What is the role of fluoroscopy and contrast in the administration of epidural steroid injections (ESIs)?

Updated: Aug 06, 2018
  • Author: Boqing Chen, MD, PhD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Reports suggest that injection without fluoroscopic guidance (ie, blind injection) results in 30-40% of needle misplacements, such as needle tip placement outside the epidural space (including intravascular injection) and placement not at the presumed level of pathologic process. Therefore, it is recommended that ESIs be performed under fluoroscopic guidance and with radiographic contrast documenting appropriate placement in order to improve the safety, accuracy, and potential efficacy of ESIs.

Fluoroscopy in conjunction with contrast is used to improve efficacy and minimize potential complications. Furman and coauthors discovered that for lumbar spine ESIs, using flash or positive blood aspirate to predict intravascular injections was 97.9% specific but only 44.7% sensitive. [20] This suggests that negative aspiration of blood does not ensure a lack of vascular uptake. Similarly, in the cervical spine, vascular uptake injections occurred at a rate of nearly 20% with the use of fluoroscopy (confirmed by contrast injection), via a transforaminal approach. Again, a visible flash of blood in the needle hub or positive aspiration of blood demonstrated similar specificity and sensitivity to the lumbar injection study.

In a prospective study involving 191 patients who underwent single-level lumbar transforaminal epidural injection, simultaneous epidural and vascular injection was found to be 8.9%. Therefore, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections. [21]

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