Incidence of simultaneous epidural and vascular injection during cervical transforaminal epidural injections.

Study Design: Prospective, observational in vivo study.
Objective: The aim of this study was to determine the incidence of simultaneous epidural and vascular contrast injection during cervical transforaminal epidural injections.
Summary of Background Data: In the lumbar spine, vascular contrast patterns are more than twice as likely to appear simultaneous to the anticipated epidural pattern, than they are to occur alone. This is important because practitioners are more likely to miss a vascular pattern when it appears simultaneous to the expected epidural flow. The incidence of intravascular penetration in cervical transforaminal epidural injections is known to exceed than that of lumbar injections, however, no study has determined the incidence of simultaneous epidural and vascular injection in the cervical spine.
Methods: Contrast patterns were observed with live fluoroscopy during 121 injections performed on 82 patients and categorized as one of the following: epidural only, vascular only, or simultaneous epidural and vascular.
Results: The incidence of simultaneous epidural and vascular injection during cervical transforaminal epidural injections was 18.9%. The incidence of vascular only injection was 13.9%, for a total vascular injection incidence of 32.8%. There was no correlation between the observed contrast pattern with patients' age, sex, side of injection, needle gauge, or diagnosis. There was a significant correlation between the level of injection and the risk of vascular injection. The higher the injection level, the higher the probability of a vascular injection. Fluoroscopy time was significantly increased when a vascular injection was identified.
Conclusion: Simultaneous epidural and vascular injection accounts for over half of all vascular injections during cervical transforaminal epidural injections. With the risk of severe complications and high incidence of vascular injections in the cervical spine, live fluoroscopy is recommended during contrast injection with specific attention to simultaneous epidural and vascular flow.