The practice of cervical transforaminal injection of steroids deserves more scrutiny.

Pain Physician Vol. 8, No. 3, 2005 To the Editor: Over the past few years, multiple articles have appeared on the subject of transforaminal epidural steroid injections. Reports of devastating neurological injuries, including death and paraplegia, fuel concern for transforaminal epidural injections (1-5). There is also a widely-held belief that many cases of severe spinal cord injury have gone unpublished because of medico legal concerns. Cervical transforaminal epidural steroid injections (CTESI), in particular, appear to pose an inherently higher risk because the solution is injected in proximity to spinal cord radicular arteries. The exact mechanism of injury is poorly understood, but may involve the distal embolization of steroid particles leading to spinal cord ischemia (6). Because of the evolving nature of this discussion, I would like to draw attention to certain aspects that deserve further scrutiny. Although it is acknowledged that real-time fluoroscopic visualization of radiographic contrast dispersal, including digital subtraction imaging, may reduce the incidence of inadvertent arterial injections, little emphasis has been placed on the use of a separate local anesthetic test dose. Most publications have described injections of local anesthetic and steroid mixtures after radiographic contrast confirmation of adequate dispersal (1-4, 6-9). It is conceivable that inadvertent intra-arterial injections have gone undetected. It has long been known, however, that small volumes of local anesthetic accidentally injected intra-arterially around the head and neck may result in easily recognizable symptoms (10). Detection of signs of local anesthetic toxicity may allow the physician to The Practice of Cervical Transforaminal Injection of Steroids Deserves More Scrutiny