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Anesthesia & Critical Care: Open Access

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Received: January 01, 1970 | Published: ,

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Abstract

Ultrasound has gained recognition within the field of pain intervention owing to its definite advantage of visually localizing the specified target and additionally owing to perceived advantages of safety, accuracy, and potency. Ultrasound permits satisfactory imaging of the posterior parts of the spine and paraspinal soft tissues. Despite the introduction of newer and less consuming time’s methods with the possibility of intravascular injection, there is still insufficient clinical evidence to prove the safety of the ultrasound as a sole image guide intervention, especially for transforaminal injection. It is essential to considering safety tips and be aware of complications that are typically terribly unpleasant and cause unwanted social and legal consequence. The most important injection warnings are damage to the spinal cord and nerve roots, intravascular injection and vascular damage, loss of consciousness, paraplegia and incontinence. The object of this review article is to discuss the untoward dangerous complication which can happen after ultrasound-guided spine injections and explain how to diagnosis and manage them. Further technical and equipment advancements are needed to improve and reduce the existing limitations associated with the ultrasound-guided spine injection technique until that time the multimodality imaging guidance is safer.

Keywords: spine, injection, ultrasound, pain management

Abbreviations

US, ultrasound; FBSS, fail back surgery syndrome; LAST, local anesthetic systemic toxicity; C, cervical; T, thoracic; L, lumbar; S, sacral; CSF, cerebrospinal fluid; DRG, dorsal root ganglion; AP, anteroposterior; ASA, anterior spinal artery syndrome; PDPH, post dural puncture headache; SAP, superior articular process; IVF, intervertebral foramen; ESI, epidural steroid injection

Introduction

Ultrasound (US) has gained recognition within the field of pain intervention owing to its definite advantage of visually localizing the specified target and additionally owing to perceived advantages of safety, accuracy, and potency. Ultrasound permits satisfactory imaging of the posterior parts of the spine and paraspinal soft tissues. There are many advantages of ultrasound-guided spine intervention and the most important one is lack of radiation exposure (Table 1). Ultrasound is an excellent tool in “visualizing” and hence “avoiding” vascular injury especially during cervical spine procedures.1 Studies on ultrasound-guided spine injection and CT scan confirmation of the needle tip showed feasibility and validity of ultrasound in spine injections.2–6 Despite the introduction of newer and less consuming times methods7 with the possibility of intravascular injection, there is still insufficient clinical evidence to prove the safety of the ultrasound as a sole image guide intervention, especially for transforaminal injection.4,8–10 The ultrasound-guided scanning will not show intravascular injection (the first injection of the test dose just will show no distribution of drug around the goal).

Advantages of ultrasound guided spine injection

 No xrays hazard

 Presentation of vessels and tissues

 Visualize the pleural and lung movements

 Portable ability

 Easily maneuver of ultrasound probe to give different axial and longitudinal view

 Applicable and practical in the outpatient clinical setting

 No limitation in difficult position

 More practical in difficult surface anatomic landmarks

 Get view of anatomical differences

 Increase first pass needle success rate

Table 1 Advantages of ultrasound guided spine injection

Ultrasound-guided spine injection has limitations and interventionist must be cautious and responsive to these limitations (Table 2). They should consider safety tips and be aware of complications that are typically terribly unpleasant and cause unwanted social and legal consequence. The most important injection warnings are damage to the spinal cord and nerve roots, intravascular injection and vascular damage, loss of consciousness, paraplegia and incontinence.11 The object of this review article is to report possibility of untoward dangerous complication with ultrasound-guided spine injections and provide prompt and timely diagnosis to prevent irreversible damage.

Possible limitations for the ultrasound guided spine injections

 The inability to correctly visualize the target in obese individuals

 The inability to accurately detect intravascular injection in such deep injections

 A longer procedure time for novice

 The potential need for larger gauge needles to improve visualization.

 Image quality in the elderly patient population

 Inaccuracy of skin marking especially in FBSS

 The learning curve for ultrasound imaging of the spine

 The inability to correctly visualize the target in obese individuals and FBSS

 The inability to accurately detect intravascular injection in such deep injections

 A longer procedure time for novice

 The potential need for larger gauge needles to improve visualization.

