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Nikolai Bogduk - One of the best experts on this subject based on the ideXlab platform.
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SPINE SECTION: CASE REPORT Temporary Neurologic Deficit After Cervical Transforaminal Injection of Local Anesthetic
2016Co-Authors: Michael Karasek, Nikolai BogdukAbstract:Objective. To describe the effects of spinal cord block after injection of local anesthetic into a cer- vical Radicular Artery. Design. Case report. Setting. Neurology practice specializing in spinal pain. Interventions. A patient underwent a C6-7 transforaminal injection. Contrast medium indicated correct and safe placement of the needle. Results. After the injection of local anesthetic, the patient developed quadriplegia. The injection was terminated. The neurologic impairment resolved after 20 minutes observation. Conclusion. Despite correct placement of the needle for a cervical transforaminal injection, injec- tate may nevertheless enter a cervical Radicular Artery. Whereas local anesthetic, so injected, appears to have only a temporary effect on spinal cord function, particulate steroids may act as an embolus and cause permanent impairment.
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Temporary neurologic deficit after cervical transforaminal injection of local anesthetic.
Pain medicine (Malden Mass.), 2004Co-Authors: Michael Karasek, Nikolai BogdukAbstract:Objective To describe the effects of spinal cord block after injection of local anesthetic into a cervical Radicular Artery. Design Case report. Setting Neurology practice specializing in spinal pain. Interventions A patient underwent a C6–7 transforaminal injection. Contrast medium indicated correct and safe placement of the needle. Results After the injection of local anesthetic, the patient developed quadriplegia. The injection was terminated. The neurologic impairment resolved after 20 minutes observation. Conclusion Despite correct placement of the needle for a cervical transforaminal injection, injectate may nevertheless enter a cervical Radicular Artery. Whereas local anesthetic, so injected, appears to have only a temporary effect on spinal cord function, particulate steroids may act as an embolus and cause permanent impairment.
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cervical transforaminal injection of corticosteroids into a Radicular Artery a possible mechanism for spinal cord injury
Pain, 2003Co-Authors: Ray M Baker, Paul Dreyfuss, Susan R Mercer, Nikolai BogdukAbstract:Spinal cord injury has been recognized as a complication of cervical transforaminal injections, but the mechanism of injury is uncertain. In the course of a transforaminal injection, an observation was made after the initial injection of contrast medium. The contrast medium filled a Radicular Artery that passed to the spinal cord. The procedure was summarily abandoned, and the patient suffered no ill effects. This case demonstrates that despite using careful and accurate technique, it is possible for material to be injected into a Radicular Artery. Consequently, inadvertent injection of corticosteroids into a Radicular Artery may be the mechanism for spinal cord injury following transforaminal injections. This observation warns operators to always perform a test injection of contrast medium, and carefully check for arterial filling using real-time fluoroscopy with digital subtraction. (C) 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.
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Cervical transforaminal injection of corticosteroids into a Radicular Artery: a possible mechanism for spinal cord injury.
Pain, 2003Co-Authors: Ray Baker, Paul Dreyfuss, Susan Mercer, Nikolai BogdukAbstract:Spinal cord injury has been recognized as a complication of cervical transforaminal injections, but the mechanism of injury is uncertain. In the course of a transforaminal injection, an observation was made after the initial injection of contrast medium. The contrast medium filled a Radicular Artery that passed to the spinal cord. The procedure was summarily abandoned, and the patient suffered no ill effects. This case demonstrates that despite using careful and accurate technique, it is possible for material to be injected into a Radicular Artery. Consequently, inadvertent injection of corticosteroids into a Radicular Artery may be the mechanism for spinal cord injury following transforaminal injections. This observation warns operators to always perform a test injection of contrast medium, and carefully check for arterial filling using real-time fluoroscopy with digital subtraction.
Franklin L Irwin - One of the best experts on this subject based on the ideXlab platform.
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Alternative approach for lumbar transforaminal epidural steroid injections.
Pain physician, 2011Co-Authors: Jie Zhu, Frank J E Falco, Ferdinand Formoso, Obi Onyewu, Franklin L IrwinAbstract:The traditional superoanterior approach for transforaminal epidural steroid injection (TFESI) carries a risk of complication by obstructing arterial flow to the anterior portion of the spinal cord by puncturing the spinal Radicular Artery that passes through the superoanterior foraminal zone or "safe triangle" zone, which does not describe vascular safety, but rather describes neural safety. Consequently, multiple disasters have been described in recent years with transforaminal epidural injections. They are utilized extensively even though their effectiveness has been debated. Here we describe a dorsal technique through transforaminal epidural injections to place the tip of the needle immediately dorsal to the dorsal root ganglion. Multiple different techniques have been discussed and described in recent years, the majority of them to avoid the Radicular Artery injection. The primary goal of this paper is to describe another posterior approach to place the tip of spinal needle directly toward the posterior epidural space to avoid puncturing the spinal Radicular Artery and minimize nerve root penetrations while delivering medication into the epidural space through the foramen.
