STUDY DESIGN A prospective, observational, human, study was conducted. OBJECTIVES To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced transforaminal cervical epidural steroid injections, and to determine whether the observation of blood in the needle hub can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA Incorrectly placed intravascular cervical spinal injections result in medication flow systemically and not to the desired target. A recently published study demonstrates a high incidence of intravascular injections in transforaminal lumbosacral epidural injections. No studies so far have evaluated the incidence of vascular injections in transforaminal cervical epidural steroid injections, nor have they calculated the ability of observed blood in the needle hub to predict a vascular injection in the cervical spine.METHODS The incidence of fluoroscopically confirmed intravascular uptake of contrast was prospectively observed in 337 patients treated with cervical transforaminal epidural steroid injections. The ability of observed blood in the needle hub to predict intravascular injection was also investigated. For each subject, the injection level was chosen on the basis of the clinical scenario including history, physical examination, and review of imaging studies. Some patients had multilevel injections. Using fluoroscopic guidance, the authors placed a 25-gauge needle into the epidural space using a transforaminal approach according to accepted standard technique. Needle tip location was confirmed with biplanar imaging. The presence or absence of blood in the needle hub spontaneously ("flash") and after attempted aspiration by pulling back on the syringe's plunger was documented. Contrast then was injected under real-time fluoroscopy to determine whether the location of the needle tip was intravascular. The results were recorded in a prospective manner indicating the presence or absence of blood in the needle hub and whether a vascular pattern was noted with contrast injection, and these were correlated. Relevant epidemiologic data also were recorded. RESULTS The study included 504 transforaminal epidural steroid injections. The overall rate of fluoroscopically confirmed intravascular contrast injections was 19.4%. Use of observed blood in the needle hub to predict intravascular injections was 97% specific, but only 45.9% sensitive. There was no significant difference in intravascular rates related to age or gender. CONCLUSIONS As compared with a previous study of lumbosacral epidural steroid injections, there is an overall higher incidence of intravascular injections with cervical transforaminal epidural steroid injections. Use of observed blood in the needle hub to predict an intravascular injection is not sensitive, and therefore the absence of blood in the needle hub despite aspiration is not reliable. The reported sensitivity and specificity rates are similar to lumbar data. Fluoroscopically guided procedures without contrast confirmation i...

There is a high incidence of intravascular injections in transforaminal ESIs that is significantly increased at S1. Using a flash or blood aspiration to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in lumbosacral transforaminal ESIs.

A prospective, observational, human, in vivo study was used to evaluate the incidence of vascular penetration during fluoroscopically guided, contrast‐enhanced, transforaminal lumbar epidural steroid injections (ESIs) and determine whether a “flash” (blood in the needle hub) or aspiration of blood can be used to predict a vascular injection. The incidence of flash or positive blood aspiration and the incidence of fluoroscopically confirmed vascular spread were observed in 670 patients treated with lumbosacral fluoroscopically guided transforaminal ESIs. Presence of a flash or positive aspiration was documented. Contrast was injected to determine whether the needle tip was intravascular. Seven hundred and sixty‐one transforaminal ESIs were included. The overall rate of intravascular injections was 11.2%. There was a statistically significant higher rate of intravascular injections (21.3%) noted with transforaminal ESIs performed at S1 (n = 178), compared with those at the lumbar levels (8.1%, n = 583). Using flash or positive blood aspirate to predict intravascular injections was 97.9% specific, but only 44.7% sensitive. Conclude there is a high incidence of intravascular injections in transforaminal ESIs that is significantly increased S1. Using a flash of blood aspiration to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in lumbosacral transforaminal ESIs. Comment by Gabor B. Racz, M.D. This is a rather sobering prospective evaluation of needle placement while carrying out transforaminal lumbosacral epidural steroid injections. The authors have done 761 transforaminal epidural steroid injections with an intravascular injection rate of 11.2%. The S‐1 transforaminal injection had a 21.3% intravascular injection rate as evidenced by contrast injection. The aspiration was only 44.7% sensitive while using a 22‐gauge spinal needle. The intravascular injections in this study have not produced significant complications. The authors are looking for the illusive and imagined safe triangle while using a technique that clearly cannot achieve such a goal. In order to have a safe technique, it should work for all sites, and the incidence of intravenous injection in the sacral nerve root area is indicating less of an understanding as to the delivery of medication by the higher intravascular injection rate. Furthermore, the safe triangle of the L‐5 nerve root area can be dramatically altered by degenerative arthritis, bulging disc, rotational scoliosis, etc. Clearly, we have a serious technical problem with the way transforaminal injections are carried out as descried by the authors. The use of the 22‐guage spinal needle has not been designed for injections in hazardous areas su...