869 - Vascular uptake in the Aorta in Lumbar Transforaminal Epidural Steroid Injection

Case Diagnosis: L3-L4 Lumbar Radiculopathy

Case Description: A 62 year old female presents to the interventional pain clinic for continued lumbar radiuclopathy, despite undergoing conservative treatment. She had a history of lumbar fusion at L4-L5 and L5-S1. CT lumbar spine showed healed L4-L5 and L5-S1 fusions with multiple levels of neuroforaminal stenosis, most significant at L3-L4 bilaterally. She was referred for a bilateral L3-L4 transformational epidural steroid injection (TFESI). Physical exam findings included limited lumbar range of motion, with accentuation of pain in flexion. Strength was 4/5 in the left lower extremity (L3 dermatome), with decreased sensation to light touch of this extremity, with equal 2+ reflexes in the lower extremities. The patient first underwent a right L3-L4 TFESI which was performed without any complications. Upon injecting contrast for the left L3-L4 TFESI, vascular uptake was noted with flow entering into the aorta as confirmed by a lateral image, therefore, the procedure was aborted.

Discussions: The L3-L4 spinal regions have the highest risk of vascular uptake due to the artery of adamkiewicz. This makes it vascular uptake in this region a very high risk procedure, with the potential to be detrimental. Therefore, it is vital to first inject contrast and verify that there is no vascular intrathecal uptake to ensure epidural spread. Secondly, it is very important to inject contrast under live fluoroscopy, using digital subtraction angiography (DSA) if available.

Conclusions: It is of the utmost importance to use a nonparticulate steroid in any region with a higher risk of vascular uptake, as if one were to miss vascular uptake on contrast, injecting a particulate steroid could be extremely harmful.