Intravascular flow detection during transforaminal epidural injections: a prospective assessment

Pain Physician. 2014 Jan-Feb;17(1):21-7.


Background: Transforaminal epidural steroid injections (TFESI) are a mainstay in the treatment of spine pain. Though this commonly performed procedure is generally felt to be safe, devastating complications following inadvertent intra-arterial injections of particulate steroid have been reported. The use of digital subtraction angiography (DSA) has been suggested as a means of detecting intra-arterial needle placements prior to medication injection.

Objective: To examine the efficacy of DSA in detecting intra-arterial needle placements during TFESI.

Study design: Prospective cohort study evaluating the impact of DSA on detecting intra-arterial needle placements during TFESI.

Methods: We enrolled 150 consecutive patients presenting to a university-affiliated spine center with discogenic and/or radicular symptoms affecting the cervical, lumbar, and sacral regions. For each injection, prior to imaging with DSA, traditional methods for vascular penetration detection were employed, including the identification of blood in the needle hub (flash), negative aspiration of blood prior to injection, and live fluoroscopic injection of contrast. Once these tests were performed and negative for signs of intra-arterial needle placement, DSA imaging was utilized prior to medication administration for identification of vascular flow.

Results: A total number of 222 TFESI were performed, 41 injections at the cervical levels (18.47%), 113 at the lumbar levels (50.9%), and 68 at the sacral levels (30.36%). Flash was observed in 13 injections performed (5.85% of the total number of injections): one (0.45%) in the cervical, 2 (0.9%) in the lumbar, and 10 (4.5%) in the sacral levels. In 11 TFESI blood aspiration was obtained (4.95% of all injections): 3 (1.3%) in cervical, 4 (1.8%) in lumbar, and 4 (1.8%) in sacral injections. Live fluoroscopy during contrast injection detected 46 (20.72%) intravascular flow patterns: 7 (3.1%) cervical, 17 (7.6%) lumbar, and 22 (9.9%) sacral. DSA identified an additional 5 intravascular injections after all previous steps had resulted in negative vascular penetration signs, which accounted for 2.25% of all injections.

Limitations: This is a prospective, single-center study with a relatively small number of patients and no control group.

Conclusion: DSA detected additional 5.26% intravascular needle placements following traditional methods. Our findings also support other studies that conclude TFESI are generally a safe procedure. We recommend that special attention should be paid to the sacral injections as vascular penetration was statistically higher than at other levels.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Angiography, Digital Subtraction
  • Back Pain / diagnostic imaging
  • Back Pain / drug therapy*
  • Cohort Studies
  • Female
  • Fluoroscopy
  • Humans
  • Injections, Epidural*
  • Lumbosacral Region
  • Male
  • Middle Aged
  • Radiculopathy / diagnostic imaging
  • Radiculopathy / drug therapy*
  • Steroids / administration & dosage*
  • Young Adult


  • Steroids