Presented at the 2013 AAPM Annual Meeting « Back

Digital Subtraction Angiography Does Not Reliably Prevent Paraplegia Associated with Lumbar Transforaminal Epidural Steroid Injection

George C. Chang Chien, DO, gchangchien@ric.org¹, Kenneth D. Candido, MD², Nebojsa Nick Knezevic, MD PhD³, (1) Rehabilitation Institute of Chicago, Chicago, Illinois, (2) Advocate Illinois Masonic Medical Center, Chicago, Illinois, (3) University of Illinois, Chicago, Chicago, Illinois

Introduction: Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to minimize complications during interventional neuraxial procedures where it is imperative to identify vascular compromise. Objective: We present a case of instantaneous paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA was used as adjuncts to fluoroscopy. Results: An 80 year-old male with chronic L5 radiculopathic pain was evaluated at a University Pain Management Center. Two previous lumbar interlaminar epidural steroid injections provided transient pain relief, and decision was made to perform right-sided L5-S1 TFESI with a 5 inch, 22-gauge Quincke type spinal needle with a curved tip. Foraminal placement of the needle tip was confirmed with tri-planar views on fluoroscopy. Aspiration was negative for blood or cerebrospinal fluid. Digital subtraction angiography was performed twice, with absence of intravascular contrast spread. Subsequently, a 0.5 mL of 1% lidocaine test dose was performed without any changes in neurological status. Next, 1 mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately the patient reported extreme bilateral lower extremity pain, marked weakness in bilateral lower extremities. He was transferred to the Emergency Department for evaluation and admitted to the neuro-critical care unit. T2W and STIR MRI showed hyperintense signal consistent with spinal cord infarction from T6 to T10 level. Conclusions: DSA use is clearly not foolproof and even in well-trained hands, may not be sufficient to identify potentially dire consequences during lumbar TFESI. References: 1) Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician 2003;6:369-372. 2) Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid two case reports. Pain Med 2009;10:1389-1394. 3) Smuck M, Maxwell MD, Kennedy D, Rittenberg JD, Lansberg MG, Plastaras CT. Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections.Spine J 2010;10:857-864. 4) Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J 2002;2:70-75. 5) McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PMR 2009;1:636-642. 6) Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology 2004;100:1595-1600. 7) Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil 2000;81:1045-1050.

Funding: None

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