Paul Verrills - One of the best experts on this subject based on the ideXlab platform.
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Reply to Comment on: Penetration of a Cervical Radicular Artery during a Transforaminal Epidural Injection
Pain Medicine, 2010Co-Authors: Paul VerrillsAbstract:Dear Editor, In the letter authored by Dr. Milton Landers, I note that he goes to some lengths to imply that the rationale for the intra-arterial injection recorded and presented in our publication is due to inappropriate needle position. I believe that his commentary is flawed on numerous grounds. The International Spine Intervention Society (ISIS) Guidelines are certainly the preeminent reference for interventional spinal procedures at this time. However, both Dr. Landers and the ISIS Guidelines do not provide any proof that the position of the needle in …
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Penetration of a Cervical Radicular Artery During a Transforaminal Epidural Injection
Pain medicine (Malden Mass.), 2010Co-Authors: Paul Verrills, Gillian Nowesenitz, A. BarnardAbstract:Background. Inadvertent cannulation or penetration of the cervical Radicular arteries during cervical transformaminal epidural injections (TFESIs) is a serious clinical risk, and purportedly, the cause of possible spinal cord injury sustained during this procedure. Case. Here, we present a case of inadvertent intravascular penetration of a cervical Radicular Artery during a C5–6 TFESI and demonstrate the best image capture to date of direct ramification of a cervical Radicular Artery into the anterior spinal Artery. Conclusion. This observation reinforces the need for contrast injection and real-time digital subtraction fluoroscopy during cervical TFESIs for the prevention of spinal cord injury and fatalities.
Bernd Turowski - One of the best experts on this subject based on the ideXlab platform.
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unique sacral location of an arteriovenous fistula of the filum terminale associated with diastematomyelia and lowered spinal cords
Neuroradiology, 2012Co-Authors: Stephan Macht, Rene Chapot, Frank Bieniek, Daniel Hanggi, Bernd TurowskiAbstract:Dear Sir, An arteriovenous fistula of the filum terminale arising from the Artery of the filum terminale has recently been reported. Other authors report spinal dural and arteriovenous fistulae with lateral sacral Artery supply [1–4]. We wish to bring to your attention an arteriovenous fistula of the filum terminale supplied by a lateral sacral Artery associated with diastematomyelia and a tethered spinal cord in a 57-year old man. The patient suffered a progressive paraparesis for 3 weeks. At admission, the paraparesis was severe and accompanied by anal sphincter disturbances. MRI of the lumbar spinal canal (Fig. 1) showed a split and tethered spinal cord ending in the sacral spinal canal in an intraspinal lipoma. Moreover, there was extensive edema of the thoracic, lumbar, and sacral segments of the spinal cord as well as pathologic flow voids surrounding the myelum, suggesting a spinal arteriovenous fistula. A digital subtraction angiography (Fig. 2) revealed an arteriovenous fistula of the filum terminale at level S3-S4 fed by an enlarged anterior spinal Artery, filling via a large sacral Radicular Artery arising from segment S2 with main supply from the left hypogastric Artery. Drainage of the fistula occurred via enlarged perimedullary veins. At higher levels, no other segments of the Artery of Adamkiewicz could be observed, but an additional tiny Radicular Artery filling the anterior spinal Artery was found at level Th9 on the left. After introduction of a crossover sheath in the left internal iliac Artery, a flow-directed microcatheter (MagicR, Balt Extrusion, Montmorency, France) was navigated via the supplying left S2-Radicular Artery into the anterior spinal Artery up to the level of the shunt. Embolization was performed with a mixture of acrylic glue (Histoacryl, Braun, Tuttlingen, Germany) and lipiodol (Lipiodol UF, Guerbet, France) in a concentration of 1:4 enabling an angiographic cure of the fistula (Fig. 3). During the postoperative phase, there was some improvement of the paraparesis. Spinal vascular malformations are rare [5–7]. Seventy percent of all spinal vascular malformations are spinal dural arteriovenous fistulae that induce progressive neurologic symptoms [8]. The arteriovenous malformations can be divided into intramedullary and perimedullary types [7, 9]. Spinal cord arteriovenous malformations at the sacral level can be of two types: first, the dural arteriovenous fistulae arising at a sacral level as reported by Mhiri et al. [2] or at the conus medullaris [3, 4] and then the arteriovenous fistulae of the filum terminale, which are single-shunt arteriovenous fistulae fed by an anterior spinal S. Macht (*) :B. Turowski Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Moorenstrasse 5, 40225 Dusseldorf, Germany e-mail: stephan.macht@med.uni-duesseldorf.de
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Unique sacral location of an arteriovenous fistula of the filum terminale associated with diastematomyelia and lowered spinal cords.
