September-October 2017

CT Fluoroscopic Cervical Transforaminal Epidural Steroid Injections: Extraforaminal Needle Tip Position Decreases Risk of Intravascular Injection

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Gerritt Lagemann

Transforaminal epidural steroid injections (TFESIs) are commonly performed in the evaluation and treatment of radicular neuropathy. Although TFESIs are widely performed in the lumbar spine, many proceduralists are reluctant to perform cervical TFESIs due to the risk of rare but serious complications such as posterior circulation stroke and spinal cord infarct. These complications are commonly thought to be caused by the accidental intravascular injection of steroids.

We hoped to find a relatively safe needle tip position for cervical TFESIs. Noting that CT allows excellent planar localization of the procedural needle relative to the patient’s adjacent vascular, soft-tissue, and osseous structures, we performed a retrospective review of single-site CT fluoroscopic cervical TFESIs over a 13-month period to determine whether a relationship exists between needle tip depth relative to the targeted neural foramen and accidental vascular injection of procedural contrast.

Our work was presented at the 2015 ASNR Annual Meeting and published in AJNR in April 2016. We found a statistically lower rate (P < .001) of accidental vascular injection when the needle tip was in a more superficial, extraforaminal position, which we defined as more than 2 mm superficial to an imaginary line connecting the adjacent anterolateral vertebral body and the lateral margin of the facet joint. We concluded that an extraforaminal needle tip position may be safer than other needle tip positions.

As a result of this work, we as a group have become less aggressive with needle positioning for our cervical TFESIs. We have subsequently shown with lumbar TFESIs an analogous correlation between needle tip position and accidental vascular injection.1 In future work, we hope to investigate further the ideal cervical TFESI procedural technique by evaluating a correlation between cervical TFESI needle tip position and procedural pain relief efficacy.


  1. Yu RK, Lagemann GM, Ghodadra A, et al. Extraforaminal needle tip position reduces risk of intravascular injection in CT-fluoroscopic lumbar transforaminal epidural steroid injection. J Spine Surg 2016;2:246–55, 10.21037/jss.2016.09.04.

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