Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections

• Published in: The spine journal 2010-10, Vol.10 (10), p.857-864
• Main Authors: Smuck, Matthew, MD, Maxwell, Matthew D., MD, Kennedy, David, MD, Rittenberg, Joshua D., MD, Lansberg, Maarten G., MD, PhD, Plastaras, Christopher T., MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Anesthetics, Local - administration & dosage; Angiography, Digital Subtraction; Blood Vessels - injuries; Cervical Vertebrae; Epidural; Female; Humans; Injection; Injections, Epidural - adverse effects; Injections, Epidural - methods; Male; Middle Aged; Orthopedics; Retrospective Studies; Spine; Test dose; Transforaminal; Young Adult
• ISSN: 1529-9430; 1878-1632
• DOI: 10.1016/j.spinee.2010.07.003

Abstract Background context Reports of serious complications from cervical transforaminal epidural corticosteroid injections often consider accidental intra-arterial injection the most likely mechanism of injury. As a result, many physicians have instituted methods to prevent intravascular injections. Routine use of the anesthetic test dose is one such method. The utility of the anesthetic test dose in this function has not been characterized in the current literature. Purpose The aim of this study was to determine the utility of injecting an anesthetic test dose before cervical transforaminal epidural corticosteroid injection and estimate the rate of false-negative intravascular contrast injection using live fluoroscopy and digital subtraction angiography (DSA). Study design Two-center retrospective study. Patient sample A consecutive cohort of men and women, ages of 23 to 83, who underwent cervical transforaminal epidural injection and received the anesthetic test dose after contrast injection was negative for vascular uptake, observed using live fluoroscopy or DSA. Outcome measures Response to the anesthetic test dose was documented in each procedure note and recorded as either positive or negative. Methods Records of three physiatrists at two academic spine centers (Center A and Center B) were reviewed to identify all patients who received a cervical transforaminal epidural injection during the preceding 5 years, resulting in a cohort of consecutively treated patients at each center. Each patient record was reviewed for demographics, indication for injection, procedure level and side, needle gauge, use of DSA, volume and type of anesthetic test dose used, and result of test dose injection. The test dose was considered positive if the following occurred: agitation or other sudden central nervous system change; gross motor deficits and/or paresthesias in the trunk, legs, or contralateral arm; systemic symptoms of anesthetic toxicity including cardiac arrhythmia, perioral numbness, metallic taste, dizziness, and/or ringing in the ear. For analysis, injections were separated into groups to compare results at Center A to Center B and to compare injections that used DSA to those that did not. The incidence of a positive response was calculated as a percentage from the total number of injections in the group. Differences between groups were analyzed for statistical significance using the Fisher exact test. Results Six hundred seventy-eight injections were inc