Curr Pain Headache Rep (2012) 16:9–18
DOI 10.1007/s11916-011-0241-z
ANESTHETIC TECHNIQUES IN PAIN MANAGEMENT (GJ BRENNER, SECTION EDITOR)
The Role of Image Guidance in Improving the Safety
of Pain Treatment
James P. Rathmell & Smith C. Manion
Published online: 30 November 2011
# Springer Science+Business Media, LLC 2011
Abstract The use of fluoroscopy, computed tomography,
and, most recently, ultrasound in the pain clinic all have
advanced rapidly, yet there is scant evidence that this
improves the safety or efficacy of pain treatment. In this
manuscript, the available evidence about the usefulness of
diagnostic imaging and image guidance in planning and
delivering pain treatment is critically reviewed. The use of
image guidance has become a routine and integral
component of pain treatment; however, there is insufficient
scientific evidence to judge whether this has improved
safety. The logical appeal is overwhelming, to the point that
it is now unlikely that scientific comparisons of most
techniques with and without radiographic guidance will
ever be conducted. This analysis can serve to guide future
investigators who set out to understand how to apply new
imaging techniques, and in the process, how to rigorously
evaluate their usefulness.
Keywords Chronic pain . Pain treatment . Fluoroscopy .
Computed tomography . Ultrasound . Patient safety .
Imaging . MRI . Nerve blocks . Spinal cord injury .
Anesthesia
J. P. Rathmell (*) : S. C. Manion
Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital,
55 Fruit Street, GRB 444,
Boston, MA 02114, USA
e-mail: rathmell.james@mgh.harvard.edu
S. C. Manion
Harvard Medical School,
Boston, MA, USA
Introduction
Until recent years, use of radiographic guidance in the pain
clinic was reserved for major procedures like neurolytic
celiac plexus block. Two forces have been at work, which
have led to the widespread use of imaging modalities in the
field of pain medicine. Patients and referring practitioners
now expect pain physicians to be familiar with use of
imaging in diagnosing pain conditions. At the same time,
pain practitioners have demonstrated the usefulness of
radiographic guidance for precise anatomic placement of
needles and catheters. The evidence to support routine use
of radiographic guidance is still evolving. The intuitive
appeal of this precise approach has already caught on to the
point where most practitioners now perform most of their
injections using fluoroscopic guidance. In patients with
intractable pain associated with metastatic cancer, diagnos-
tic imaging studies have proven invaluable in the planning
and implementation of therapy. The use of fluoroscopy,
computed tomography (CT), and, most recently, ultrasound
in the pain clinic all have advanced rapidly, yet there is
scant evidence that this improves the safety or efficacy of
pain treatment. This article reviews the available evidence
about the usefulness of diagnostic imaging and image
guidance in planning and delivering pain treatment.
Definition and Scope
Use of Diagnostic Imaging to Improve Safety
Pain is among the most common presenting symptoms that
lead patients to seek medical care. Diagnostic imaging is
10 Curr Pain Headache Rep (2012) 16:9–18

