Skip to main content
Advertisement

Main menu

  • Home
  • Content
    • Current Issue
    • Accepted Manuscripts
    • Article Preview
    • Past Issue Archive
    • Video Articles
    • AJNR Case Collection
    • Case of the Week Archive
    • Case of the Month Archive
    • Classic Case Archive
  • Special Collections
    • AJNR Awards
    • Low-Field MRI
    • Alzheimer Disease
    • ASNR Foundation Special Collection
    • Photon-Counting CT
    • View All
  • Multimedia
    • AJNR Podcasts
    • AJNR SCANtastic
    • Trainee Corner
    • MRI Safety Corner
    • Imaging Protocols
  • For Authors
    • Submit a Manuscript
    • Submit a Video Article
    • Submit an eLetter to the Editor/Response
    • Manuscript Submission Guidelines
    • Statistical Tips
    • Fast Publishing of Accepted Manuscripts
    • Graphical Abstract Preparation
    • Imaging Protocol Submission
    • Author Policies
  • About Us
    • About AJNR
    • Editorial Board
    • Editorial Board Alumni
  • More
    • Become a Reviewer/Academy of Reviewers
    • Subscribers
    • Permissions
    • Alerts
    • Feedback
    • Advertisers
    • ASNR Home

User menu

  • Alerts
  • Log in

Search

  • Advanced search
American Journal of Neuroradiology
American Journal of Neuroradiology

American Journal of Neuroradiology

ASHNR American Society of Functional Neuroradiology ASHNR American Society of Pediatric Neuroradiology ASSR
  • Alerts
  • Log in

Advanced Search

  • Home
  • Content
    • Current Issue
    • Accepted Manuscripts
    • Article Preview
    • Past Issue Archive
    • Video Articles
    • AJNR Case Collection
    • Case of the Week Archive
    • Case of the Month Archive
    • Classic Case Archive
  • Special Collections
    • AJNR Awards
    • Low-Field MRI
    • Alzheimer Disease
    • ASNR Foundation Special Collection
    • Photon-Counting CT
    • View All
  • Multimedia
    • AJNR Podcasts
    • AJNR SCANtastic
    • Trainee Corner
    • MRI Safety Corner
    • Imaging Protocols
  • For Authors
    • Submit a Manuscript
    • Submit a Video Article
    • Submit an eLetter to the Editor/Response
    • Manuscript Submission Guidelines
    • Statistical Tips
    • Fast Publishing of Accepted Manuscripts
    • Graphical Abstract Preparation
    • Imaging Protocol Submission
    • Author Policies
  • About Us
    • About AJNR
    • Editorial Board
    • Editorial Board Alumni
  • More
    • Become a Reviewer/Academy of Reviewers
    • Subscribers
    • Permissions
    • Alerts
    • Feedback
    • Advertisers
    • ASNR Home
  • Follow AJNR on Twitter
  • Visit AJNR on Facebook
  • Follow AJNR on Instagram
  • Join AJNR on LinkedIn
  • RSS Feeds

AJNR Awards, New Junior Editors, and more. Read the latest AJNR updates

Letter

Is There a Need for Contrast and Local Anesthetic in Cervical Epidural Steroid Injections?

M.P. Bolger, P.J. MacMahon and E.C. Kavanagh
American Journal of Neuroradiology September 2016, 37 (9) E61; DOI: https://doi.org/10.3174/ajnr.A4881
M.P. Bolger
aDepartment of Radiology Mater Misericordiae University Hospital Dublin, Ireland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for M.P. Bolger
P.J. MacMahon
aDepartment of Radiology Mater Misericordiae University Hospital Dublin, Ireland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for P.J. MacMahon
E.C. Kavanagh
aDepartment of Radiology Mater Misericordiae University Hospital Dublin, Ireland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for E.C. Kavanagh

We read with great interest the recent article by Lagemann et al1 regarding the extraforaminal needle tip position for CT-fluoroscopic cervical transforaminal epidural steroid injections to reduce the risk of intravascular injection.

The technique for injection is outlined in the “Materials and Methods” section. The authors administered a trial dose of 0.3 mL of iohexol contrast (Omnipaque 300; GE Healthcare, Piscataway, New Jersey) to determine whether the needle was intravascular, followed by a cocktail of 1.2 mL of 2.5–5 mg/mL of bupivacaine analgesic, 8 mg of dexamethasone, and 0.3 mL of iohexol.

