Affiliation:
1. Tri-State Spine Care Institute, Cincinnati, OH
Abstract
Background: Transforaminal technique for epidural steroid injections, unlike other
approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis.
Objective: To review the literature and analyze the reported cases of paralysis from lumbar
transforaminal epidural steroid injections to possibly establish a cause and to prevent this
complication.
Study Design: Eighteen cases of paralysis from transforaminal epidural injection have been
reported. We could analyze the position of the needle within the neural foramen based on the
available images and/or description among 10 of these 18 cases. Five cases were performed
with computed tomography guidance and 12 cases were performed with fluoroscopic guidance
[unknown in one case]. Additionally, other variables associated with the procedure, including
the technique, were also examined.
Methods: Analysis of the needle position in the neural foramen in cases of paralysis from
transforaminal epidural steroid injections. This analysis is based on images and/or description
provided in published reports.
Results: Paralysis in these cases seems to be associated with a well performed traditional safe
triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the
time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was
in the anterior part of the foramen. This coincides with the location of the radicular artery in the
foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone).
No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events
happened during a left-sided procedure and 8 during a right-sided procedure. No relation to
this complication was noted when other variables like type and size of the needles, side of the
injection, local anesthetic, contrast, or volume of injectate were taken into consideration.
Limitations: Only 18 cases of paralysis from transforaminal epidurals have been reported.
Out of these, only 10 cases included images or descriptions which could be evaluated for our
study.
Conclusion: In light of the anatomical and radiological evidence in the literature that radicular
arteries dwell in the superior part of the foramen and along with our needle position analysis,
we suggest that the traditional technique of placing the needle in the superior and anterior part
of the foramen must be reexamined. Alternative, safer techniques must be considered, one of
which is described.
Key words: Lumbar epidural injection, lumbar transforaminal, approach, selective nerve root
block, paralysis, steroid, particulate, nonparticulate, safe triangle, radicular artery, artery of
Adamkiewicz
Publisher
American Society of Interventional Pain Physicians
Subject
Anesthesiology and Pain Medicine
Cited by
11 articles.
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