used broadly to search for the anatomic basis for new onset
of many symptoms, including pain. Indeed, diagnostic
imaging is the cornerstone of diagnosis in many cases, such
as new onset of sciatica associated with disc herniation. A
broad discussion of the use of diagnostic imaging is beyond
the scope of this article, but several examples where
diagnostic imaging can provide critical information for
planning treatment will be reviewed.
There is moderate scientific evidence that epidural
injection of steroids can speed the resolution of radicular
pain early after acute lumbar disc herniations [1–3], and this
treatment is in widespread use. By extrapolation from the
evidence for lumbar disc herniation, the technique also has
been used for pain associated with thoracic and cervical
disc herniations and spinal stenosis. Use of diagnostic
imaging to establish the exact anatomic level of disc
herniation was unusual just 10 years ago. At that time,
most practitioners doing epidural injections were doing so
with no experience in interpreting imaging studies; most
often, they were using the blind loss-of-resistance technique
to identify the epidural space [4]. Conventional wisdom at
that time held that the injection should be placed at the level
of the disc herniation to produce maximal benefit. Most
practitioners simply placed epidural injections guided only
by the radiologists report: if there was a disc herniation at
C6/7, then the injection was placed at that level. Reports of Fig. 1 Cervical MRI in a patient with a large C6/7 disc herniation that
spinal cord injury during these injections began to appear, causes significant stenosis of the central spinal canal. This patient
and a connection between spinal cord injury during developed neuropathic pain suggestive of minor spinal cord injury
during epidural steroid injection conducted using a blind technique at
injection and high-grade spinal stenosis was made [4].
the C6/7 level. Review of diagnostic imaging studies before injection
Indeed, in high-grade stenosis of the central spinal canal would have identified this high-grade stenosis and use of fluoroscopy
from any cause, there is often complete loss of the to select an intervertebral level where the stenosis was less severe may
cerebrospinal fluid and epidural fat surrounding the cord, have prevented this injury. Sagittal T2-weighted image at the midline
of the cervical spine. There is a large disk herniation at the C6/7 level,
often with direct pressure on the spinal cord. This is the
causing posterior displacement of the spinal cord (arrow) and
case in a few patients with large disc herniations (Fig. 1). In effacement of the cerebrospinal fluid signal anterior to the spinal cord
such cases, it is critical to recognize the lack of enough (From Field et al. [4], with permission.) MRI—magnetic resonance
space in the posterior epidural canal to allow for safe needle imaging
entry and placement of the epidural steroid. The use of
diagnostic imaging and careful review of the actual images celiac plexus neurolysis. Analysis of the diagnostic studies
before epidural injection is now routine. When there is can assist in planning the spinal level of needle entry, as
severe spinal canal stenosis, injection at the stenotic levels well as the angle and depth of needle advancement. These
is avoided by using fluoroscopy to guide needle placement planning measurements are made on the diagnostic images
at an anatomic level where prior diagnostic imaging has and used to guide needle placement during celiac plexus
demonstrated room for needle entry. block done subsequently using either CT or fluoroscopy
Neurolytic celiac plexus block is another technique that (Fig. 2). Existing diagnostic studies can be help to avoid
has moderate scientific evidence from controlled trials adjacent structures thus improving safety.
demonstrating reduced pain and analgesic use in patients
with painful intraabdominal malignancies, particularly Use of Image Guidance to Improve Safety
pancreatic cancer. The complications associated with this
technique include renal trauma, trauma to the large vessels Early work suggests that image guidance can increase the
of the abdomen, and pneumothorax. Diagnostic imaging for precision of epidural. One of the most quoted studies
identification and staging of pancreatic cancer is standard demonstrated that using a blind loss-of-resistance technique
practice worldwide; thus, imaging studies are almost correctly identified the epidural space in only 30% of cases
universally available at the time patients are referred for [5]. This study has been criticized because the investigators
Curr Pain Headache Rep (2012) 16:9–18 11

Fig. 2 Use of diagnostic computed tomography (CT) angiography

study of the abdomen in a patient referred for celiac plexus block to
plan position and depth of needle placement. The diagnostic CT
angiogram can be used to determine the safest position to place
needles and plan the final depth on needle insertion; these measure-
ments then can be used to carry out the block with either fluoroscopy
or CT guidance. Axial image located 1 cm inferior to the origin of the
celiac artery from the anterior aorta, below the inferior reflections of
the pleura. The distance from the anterolateral surface of the aorta to
the skin surface (124 mm) and from the spinous process to the point of
needle entry (41 mm); similar measurements can be made for
placement of the needle on the right side. Performing the celiac
plexus block somewhat inferior to the celiac artery in this patient was
carried out successfully: the needles were well below the pleura at this
level (Adapted from Rathmell [30], with permission)

were not frequent users of the loss-of-resistance technique.

When experienced physicians placed epidurals in the setting
of labor and delivery, the success rose to 61.7%, in
comparison to a success rate of 47.7% in those who had
performed few injections previously [6]. Subsequent inves-
tigators reported successful caudal epidural injection in
97.5% of cases performed using fluoroscopic guidance [7].
Radiographic guidance can be used to display images in
multiple planes at all spinal levels, and the epidural space can
be identified the vast majority of the time (Figs. 3 and 4).
Use of radiographic guidance employing a coaxial Fig. 3 Radiographic identification of the cervical epidural space. a
Lateral radiograph of the cervical spine near the cervicothoracic
technique also can improve the precision of needle
junction during interlaminar cervical epidural injection. A 22-gauge
placement, reducing or eliminating the need for redirection Tuohy needle is in place in the C7/T1 interspace extending toward the
of the needle to reach the epidural space [8]. By aligning dorsal epidural space after injection of 1 mL of radiographic contrast
the axis of the x-ray beam with the final radiographic target, (iopamidol, 200 mg/mL). The contrast extends in a linear stripe in a
cephalad and caudad direction from the needle tip that outlines the
the skin directly overlying the target can be anesthetized,
dorsal (posterior) border of the dura mater. b Labelled image before
and a needle passed directly from the skin’s surface to the contrast injection. The anterior-most extent of the spinous process and
target at a depth in a single pass. Anteroposterior radio- the posterior-most extent of the ligamentum flavum and spinal canal
graphs demonstrate the needle position from lateral to coincide with the “J-point” (the point where the inferior margin of the
spinous process begins to arc in a cephalad direction, taking the
medial and cephalad to caudad; lateral radiographs demon-
appearance of the letter “J”). The area outlined to the left of the image
strate the needle’s depth from the skin’s surface. While in the dashed box has been enlarged in the inset to the right, where the
radiographic guidance can bring the needle into close approximate borders of the ligamentum flavum have been outlined
proximity to the epidural space, only bony structures can (Adapted from Rathmell [30], with permission)
be identified using fluoroscopy; thus, final needle advance-
12 Curr Pain Headache Rep (2012) 16:9–18

