Unintentional lumbar facet joint injection guided by fluoroscopy during interlaminar epidural steroid injection: a retrospective analysis

( Min Jae Kim ),( Yun Suk Choi ),( Hae Jin Suh ),( You Jin Kim ),( Byeong Jin Noh ) 대한통증학회 2018 The Korean Journal of Pain Vol.31 No.2

Background: An epidural steroid injection (ESI) is a commonly administered procedure in pain clinics. An unintentional lumbar facet joint injection during interlaminar ESI was reported in a previous study, but there has not been much research on the characteristics of an unintentional lumbar facet joint injection. This study illustrated the imaging features of an unintentional lumbar facet joint injection during an interlaminar ESI and analyzed characteristics of patients who underwent this injection. Methods: From December 2015 to May 2017, we performed 662 lumbar ESIs and we identified 24 cases (21 patients) that underwent a lumbar facet joint injection. We gathered data contrast pattern, needle approach levels and directions, injected facet joint levels and directions, presence of lumbar spine disease as seen on magnetic resonance images (MRI), and histories of lumbar spine surgeries. Results: The contrast pattern in the facet joint has a sigmoid or ovoid contrast pattern confined to the vicinity of the facet joint. The incidence of unintentional lumbar facet joint injection was 3.6%. The mean age was 68.47 years. Among these 21 patients, 14 (66.7%) were injected in the facet joint ipsilaterally to the needle approach. Among the 20 patients who received MRI, all (100%) had central stenosis and 15 patients (75%) had severe stenosis. Conclusions: When the operator performs an interlaminar ESI on patients with central spinal stenosis, the contrast pattern on the fluoroscopy during interlaminar ESI should be carefully examined to distinguish between the epidural space and facet joint. (Korean J Pain 2018; 31: 87-92)

Accuracy of Live Fluoroscopy to Detect Intravascular Injection During Lumbar Transforaminal Epidural Injections

Lee, Min-Hye,Yang, Kyung-Seung,Kim, Young-Hoon,Jung, Hyun-Do,Lim, Su-Jin,Moon, Dong-Eon The Korean Pain Society 2010 The Korean Journal of Pain Vol.23 No.1

Background: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. Methods: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. Results: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). Conclusions: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

Epidural hematoma treated by aspiration after transforaminal epidural steroid injection - A case report -

Kim Go Eun,Hong Sung Jun,Kang Sang Soo,Ki Ho Joon,Park Jae Hyun 대한마취통증의학회 2021 Anesthesia and pain medicine Vol.16 No.2

Background: Spinal epidural hematoma is rare condition that can rapidly develop into severe neurologic deficits. The pathophysiology of this development remains unclear. There are several case reports of emergency hematoma evacuations after epidural steroid injection. Case: We report on two patients who developed acute, large amounts of epidural hematoma without neurological deficits after transforaminal epidural steroid injection. After fluoroscopy guided aspiration for epidural hematoma was performed, neurological defects did not progress and the hematoma was shown to be absorbed on magnetic resonance imaging. Conclusions: These reports are believed to be the first of treating epidural hematoma occurring after transforaminal epidural steroid injection through non-surgical hematoma aspiration. If large amounts of epidural hematoma are not causing neurological issues, it can be aspirated until it is absorbed.

Comparison of Clinical Outcomes of Different Rates of Infusion in Caudal Epidural Steroid Injection: A Randomized Controlled Trial

Thiengwittayaporn Satit,Koompong Punsang,Khamrailert Supat,Wetpiriyakul Pumibal 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.2

