians and patients and the high cost of the new and upgraded fluoroscopic equipment (15). DSA was reported to increase the effective radiation dose incurred by 2.3 ~ 4.3 fold for TFEI compared to conventional fluoroscopy (23).…”

Section: E185mentioning

confidence: 99%

Detection of Intravascular Injection During Cervical Transforaminal Epidural Injection: A Comparison of Digital Subtraction Angiography and Real Time Fluoroscopy

Kim

2018

Pain Phys

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Background: Transforaminal epidural injection (TFEI) with local anesthetics and steroids are effective in treating spinal radicular pain. However, inadvertent intravascular injection can lead to severe neurologic complications. To reduce complications of intravascular injection, use of imaging modality, such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA), has been recommended. DSA is an imaging technique that can clearly visualize the blood vessels from surrounding bones or dense soft tissues by subtracting the pre-contrast image from the image after injecting contrast medium. Objective: In this study, we investigated whether there is a difference between RTF and DSA in the detection of intravascular injection during cervical TFEI. Study Design: Clinical study. Setting: Pain clinic in South Korea. Methods: We prospectively examined 137 cervical TFEIs on 128 patients who have a radiating pain from spinal stenosis and herniated nucleus pulposus. The needle position was confirmed using biplanar fluoroscopy and 2 mL of nonionic contrast medium was injected at the rate of 0.5 mL/sec under RTF. Thirty seconds later, 2 mL of nonionic contrast medium was injected at the rate of 0.5 mL/sec under DSA. Intravascular injection was defined as contrast medium spreading throughout the vascular channel during injection of contrast medium under RTF and DSA. This study is registered in the ClinicalTrials.gov (NCT03040648). Results: The detection rate of intravascular injection in RTF was not statistically different compared to that in DSA (30.7 % vs. 34.3%, P > 0.05). Limitations: We injected 2 mL of contrast medium at the rate of 0.5 mL/sec. Further studies about the ideal injection speed and volume of contrast medium for improvement of detection of intravascular injection during TFEI are needed. This study was a single center study. Therefore, multi-center studies are needed to obtain the high level of evidence. Additionally, the procedural pain physician was not blinded to the type of imaging modality, such as RTF and DSA, to detect intravascular injection. To minimize this confirmation bias and provide homogenous procedural conditions for TFEI, the same procedural physician performed all 137 injections. Conclusions: In this study, there is no significant difference in detection rate of intravascular injection between RTF and DSA during cervical TFEI. Key words: Analgesia, bleeding, clinical trials, complications, diagnostic equipment, epidural, radiculopathy, spine

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Section: E185mentioning

confidence: 99%

Detection of Intravascular Injection During Cervical Transforaminal Epidural Injection: A Comparison of Digital Subtraction Angiography and Real Time Fluoroscopy

Kim

2018

Pain Phys

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“…Third, as previously reported in the neurointerventional literature, DSA is associated with significant radiation exposure [19,20]. Maus et al have shown that during transforaminal epidural steroid injections, DSA delivered approximately 2-4-fold more radiation than conventional fluoroscopy during a 5s exposure [21]. A limitation inherent to both CDM and DSM is the use of planar rather than cross-sectional imaging.…”

Section: Discussionmentioning

confidence: 93%

Role of Conventional Dynamic Myelography for Detection of High-Flow Cerebrospinal Fluid Leaks

et al. 2020

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Background Spinal imaging is essential to identify and localize cerebrospinal fluid (CSF) leaks in spontaneous intracranial hypotension (SIH) patients when targeted treatment is necessary. Purpose Provide an in-depth presentation of the conventional dynamic myelography (CDM) technique for localizing spinal CSF leaks in SIH patients. Material and Methods Consecutive SIH patients with a CSF leak confirmed on CDM and postmyelography computed tomography (CT) investigated at our institution between 2013 and 2019 were retrospectively analyzed. Intraoperative reports were reviewed to confirm the accuracy of CDM. Results In total, 62 patients (mean age 45 years) were included; 48 with a ventral dural tear, 12 with a meningeal diverticulum, and in 2 patients positive for spinal longitudinal extradural CSF collection the site remained unclear. The leak was identified during the first and the second CDM in 43 and 17 patients, respectively. The use of CDM correctly identified the site of the CSF leak in all but one patient undergoing surgical closure (45/46, 98%). The mean fluoroscopy time was 7.8 min (range 1.8-14.4 min) with a radiation dose for a single examination of 310 mGy (range 28-1237 mGy). ConclusionThe CDM procedure has a high accuracy for spinal CSF leak localization including dural tears and spinal nerve diverticula. It is the technique with the highest temporal resolution, is robust to breathing artifacts, allows great flexibility regarding patient positioning, compares favorably to other dynamic examinations with respect to the radiation dose and does not require general anesthesia. For CSF venous fistulas, however, other dynamic examinations, such as digital subtraction myelography, seem more appropriate. Keywords Spontaneous intracranial hypotension • CSF leak • Conventional dynamic myelographyAvailability of data and material The datasets analyzed during the current study are not publicly available owing to preclusion from dissemination under Swiss Federal Law regulations; however, they are available from the corresponding author on reasonable request. Where not in conflict with constraints of the original ethical approval under which the data were collected, pseudoanonymized data will be made available for appropriate collaborative research, subject to appropriate ethical approval being gained for such use.

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“…In order to minimize the potential for an inadvertent vascular injection during lumbar TFESI, a test dose of contrast medium is recommended before any other agent is injected [3]. Digital subtraction imaging (DSI) has been found to increase the detection of intravascular uptake of contrast compared to live fluoroscopy alone [4,5], but DSI may not be readily available and does increase radiation exposure to both patients and providers [6]. Real time fluoroscopy has been shown to be superior to aspiration tests and static fluoroscopic images [7].…”

Section: N T E R V E N T I O N S O C I E T Ymentioning

confidence: 99%

Strategies to Minimize Risk in Lumbar Transforaminal Injections: Imaging and Injectate

2019

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Radiation Dose Incurred in the Exclusion of Vascular Filling in Transforaminal Epidural Steroid Injections: Fluoroscopy, Digital Subtraction Angiography, and CT/Fluoroscopy

Cited by 21 publications

References 16 publications

Detection of Intravascular Injection During Cervical Transforaminal Epidural Injection: A Comparison of Digital Subtraction Angiography and Real Time Fluoroscopy

Detection of Intravascular Injection During Cervical Transforaminal Epidural Injection: A Comparison of Digital Subtraction Angiography and Real Time Fluoroscopy

Role of Conventional Dynamic Myelography for Detection of High-Flow Cerebrospinal Fluid Leaks

Strategies to Minimize Risk in Lumbar Transforaminal Injections: Imaging and Injectate

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