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ANALGESIA

Intravascular Injection in Lumbar Medial Branch Block: A Prospective Evaluation of 1433 Injections

Chul Joong Lee, MD, PhD^*, Yong Chul Kim, MD, PhD, Jae Hyuck Shin, MD, Francis Sahngun Nahm, MD, Hyo Min Lee, MD, Yun Suk Choi, MD, Sang Chul Lee, MD, PhD, Justin Sang Ko, MD^*, Tae Hyeong Kim, MD^*, Woo Seok Sim, MD, PhD^*, Chung Su Kim, MD, PhD^*, and Hyun Sung Cho, MD, PhD^*

From the *Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Address Correspondence and reprint requests to Yong Chul Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University School of Medicine, 28 Yeongeon-dong, Chongno-gu, Seoul 110-744, Korea. Address e-mail to pain{at}snu.ac.kr.

Abstract

BACKGROUND: The successful outcome and validity of lumbar medial branch block (MBB) are largely dependent on technique accuracy. Intravascular uptake of injectate causes a false-negative response to block and is associated with various possible complications. In the current study, we prospectively evaluated the incidence of, and the factors associated with, intravascular injection during block. In addition, we assessed the efficiencies of generally accepted safety measures, such as preinjection aspiration and intermittent fluoroscopy to avoid intravascular injections.

METHODS: We prospectively examined 1433 lumbar MBBs in 456 patients performed by seven physicians. Aspiration test, spot radiography, and contrast injection under real-time fluoroscopic visualization were performed sequentially without repositioning the needle. Incidences of blood flashback and the presence of intravascular contrast spread on spot radiographic images and during real-time fluoroscopy were checked. The factors studied for intravascular injection included physician experience, patient age and sex, needle gauge, and block spinal level.

RESULTS: No specific factors were found to affect the incidence of intravascular uptake during block. The overall incidence of intravascular uptake was 6.1% per nerve block (88/1433), and 30 of these were predicted by preinjection aspiration (sensitivity = 34.1%) and 52 by spot radiography (sensitivity = 59.1%).

CONCLUSIONS: The aspiration test with or without spot radiography frequently missed the intravascular uptake of contrast during lumbar MBBs. We strongly advocate the use of real-time fluoroscopy during contrast injection to increase diagnostic and therapeutic value and to avoid possible complications.

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