 Image quality in the elderly patient population

 Inaccuracy of skin marking

 The learning curve for ultrasound imaging of the spine(sacrum)

Table 2 Possible limitations for the ultrasound guided spine injections

Discussion

The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column. The brain and spinal cord together make up the central nervous system. The spinal cord is the main pathway for information connecting the brain and peripheral nervous system. Spinal injections are delicate and dangerous. Spine injection has many complications (Table 3).12 There are also complications due to the incorrect injection in the non-epidural space which is especially warning after ultrasound-guided spine injection. Knowledge about such complications, time of presentation, signs and symptoms and supporting control is mandatory before starting every spine injection (Table 4).

Complication of spine injection

Post procedural pain

Anterior spinal artery syndrome(ASA)

Embolism lead to paraplegia or quadriplegia, nystagmous, confusion and coma

Directed injury of the spinal cord

Dissection of the vertebral artery and breakup of blood brain barrier causes ischemia and brain death followed by high pressure in the cranium

Neurological complains caused by directing nerve damage

Transient blindness followed by temporarily increase of intraepidural pressure

Pneumothorax

Meningitis ,vertebral osteomyelitis, discitis)

Bleeding (epidural hematoma) and retroperitoneal hematoma

Allergic reaction

Dural puncture and following headaches

Intravascular injection (in the sacral zone there is a high possibility of intravascular injection because of high vascularity

Arachnoiditis

Consequent of steroid injection , like suppression of cortisone level for up to 2 weeks and increase in blood glucose level

Vasovagal reaction

Ataxia especially for cervical block

Epidural lipomatosis

Cauda equina syndrome

Table 3 Spine injection complication

Meningeal space

Clinical presentation

The onset

Sign & Symptom

Subdural space

 

 

Subarachnoid

 

 

 

 

 

 

 

 

Local anesthetic toxicity via systemic absorption or accidental
intravascular injection.

 

 

 

Spinal cord or Root injury

 

 

Intravascular injection

Subdural block

 

 

Spinal block

Post dural puncture headache PDPH

 

 

 

Total spinal block(although it is more possible after epidural injection)

 

Gradual/delayed onset (1030 or 1520 minutes)

 

Minutes

Typically occurs hours to days

 

 

 

 

The onset is fast approximately minutes after the injection however, delay up to 30 minute

IV injection results in rapid onset and
systemic absorption normally has a delayed onset

 

 

 

 

Immediately and delay onset (hours)

 

 

Minutes ,days

Extensive sensory block with minimal motor block, hypotension (more than with epidural, less than with spinal)and in worst case scenario, intracranial tracking leads to dyspnea and loss of consciousness

Deep and prolong motor and sensory block

Headache is severe and described as "searing and spreading like hot metal," involving the back and front of the head, and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement, and sitting or standing, and relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are common

Complete bilateral sympathetic, sensory and motor blockade below a certain level. The patient suddenly became apneic, unresponsive, and totally flaccid, with bilateral dilated nonreactive pupils,hypotension and bradycardia

Classically, systemic toxicity begins with symptoms of CNS excitement such as the following: circumoral and/or tongue numbness ,metallic taste ,lightheadedness ,dizziness ,visual and auditory disturbances (difficulty focusing and tinnitus) disorientation ,drowsiness ,With higher doses, initial CNS excitation is often followed by a rapid CNS depression, with the following features: muscle twitching ,convulsions ,unconsciousness ,coma ,respiratory depression and arrest, cardiovascular depression and collapse

Neurogenic shock with severe pain ,bradycardia and hypotension
delay onset (hours) of compelet sensory and motor loss, paraplegia,compelet loss of bowel and bladder sensation

Spinal cord infarction,cell necrosis and ischemia and serious functional deficit and clinically presented as ASA syndrome. ASA syndrome characterizes by a sudden bilateral loss of pain and temperature below the spinal lesion level, with the preservation of vibration and position sensation, loss of motor function (usually paraplegia) and absence of urine and stool control

Table 4 Misleading spine injection and its consequences

Subdural block

The spinal cord protected by layers of tissue or membranes referred to meningeal membranes. There are also some spaces between these layers; epidural space which is outer layers between flavum ligament and dura mater, subdural space that is a virtual space between dura and arachnoids (it is more prominent in FBSS) and subarachnoid space which includes CSF. Spine intervention therapeutically performs in the epidural space (e.g. radiculopathy) and injection in other spaces (subdural, arachnoid) lead to injection complication.Ultrasound is a valuable modality for close monitoring of these spaces to inject directly into epidural space and prevent unwanted injection to other layers or injury to the spinal cord and nerve root although itis not enough (Figure 1).

