Lumbosacral epiduroscopy complicated by intravascular injection.

INTRAVASCULAR injection, either intraarterial or intravenous, is an undesired event that can occur during attempted epidural injections through needles and catheters. When it occurs, it is attributed to entry of the needle or catheter into a blood vessel. There are no reports in the literature of this being observed during epiduroscopy. We report two cases of intravascular appearance of radiopaque contrast material on fluoroscopy during injection through the working channel of an epiduroscope that we believe cannot be explained by entry of the epiduroscope tip into an epidural blood vessel. No previous reports of intravascular injections during epiduroscopy were found. Lumbosacral epiduroscopy is a relatively new technique used in the diagnosis and treatment of low back pain and/or radiculopathy involving the lower extremities. All available epiduroscopes transmit light to illuminate the epidural space and transmit images from the space back to an observer. Other features include a working channel through which saline, radiopaque contrast material, and drugs can be injected and instruments can be introduced, and a mechanism for steering the tip of the epiduroscope. The round tip of the flexible epiduroscope used for the cases reported here (Storz Epiduroscope, Karl Storz, Tuttlingen, Germany) is 2.8 mm in diameter, and the end is flat. The end has a 1-mm opening for the working channel plus a lens for light delivery and one for transmission of optical images. Epiduroscopes usually are inserted via access established through the sacral hiatus and advanced cephalad to areas of interest (usually not beyond L2). Fluoroscopy is used intermittently during epiduroscopy. Saline is infused to expand the epidural space and wash away extravascular blood and tissue debris to facilitate visual inspection. After a site of pathology is found and examined, treatment is begun, which usually consists of hyaluronidase injection and application of hydrostatic and/or mechanical forces to remove barriers to fluid flow, and local anesthetic and corticosteroid injection. Before and during treatment, radiopaque contrast material usually is injected to confirm that injected fluids (1) do not go intravascular and (2) distribute as intended in the epidural space and/or through a targeted intervertebral foramen.