First, we question the use of bupivacaine in transforaminal epidural steroid injections. The inadvertent intravascular injection of bupivacaine has been associated with vasospasms of arterioles and increases the risk of CNS infarction.2 There is also no lasting analgesic benefit from the extraforaminal injection of local anesthetic; thus, we propose the use of local anesthetic to the skin at the time of induction of the needle and none further in the procedure.

As highlighted in our Letter previously published in this journal, we question the use of contrast in cervical injections.3 The inclusion of contrast gives the radiologist a false sense of security (as seen in the article by Lagemann et al with over half [55%] of the intravascular injections of dexamethasone having no evidence of the intravascular positioning on the trial contrast dose). Real-time imaging, such as digital subtraction angiography, would be needed to accurately detect the intravascular injection. Evidence shows that dexamethasone is likely safe when inadvertently injected intravascularly.4,5 By including contrast in this cocktail, you also introduce the risk of contrast reaction. Given the lack of adverse events with intravascular injection of dexamethasone and the poor sensitivity for identifying intravascular positioning, we propose the omission of contrast from this procedure.

In our center during the past 8 years of transforaminal extraforaminal injections with this technique, there have been no adverse events. We propose the use of a small volume of 1% lidocaine to the skin and 2–8 mg of dexamethasone injected extraforaminally under CT guidance.

References

  1. 1.
    1. Lagemann GM,
    2. Yannes MP,
    3. Ghodadra A, et al
    . CT-fluoroscopic cervical transforaminal epidural steroid injections: extraforaminal needle tip position decreases risk of intravascular injection. AJNR Am J Neuroradiol 2016;37:766–72 doi:10.3174/ajnr.A4603 pmid:26611993
  2. 2.
    1. MacMahon PJ,
    2. Eustace SJ,
    3. Kavanagh EC
    . Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology 2009;252:647–61 doi:10.1148/radiol.2523081929 pmid:19717750
  3. 3.
    1. Ryan TM,
    2. Kavanagh EC,
    3. MacMahon PJ
    . Is there a need for contrast administration prior to CT-guided cervical nerve root block? AJNR Am J Neuroradiol 2013;34:E45 doi:10.3174/ajnr.A3544 pmid:23493897
  4. 4.
    1. Scanlon GC,
    2. Moeller-Bertram T,
    3. Romanowsky SM, et al
    . Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine 2007;32:1249–56 doi:10.1097/BRS.0b013e318053ec50 pmid:17495784
  5. 5.
    1. Okubadejo GO,
    2. Talcott MR,
    3. Schmidt RE, et al
    . Perils of intravascular methylprednisolone injection into the vertebral artery: an animal study. J Bone Joint Surg Am 2008;90:1932–38 doi:10.2106/JBJS.G.01182 pmid:18762654
  • © 2016 by American Journal of Neuroradiology
Advertisement

Indexed Content

  • Current Issue
  • Accepted Manuscripts
  • Article Preview
  • Past Issues
  • Editorials
  • Editor's Choice
  • Fellows' Journal Club
  • Letters to the Editor
  • Video Articles

Cases

  • Case Collection
  • Archive - Case of the Week
  • Archive - Case of the Month
  • Archive - Classic Case

More from AJNR

  • Trainee Corner
  • Imaging Protocols
  • MRI Safety Corner
  • Book Reviews

Multimedia

  • AJNR Podcasts
  • AJNR Scantastics

Resources

  • Turnaround Time
  • Submit a Manuscript
  • Submit a Video Article
  • Submit an eLetter to the Editor/Response
  • Manuscript Submission Guidelines
  • Statistical Tips
  • Fast Publishing of Accepted Manuscripts
  • Graphical Abstract Preparation
  • Imaging Protocol Submission
  • Evidence-Based Medicine Level Guide
  • Publishing Checklists
  • Author Policies
  • Become a Reviewer/Academy of Reviewers
  • News and Updates

About Us

  • About AJNR
  • Editorial Board
  • Editorial Board Alumni
  • Alerts
  • Permissions
  • Not an AJNR Subscriber? Join Now
  • Advertise with Us
  • Librarian Resources
  • Feedback
  • Terms and Conditions
  • AJNR Editorial Board Alumni

American Society of Neuroradiology

  • Not an ASNR Member? Join Now

© 2025 by the American Society of Neuroradiology All rights, including for text and data mining, AI training, and similar technologies, are reserved.
Print ISSN: 0195-6108 Online ISSN: 1936-959X

Powered by HighWire