Study Design: Prospective randomized controlled equivalence trial.Purpose: To compare the clinical outcomes between patients with lumbosacral radiculopathy that received caudal epidural steroid injection (CESI) at injection rates of 40 mL/min (fast rate) and 20 mL/min (slow rate) and to identify the complications associated with these different CESI rates.Overview of Literature: CESI is widely used for chronic low back pain with lumbar radiculopathy. However, the influence of CESI rates on clinical outcomes has not been well studied.Methods: Ninety patients were randomized into two CESI groups. Two patients did not complete the study. Eighty-eight were included in the final analysis: 44 patients were in the fast infusion group, and 44 patients were in the slow infusion group. Intragroup and intergroup comparisons were conducted with regard to the Visual Analog Scale (VAS), Roland 5-point pain scale, standing tolerance test, walking tolerance test, and patient satisfaction scale at pre-injection, 2 weeks, 6 weeks, and 12 weeks post-injection. Complications associated with the different rates were recorded.Results: Both groups demonstrated clinical improvement in all parameters, except for VAS, after injection. There were no statistically significant differences in any outcomes at each time point between the two groups. One patient in the fast rate group and no patients in the slow rate group experienced nausea and vomiting after injection (<i>p</i> =0.320). Eight patents in the fast rate group and two patients in the slow rate group experienced pain at the injection site (<i>p</i> =0.044).Conclusions: Although there were no significant differences between injection rates in the short-term clinical improvement outcomes, the fast injection rate group experienced more pain at the injection site, suggesting that the use of the slow injection rate may be considered.

Effect of needle type on intravascular injection in transforaminal epidural injection: a meta-analysis

Jae Yun Kim,Soo Nyoung Kim,Chulmin Park,Ho Young Lim,Jae Hun Kim 대한통증학회 2019 The Korean Journal of Pain Vol.32 No.1

Background: Lumbosacral transforaminal epidural injection (TFEI) is an effective treatment for spinal disease. However, TFEI may have several types of complications, some of which can be attributed to intravascular injection. We reviewed studies to compare the intravascular injection rate among different needle types. Methods: We searched the literature for articles on the intravascular injection rate among different needle types used in TFEI. The search was performed using PubMed, MEDLINE, the Cochrane Library, EMBASE, and Web of Science. Results: A total of six studies comprising 2359 patients were identified. Compared with the Quincke needle, the Whitacre needle reduced the intravascular injection rate (OR = 0.57, 95% CI = [0.44–0.73], P < 0.001). However, compared with the Quincke needle, the Chiba needle did not reduce the intravascular injection rate (OR = 0.80, 95% CI = [0.44–1.45], P = 0.46). In one study, the intravascular injection rate using a blunt-tip needle was lower than that using a sharp needle. In another study, the Whitacre and the blunt-tip needle have similar intravascular injection rates, while, the catheter-extension needle showed a reduced intravascular injection rate. Conclusions: This meta-analysis showed that the Whitacre needle reduced the intravascular injection rate as compared with the Quincke needle, but failed to establish that the Chiba needle can decrease the intravascular injection rate in TFEI. Moreover, the blunt-tip needle can reduce the intravascular injection rate compared with the Quincke needle, and the catheter-extension needle can reduce the intravascular injection rate compared with the Whitacre and the blunt-tip needle.

Effect of needle type on intravascular injection in transforaminal epidural injection: a meta-analysis

Kim, Jae Yun,Kim, Soo Nyoung,Park, Chulmin,Lim, Ho Young,Kim, Jae Hun The Korean Pain Society 2019 The Korean Journal of Pain Vol.32 No.1

