title: CT-Fluoroscopic Cervical Transforaminal Epidural Steroid Injections: Extraforaminal Needle Tip Position Decreases Risk of Intravascular Injection.
abstract: OBJECTIVE
  Cervical transforaminal epidural steroid injections are commonly performed for temporary pain relief or diagnostic presurgical planning in patients with cervical radiculopathy. Intravascular injection of steroids during the procedure can potentially result in cord infarct, stroke, and even death. CT-fluoroscopy allows excellent anatomic resolution and precise needle positioning. This study sought to determine the safest needle tip position during CT-guided cervical transforaminal epidural steroid injection as determined by the incidence of intravascular injection.
  
  
  METHODS
  We retrospectively evaluated procedural imaging for consecutive single-site CT-fluoroscopic cervical transforaminal epidural steroid injection performed during a 13-month period. Intravascular injections were identified and classified by volume, procedure phase, vessel type, and needle tip position relative to the targeted neural foramen. ANOVA, Wilcoxon, or Pearson χ(2) testing was used to assess differences among groups as appropriate.
  
  
  RESULTS
  Intravascular injections occurred in 49/201 (24%) procedures. Of the intravascular injections, 13/49 (27%) were large, 10/49 (20%) were small, and 26/49 (53%) were trace volume. Sixteen of 49 (33%) intravascular injections occurred with a trial contrast dose; 27/49 (55%), with a steroid/analgesic cocktail; and 6/49 (12%), with both. Twenty-seven of 49 (55%) intravascular injections were likely venous, 22/49 (45%) were indeterminate, and none were likely arterial. The intravascular injection rate was significantly lower (P < .001) for the extraforaminal needle position (8/82, 10%) compared with junctional (27/88, 31%) and foraminal (14/31, 45%) needle tip positions.
  
  
  CONCLUSIONS
  An extraforaminal needle position for CT-guided cervical transforaminal epidural steroid injection decreases the risk of intravascular injection and therefore may be safer than other needle tip positions.
authors.affiliation: From the Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. lagemanngm@upmc.edu.
authors.forename: G M
authors.identifier: http://orcid.org/0000-0001-5718-2712
authors.initials: GM
authors.lastname: Lagemann
authors.affiliation: From the Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: M P
authors.identifier: http://orcid.org/0000-0003-4752-201X
authors.initials: MP
authors.lastname: Yannes
authors.affiliation: From the Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: A
authors.identifier: http://orcid.org/0000-0003-4548-5577
authors.initials: A
authors.lastname: Ghodadra
authors.affiliation: From the Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: W E
authors.identifier: http://orcid.org/0000-0001-9772-9604
authors.initials: WE
authors.lastname: Rothfus
authors.affiliation: From the Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: V
authors.identifier: http://orcid.org/0000-0002-7086-0239
authors.initials: V
authors.lastname: Agarwal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural / Q000009:adverse effects* / Q000379:methods*; D002574:Cervical Vertebrae; D004824:Epidural Space / Q000000981:diagnostic imaging*; D005260:Female; D005471:Fluoroscopy; D005539:Foramen Magnum; D006801:Humans; D007091:Image Processing, Computer-Assisted; D007268:Injections, Epidural; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D008875:Middle Aged; D009339:Needles; D011843:Radiculopathy / Q000188:drug therapy; D015641:Radiography, Interventional; D012189:Retrospective Studies; D013256:Steroids / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D013256:Steroids