FACTFINDERS FOR PATIENT SAFETY: Minimizing risks with cervical epidural injections.
Eric K Holder, Haewon Lee, Aditya Raghunandan, Benjamin Marshall, Adam Michalik, Minh Nguyen, Mathew Saffarian, Byron J Schneider, Clark C Smith, Christin A Tiegs-Heiden, Patricia Zheng, Jaymin Patel, David Levi, International Pain and Spine Intervention Society's Patient Safety Committee
Author Information
Eric K Holder: Yale University School of Medicine, Department of Orthopedics and Rehabilitation, New Haven, CT, USA.
Haewon Lee: Jefferson Moss-Magee Rehab, Philadelphia, PA, USA.
Aditya Raghunandan: UT Health San Antonio, San Antonio, TX, USA.
Benjamin Marshall: University of Colorado, Denver, CO, USA.
Adam Michalik: Twin Cities Orthopedics, Minneapolis, MN, USA.
Minh Nguyen: University of Texas, Southwestern Medical Center, Dallas, TX, USA.
Mathew Saffarian: Michigan State University, Department of Physical Medicine and Rehabilitation, East Lansing, MI, USA.
Byron J Schneider: Vanderbilt University Medical Center, Dept of Physical Medicine & Rehabilitation, Nashville, TN, USA.
Clark C Smith: Columbia University Medical Center, Rehabilitation and Regenerative Medicine, New York, NY, USA.
Christin A Tiegs-Heiden: Mayo Clinic, Rochester, MN, USA.
Patricia Zheng: University of California, San Francisco, USA.
Jaymin Patel: Emory University, Department of Orthopaedics, Atlanta, GA, USA.
David Levi: Jordan Young Institute, Virginia Beach, VA, USA.
This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections. Evidence in support of the following facts is presented. - 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks. -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes. Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.