ƒFig. 4 Radiographic identification of the lumbar epidural space. a

Lateral radiograph of the lumbar spine during interlaminar lumbar
epidural injection. A Tuohy needle is in place in the L5/S1 interspace
extending to the posterior epidural space. Clarity of lateral radiographs
of the lumbar spine is often hindered by the overlying iliac crests. b
Labeled image. During lumbar interlaminar epidural injection, the
needle can be safely advanced using the lateral radiograph to guide
depth. The posterior-most extent of the ligamentum flavum lies just
anterior to the junction of the spinous process with the laminae (red
arrows). The needle can be safely advanced to this depth before
starting the LOR technique during the last few millimeters of
advancement through the ligamentum flavum to precisely identify
the epidural space. The junction of the spinous process with the
lamina can be easily identified in the lateral radiograph by following
the inferior margin of the spinous processes anteriorly until the
junction with the lamina is seen as a line that extends in an inferior
and anterior direction (dashed line). The approximate location of the
thecal sac is shown (gray lines indicate the approximate location of
the anterior and posterior aspects of the dura mater) (Adapted from
Rathmell [30], with permission.) LOR—loss of resistance

ance of confusing patterns of contrast spread, particularly in

patients who have had prior surgery, including fusion
masses along the bony spine or scarring in the epidural
space. Use of radiographic guidance does not assure the
safety of image-guided injections, but the use of these
techniques has strong face validity as a means to improve
safety: if you can directly visualize or more precisely infer
the position of critical structures like blood vessels and the
spinal cord, then it stands to reason that these structures can
be avoided with the use of image guidance. Caution is in
order: images are often confusing, the skill of practitioners
is variable, and there is still little evidence for improved
safety with image guidance. A recent study published by the
American Society of Anesthesiologists (ASA) examined
closed malpractice claims in a subgroup of patients who