Figure 1 Meningeal layers & spaces.

Subdural space is a potential space between arachnoids and dura, which contains serous fluid. This spreads across the cranial cavity throughout the distribution of meanings, covering all nerve structures. Space ends in the lower boundary region of the S2, where the film terminal ends. It is the widest in the cervical area and is narrow in the lumbar region and is expanded over dorsal root ganglion (DRG). The dorsum and lateral subdural space have a higher potential capacity. Both dura and arachnoids are connected together in the ventral root and thus the potential subdural space is much smaller ventrally. Subdural injection located in the posterior part and spare the anterior nerve roots which carries sympathetic and motor .The incidence of subdural injectionduring epidural injection of the lumbar spine is 0.8 %. The subdural space in the cervical region is larger than the lumbar region, so the risk of unintended subdural injection may also be higher in the cervical area.13,14 The onset of the block is intermediate betweensubarachnoid and epidural block and distinguish by a fastunexpectedly high sensory block . Clinical diagnosisof subdural injection is a moderate decrease in blood pressure, slow onset of symptoms, progressive respiratory problem, and complete recovery in two hours’ time followed by a full recovery.15–17 Accidental injection into the subduralspaces ought to be suspected if there's less pronounced resistance once the needle is placed within the epidural space or if the patient complains of a frontal headache.The tiny volume of sunduralspace might permit local anesthethic to succeed in intracranial structures (e.g. brainstem) resulting in important neurologic and hemodynamic complications with a period of unconscious state and apnea lasting many hours. Patients with previous back surgery were a lot of probably to possess the subdural injection, because of secondary anatomy that was liable to scarring and potential loss of epidural space. A recent spinal block may also be a predisposingfactor to subdural injection. Patients with a subdural block should closely monitor for vital supportand assurethat this is often a reversible and temporary event.18–22

Flouroscopicview of contrast injection in meningeal spacs

Fluoroscopy helps you to differentiated epidural block from the subduralor subarachnoid injection. The AP fluoroscopy of subdural injection shows a dense contrast in the center of the vertebral canal with a small amount of contrast extend laterally, delineating the nerve roots that are not affected by a change in posture and can be unilateral. The AP fluoroscopy of the epidural injection demonstrates afoamy pattern which is due to the fatty content of epidural space with a flow outward through the IVFand along nerve roots.The AP fluoroscopy view of subdural injection is similar to the subarachnoid injection, but the contrast agent rapidly descends in the CSF with gravity and dilute, so appear less opaque although outlines the exiting nerve roots in AP view. The lateral fluoroscopy view of subdural injection represents a dense collection confined to the posterior aspect of the spinal canal, spreading mainly in a cephalic direction. Due to the small volume of the subdural space relative to the epidural space, the cephalocaudal spreading of the contrast agent is far more compared to the epidural space even with low volume contrast injection. While the posterior line of the subdural injection is soft due to the dura, the anterior boundary appears irregular due to the arachnoids andthere are a regular posterior border and an irregular anterior border of condensed contrast. Comparingto the typical lateral lumbar epidurogram demonstrates the “double-line” or “railroad track” appearance of radiographic contrast in the anterior and posterior epidural space in epidural block, the subdural block looks like a "railroad track", however, contrast did not fill along the exiting nerve root in AP view unlike an epidural "railroad track"23–25 (Figures 2-4) (Table 5).

Figure 2 AP fluoroscopy of epidural block and distribution of contrast with foamy pattern that flow outward through the intervertebral foramina along nerve roots, lateral view of epidural block and double-line” or “railroad track”.

Figure 3 The AP fluoroscopy view of subdural injection(A) shows a dense contrast in the center of the vertebral canal compare to the foamy pattern of fatty content of epidural space(B) and a wide distribution which tends to flow outward through the intervertebral foramina along nerve roots however in subdural injection a small amount of contrast may extend laterally, delineating the nerve roots, spread can be unilateral.

