Digital Subtraction Angiography Use During Epidural Steroid Injections Does Not Reliably Distinguish Artery from Vein

Area of Science:

• Interventional Pain Management
• Medical Imaging Techniques
• Neurology

Background:

• Epidural steroid injections (ESIs) are common pain management procedures, with transforaminal approaches carrying risks of severe complications.
• Digital subtraction angiography (DSA) is a fluoroscopic technique proposed to detect arterial needle placement during ESIs, aiming to prevent adverse events.
• Catastrophic complications from ESIs are often linked to inadvertent arterial injection of steroids or local anesthetics.

Purpose of the Study:

• To review the scientific literature and determine if digital subtraction angiography (DSA) can differentiate between arterial and venous uptake during epidural injections.
• To assess the efficacy of DSA as a safety measure in interventional pain management.

Main Methods:

• A narrative review of existing scientific pain literature was conducted.
• A PubMed search utilized keywords including 'digital subtraction angiography,' 'epidural,' 'fluoroscopy,' 'intravascular injection,' 'paraplegia,' and 'quadriplegia.'
• Studies were screened according to PRISMA guidelines, with 10 articles selected for review based on inclusion/exclusion criteria.

Main Results:

• While studies suggest DSA can detect vascular spread, none conclusively demonstrated its ability to specifically identify arterial spread.
• The reviewed literature did not provide significant evidence of DSA's capability to predict or prevent arterial injection during ESIs.
• The potential benefit of detecting arterial contrast spread during fluoroscopy remains theoretical, as specific arterial detection by DSA is not well-reported.

Conclusions:

• Current scientific evidence does not support the use of digital subtraction angiography (DSA) for predicting arterial spread during epidural steroid injections.
• DSA exposes patients and practitioners to increased radiation levels without demonstrable improvements in safety parameters.
• Further research is needed to evaluate alternative or improved methods for ensuring safety during transforaminal epidural injections.