ment into the epidural space requires use of the loss-of-

resistance technique. Once the needle is in final position,
epidural location can be confirmed by injecting radiographic
contrast. If the contrast spreads in a characteristic pattern
without evidence of vascular flow, then epidural location is
confirmed (Fig. 5).
Identification of intravascular needle location using
fluoroscopy requires special attention. Use of a live or
real-time technique rather than static images is essential. Fig. 5 Lateral epidurogram of the lumbosacral spine. When larger
Any contrast placed within a blood vessel will be rapidly volumes of injectate are used (in this image, 10 mL of contrast-
containing solution), the injectate spreads extensively within the
carried away in the bloodstream and will no longer be anterior and posterior epidural space and has a characteristic double
visible on static images taken subsequently. Another line or railroad track appearance (Adapted from Rathmell et al. [31],
difficulty with use of radiographic guidance is the appear- with permission)
Curr Pain Headache Rep (2012) 16:9–18
sustained spinal cord injuries during the course of cervical
spinal injections [9••]. Radiographic guidance was more
common in those who sustained spinal cord injuries than in
those who had cervical procedures performed without
radiographic guidance. Did use of radiographic guidance
make spinal cord injury more likely? Perhaps, but it is equally
plausible that injections that led to spinal cord injury (eg,
cervical epidural steroid injection using an interlaminar
technique) were done more often with radiographic guidance.
Without knowledge about how many total injections were
done with and without radiographic guidance, there is no
means to know the actual incidence of injury with each
method. Nonetheless, the ASA Closed Claims report does
demonstrate that direct trauma to the spinal cord can occur
during transforaminal injection, interlaminar epidural injec-
tion, and trigger point injection at the level of the cervical
spine, even when image guidance is used.
Intravascular injection can lead to local anesthetic
toxicity or catastrophic neural injuries to the brain or spinal
cord. With disciplined use of radiographic guidance,
intravascular needle location can be detected before local
anesthetic or steroid is injected. In this way, use of
radiographic guidance can improve safety. Intravascular
needle location exceeds 20% during cervical transforaminal
injection [10, 11], and it is unclear what proportion are
intravenous versus intraarterial [12]. Use of digital subtrac-
tion appears to further increase the likelihood of detection
of intravascular injection [13]. Intravascular injection is
common during cervical transforaminal injection, but the
incidence during other techniques is unclear. The proximity
of the vertebral artery during stellate ganglion block and the
proximity of the aorta during celiac plexus block make
intraarterial injection distinctly possibility. Means to detect
intraarterial needle location before injection must be a
routine part of performing these techniques.
Without any direct reporting mechanism, any real
estimate of the incidence of injuries occurring during the
course of pain treatment is impossible. The ASA Closed
Claims study gives us a glimpse of injuries that can occur.
The incidence of these injuries appears to be low, likely less
than 1 in 10,000 injections, and perhaps even lower; while
it is difficult to estimate this risk with accuracy, in 2006,
nearly 800,000 Medicare patients in the United States [14]
underwent epidural injections. Catastrophic neural injuries
on record number less than 100. From published studies, it
is clear that the use of common injections for pain treatment
has risen exponentially in the United States during the last
decade [14] and use of fluoroscopy to guide needle
placement during these treatments is now the rule rather
than the exception. We need large-scale prospective studies
that examine the frequency of use of these treatments and
their safety and effectiveness to guide practitioners in
making rational treatment decisions.
13
Mechanism of Causation
Injuries associated with image-guided pain treatment fall
into several broad categories. Bleeding and infectious
complications, while devastating, are rare: epidural hema-
toma and epidural abscess. Use of image guidance is
unlikely to impact either of these complications, but
diagnostic imaging plays a major role in prompt diagnosis
and treatment. Image guidance does play a critical role in
avoiding direct trauma to neural structures and preventing
intravascular or intrathecal injection.
Direct Trauma to Neural Structures
Trauma to neural structures, including spinal nerves, the
cauda equina, or the spinal cord itself, all have been
associated with injections used in pain treatment. Specifi-
cally, direct needle contact with spinal nerves during
transforaminal injection is common. This may cause a
transient paresthesia, which resolves with redirection of the
needle or can lead persistent pain. Transforaminal injection
is often performed to treat radicular pain associated with
foraminal stenosis or nerve compression associated with
disc herniation. With these conditions, there is little space
around the spinal nerve to accommodate the injected fluid,
and the injected fluid may lead to worsened nerve
compression. The spinal cord lies in front of the advancing
needle during both transforaminal and interlaminar epidural
injections at the cervical level, and direct needle trauma to
the cord can occur [9••]. Patients with severe central spinal
stenosis may be at particular risk for spinal cord injury,
especially when using an interlaminar technique [4].
Vascular Compromise
Evidence for vascular compromise has arisen in two areas:
paraplegia after neurolytic celiac plexus block [15, 16], and
catastrophic neural injuries associated with injection of
particulate steroid during cervical transforaminal injection
[17]. Celiac plexus block is commonly performed at the
T12/L1 vertebral level. Injectate is placed over the antero-
lateral vertebral bodies or around the anterolateral aspect of
the aorta. The artery of Adamkiewicz arises from the
posterolateral aspect of the aorta, most often on the left
between the T10 and L2 vertebral levels, near where the
