To the Editor

To the Editor Dear Editor, Cervical transforaminal epidural steroid injections can be an effective treatment for radicular pain [1–3]. Rare complications include spinal cord injury from direct needle trauma, spinal cord infarction, stroke, and nerve damage [2,4,5]. The use of contrast dye, live fluoroscopy, digital subtraction angiography, and a test dose of lidocaine prior to injection of the steroid can help to reduce the potential for these complications [6]. The typical contrast agents utilized for injection are nonionic iodinated preparations. In cases where severe anaphylaxis secondary to iodinated agents are known, a preprocedure preparation including an antihistamine, steroid, and possibly an H2 blocker can be considered, but evidence of the efficacy of this is minimal. Case reports also describe using gadolinium as an alternative agent as it is non–iodine containing [7–9]. The following images show a right C7 transforaminal epidural steroid injection using gadolinium and digital subtraction angiography in a patient referred for persistent radicular symptoms secondary to a right-sided disc protrusion at C6-7 a year after a C4-5 and C5-6 anterior cervical discectomy and fusion. The patient was sent as a direct referral from an orthopedic spine surgeon to an interventional physiatrist (JIS) for a right C6-7 transforaminal epidural steroid injection but did not receive the standard preparation for iodinated material allergy. It was decided to try the injection with gadopentetate dimeglumine contrast and, if the visualization was poor, administer intravenous antihistamine and steroids for prophylaxes and utilize an iodine-containing preparation. The injection was performed with cardiac and respiratory monitoring by an anesthesiologist present throughout the case. The patient was prepped and draped in a sterile fashion in the supine position after obtaining verbal and written consent. The C-arm was positioned so that an oblique view of the C6-7 foramen was identified. The soft tissues overlying this structure were infiltrated with 1 cc of 1% lidocaine without epinephrine. A 25-gauge spinal needle was inserted down to the posterior aspect of the intervertebral foramen, and os was contacted at the superior articular process of C7. Under PA visualization, the needle was advanced, so it did not go beyond the middle of the articular pillar. After negative aspirate for blood or CSF, a 1 cc volume of gadopentetate dimeglumine (Magnevist Bayer lot #52570G, containing 469.01 mg gadopentetate dimeglumine, 0.99 mg meglumine, 0.40 mg diethylenetriamine pentaacetic acid per 1 cc in saline) was injected and flow of contrast was noted along the peripheral nerve root sheath. Digital subtraction was utilized to confirm the absence of vascular uptake and epidural flow. Then, 1 cc of 1% lidocaine without epinephrine was utilized for a test dose. After waiting two minutes, no adverse reaction was noted. The injectate of 1.5 cc of 10 mg/cc dexamethone and 1.5 cc of 1% lidocaine without epinephrine was administered transforaminally. The images were clear using the gadopentetate dimeglumine and are pictured below. Figure 1 shows the posterior-anterior digital subtraction image, clearly highlighting the C7 spinal nerve without vascular uptake. Figure 2 shows the posterior-anterior fluoroscopy image, clearly highlighting the C7 spinal nerve. Figure 1 View largeDownload slide The posterior-anterior digital subtraction image clearly highlighting the C7 spinal nerve without vascular uptake. Figure 1 View largeDownload slide The posterior-anterior digital subtraction image clearly highlighting the C7 spinal nerve without vascular uptake. Figure 2 View largeDownload slide The posterior-anterior fluoroscopy image clearly highlighting the C7 spinal nerve. Figure 2 View largeDownload slide The posterior-anterior fluoroscopy image clearly highlighting the C7 spinal nerve. This commentary illustrates that, in cases where severe allergy to iodinated contrast medium is known, gadolinium and digital subtraction angiography for a cervical transforaminal epidural steroid injection may be considered as an alternative. References 1 Costandi SJ, Azer G, Eshraghi Y, et al.   Cervical transforaminal epidural steroid injections: Diagnostic and therapeutic value. Reg Anesth Pain Med  2015; 40: 674– 80. Google Scholar CrossRef Search ADS PubMed  2 Engel A, King W, MacVicar J; Standards Division of the International Spine Intervention S. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: A systematic review with comprehensive analysis of the published data. Pain Med  2014; 15: 386– 402. Google Scholar CrossRef Search ADS PubMed  3 Abdi S, Datta S, Trescot AM, et al.   Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician  2007; 10: 185– 212. Google Scholar PubMed  4 Moon J, Kwon HM. Spinal cord infarction after cervical transforaminal epidural steroid injection: Case report and literature review. Case Rep Neurol  2017; 9: 1– 5. Google Scholar CrossRef Search ADS PubMed  5 Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep  2015; 19: 482. Google Scholar CrossRef Search ADS PubMed  6 Bogduk N. Practice Guidelines for Spinal Diagnositic and Treatement Procedures , 2nd edition. Spine Intervention Society; 2014. 7 Falco FJ, Rubbani M. Visualization of spinal injection procedures using gadolinium contrast. Spine (Phila Pa 1976)  2003; 28: E496– 8. Google Scholar CrossRef Search ADS PubMed  8 Shetty SK, Nelson EN, Lawrimore TM, Palmer WE. Use of gadolinium chelate to confirm epidural needle placement in patients with an iodinated contrast reaction. Skeletal Radiol  2007; 36: 301– 7. Google Scholar CrossRef Search ADS PubMed  9 Safriel Y, Ali M, Hayt M, Ang R. Gadolinium use in spine procedures for patients with allergy to iodinated contrast—experience of 127 procedures. AJNR Am J Neuroradiol  2006; 27: 1194– 7. Google Scholar PubMed  © 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Pain Medicine Oxford University Press

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Publisher
Blackwell Publishing Inc.
Copyright
© 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
1526-2375
eISSN
1526-4637
D.O.I.
10.1093/pm/pnx150
Publisher site
See Article on Publisher Site