Background: Lumbosacral transforaminal epidural injection (TFEI) is an effective treatment for spinal disease. However, TFEI may have several types of complications, some of which can be attributed to intravascular injection. We reviewed studies to compare the intravascular injection rate among different needle types. Methods: We searched the literature for articles on the intravascular injection rate among different needle types used in TFEI. The search was performed using PubMed, MEDLINE, the Cochrane Library, EMBASE, and Web of Science. Results: A total of six studies comprising 2359 patients were identified. Compared with the Quincke needle, the Whitacre needle reduced the intravascular injection rate (OR = 0.57, 95% CI = [0.44-0.73], P < 0.001). However, compared with the Quincke needle, the Chiba needle did not reduce the intravascular injection rate (OR = 0.80, 95% CI = [0.44-1.45], P = 0.46). In one study, the intravascular injection rate using a blunt-tip needle was lower than that using a sharp needle. In another study, the Whitacre and the blunt-tip needle have similar intravascular injection rates, while, the catheter-extension needle showed a reduced intravascular injection rate. Conclusions: This meta-analysis showed that the Whitacre needle reduced the intravascular injection rate as compared with the Quincke needle, but failed to establish that the Chiba needle can decrease the intravascular injection rate in TFEI. Moreover, the blunt-tip needle can reduce the intravascular injection rate compared with the Quincke needle, and the catheter-extension needle can reduce the intravascular injection rate compared with the Whitacre and the blunt-tip needle.

Original Articles : Analysis of Influencing Factors to Depth of Epidural Space for Lumbar Transforaminal Epidural Block in Korean

( Sung Sick Shin ),( Lee Kyoung Kim ),( Jung Ryul Kim ),( In Ji Kim ),( Bac Ne Kim ),( Gan Tac Hwang ) 대한통증학회 2011 The Korean Journal of Pain Vol.24 No.4

Background: Transforaminal epidural steroid injection is one of the effective treatments in managing radicular pain. There have been some prospective studies on the depth to the epidural space with the transforaminal approach. However, there have been no studies about the depth in Asians, especially Koreans. This study was carried out in order to evaluate the depth to the epidural space and the oblique angle and factors that influence the depth to the epidural space during lumbar transforaminal epidural injection. Methods: A total of 248 patients undergoing fluoroscopically guided transforaminal epidural steroid injections were evaluated. At the L3-4, L4-5, L5-S1, and S1 levels, we measured the oblique angle and depth to the epidural space. Results: Needle depth was positively associated with body mass index (correlation coefficient 0.52, P = 0.004). The median depths (in centimeters) to the epidural space were 6.13 cm, 6.42 cm, and 7.13 cm for 50-60 kg, 60-70 kg, and 70-80 kg groups, respectively, at L5-S1. Age and height were not significantly associated with the needle depth. Conclusions: There is a positive association between the BMI (and weight) and transforaminal epidural depth but not with age, sex, and height.

A Comparison of Two Techniques for Ultrasound-guided Caudal Injection: The Influence of the Depth of the Inserted Needle on Caudal Block

( A Ram Doo ),( Jin Wan Kim ),( Ji Hye Lee ),( Young Jin Han ),( Ji Seon Son ) 대한통증학회 2015 The Korean Journal of Pain Vol.28 No.2

Background: Caudal epidural injections have been commonly performed in patients with low back pain and radiculopathy. Although caudal injection has generally been accepted as a safe procedure, serious complications such as inadvertent intravascular injection and dural puncture can occur. The present prospective study was designed to investigate the influence of the depth of the inserted needle on the success rate of caudal epidural blocks. Methods: A total of 49 adults scheduled to receive caudal epidural injections were randomly divided into 2 groups: Group 1 to receive the caudal injection through a conventional method, i.e., caudal injection after advancement of the needle 1 cm into the sacral canal (n = 25), and Group 2 to receive the injection through a new method, i.e., injection right after penetrating the sacrococcygeal ligament (n = 24). Ultrasound was used to identify the sacral hiatus and to achieve accurate needle placement according to the allocated groups. Contrast dyed fluoroscopy was obtained to evaluate the epidural spread of injected materials and to monitor the possible complications. Results: The success rates of the caudal injections were 68.0% in Group 1 and 95.8% in Group 2 (P = 0.023). The incidences of intravascular injections were 24.0% in Group 1 and 0% in Group 2 (P = 0.022). No intrathecal injection was found in either of the two groups. Conclusions: The new caudal epidural injection technique tested in this study is a reliable alternative, with a higher success rate and lower risk of accidental intravascular injection than the conventional technique. (Korean J Pain 2015; 28: 122-128)