Figure 4 AP & lateral fluoroscopy of subarachnoid block .The spinal cord and exiting nerve roots are visible within the contrast collection, the contrast extends all the way from the posterior to the anterior limits of the thecal space in lateral view.

Anatomic space

Lateral view

AP view

Epidural

“Doubleline” or “railroad track” appearance of radiographic contrast in the anterior and posterior epidural space

Foamy pattern of fatty content of epidural space and a wide distribution which tends to flow outward through the intervertebral foramina along nerve roots

Subdural

The regular posterior border and irregular anterior border of loculated contrast

A dense contrast in the center of the vertebral canal

Subarachnoid

The contrast extends all the way from the posterior to the anterior limits of the thecal space
in cervical Lateral view shows linearly sunk contrast in ventral aspect of the spinal canal and small amount of dorsal contrast filling even if the needle tip is located in the dorsal aspect of the spinal canal
CSF pulsation and movement could visualized due to intrathecal contrast in real time fluoroscopy

CSF dilutes contrast and it appears less opaque, the spinal cord and exiting nerve roots are visible within the contrast collection

Table 5 Comparing AP & Lateral fluoroscopic view of epidural & subdural and subarachnoid space after contrast injection

Complete or total spinal block

Total spinal block is a high block involving the cervical spine and above (such as brain stem and cranial nerves). It is more frequent with epidural block to spinal block and depend on anatomic variation.26 Symptoms and signs (hypotension, bradycardia, nausea and anxiety, arm/hand dysaesthesia or paralysis respiratory compromise, apnea, reduced oxygen saturation, difficulty speaking/coughing, loss of consciousness, cardiac arrest ) usually occur within minutes, however, delay up to 30minutes has been reported. Nausea and high sensory level block (>T1) may be early indicators. Management is supportive and dependent on degree and height of the block. Early recognition is vital to prevent serious cardio respiratory compromise.21

Local anesthetic systemic toxicity (LAST)

Local anesthetic reaches the circulation via systemic absorption or accidental intravascular injection. The incidence of LAST for epidural anesthesia is 1.2–11 per 10 000 anesthetics. It is more frequent with the epidural block to spinal block. After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest (cardiovascular collapse may occur without preceding neurological changes) should raise suspicion of LAST. Central nervous system toxicity is classically described as a two-stage process. An initial excitatory state is followed by a depressive phase. Early neurological features include perioral tingling, tinnitus, and slurred speech. Lightheadedness and tremor may also occur, as may a change in mental status with confusion or agitation. However, LAST can occur without characteristic premonitory signs. The excitatory neurological phase culminates in generalized convulsions. This may lead to the depressive phase of coma and respiratory depression. Cardiovascular system toxicity is classically in three phases. The initial phase includes hypertension and tachycardia. The intermediate phase is associated with myocardial depression and hypotension. The terminal phase includes peripheral vasodilatation, severe hypotension, and a variety of arrhythmias such as sinus bradycardia, conduction blocks, ventricular tachyarrhythmia, and asystole.27

While prevention is clearly the most important element in avoiding morbidity and mortality associated with LAST, such cases still occur despite best practice. The block should take place in a setting with standards monitoring, resuscitation equipment, and capable help nearby knowing how to manage this uncommon event. The key is to recognize it immediately and institute appropriate management and follow up.28 Keep in mind ultrasound guidance injection reduces the risk of local anesthetic systemic toxicity.29