Abstract

Dear Editor, Cervical transforaminal epidural steroid injections can be an effective treatment for radicular pain [1–3]. Rare complications include spinal cord injury from direct needle trauma, spinal cord infarction, stroke, and nerve damage [2,4,5]. The use of contrast dye, live fluoroscopy, digital subtraction angiography, and a test dose of lidocaine prior to injection of the steroid can help to reduce the potential for these complications [6]. The typical contrast agents utilized for injection are nonionic iodinated preparations. In cases where severe anaphylaxis secondary to iodinated agents are known, a preprocedure preparation including an antihistamine, steroid, and possibly an H2 blocker can be considered, but evidence of the efficacy of this is minimal. Case reports also describe using gadolinium as an alternative agent as it is non–iodine containing [7–9]. The following images show a right C7 transforaminal epidural steroid injection using gadolinium and digital subtraction angiography in a patient referred for persistent radicular symptoms secondary to a right-sided disc protrusion at C6-7 a year after a C4-5 and C5-6 anterior cervical discectomy and fusion. The patient was sent as a direct referral from an orthopedic spine surgeon to an interventional physiatrist (JIS) for a right C6-7 transforaminal epidural steroid injection but did not receive the standard preparation for iodinated material allergy. It was decided to try the injection with gadopentetate dimeglumine contrast and, if the visualization was poor, administer intravenous antihistamine and steroids for prophylaxes and utilize an iodine-containing preparation. The injection was performed with cardiac and respiratory monitoring by an anesthesiologist present throughout the case. The patient was prepped and draped in a sterile fashion in the supine position after obtaining verbal and written consent. The C-arm was positioned so that an oblique view of the C6-7 foramen was identified. The soft tissues overlying this structure were infiltrated with 1 cc of 1% lidocaine without epinephrine. A 25-gauge spinal needle was inserted down to the posterior aspect of the intervertebral foramen, and os was contacted at the superior articular process of C7. Under PA visualization, the needle was advanced, so it did not go beyond the middle of the articular pillar. After negative aspirate for blood or CSF, a 1 cc volume of gadopentetate dimeglumine (Magnevist Bayer lot #52570G, containing 469.01 mg gadopentetate dimeglumine, 0.99 mg meglumine, 0.40 mg diethylenetriamine pentaacetic acid per 1 cc in saline) was injected and flow of contrast was noted along the peripheral nerve root sheath. Digital subtraction was utilized to confirm the absence of vascular uptake and epidural flow. Then, 1 cc of 1% lidocaine without epinephrine was utilized for a test dose. After waiting two minutes, no adverse reaction was noted. The injectate of 1.5 cc of 10 mg/cc dexamethone and 1.5 cc of 1% lidocaine without epinephrine was administered transforaminally. The images were clear using the gadopentetate dimeglumine and are pictured below. Figure 1 shows the posterior-anterior digital subtraction image, clearly highlighting the C7 spinal nerve without vascular uptake. Figure 2 shows the posterior-anterior fluoroscopy image, clearly highlighting the C7 spinal nerve. Figure 1 View largeDownload slide The posterior-anterior digital subtraction image clearly highlighting the C7 spinal nerve without vascular uptake. Figure 1 View largeDownload slide The posterior-anterior digital subtraction image clearly highlighting the C7 spinal nerve without vascular uptake. Figure 2 View largeDownload slide The posterior-anterior fluoroscopy image clearly highlighting the C7 spinal nerve. Figure 2 View largeDownload slide The posterior-anterior fluoroscopy image clearly highlighting the C7 spinal nerve. This commentary illustrates that, in cases where severe allergy to iodinated contrast medium is known, gadolinium and digital subtraction angiography for a cervical transforaminal epidural steroid injection may be considered as an alternative. References 1 Costandi SJ, Azer G, Eshraghi Y, et al.   Cervical transforaminal epidural steroid injections: Diagnostic and therapeutic value. Reg Anesth Pain Med  2015; 40: 674– 80. Google Scholar CrossRef Search ADS PubMed  2 Engel A, King W, MacVicar J; Standards Division of the International Spine Intervention S. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: A systematic review with comprehensive analysis of the published data. Pain Med  2014; 15: 386– 402. Google Scholar CrossRef Search ADS PubMed  3 Abdi S, Datta S, Trescot AM, et al.   Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician  2007; 10: 185– 212. Google Scholar PubMed  4 Moon J, Kwon HM. Spinal cord infarction after cervical transforaminal epidural steroid injection: Case report and literature review. Case Rep Neurol  2017; 9: 1– 5. Google Scholar CrossRef Search ADS PubMed  5 Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep  2015; 19: 482. Google Scholar CrossRef Search ADS PubMed  6 Bogduk N. Practice Guidelines for Spinal Diagnositic and Treatement Procedures , 2nd edition. Spine Intervention Society; 2014. 7 Falco FJ, Rubbani M. Visualization of spinal injection procedures using gadolinium contrast. Spine (Phila Pa 1976)  2003; 28: E496– 8. Google Scholar CrossRef Search ADS PubMed  8 Shetty SK, Nelson EN, Lawrimore TM, Palmer WE. Use of gadolinium chelate to confirm epidural needle placement in patients with an iodinated contrast reaction. Skeletal Radiol  2007; 36: 301– 7. Google Scholar CrossRef Search ADS PubMed  9 Safriel Y, Ali M, Hayt M, Ang R. Gadolinium use in spine procedures for patients with allergy to iodinated contrast—experience of 127 procedures. AJNR Am J Neuroradiol  2006; 27: 1194– 7. Google Scholar PubMed  © 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Journal

Pain MedicineOxford University Press

Published: Feb 1, 2018

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