Chapter 41

### INTRODUCTION

Minimally invasive procedures/injections are used to diagnose and treat pain emanating from intervertebral joints, spinal nerves, nerve roots, spinal cord, and sympathetic ganglia. These procedures are performed in the lumbosacral, thoracic, and cervical spinal canal. Vascular complications can and do occur in all areas of the spine and are of grave concern to all practitioners secondary to their irreversibility (Figures 41-1 and 41-17).

###### Figure 41-1.

Spinal cord infarction following left L3-4 transforaminal ESI. (Reproduced with permission from Murthy, et al. Mayo Clinic Department of Radiology.)

Based on the literature and expert opinions, it is clear that these complications occur more commonly following procedures performed in the cervical spine. This is based on a few factors including:

• Lower margin of safety because of the proximity of arteries supplying the brain and the proximity of the spinal cord itself.

• Random nature of the location of the vascular feeder arteries to the spinal cord within the cervical foramen and the lack of a foolproof strategy for avoiding them while performing procedures.

• Complications following cervical procedures appear to be related to the injury or transection of these arteries or embolism from injections into them.

In contradistinction to the cervical spine, the arterial supply to the thoracolumbar spinal cord follows a regular and recurring path along the vertebra and within the thoracic and lumbar foramen. The critical knowledge of vascular contents of the foramen cannot be ignored as the procedures performed in all three areas of the spine, especially transforaminal interventions, carry the risks of disastrous complications. Poor anatomicak knowledge has led to multiple cases of spinal cord damage and death documented in the peer reviewed literature and even more undocumented cases throughout the world.

The incidence of vascular complications following procedures in the thoracolumbar area of the spine clearly can be mitigated based on the knowledge of the location of the arterial blood supply. The following section of this chapter describes the important anatomy and provides a strategy for avoiding these arteries during procedures that put them at risk. Following that is a section on the cervical spine and the increased risks of procedures performed in that area of the spine and the pros and cons of strategies to reduce the risk of vascular complications.

### THE RISK OF VASCULAR COMPLICATIONS IN THE THORACOLUMBAR SPINE

Indications for interventional procedures in the thoracolumbar spine include pain that originates from:

• Facet joints (arthropathy, synovitis)

• Intervertebral discs (herniated, degenerative)

• Spinal nerves

• Spinal stenosis

• Vertebral compression fractures

• Sympathetically maintained pain from the abdomen, pelvis, and lower extremities

• Neuropathic lower extremity pain

• Shingles and postherpetic neuralgia

• Coccygodynia

• Intercostal neuralgia

• Metastatic carcinoma

Representative procedures in the thoracolumbar spine include:

• Transforaminal epidural steroid injections

• Interlaminar epidural steroid injections

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