Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, Korea.
Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
Pain Physician. 2018 Mar;21(2):E181-E186.
Transforaminal epidural injection (TFEI) with local anesthetics and steroids are effective in treating spinal radicular pain. However, inadvertent intravascular injection can lead to severe neurologic complications. To reduce complications of intravascular injection, use of imaging modality, such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA), has been recommended. DSA is an imaging technique that can clearly visualize the blood vessels from surrounding bones or dense soft tissues by subtracting the pre-contrast image from the image after injecting contrast medium.
In this study, we investigated whether there is a difference between RTF and DSA in the detection of intravascular injection during cervical TFEI.
Clinical study.
Pain clinic in South Korea.
We prospectively examined 137 cervical TFEIs on 128 patients who have a radiating pain from spinal stenosis and herniated nucleus pulposus. The needle position was confirmed using biplanar fluoroscopy and 2 mL of nonionic contrast medium was injected at the rate of 0.5 mL/sec under RTF. Thirty seconds later, 2 mL of nonionic contrast medium was injected at the rate of 0.5 mL/sec under DSA. Intravascular injection was defined as contrast medium spreading throughout the vascular channel during injection of contrast medium under RTF and DSA. This study is registered in the ClinicalTrials.gov (NCT03040648).
The detection rate of intravascular injection in RTF was not statistically different compared to that in DSA (30.7 % vs. 34.3%, P > 0.05).
We injected 2 mL of contrast medium at the rate of 0.5 mL/sec. Further studies about the ideal injection speed and volume of contrast medium for improvement of detection of intravascular injection during TFEI are needed. This study was a single center study. Therefore, multi-center studies are needed to obtain the high level of evidence. Additionally, the procedural pain physician was not blinded to the type of imaging modality, such as RTF and DSA, to detect intravascular injection. To minimize this confirmation bias and provide homogenous procedural conditions for TFEI, the same procedural physician performed all 137 injections.
In this study, there is no significant difference in detection rate of intravascular injection between RTF and DSA during cervical TFEI.
Analgesia, bleeding, clinical trials, complications, diagnostic equipment, epidural, radiculopathy, spine.
经椎间孔硬膜外注射（TFEI）联合局麻药和皮质类固醇治疗神经根性颈椎病疼痛效果显著。但如果操作不慎，可能会导致严重的神经并发症。为了减少血管内注射的并发症，建议使用影像学方法，如实时透视（RTF）或数字减影血管造影（DSA）。DSA 是一种通过减去注射对比剂前后的图像，从而从周围骨骼或致密软组织中清晰地显示血管的成像技术。
本研究旨在比较 RTF 和 DSA 在颈椎 TFEI 中检测血管内注射的差异。
临床研究。
韩国疼痛诊所。
我们前瞻性地检查了 128 例患有椎管狭窄和椎间盘突出症引起的放射性疼痛的患者的 137 例颈椎 TFEI。采用双平面透视确认针尖位置，在 RTF 下以 0.5mL/sec 的速度注射 2mL 非离子型对比剂。30 秒后，在 DSA 下以 0.5mL/sec 的速度注射 2mL 非离子型对比剂。在 RTF 和 DSA 下注射对比剂时，如果对比剂在血管内扩散，则定义为血管内注射。本研究已在 ClinicalTrials.gov（NCT03040648）注册。
RTF 与 DSA 检测血管内注射的检出率无统计学差异（30.7% vs. 34.3%，P＞0.05）。
我们以 0.5mL/sec 的速度注射 2mL 对比剂。需要进一步研究在 TFEI 中提高血管内注射检出率的理想对比剂注射速度和剂量。本研究为单中心研究。因此，需要多中心研究来获得更高水平的证据。此外，进行程序的疼痛医师无法对 RTF 和 DSA 等检测血管内注射的影像学方法进行盲法。为了尽量减少这种确认偏倚，并为 TFEI 提供同质的程序条件，同一位程序医师进行了所有 137 次注射。
本研究中，颈椎 TFEI 中 RTF 和 DSA 检测血管内注射的检出率无显著差异。
镇痛，出血，临床试验，并发症，诊断设备，硬膜外，神经根病，脊柱。
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