Spinal cord & nerve root injury

Intraneural injection, a direct trauma to the nerve root or dorsal root ganglion can occur by inadvertent needle placement, especially during transforaminal ESI. Transoraminal injection performs in three ways. In classic or sub-pedicle technique needle enter below the pedicle and above the superior articular process (SAP). Concentration of the contrast medium is located along the nerve and the posterior and anterior epidural space. The other method is retroneural injection more posterior than the subpedicular technique and lateral to nerve root, so the contrast agent spreads along the nerve and posterior epidural space. In the last technique or retrodiscal method, needle enter from the outside of the SAP of the lower vertebra to the medial aspect of nerve and anterior epidural space. Retroneural approach may help to avoid such nerve trauma.30–32 (Figure 5) In cases of intraepineural injection, the patients may have severe radiating pain during the procedure, and it may cause mechanical neuritis or nerve injury inside the nerve root. When a patient presents severe pain during the procedure or distinct type of contrast spread pattern is identified, the needle should be slightly withdrawn and reassessment of the needle position is recommended. Do not over sedate patient before the procedure for not masking patient reaction. Sign and symptoms of spinal cord injury are more severe: neurogenic shock with severe pain, bradycardia, and hypotension with delay onset (hours) of complete sensory and motor loss, paraplegia, complete loss of bowel and bladder sensation.

Figure 5 Intraepineural contrast spread, the nerve root has several thin linear contrast fillings inside the nerve root as a feathery appearance.

Inadvertent intravascular injection or injury

The posterior and anterior radicular arteries majorly supply spinal cord below the neck. These arteries run into the spinal cord alongside the dorsal and ventral nerve roots. The Adamkiewicz artery is the largest anterior radicular arteries, which usually arises between L1 and L2 or anywhere from T9 to L5. Although doppler ultrasound is useful for scanning of a blood vessel, because of the risk of intra-arterial injection, insoluble corticosteroids must not be used when real-time contrast dye injection with fluoroscopy and/ or digital subtraction angiography is not used. The mechanism of injury may be related to vascular injury, not steroid embolism. Vascular injury may be to direct trauma with or without injection. Since the Adamkiewicz artery is the only artery that gives a lot of blood flow to the spinal cord of the lumbosacral region, it is clinically important. Unfortunately and rarely the radiculomedulary blood flow during the pain injections is cut off. Any disruption of the spinal cord blood flow is clinically important due to the cell necrosis, ischemia and serious functional deficit which clinically presented as ASA syndrome.

ASA syndrome characterizes by a sudden bilateral loss of pain and temperature below the spinal lesion level, with the preservation of vibration and position sensation, loss of motor function (usually paraplegia) and absence of urine and stool control. Even though the radicular artery is visible by ultrasound, it is advisable to inject contrast agent at the end of the procedure and take a contrast injection fluoroscopy view to rollout intravascular injection. Intravenous contrast injection is typically not seen on still images because the contrast material is rapidly diluted in the bloodstream. During real-time or live fluoroscopy, intravenous contrast can be seen flowing away and lateral from the spinal canal toward the venous circulation. Intra-arterial contrast injection is typically not seen on still images because the contrast material is rapidly diluted in the bloodstream. During real-time or live fluoroscopy, intra-arterial contrast injection can be seen flowing toward the midline (e.g. lumbar spinal cord)33,34 (Figure 6) (Figure 7).

Figure 6 Inadvertent intravenous contrast can be seen flowing away and lateral from the spinal canal toward the venous circulation during cervical transforaminal block(A)& caudal block(B).

Figure 7 intra-arterial injection disappear soon and contrast injection can be seen flowing toward the midline during cervical transforaminal block.

Transforaminal ESI injection has more chance of intravascular injection. As mention before transforaminal epidural injection perform with different techniques: classic sub-pedicular approaches through the safe triangle zone, retroneural technique (periradicular or selective nerve root block) to the posterior neural foramen and retrodiscal technique (kambin triangle) into the neural foramen and medial aspect of the spinal nerve (retrodiscal area).32 The safe triangle zone is not really safe. Retroneural approach may help to avoid intravascular injection. It is safer to place needle lateral the exiting nerve root and farther from IVF and epidural space to obviate the risk of placing the needle in the area of foramen that contains the blood supply to the spinal cord. There is no significant correlation between pain relief and needle tip position retroneural or subpedicular approach in relation to the neural foramen and success rate is not dependent on the distance between the needle tip and the nerve root.33–39 The predisposing factor for intravascular injection are the size, sharpness, positioning of the needle within the foramen, rate of injection, and vascular engorgement.40 The ability of the ultrasound to show vessels and increase first pass needle success rate reduces this complication.