injectate is placed for celiac plexus block. This artery often
provides critical blood supply to the anterolateral spinal
cord at the low thoracic level, and compromise can lead to
spinal cord ischemia or infarction. The injection of neuro-
lytic solution in this region has been hypothesized to lead to
vasospasm of this critical reinforcing artery, and there is at
least one case of transient paraplegia [15]. The neurologic
insult is more often permanent. While the mechanism may
14
be arterial spasm and resultant ischemia, it seems more
plausible that spinal cord injury is the result of intraarterial
injection of the neurolytic solution.
Catastrophic neural injury after intraarterial injection of
particulate steroid has been well-described with transfor-
aminal injections [17], stellate ganglion block [9••], and
cervical facet injections [18]. Several mechanisms of injury
have been postulated, including arterial spasm or dissection,
but no evidence to support these alternate mechanisms has
appeared. The most likely mechanism is direct intraar-
terial injection of steroid particles that occlude the end-
arteriolar circulation, leading to ischemia and infarction.
During transforaminal injection, injection into the spinal
medullary arteries can lead to spinal cord infarction, and
injection into the vertebral artery can lead to stroke
involving the posterior cerebral, resulting in cortical
blindness, cerebellar infarction, and death from intracra-
nial hypertension. Direct injection into the vertebral
artery also can occur with stellate ganglion block or
high cervical facet injections. Studies in experimental
animals strongly support this mechanism of injury [19,
20], as do case reports [18]. In anesthetized swine,
injection of particulate steroid into the vertebral artery
resulted in massive posterior circulation stokes on mag-
netic resonance imaging and persistent coma without
return of spontaneous respiratory [19]; in contrast,
intraarterial injection of the nonparticulate steroid dexa-
methasone caused no apparent injury. In a report of a man
receiving a C1/C2 intraarticular facet injection with particulate
steroid, intraarterial injection into the vertebral artery resulted
in a fatal posterior circulation stroke [18]. These publications
strongly support the mechanism of injury of particulate
steroid causing end-arteriolar occlusion.
Prevention
Prevention of Direct Trauma to Neural Structures
Neural structures cannot be directly visualized using
fluoroscopy. Their position must be inferred from their
typical proximity to bony structures that can be seen.
Prevention of trauma starts with review of available
diagnostic studies and careful planning of needle placement
for the injection. Severe spinal stenosis caused by cervical
spondyloarthropathy or disc herniation can lead to complete
effacement of the epidural fat and spinal fluid surrounding
the spinal cord. Needle entry into the spinal canal at such a
severely stenotic level can lead to direct cord trauma, even
without dural puncture [4]. Interlaminar epidural injection
at severely stenotic levels should be avoided. In a similar
fashion, severe spinal foraminal stenosis can lead to neural
compression when even small volumes of injectate are
Curr Pain Headache Rep (2012) 16:9–18
placed within the foramina. The only means to avoid neural
injury is to monitor any symptoms reported during
injection, and to slow or halt the injection if symptoms
appear.
The use of deep sedation or general anesthesia during the
conduct of pain treatment techniques has been the subject
of much debate [21]. Proponents hold that sedation
improves safety by assuring that the patient will remain
relatively immobile when the needle is near critical
structures; opponents point out that deep sedation elimi-
nates the ability of the patient to report contact with neural
structures, eliminating any possibility of using the patient’s
early report of symptoms as an early warning sign of
impending neural injury. In the ASA Closed Claims study,
use of deep sedation unresponsiveness was associated with
an increase in the probability of permanent spinal cord
injury during pain treatment at the cervical spinal level
[9••]. When the patient does report a paresthesia, the
practitioner should suspect contact with a spinal nerve if
the pain is localized to an extremity or the spinal cord if the
patient reports both upper and lower extremity pain. If this
occurs, the needle should be withdrawn and redirected. The
spinal cord can be entered without producing neural injury;
however, if the spinal cord is penetrated and any substance
is injected, it is likely that neurologic injury will occur. The
neuronal disruption caused by placing injectate into the
substance of the cord appears to be what causes the most
severe injury, rather than direct trauma caused by needle
entry alone. However, if an arterial structure within the cord
is disrupted, bleeding into the cord can also produce
significant injury.
Once the needle is in final position, it is critical to use
images obtained in multiple planes to establish the final
needle position. An anteroposterior image tells little about
the needle’s depth, while a lateral image tells little about the
medial to lateral deviation of the needle. Combining the
two images, an accurate measure of the needle’s position in
three dimensions can be reconstructed (see Figs. 3 and 4).
Use of ultrasound has gained rapid acceptance for
performing peripheral nerve blocks for surgical anesthesia
[22]. Ultrasound can be used to directly visualize superfi-
cial neural structures, like the brachial plexus. The success
rate of many peripheral nerve blocks has improved with use
of ultrasound. It is less clear if ultrasound will improve the
safety of these techniques [23]. Direct intraneural injection
and intravascular injection can still occur with the use of
ultrasound. In pain treatment, use of ultrasound has not
advanced as rapidly. Pain practitioners have been using
fluoroscopy for years and fluoroscopy allows direct and
precise visualization of the bony elements of the neuraxis.
Use of ultrasound to image neuraxial structures is limited
by the echogenicity of the bony elements of the spine,
preventing direct visualization of many structures. None-
Curr Pain Headache Rep (2012) 16:9–18 15

