title: Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections.
abstract: BACKGROUND
  The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported.
  
  
  OBJECTIVE
  To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections.
  
  
  METHODS
  A prospective, observational, in vivo, study.
  
  
  METHODS
  Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center.
  
  
  METHODS
  Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns.
  
  
  METHODS
  One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy.
  
  
  RESULTS
  The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis.
  
  
  CONCLUSIONS
  Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.
authors.affiliation: Department of Physical Medicine and Rehabilitation, The Spine Program, University of Michigan, Suite 202, 325 E. Eisenhower Pkwy, Ann Arbor, MI 48108-0744, USA. msmuck@med.umich.edu
authors.forename: Matthew
authors.initials: M
authors.lastname: Smuck
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Fuller
authors.forename: Brian
authors.initials: B
authors.lastname: Yoder
authors.forename: Joyce
authors.initials: J
authors.lastname: Huerta
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001808:Blood Vessels / Q000187:drug effects / Q000293:injuries* / Q000473:pathology; D003287:Contrast Media / Q000009:adverse effects; D004388:Dura Mater / Q000187:drug effects / Q000473:pathology; D004824:Epidural Space / Q000187:drug effects / Q000473:pathology; D005119:Extravasation of Diagnostic and Therapeutic Materials; D005260:Female; D005471:Fluoroscopy / Q000379:methods; D006785:Hospitals, University; D006801:Humans; D015994:Incidence; D007268:Injections, Epidural / Q000009:adverse effects*; D007431:Intraoperative Complications / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D008161:Lumbosacral Region; D008297:Male; D008824:Michigan / Q000453:epidemiology; D008875:Middle Aged; D011446:Prospective Studies
chemical_list: D003287:Contrast Media