Conclusion

The question is that how to perform a safe injection nevertheless such side effect and complications. Although ultrasound guidance regional anesthesia is a gold standard technique41 but ultrasound guide spine injection is a little different .It is not easy and has limitations as a result of depth, bony acoustic shadowing, and complicated three- dimensional anatomy. Preliminary studies suggest that having acquired the basic knowledge on ultrasound of the lumbar spine, the experience of 40 or more cases may be required to attain competency in just spine scanning.42 Safety tips should be considered before every ultrasound guide spine injection. These include: patient selection, sterilization, monitoring of the vital signs, preparation of the emergency rescue equipment, and limitation of drug dosage to the comprehensive familiarity with the ultrasound device, settings, and secondary confirmation technique (Table 6).43,44Real-time fluoroscopy at the end of every spine procedures can show the intravascular pattern of injection or inadvertent space clearly. Interventional pain physicians must have an adequate knowledge of normal and abnormal patterns of epidural and perinural fluoroscopy guided contrast dispersion and flow in order to avoid harm to the patients. This complication probably occurs more often than is recognized and may lead not only to a lack of efficacy but also to a potential hazard. Further technical and equipment advancements are needed to improve and reduce the existing limitations associated with the ultrasound-guided spine injection technique until that time the multimodality imaging guidance is safer.

Safety recommendation for spinal injections

 Choice of the patient carefully for the specific processor

 Obtain and view MRI scans prior to performing the procedure. Disc herniation may shift the
cord posteriorly and obliterate the posterior subarachnoid space. In patients with previous
cervical spine surgery there may be scar formation and adherence of dura to more superficial
tissues at the proposed level of injection, increasing the risk of direct needle trauma to the cord.
If there is preexisting canal stenosis and spinal cord compression, the additional pressure created by the
volume of drug injected, or by the pharmacological effect of those drugs, may result in neurological
injury, particularly if there is already some loss of function

 Know the contraindication of spine injection, such as patient dissatisfaction and uncontrolled coagulation disorder

 Be aware of patient medical history(e.g. diabetes, hypertension and cardiovascular disease)

 Consider the possibility of increasing blood glucose after steroid injection in diabetics

 Discontinue medications that increase the likelihood of bleeding, according to the protocol before and after
the injection (e.g. Aspirin, Nonsteroidal antiinflammatory drugs, Warfarin, Plavix)and Fluoxetine

 Use sedation as needed, minimize it in the cervical injections

 Completely adhere to the sterilization

 Monitor the vital signs

 Prepare emergency rescue equipment for emergency situations

 The correct counting of the vertebrae that you can use for signs of the occipital promontory,
prominent C7 Spinous process, and the 12 ribs for T12L1 interspaces and iliac crest for the disc of L45

 Comprehensive familiarity with ultrasound device and settings. Consider the types of probes
and their application, although most spine injections are done with the help of a curved probe due
to the depth of the tissues, there are always exception

 Avoid deep sedation. The deeply sedated patient may become agitated and may move unexpectedly.
Also, paresthesias may alert us to the fact that we have contacted the cord.

 Use local anesthetic before needling

 Speak with your patient during procedure to aware of the patient vigilance and show the
ultrasound screen where possible for document

 Perform a systematic scan

 Visualize key landmark structures

 Identify target on shortaxis imaging(preferred) or long axis

 Plan for safe needle approach as far as possible from vital organs and vascular

 Follow the tip of the needle in real time

 Inject small amount of a test dose before drug injection

 Monitor spreading of injection under real time

 Remember there is increase chance of neurologic injury with transforaminal epidural
approach compared to the interlaminar approach

 Consider the use of nonparticulate steroids.
This is controversial, as there is little evidence that soluble steroids have equivalent efficacy,
and early studies indicated that soluble steroid preparations remain in the spinal canal only for brief periods

 There is an increased chance of neurologic injury when particulate steroids are used for
transforaminal injections, so put the needle as far as possible in posterior aspect of foramen and consider
periradicular injection for patient safety

 Limit the total local anesthetic to an amount that is safe if delivered intrathecally. Provide
close monitoring initially, which should be continued until total recovery if an intrathecal injection occurs

 Rule out intrathecal needle placement with a local anesthetic test dose. Abandon the procedure
if dural puncture is evident. Do not attempt the procedure at another level at that time.
Allow time for the dural puncture to heal before reattempting.