Fig. 6 Stellate ganglion block. a AP radiograph of the cervical spine„

during stellate ganglion block at C6. The needle is in position at the
junction of the C6 transverse process and the vertebral body, just
inferior to the uncinate process of C6. Radiographic contrast (1.5 mL
of iohexol 180 mg/mL) has been injected and spreads along the
anterolateral surface of C6 to reach the adjacent vertebra. Typically, 5
to 10 mL of volume is necessary to see spread to the level of the
stellate ganglion at T1. b Anatomy relevant to stellate ganglion block
as seen on ultrasound. Transverse (short-axis) ultrasound view at the
level of the transverse process of C7. c Labeled image. Note that the
vertebral artery can be seen anterior to the echogenic transverse
process at the level of C7. The vertebral artery cannot be seen clearly
at the C6 level on ultrasound because it lies posterior to the echogenic
transverse process within the foramen transversarium. At the level of
C7, the superior margin of the thyroid is seen just lateral to the
trachea. Dashed arrow indicates the optimal trajectory for placing a
needle using an in-plane approach; for example, placing the needle in
a lateral to medial direction with the shaft in the transverse plane of
the ultrasound image AP—anteroposterior (Adapted from Rathmell
[30], with permission. Ultrasound image courtesy of Urs Eichenberger
MD, PhD, University Department of Anesthesiology and Pain
Therapy, University Hospital of Bern, Bern, Switzerland, 2011)

