How safe are cervical transforaminal epidural steroid injections (ESIs)?

Updated: Aug 06, 2018
  • Author: Boqing Chen, MD, PhD; Chief Editor: Stephen Kishner, MD, MHA  more...
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An anatomic study of 95 cervical intervertebral neuroforamina in 10 embalmed cadavers was conducted. Twenty-one arterial branches were found in the posterior aspect of neuroforamina. Seven of them were potential radicular or segmental medullary vessels to the spinal cord. There were variable anastomoses between vertebral arteries and cervical arteries. The study demonstrated that the critical arteries are found in the posterior aspect of the intervertebral neuroforamina and that they may be vulnerable to injection or injury during transforaminal ESI. [22]

Therefore, aside from the use of live-time fluoroscopy with contrast injection during the cervical transforaminal ESIs to visualize and avoid intravascular injections, the use of smaller-particulate corticosteroid preparations was also recommended to further reduce the risk of central nervous system infarct.

Digital subtraction angiography (DSA) has demonstrated the ability to be able to pick up more venous flow and nonvisible arterial flow during cervical transforaminal ESIs. [23] Therefore, applying DSA during the cervical transforaminal ESIs is recommended to increase safety.

Using smaller-particulate corticosteroid such as dexamethasone may reduce the probability of vascular embolism in case of inadvertent intraarterial needle placement during ESIs. A randomized study comparing the effectiveness of dexamethasone and triamcinolone used in cervical transforaminal epidural injection found that at 4 weeks postinjection, both groups exhibited statistically and clinically significant improvement. Although the dexamethasone was slight less effective than triamcinolone, the difference was neither statistically nor clinically significant. [24] To date, the authors are unaware of any published literature pertaining to central nervous infarcts secondary to the dexamethasone used in the ESIs.

It is advocated injecting a test dose of local anesthetic (nonparticulate medication) after the needle is placed and the correct position is verified with contrast and then waiting for up to 2 minutes to ensure that the patient does not experience adverse central nervous system effects. These adverse effects, including seizures, transient paresis, and respiratory depression, are generally thought to be reversible and an additional indicator of possible vascular uptake.

Additionally, avoidance of heavy sedation during procedures has been recommended to decrease adverse effects.

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