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Director, Fellowship Pain Medicine Program, University of Cincinnati, School of Medicine, Department of Anesthesia, Cincinnati, OH, munirma{at}ucmail.uc.edu (Munir) Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO (Rastogi) Fellowship Director, Pain Management Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (Nedeljkovic)
To the Editor:
Tripathi et al.'s report (1) describing a case of paraplegia in an awake patient who underwent a spinal injection procedure with the use of fluoroscopy contains the remark, "it seems fluoroscopy guidance may not prevent intrathecal perforation or spinal cord penetration." The implications of this statement cannot be understated. This report points out yet another example of how using fluoroscopy does not protect patients from injection-related complications. Of note, a recent report published in the APSF Newsletter (2), reviewing closed-claims data, analyzed 13 anesthesiology claims related to alleged complications after cervical epidural steroid injections. Twelve of these 13 cases involved the use of fluoroscopy.
Whereas fluoroscopy, computed tomography, magnetic resonance imaging, and, more recently, ultrasound have been used for needle localization for spinal injection procedures, it is important to remember that imaging alone cannot guarantee against potential complications. In fact, radiographic guidance for injection procedures may provide a false sense of safety and, without proper training of the operator, may lead to worse patient safety outcomes (1–3).
The authors of the case report fail to mention several important factors relevant to the apparent complication that resulted from the procedure. First, they did not comment whether any leakage of cerebrospinal fluid was noted at the time of the needle placement. They did not describe any difficulty in injecting a volume of 14 mL, as one would expect if an injection were given directly into the spinal cord. Finally, there was no mention of the use of fluoroscopy to obtain a cross-table lateral projection. A lateral view may have clarified the depth of the Tuohy needle. It is apparent from the case report that the use of fluoroscopy did not add to the safety of the procedure. In addition, the use of contrast may have precluded injection of 14-mL of injectate into the spinal cord.
Fluoroscopic guidance for spinal procedures may offer precision for needle placement but it does not provide improved patient safety if the operator is not properly trained. In reality, even under fluoroscopic guidance, imprecise needle placement at an unintended spinal level or performance of an altogether different procedure has been reported (4). The American Board of Medical Specialties, insurance providers, and policy makers should consider limiting the performance of interventional pain procedures to physicians who have trained in Accreditation Council for Graduate Medical Education-accredited pain medicine fellowship programs. It is our belief that allowing only pain medicine fellowship-trained physicians to perform spinal injection therapies will result in improved safety for this group of patients.
References
This article has been cited by other articles:
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  M. Tripathi Fluoroscopy and Safety of Spinal Interventional Procedures Anesth. Analg., May 1, 2006; 102(5): 1587 - 1587. [Full Text] [PDF]
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