We appreciate the effort of Drs. De Córdoba and Bernal to reaffirm that transforaminal cervical epidural injections should be performed only by skilled spinal injectionists with documented training and experience in advanced fluoroscopic techniques. We agree. These authors suggest that the description of the technical details of the transforaminal cervical injection procedure are insufficient. We maintain that the information presented is not intended to serve as a tutorial on the procedure under discussion, but is meant to provide a knowledgeable reader with adequate technical details to visualize what was done. 1Second, when blood was initially aspirated at C5–C6, no further injections were performed until the needle was repositioned in the foramen and aspiration was negative. Only then was 1 ml air, followed by 2 ml appropriate radiocontrast, injected. The use of air to identify the epidural space is well established in anesthetic practice, and no admonitions against its use in transforaminal cervical or lumbar procedures have been published previously. Radiocontrast was subsequently injected, with the resultant appearance of the epidurogram judged to be unacceptable based on previous experience, and the procedure was aborted at that level. We believe that anatomic abnormalities resulting from extensive previous spinal surgery likely contributed to these findings and that a second attempt to enter the epidural space at another level was justified. Foraminal entry at C4–C5 was accomplished smoothly and precisely without technical difficulty. The procedure was aborted at this level because the patient became restless, agitated, and uncooperative, making safe performance of injection impossible, presumably related to the developing neurologic injury that forms the basis for this report.

Our report emphasizes the previously unreported risk of cortical blindness associated with cervical transforaminal injections, including the relatively obscure risk of this complication reported in association with radiocontrast agents. 2The potential for direct neurotoxicity caused by these agents when placed in the vertebral intracranial circulation is obviously relevant to spinal injectionists who use them as a means of avoiding complications resulting from unrecognized intravascular puncture. This additional potential risk of radiocontrast agents has not been widely recognized in the interventional pain management community. In addition, the additional potential risks of cervical transforaminal injections in patients with anatomic alterations resulting from previous cervical spinal surgery have not been previously addressed. We believe that appreciation and discussion of these risks will facilitate greater informed consent by patients and allow recognition, modification, and avoidance of risk factors associated with specific complications. Although “technical misadventure” may be associated with adverse outcomes, it is naive to overlook the fact that complications also result from patient-specific factors as well as the adverse effects of therapeutic agents and established techniques, known and unknown. Because we now know that radiocontrast agents themselves are not necessarily benign, it is important to know that cervical transforaminal injections have been safely performed without their use and reported in the literature. 3Although the imaging findings and clinical course of our patient are not specific for ischemic brain injury, the use of air to identify the periradicular cervical epidural space likely increases the risk of this complication and adds little to the successful performance of cervical transforaminal injections. Given the increased recognition of the significant risks associated with epidural steroid injections, a procedure that does not change the natural history of cervical radiculopathy or any other disorder associated with chronic spinal pain, perhaps the risk:benefit ratio of cervical transforaminal and all therapeutic epidural injections of corticosteroids should be reexamined. In their recent analysis of closed liability claims for chronic pain management, Fitzgibbon et al.  4reported that fully 40% of all chronic pain claims were associated with epidural steroid injection procedures. Newer, minimally invasive procedures, such as coblation nucleoplasty 5and percutaneous laser disc decompression, 6may offer greater potential for long-term remission of spinal pain symptoms as well as an enhanced safety profile compared with existing palliative therapies, such as epidural corticosteroid injections. 7 

Foothills Regional Pain Center, Seneca, South Carolina. marionmc@att.net

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