Neuroradiology, 2011Co-Authors: Stephan Macht, Rene Chapot, Frank Bieniek, Daniel Hanggi, Bernd TurowskiAbstract:Dear Sir, An arteriovenous fistula of the filum terminale arising from the Artery of the filum terminale has recently been reported. Other authors report spinal dural and arteriovenous fistulae with lateral sacral Artery supply [1–4]. We wish to bring to your attention an arteriovenous fistula of the filum terminale supplied by a lateral sacral Artery associated with diastematomyelia and a tethered spinal cord in a 57-year old man. The patient suffered a progressive paraparesis for 3 weeks. At admission, the paraparesis was severe and accompanied by anal sphincter disturbances. MRI of the lumbar spinal canal (Fig. 1) showed a split and tethered spinal cord ending in the sacral spinal canal in an intraspinal lipoma. Moreover, there was extensive edema of the thoracic, lumbar, and sacral segments of the spinal cord as well as pathologic flow voids surrounding the myelum, suggesting a spinal arteriovenous fistula. A digital subtraction angiography (Fig. 2) revealed an arteriovenous fistula of the filum terminale at level S3-S4 fed by an enlarged anterior spinal Artery, filling via a large sacral Radicular Artery arising from segment S2 with main supply from the left hypogastric Artery. Drainage of the fistula occurred via enlarged perimedullary veins. At higher levels, no other segments of the Artery of Adamkiewicz could be observed, but an additional tiny Radicular Artery filling the anterior spinal Artery was found at level Th9 on the left. After introduction of a crossover sheath in the left internal iliac Artery, a flow-directed microcatheter (MagicR, Balt Extrusion, Montmorency, France) was navigated via the supplying left S2-Radicular Artery into the anterior spinal Artery up to the level of the shunt. Embolization was performed with a mixture of acrylic glue (Histoacryl, Braun, Tuttlingen, Germany) and lipiodol (Lipiodol UF, Guerbet, France) in a concentration of 1:4 enabling an angiographic cure of the fistula (Fig. 3). During the postoperative phase, there was some improvement of the paraparesis. Spinal vascular malformations are rare [5–7]. Seventy percent of all spinal vascular malformations are spinal dural arteriovenous fistulae that induce progressive neurologic symptoms [8]. The arteriovenous malformations can be divided into intramedullary and perimedullary types [7, 9]. Spinal cord arteriovenous malformations at the sacral level can be of two types: first, the dural arteriovenous fistulae arising at a sacral level as reported by Mhiri et al. [2] or at the conus medullaris [3, 4] and then the arteriovenous fistulae of the filum terminale, which are single-shunt arteriovenous fistulae fed by an anterior spinal S. Macht (*) :B. Turowski Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Moorenstrasse 5, 40225 Dusseldorf, Germany e-mail: stephan.macht@med.uni-duesseldorf.de
Marc A Huntoon - One of the best experts on this subject based on the ideXlab platform.
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anatomy of the cervical intervertebral foramina vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections
Pain, 2005Co-Authors: Marc A HuntoonAbstract:Cervical transforaminal epidural steroid injections are performed for the treatment of Radicular pain. Multiple recent case reports have raised safety concerns regarding neurologic deficits such as anterior spinal Artery syndrome and cerebellar injury after these injections. To investigate the potential causes of these injuries, an anatomic study was conducted. In this study of 10 embalmed cadavers, the cervical intervertebral foramina were examined to determine if the ascending or deep cervical arteries supplied Radicular or segmental medullary arteries potentially susceptible to cannulation or needle trauma during transforaminal injection. In two specimens, dissection was carried down to the spinal cord, demonstrating the anterior spinal, Radicular, and segmental medullary arteries. Of 95 intervertebral foramina dissected, 21 had an arterial vessel proximal to the posterior aspect of the foraminal opening. Seven of these 21 were spinal branches that entered the foramen posteriorly, potentially forming Radicular or segmental medullary vessels to the spinal cord. One additional ascending cervical Artery formed a segmental medullary Artery that joined the anterior spinal Artery. This would only be injured by anterior needle misplacement. Of the seven foraminal branches, three were included in the deep dissections. Two contributed to segmental medullary arteries and one to a Radicular Artery. Variable anastomoses between the vertebral and cervical arteries were found. Therefore, it is possible to introduce steroid particles into the vertebral circulation via the cervical arteries. Critical arteries are located in the posterior aspect of the intervertebral foramen and may be vulnerable to injection or injury during transforaminal epidural steroid injection.