Complications

It is important for the injectionist to be aware that the vertebral artery lies anterior to the spinal nerve and anterior ramus within the foramen (Fig. 14). A radicular artery is present anterior to the nerve and may have a communication with the anterior spinal artery supplying the spinal cord.

The most serious complication to avoid is the injection of particulate corticosteriod into the anterior spinal artery, which can lead to irreversible and sudden central cord infarction (39,40). The inadvertent injection of local anesthetic in the subarachnoid space may induce high spinal anesthesia with potential pulmonary arrest. The perforation of an epidural vein can also lead to epidural hematoma (21).

FIGURE 14 (A) Axial computed tomography (CT) scan C7-T1 with infusion. The arrow delineates the needle course to abut the posterior lateral wall of the foramen. Note that the position is posterior to the vertebral artery and the carotid bundle. (B) Axial CT scan. A 22-gauge needle is parallel to the posterior cortex of the foramen. Contrast outlines the C8 spinal nerve before administration of the corticosteroid. (C) Axial CT scan C4-C5. The carotid vascular bundle (arrow) is lateral to the foramen, and the vertebral artery (arrowhead ) is anterior to the foramen. (D) Axial CT scan at C5-C6. Severe foraminal stenosis. Note the close proximity of the vertebral artery to the posterior wall cortex.

FIGURE 14 (A) Axial computed tomography (CT) scan C7-T1 with infusion. The arrow delineates the needle course to abut the posterior lateral wall of the foramen. Note that the position is posterior to the vertebral artery and the carotid bundle. (B) Axial CT scan. A 22-gauge needle is parallel to the posterior cortex of the foramen. Contrast outlines the C8 spinal nerve before administration of the corticosteroid. (C) Axial CT scan C4-C5. The carotid vascular bundle (arrow) is lateral to the foramen, and the vertebral artery (arrowhead ) is anterior to the foramen. (D) Axial CT scan at C5-C6. Severe foraminal stenosis. Note the close proximity of the vertebral artery to the posterior wall cortex.

Direct puncture of the spinal cord has been reported by Hodges et al. (41). In their report, the needle tip was placed into the spinal canal without the injectionist being aware of its initial position prior to the injection of a corticosteroid due to incomplete fluoroscopic assessment, AP fluoroscopic assessment. In a series of 1036 fluoroscopically guided extraforaminal cervical nerve blocks in 844 patients Ma et al. reported only 1.66% minor complications with this procedure without catastrophic complications (42).

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