 Avoid the addition of epidural opioids, especially morphine

 Because of the risk of intra arterial injection, insoluble corticosteroids must not be used
when real time contrast dye injection with fluoroscopy and/ or digital subtraction angiography is not used

 Avoid epidural needle placement above C67. There is typically a small amount of epidural fat
in the midline posteriorly at C7T1, creating a narrow space between the ligamentum flavum and the dura.
Midline epidural fat is minimal at C67, and there is none at C56 and above. And low volume
cervical injections often spread upward several segments

 Ultrasound allows direct visualization of soft tissue structures and may play an important role in
performing such high risk procedures as AAJ injections. It may improve the safety of AAJ injections
by avoiding injury of nearby structures (vertebral artery and C2DRG)

 Consider a secondary confirmation technique (e.g. fluoroscopy after contrast injection)

 Maintain appropriate document

Table 6 Safety recommendation for spinal injections

Acknowledgements

None.

Conflict of interest

The author declares no conflict of interest.

References

  1. Galletti S, Galletti R, Schiavone C, et al. Localized cervical pain: advantages and limits of ultrasound evaluation. Journal of Ultrasound. 2016;19(4):257–263.
  2. Narouze S, Peng PW. Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part II: axial structures. Reg Anesth Pain Med. 2010;35(4):386–96.
  3. Galiano K, Obwegeser AA, Bodner G, et al. Real-time sonographic imaging for periradicular injections in the lumbar spine: a sonographic anatomic study of a new technique. J Ultrasound Med. 2005;24(1):33–38.
  4. Gofeld M, Bristow SJ, Chiu SC, et al. Ultrasound-guided lumbar transforaminal injections: feasibility and validation study. Spine. 2012;37(9):808–812.
  5. Obernauer J, Galiano K, Gruber H, et al. Ultrasound-guided versus computed tomography-controlled periradicular injections in the middle and lower cervical spine: a prospective randomized clinical trial. Eur Spine J. 2013;22(11):2532–2537.
  6. Obernauer J, Galiano K, Gruber H, et al. Ultrasound-guided versus Computed Tomography-controlled facet joint injections in the middle and lower cervical spine: a prospective randomized clinical trial. Med Ultrason. 2013;15(1):10–15.
  7. Loizides A, Gruber H, Peer S, et al. Ultrasound guided versus CT-controlled pararadicular injections in the lumbar spine: a prospective randomized clinical trial. AJNR Am J Neuroradiol. 2013;34(2):466-70.
  8. Nahm FS1, Lee CJ, Lee SH, et al. Risk of intravascular injection in transforaminal epidural injections. Anesthesia. 2010;65(9):917–921.
  9. Verrills P, Mitchell B, Vivian D, et al. The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines. Spine. 2008;33(6):E174–E177.
  10. Lee CJ, Kim YC, Shin JH, et al. Intravascular injection in lumbar medial branch block: a prospective evaluation of 1433 injections. Current Researches in Anesthesia & Analgesia. 2008;106:1274.
  11. Gharrie H. Spine sono-intervention warning & safety recommendations. J Pain Relief. 2017.
  12. Gharrie H. Transforaminal epidural block or selective nerve root block. EC Anaesthesia. 2015;23:110–112.
  13. Ajar AH, Rathmell JP, Mukherji SK. The subdural compartment. Reg Anesth Pain Med. 2002;27:72–76.
  14. Reina MA1, De Leon Casasola O, López A, et al. The origin of the spinal subdural space: ultrastructure findings. Anesth Analg. 2002;94(4):991–995.
  15. Kalil A. Unintended subdural injection: a complication of epidural anesthesia, a case report. AANA J. 2006;74(3):207–211.
  16. Bansal S, Turtle MJ. “Inadvertent subdural spread complicating cervical epidural steroid injection with local anaesthetic agent”. Anaesthesia and Intensive Care. 2003;31(5):570–572.
  17. Agarwal D, Mohta M, Tyagi A, et al. “Subdural block and the anaesthetist”. Anaesthesia and Intensive Care. 2010;38(1):20–26.
