Comparison between digital subtraction angiography and real-time fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections

Background and Objective: Infrequent but serious complications of transforaminal epidural steroid injection (TFESI) are thought to be due to inadvertent intravascular injection (embolization of corticosteroid particulates via the vertebral or thoracolumbar radiculomedullary arteries). Recent studies suggest that real-time fluoroscopy often fails to detect intravascular injection and that digital subtraction angiography (DSA) may help reduce the incidence of accidental vascular injection. The goal of this prospective study was to evaluate the sensitivity of real-time fluoroscopy versus DSA in detecting intravascular injection during TFESI. METHODS: From September 2012 to July 2013, 239 consecutive patients were enrolled and received 249 fluoroscopically guided TFESI using the classic technique by one physician. We collected data of patient demographics, reason for TFESI, occurrence of accidental intravascular injection based on real-time fluoroscopic images and DSA, and spinal levels at which TFESI was performed. Intravascular spread was assessed initially using real-time fluoroscopy and subsequently with DSA. RESULTS: The overall incidence of intravascular injection was 12.4% (31/249). Real-time fluoroscopy failed to detect 9 cases of intravascular injections that were subsequently detected by DSA (real-time fluoroscopy sensitivity, 71.0%). CONCLUSIONS: Digital subtraction angiography is superior to real-time fluoroscopy for detecting intravascular injections.