Koehler Philip J, Kitei Paul M, Stolzenberg David S, Hatch Elaine H
Department of Physical Medicine and Rehabilitation, Rothman Orthopaedic Institute, Philadelphia, PA, USA.
Department of Rehabilitation, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
Interv Pain Med. 2024 Dec 2;3(4):100523. doi: 10.1016/j.inpm.2024.100523. eCollection 2024 Dec.
A 78-year-old female with a remote history of L3-4 decompression and fusion presented with several months of low back and radicular leg pain. MRI revealed moderate L2-L3 spinal canal stenosis, ligamentum flavum infolding, moderate bilateral foraminal stenosis, and a grade I retrolisthesis. A right sided L2-L3 TFESI was performed using multiplanar fluoroscopic imaging with a subpedicular supraneural approach. During live iodinated contrast injection, imaging revealed concomitant epidural and central arterial contrast spread. The needle was retracted and repeat live fluoroscopic imaging demonstrated no vascular uptake. Desired epidural and nerve root contrast spread remained in place with repeat still imaging. Dexamethasone and lidocaine were then injected. The patient suffered no adverse events. This case demonstrates that during a lumbar TFESI, it is possible to have an inadvertent arterial injection with desired epidural contrast spread, despite appropriate needle placement. It emphasizes the importance of necessary precautions, including real-time live fluoroscopy, in order to detect arterial uptake before the delivery of injectate. Without live fluoroscopy, optimal epidural flow at the targeted level can distract interventionalists from the fleeting vascular flow multiple vertebral levels away and risks continuation of the procedure with delivery of injectate.
一名78岁女性，有L3 - 4减压融合病史，出现数月的下背部和腿部放射性疼痛。MRI显示L2 - L3中度椎管狭窄、黄韧带折叠、双侧中度椎间孔狭窄以及I度椎体滑脱。采用多平面荧光透视成像和椎弓根下神经上入路进行了右侧L2 - L3经椎间孔硬膜外类固醇注射（TFESI）。在注射碘化造影剂时，成像显示同时有硬膜外和中央动脉造影剂扩散。将针撤回，重复实时荧光透视成像显示无血管摄取。重复静态成像时，所需的硬膜外和神经根造影剂扩散仍在原位。然后注射了地塞米松和利多卡因。患者未出现不良事件。该病例表明，在腰椎TFESI过程中，尽管针放置正确，但仍可能意外发生动脉注射并伴有所需的硬膜外造影剂扩散。它强调了必要预防措施的重要性，包括实时荧光透视，以便在注射药物前检测到动脉摄取。如果没有实时荧光透视，目标水平的最佳硬膜外血流可能会使介入医生忽略多个椎体水平外短暂的血管血流，并且存在在注射药物时继续进行手术的风险。