Effect of epidural corticosteroid injection on magnetic resonance imaging findings

( Min Soo Kim ),( Tae Yoon Jeong ),( Yu Seon Cheong ),( Young Wook Jeon ),( So Young Lim ),( Seong Sik Kang ),( In Nam Kim ),( Tsong Bin Chang ),( Hyun Ho Seong ),( Byeong Mun Hwang ) 대한통증학회 2017 The Korean Journal of Pain Vol.30 No.4

Background: Magnetic resonance imaging (MRI) of the spine is the preferred diagnostic tool for pathologic conditions affecting the spine. However, in patients receiving epidural corticosteroid injection (ESI) for treatment of spinal diseases, there is a possibility of misreading of MR images because of air or fluid in the epidural space after the injection. Therefore, we defined the characteristics of abnormal changes in MRI findings following an ESI in patients with low back pain. Methods: We reviewed the medical records of 133 patients who underwent MRI of the lumbar spine within 7 days after ESI between 2006 and 2015.All patients were administered an ESI using a 22-gauge Tuohy needle at the lumbar spine through the interlaminar approach. The epidural space was identified by the loss of resistance technique with air. Results: The incidences of abnormal changes in MRI findings because of ESI were 54%, 31%, and 25% in patients who underwent MRI at approximately 24 h, and 2 and 3 days after ESI, respectively. Abnormal MRI findings included epidural air or fluid, needle tracks, and soft tissue changes. Epidural air, the most frequent abnormal finding (82%), was observed in 41% of patients who underwent MRI within 3 days after injection. Abnormal findings due to an ESI were not observed in MR images acquired 4 days after ESI or later. Conclusions: Pain physicians should consider the possibility of abnormal findings in MR images acquired after epidural injection using the interlaminar approach and the loss of resistance technique with air at the lumbar spine. (Korean J Pain 2017; 30: 281-6)

요통 환자에서 카이로프랙틱 수기치료와 경막외 주사요법의 비교

장재호,김정렬 KOSIN UNIVERSITY COLLEGE OF MEDICINE 2006 高神大學校 醫學部 論文集 Vol.21 No.1

Objectives: To compare the pain patterns after applying chiropractic manipulation and epidural injection in back pain patients, and to investigate the pain-relieving effects of chiropractic manipulation. Materials and Methods: A follow-up observation has been made after applying chiropractic manipulation in 42 patients with back pain admitted through OPD, from March, 2004 to February, 2005. The patients were comprised of 16 cases of intervertebral disk herniation, 7 cases of spinal stenosis, 1 case of ankylosing spondylitis, 18 cases of non-specific chronic back pain. Pain decrement levels were compared to those of another 42 patients who were admited in the some period, treated their back pain by epidural steroid injection, and the effects of chiropractic manipulation and epidural injection were observed. Results of this study was evaluated using Short-Form McGill Pain Questionnaire, Roland-Morris Questionnaire, and RAND-36 Questionnaire. Results: In the Short-Form McGill Pain Questionnaire, the Pain Relating Index in chiropractic manipulation was on average 11.9 before operation and on average 3.1 after operation, while the PRI in epidural injection recorded an average 11.8 before operation and 5.3 after operation. The Visual Analog Scale showed pain decrement from 6.2 to 1.9 in manipulation, and from 6.8 to 3.1 in epidural injection. The present Pain Index decreased from 2.9 to 1.5 in manipulation, and from 2.4 to 1.5 in epidural injection. In the Roland-Morris Questionnaire, which questions the level of limitation in the daily living due to pain, the decrement of level on average from 8.8 to 4.0 in manipulation, while the decrement was from 10.5 to 4.1 in epidural injection. Conclusion: Chiropractic manipulation can be used extensively as a non-invasive method of treatment.