  18. Sadacharam K, Petersohn JD, Green MS. Inadvertent subdural injection during cervical transforminal epidural steroid injection. Case Rep Anesthesiol. 2013;2013:847085.
  19. Stevens DS, Balkany AD. Appearance of Plica Mediana Dorsalis during Epidurography. Pain Physician. 2006;9(3):268–270.
  20. Collier CB. Accidental subdural injection during attempted lumbar epidural bock may present as a failed or inadequate block: radiographic evidence. Reg Anesth Pain Med. 2004;29(1):45–51.
  21. Goodman BS, Bayazitoglu M, Mallempati S, et al. Dural puncture and subdural injection: a complication of lumbar transforaminal epidural injections. Pain Physician. 2007;10(5):697–705.
  22. Stojanovic MP, Vu T, Caneris O, et al. The role of fluoroscopy in cervical epidural steroid injections. An analysis of contrast dispersal pattern. Spine. 2002;27(5):509–514.
  23. Botwin KP, Natalicchio J, Hanna A. Fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician. 2004;7(1):77–80.
  24. Manchikanti L, Cash KA, Pampati V, et al. valuation of fluoroscopically guided caudal epidural injections. Pain Physician. 2004;7(1):81–92.
  25. Rathmell JP, Song T, Torian D, et al. Lumbar epidurography. Reg Anesth Pain Med. 2000;25(5):540–545.
  26. Joo J, Kim J, Lee J. The prevalence of anatomical variations that can cause inadvertent dural puncture when performing caudal block in Koreans: a study using magnetic resonance imaging. Anaesthesia. 2010;65(1):23–26.
  27. Dippenaar JM. Local anaesthetic toxicity. South Afr J Anaesth Analg. 2007;13:23–28.
  28. Mercado P, Weinberg G. Local anesthetic systemic toxicity: prevention and treatment. Anesthesiol Clin. 2011;29(2):233–242.
  29. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38:289–299.
  30. Goodman BS, Posecion LW, Mallempati S, et al. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med. 2008;1(3–4):212–222.
  31. Barrington MJ, Watts SA, Gledhill SR, et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. 2009;34(6):534–541.
  32. Pfirrmann CW, Oberholzer PA, Zanetti M, et al. Selective nerve root blocks for the treatment of sciatica: evaluation of injection site and effectiveness--a study with patients and cadavers. Radiology. 2001;221(3):704–711.
  33. Baker R, Dreyfuss P, Mercer S, et al. “Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury”. Pain. 2003;103(1-2):211–215.
  34. Brouwers PJ, Kottink EJ, Simon MA, et al. “A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root”. Pain. 2001;91(3):397–399.
  35. Hong JH, Kim SY, Huh B, et al. Analysis of inadvertent intradiscal and intravascular injection during lumbar transforaminal epidural steroid injections: a prospective study. Reg Anesth Pain Med. 2013;38(6):520–525.
  36. El Abd OH, Amadera JE, Pimentel DC, et al. Intravascular flow detection during transforaminal epidural injections: a prospective assessment. Pain Physician. 2014;17(1):21–27.
  37. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005;117(1–2):104–111.
  38. Zhu J, Falco FJ, Formoso F, et al. Alternative Approach for Lumbar Transforaminal Epidural Steroid Injections. Pain Physician. 2011;14(4):331–341.
  39. Ignjatovic S, Omidi R, Kubik-Huch RA, et al. The retroneural approach: an alternative technique for lumbar transforaminal epidural steroid injections. Acta Radiologica. 2018:284185118762248.
  40. Jasper JF. Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician. 2003;6(3):369–372.
  41. Hopkins PM. Ultrasound guidance as a gold standard in regional anaesthesia. Br J Anaesth. 2007;98(3):299–301.
  42. Chin K J, Karmakar M K. Ultrasonography of the Adult Thoracic and Lumbar Spine for Central Neuraxial Blockade. Anesthesiology. 2011;114(6):1459–1485.
  43. Samer n narouze. Ultrasound guidance for interventional pain management of cervical pain syndromes. An anatomical and clinical study. 1st ed. Thesis maastricht medical center; 2012.
  44. Gharries H. Epidural Steroid Injection Warning & Safety Recommendations. J Anesth Crit Care Open Access. 2015;2(5):00069.
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