theless, the safety of several pain treatment techniques may

be improved by the use of ultrasound. Stellate ganglion
block is foremost among these. The position of the great
vessels of the neck, the thyroid gland, the esophagus, and
the vertebral artery can only be inferred from the position of
the bony elements of the spine using fluoroscopy (Fig. 6a).
These structures can be directly visualized using ultrasound
(Fig. 6b and c). Techniques for using ultrasound to safely
perform this block have been described [24]. The use of
ultrasound is likely to quickly replace the use of fluoros-
copy based for stellate ganglion block. The position of the
pleura during intercostal block can only be inferred from
the position of the inferior margin of the rib during
intercostal nerve block when using fluoroscopy. The
pleura and the neurovascular bundle both can be seen
directly using ultrasound, facilitating precise placement
of the injectate adjacent to the intercostal nerve while
avoiding penetration of the pleura. If a pneumothorax is
suspected after injection, M-mode ultrasound provides a
simple bedside means to detect even the smallest air
collections [25].

Prevention of Intraarterial Injection

Prevention of intravascular injection relies on the ability to

identify when the tip of a needle or catheter lies within a
vascular structure before local anesthetic or particulate
steroid is administered. The consequences of intravascular
injection depend on the vascular structure into which the
injectate is placed and the nature of the injectate. Local
anesthetic and neurolytic solutions are often administered in
relatively large doses for specific procedures. In pain
treatment, doses of local anesthetic large enough to produce procedures, like celiac plexus block. Conventional means
systemic toxicity are employed only during less common for detecting intravascular injection rely on visual evidence
16
of blood on aspiration or detection of signs and symptoms
associated with intravascular injection. Local aesthetics can
produce unique symptoms when injected into the blood
stream, including tinnitus, circumoral paresthesias, and
metallic taste, but these symptoms do not occur reliably,
particularly with more potent agents like bupivacaine.
The addition of epinephrine to the injectate in small
concentrations (eg, 1:200,000) can lead to an increase in
heart rate after intravascular injection, but this also can
be unreliable, particularly in those with cardiac disease
receiving β-blockers. Local anesthetic toxicity can occur
after either intravenous or intraarterial injection; recog-
nition and treatment have been discussed in detail in
previous reviews [26].
Intraarterial injection of particulate steroid can lead to
devastating neurologic injury. Radiographic guidance lends
a unique and sensitive means to detect intravascular needle
or catheter location, and this approach can be used to
prevent inadvertent injection of local anesthetic or steroid
into a vascular structure. Injection of radiographic contrast
into a vascular structure can only be detected reliably by
using a live technique. If contrast is injected followed by
obtaining a single static image thereafter, any contrast that
was injected intravascularly will have been carried away
from the site of injection by the passing blood flow. The
contrast must be injected under continuous x-ray exposure.
The use of digital subtraction improves visualization of
vascular structures by subtracting the baseline image and
Fig. 7 Posterior-Anterior view of the cervical spine during C7/T1
transforaminal injection, including a digital subtraction sequence after
contrast injection. An anteroposterior view of an angiogram obtained
after injection of contrast medium, before planned transforaminal
injection of corticosteroids. Left panel Image as seen on fluoroscopy.
The needle lies in the left C7/T1 intervertebral foramen. Contrast
medium outlines the spinal nerve. The spinal medullary artery (also
Curr Pain Headache Rep (2012) 16:9–18
leaving only those structures that are in motion as the image
sequence is taken (Fig. 7). Live fluoroscopy, with or
without digital subtraction, increases the sensitivity of
detecting intravascular needle location. In one series, 20%
of cervical transforaminal injections were identified with
live fluoroscopy [10], while only 20% had evidence of
blood return on aspiration [11]. The addition of digital
subtraction increases the sensitivity for detection of
intravascular location [13]. After intravascular needle
position has been ruled out using contrast injection and a
live x-ray technique, it is critical to assure that the needle
position does not move. Attaching a short flexible
extension tubing to the needle at the start of the procedure
allows the practitioner performing the injection to attach
and detach syringes to the catheter without touching the
needle, thus reducing the chance of any change in needle
position before the particulate steroid is administered.
Using this combination of live x-ray and radiographic
contrast, there have been no reports of neural injury
attributed to particulate steroid. It is important to remain
vigilant because patient movement and confusing patterns
of contrast spread can easily be missed and intravascular
needle position could be overlooked.
Prevention of Intrathecal Injection
Use of radiographic guidance and injection of small volumes
of radiographic contrast also can be used to identify when a
termed the radicular or spinal radiculomedullary artery) appears as a
thin tortuous line of contrast passing medially from the site of
injection. Right panel Digital subtraction angiogram reveals that the
spinal medullary artery extends to the midline to join the anterior
spinal artery and much of the contrast is located in the correct location
surrounding the spinal nerve (From Rathmell et al. [17], with
permission)
Curr Pain Headache Rep (2012) 16:9–18
needle has penetrated the dura. Injection of subarachnoid local
anesthetic will lead to a sensory and motor block when
administered at the lumbar level and total spinal anesthesia
accompanied by respiratory arrest when injected at the
cervical level. While the topic of ongoing debate, intrathecal
injection of particulate steroid preparations may lead to
neurotoxicity. Practitioners must learn to recognize the
characteristic patterns of epidural and intrathecal contrast
spread. It is also important to recognize unusual patterns like
the loculated posterior contrast collections that signal subdural
injection [27]. During epidural steroid injection, it is wise to
abort the procedure before placing steroid when either
subdural or intrathecal needle position is suspected.
Treatment and When to Seek Consultation
Prevention of injury is the only reliable means to assure the
safety of image-guided pain interventions. Once either
direct trauma to neural structures or intraarterial injection of
particulate steroid has occurred, there is no effective means
to improve the outcome. Immediate supportive care should
be given, including airway management, hemodynamic
resuscitation, and treatment of seizures. Diagnostic imaging
should be obtained when feasible to establish the location,
nature, and magnitude of the injury. Thereafter, transfer to
