Fluoroscopically guided lumbar spine interlaminar and transforaminal epidural injections: inadvertent intravascular injection.

ABSTRACT

BACKGROUND: Inadvertent intravascular injection is a rare but catastrophic complication of lumbar epidural injections. PURPOSE: To determine risk factors for inadvertent intravascular injection in fluoroscopically guided lumbar spine epidural injections. MATERIAL AND METHODS: A total of 212 patients who presented for lumbar interlaminar or transforaminal injection were prospectively enrolled. Patient demographics, history of surgery, injection side, site and approach, and volume of contrast injected were recorded. RESULTS: There were 89 (42%) interlaminar and 123 (58%) transforaminal injections. For 36 (17%) patients, there had been surgery at the injected or adjacent lumbar level. There were 25 (12%) inadvertent intravascular injections, with an incidence of 2/93 (2%) for interlaminar and 23/119 (19%) for transforaminal injections. The patients with inadvertent intravascular injection were older (P = 0.017) and had prior surgery at or adjacent to the level of injection (P < 0.0001). Transforaminal approach had a higher intravasation rate than interlaminar injections, both when comparing the entire cohort (P = 0.0001) and only patients without prior surgery (P = 0.01). In multivariable logistic regression analysis, transforaminal injections (odds ratio [OR] 9.77, 95% confidence interval [CI] 2.14-44.6, P = 0.003) and prior surgery at or adjacent to the level of injection (OR 5.71, 95% CI 2.15-15.15, P < 0.001) were independently associated with increased risk of inadvertent intravascular injections. CONCLUSION: Inadvertent intravascular injection occurred in 12% of our lumbar injection cohort and is more common with transforaminal injections, in older patients, and with prior lumbar surgery at or adjacent to the level of injection.