Utility of Digital Subtraction Angiography in Cervical Transforaminal Epidural Steroid Injections: Does Digital Subtraction Improve Safety Over Live Fluoroscopy? -

919 Scientific abstract: Chronic pain Utility of Digital Subtraction Angiography in Cervical Transforaminal Epidural Steroid Injections: Does Digital Subtraction Improve Safety Over Live Fluoroscopy? Andrew Rubens, Carlos A. Pino, Clarence Ivie The University of Vermont Medical Center Introduction Cervical transforaminal epidural steroid injections (CTFESI) have been used for many years in the conservative management of cervical radicular pain. Reports of severe neurological complications from CTFESI often implicate accidental intravascular injections as the mechanism of injury. In order to reduce the risk of serious injury during CTFESI, our ability to reliably identify intravascular needle placement is paramount. Materials and methods (NA for case report) IRB approval was obtained. We reviewed records from CTFESIs performed in an academic outpatient clinic from November 2008 to June 2015. Over 385 studies were performed; however, only 382 patients had complete documentation available for review. These injections were performed or supervised by fellowship trained pain physicians. When aspiration revealed blood, the event was documented and the needle was immediately repositioned. Contrast dye flow studies were performed only if aspiration was negative. Results/Case report Flow studies detected 52 intravascular needles despite negative aspiration of blood. Of the 52 positive cases, 20 were detected with standard real-time fluoroscopy without need for DSA. An additional 32 cases were found to be positive for intravascular flow using DSA despite negative blood aspiration and negative flow study using live fluoroscopy. Of the positive flow studies reviewed, DSA nearly doubled the total number of intravascular needles (32) detected by live, real-time fluoroscopy (20) following negative aspiration. Furthermore, the rate of intravascular detection for live fluoroscopy (5.2%) (95% CI: 3.2% 8.0%) and DSA (13.6%) (95% CI: 10.3% 17.5) were significantly different (p<0.0001) when analyzed utilizing a test of marginal homogeneity, which suggests that the likelihood of detecting intravascular uptake is not the same between these two flow studies. Discussion Intravascular needle placement during CTFESI is not uncommon and inadvertent injection into the arterial blood supply of the cervical spine may create major morbidity. An early article by Furman MB, et al concluded through a prospective study of 504 cervical transforaminal epidural steroid injections that the overall rate of confirmed intravascular contrast injections was 19.4% when using real-time fluoroscopy. Another larger study by Nahm et. al., a total of 2145 transforaminal injections at different spine levels were performed with the overall incidence of intravascular injection being 10.5%. Of these intravascular injections, the most frequent incidence occurred with CTFESI at 20.6%. These studies used negative aspiration and contrast injection with i xiii xiv 14th Annual Pain Medicine Meeting Thursday, November 19, 2015–Saturday, November 21, 2015 Miami