- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
DOI:10.4103/2152-7806.120784Copyright: © 2013 Ilkhchoui Y. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Ilkhchoui Y, Koshkin E. A blunt needle (Epimed®) does not eliminate the risk of vascular penetration during transforaminal epidural injection. Surg Neurol Int 29-Oct-2013;4:
How to cite this URL: Ilkhchoui Y, Koshkin E. A blunt needle (Epimed®) does not eliminate the risk of vascular penetration during transforaminal epidural injection. Surg Neurol Int 29-Oct-2013;4:. Available from: http://sni.wpengine.com/surgicalint_articles/a-blunt-needle-epimed-does-not-eliminate-the-risk-of-vascular-penetration-during-transforaminal-epidural-injection/
Background:Transforaminal epidural injection of local anesthetics and corticosteroids is a common practice in patients with radicular pain. However, serious morbidity has also been reported, which can be attributed to an arterial or venous injection of the medication especially particulate glucocorticoid preparations. Using a blunt needle in contrast to sharp needle has been suggested to reduce this risk in a study on animals.
Case Description:We present a 59-year-old female with L5 lumbar radicular symptoms and left L5-S1 foraminal narrowing who underwent transforaminal epidural injection with fluoroscopic guidance using a 22-gauge blunt curved needle (Epimed®, Johnstown, NY). Intravascular needle placement was detected during real-time contrast injection under live fluoroscopy after a negative aspiration and local anesthetic test dose. The needle was slightly withdrawn and correct distribution of the contrast was confirmed along the target nerve root and into the epidural space.
Conclusion:This case report discusses vascular penetration utilizing an Epimed® blunt needle to perform transforaminal injections in a clinical setting. This topic was previously discussed in earlier animal studies. We also reemphasize that neither negative aspiration or local anesthetic test doses are reliable techniques to ensure the safety of transforaminal epidural injections.
Keywords: Blunt needle, fluoroscopy, intravascular penetration, radicular pain, transforaminal epidural injection
Transforaminal epidural injection of anesthetics and corticosteroids is a common practice in patients with radicular pain and generally considered to be safe with a complication rate of 9.6% in the lumbar spine.[
The incidence of inadvertent vascular injection ranges from 9% to 26% in fluoroscopically guided transforaminal epidural injections depending upon the level of injection.[
A 59-year-old female presented with chronic lumbar radiculopathy attributed to L5-S1 foraminal stenosis documented by magnetic resonance imaging (MRI) [
The number of epidural injections performed in the United States has increased dramatically during the past decade. These injections are generally considered to be safe with a reported incidence of minor complications in the lumbar spine of up to 9.6%.[
However, inadvertent intravascular needle placement within the epidural space occurs commonly in cervical and lumbar transforaminal epidural injections (range 9-26%), with the incidence depending on the TFESI site.[
Several methods have been proposed in order to avoid intravascular injections; using a short bevel or blunt vs. sharp needle, aspiration with a syringe, utilizing an anesthetic test dose, and employing real-time fluoroscopy or digital subtraction angiography during contrast injection. Animal studies have demonstrated that blunt needles are less likely than sharp needles to enter blood vessels.[
This report focuses on the utilization of an Epimed® blunt tip needle to perform a TFESI in a single patient. Our case emphasizes that live fluoroscopy is critical for observing dynamic contrast flow while performing TFESIs, and is still a reasonable adjunct to detect intravascular injections even with newer blunt needles. Future randomized controlled clinical trials are needed to further study the safety/efficacy of such blunt tip needles for performing TFESI in the lumbar spine.
1. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: A possible mechanism for spinal cord injury. Pain. 2003. 103: 211-5
2. Bogduk N, Sharp VS. Blunt needles. International Spine Intervention Society White Paper. Interventional Spine. 2005. 5: 7-13
3. Botwin K, 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: 1045-50
4. Furman MB, Giovanniello MT, O’Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine. 2003. 28: 21-5
5. Heavner JE, Racz GB, Jenigiri B, Lehman T, Day MR. Sharp versus blunt needle: A comparative study of penetration of internal structures and bleeding in dogs. Pain Pract. 2003. 3: 226-31
6. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: Report of three cases. Spine J. 2002. 2: 70-5
7. Smuck M, Yu AJ, Tang CT, Zemper E. Influence of needle type on the incidence of intravascular injection during transforaminal epidural injections: A comparison of short-bevel and long-bevel needles. Spine J. 2010. 10: 367-71
8. Smuck M, Fuller BJ, Yoder B, Huerta J. Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections. Spine J. 2007. 7: 79-82
9. Somayaji HS, Saifuddin A, Casey AT, Briggs TW. Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection. Spine. 2005. 30: 106-8
10. Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P. Incidence of intravascular uptake in lumbar spinal injection procedures. Spine. 2000. 25: 481-6