the care of a neurologist or neurosurgeon for supportive
care is likely the best route. In the case of spinal cord injury,
there is some evidence that use of high-dose intravenous
steroids after traumatic spinal cord transection can improve
neurologic outcome [28, 29], and on this basis, some
experts advocate treatment of spinal cord injury secondary
to needle trauma or ischemia in the same way. Permanent
disabling spinal cord injury is the most likely long-term
outcome [9••]. After acute stabilization, most patients will
need rehabilitation aimed at regaining functional capacity.
Conclusions
The use of image guidance has become a routine and
integral component of pain treatment; however, there is
insufficient scientific evidence to judge whether this has
improved safety. The logical appeal is overwhelming, to the
point that it is now unlikely that scientific comparisons of
most techniques with and without radiographic guidance
will ever be conducted. This article is meant to be a
pragmatic discussion of what we know about the utility of
imaging in improving the safety of interventional pain
treatments. This analysis can also serve to guide future
investigators who set out to understand how to apply new
imaging techniques, and in the process, how to rigorously
evaluate their usefulness.
17
Disclosures No potential conflicts of interest relevant to this article
were reported.
References
Papers of particular interest, published recently, have been
highlighted as:
•• Of major importance
1. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical
interventional therapies for low back pain: a review of the
evidence for an American Pain Society clinical practice guideline.
Spine (Phila Pa 1976) 2009; 34:1078–93.
2. Sethee J, Rathmell JP. Epidural steroid injections are useful for the
treatment of low back pain and radicular symptoms: pro. Curr
Pain Headache Rep. 2009;13:31–4.
3. Armon C, Argoff CE, Samuels J, Backonja MM. Therapeutics
and Technology Assessment Subcommittee of the American
Academy of Neurology. Assessment: use of epidural steroid
injections to treat radicular lumbosacral pain: report of the
Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology. Neurology. 2007;68:723–9.
4. Field J, Rathmell JP, Stephenson JH, Katz NP. Neuropathic pain
following cervical epidural steroid injection. Anesthesiology.
2000;93:885–8.
5. White AH, Derby R, Wynne G. Epidural injections for the
diagnosis and treatment of low back pain. Spine. 1980;5:78–
86.
6. Renfrew DL, Moore TE, Kathol MH, et al. Correct placement of
epidural steroid injections: fluoroscopic guidance and contrast
administration. AJNR Am J Neuroradiol. 1991;12:1003–7.
7. El-Khoury G, Ehara S, Weinstein JN, et al. Epidural steroid
injection: a procedure ideally performed with fluoroscopic control.
Radiology. 1988;168:554–7.
8. Stevens DS, Balatbat GR, Lee FM. Coaxial imaging technique for
superior hypogastric plexus block. Reg Anesth Pain Med. 2000;25
(6):643–7.
9. •• Rathmell JP, Michna E, Fitzgibbon DR, Stephens LS, Posner
KL, Domino KB. Injury and liability associated with cervical
procedures for chronic pain. Anesthesiology 2011;114:918–26.
This report details the injuries that can occur during the conduct
of pain treatment procedures at the level of the cervical spine.
Permanent, disabling spinal cord injuries do occur and most often
result from direct needle trauma to the spinal cord. Performing
procedures in patients under deep sedation or who are unresponsive
is associated with a higher risk of injury.
10. Nahm FS, Lee CJ, Lee SH, Kim TH, Sim WS, Cho HS, Park SY,
Kim YC, Lee SC. Risk of intravascular injection in transforaminal
epidural injections. Anaesthesia. 2010;65:917–21.
11. Kim do W, Han KR, Kim C, Chae YJ. Intravascular flow patterns
in transforaminal epidural injections: a comparative study of the
cervical and lumbar vertebral segments. Anesth Analg.
2009;109:233–9.
12. Rathmell JP. Toward improving the safety of transforaminal
injection. Anesth Analg. 2009;109:8–10.
13. McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD.
The rate of detection of intravascular injection in cervical
transforaminal epidural steroid injections with and without digital
subtraction angiography. PM R. 2009;1:636–42.
14. Manchikanti L, Pampati V, Boswell MV, Smith HS, Hirsch JA.
Analysis of the growth of epidural injections and costs in the
Medicare population: a comparative evaluation of 1997, 2002, and
2006 data. Pain Physician. 2010;13:199–212.
18
15. Wong GY, Brown DL. Transient paraplegia following alcohol
celiac plexus block. Reg Anesth. 1995;20:352–5.
16. Abdalla EK, Schell SR. Paraplegia following intraoperative celiac
plexus injection. J Gastrointest Surg. 1999;3:668–71.
17. Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal
injection of steroids. Anesthesiology. 2004;100:1595–600.
18. Edlow BL, Wainger BJ, Frosch MP, Copen WA, Rathmell JP, Rost
NS. Posterior circulation stroke after C1-C2 intraarticular facet
steroid injection: evidence for diffuse microvascular injury.
Anesthesiology. 2010;112:1532–5.
19. Okubadejo GO, Talcott MR, Schmidt RE, Sharma A, Patel AA,
Mackey RB, Guarino AH, Moran CJ, Riew KD. Perils of
intravascular methylprednisolone injection into the vertebral
artery. An animal study. J Bone Joint Surg Am. 2008;90:1932–8.
20. Dawley JD, Moeller-Bertram T, Wallace MS, Patel PM. Intra-arterial
injection in the rat brain: evaluation of steroids used for trans-
foraminal epidurals. Spine (Phila Pa 1976). 2009;34:1638–43.
21. Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia
in anesthetized or heavily sedated patients. Reg Anesth Pain Med.
2008;33:449–60.
22. Sites BD, Chan VW, Neal JM, Weller R, Grau T, Koscielniak-
Nielsen ZJ, Ivani G. The American society of regional anesthesia
and pain medicine and the European society of regional
anaesthesia and pain therapy joint committee recommendations
Curr Pain Headache Rep (2012) 16:9–18
for education and training in ultrasound-guided regional anesthe-
sia. Reg Anesth Pain Med. 2010;35(2 Suppl):S74–80.
23. Neal JM. Ultrasound-guided regional anesthesia and patient
safety: an evidence-based analysis. Reg Anesth Pain Med.
2010;35(2 Suppl):S59–67.
24. Gofeld M, Bhatia A, Abbas S, Ganapathy S, Johnson M. Develop-
ment and validation of a new technique for ultrasound-guided stellate
ganglion block. Reg Anesth Pain Med. 2009;34:475–9.
25. Ueda K, Ahmed W, Ross AF. Intraoperative pneumothorax identified
with transthoracic ultrasound. Anesthesiology. 2011;115:653–5.
26. Neal JM, Bernards CM, Butterworth 4th JF, Di Gregorio G,
Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW,
Weinberg GL. ASRA practice advisory on local anesthetic
systemic toxicity. Reg Anesth Pain Med. 2010;35:152–61.
27. Ajar AH, Rathmell JP, Mukherji SK. The subdural compartment.
Reg Anesth Pain Med. 2002;27:72–6.
28. Delamarter RB, Coyle J. Acute management of spinal cord injury.
J Am Acad Orthop Surg. 1999;7:166–75.
29. Kwon BK, Tetzlaff W, Grauer JN, Beiner J, Vaccaro AR.
Pathophysiology and pharmacologic treatment of acute spinal cord
injury. Spine J. 2004;4:451–64. Anesthesiology 2011;115:653–5.
30. Rathmell JP. Atlas of image guided intervention in regional
anesthesia and pain medicine. Philadelphia: Lippincott Williams
and Wilkins; 2012 (in press).