In the Category of Proving What We Already Know, the Award Goes to:

[ampaphb]

Accuracy of intermittent fluoroscopy to detect intravascular injection during transforaminal epidural injections.
[SIZE=-1]Spine. 2008 Apr 1;33(7):E205-10.

[/SIZE]STUDY DESIGN: Prospective validity study.

OBJECTIVE: To determine how accurately intermittent fluoroscopy detects inadvertent intravascular injection during transforaminal epidurals.

SUMMARY OF BACKGROUND DATA: Serious morbidity caused by transforaminal epidural injections is frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection, but none have demonstrated efficacy. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. Despite this, many practitioners continue to use intermittent fluoroscopy.

METHODS: During 50 epidural injections dynamic contrast flow was observed under live fluoroscopy, and the "dynamic true" image was determined. Two intermittent fluoroscopy images were saved from each injection, the first just before completing the contrast injection ("static C" image), and another 1 second after the contrast injection ceased ("static PC" image). Five physicians with experience performing these injections independently interpreted the 100 randomly ordered static images. Accuracy of intermittent fluoroscopy was determined by comparing the interpretation of the 100 static images with the dynamic true patterns observed under live fluoroscopy.

RESULTS: Overall, interpretation of the static images missed 57% of the vascular injections. Timing of the static images influenced accuracy with the static C images missing 50% of vascular injections, and the static PC images missing 68% of vascular injections (P = 0.075). Accuracy was significantly worse when vascular injections occurred simultaneous to the expected epidural injection (P = 0.041), and in lumbar images (P = 0.012).

CONCLUSION: Based on these findings, we recommend use of live fluoroscopy to observe dynamic contrast flow during transforaminal epidural steroid injections.

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[inscape2004]

this is freaking hillarious

 

[Ligament]

I'm missing the joke here. This is a valuable study to the 95% of pain docs out there that have missed the boat on the need for live fluoro. There are still a ton doing blind interlaminars!

(I admit to bias since this is from my home institution)

 

[ampaphb]

I'm missing the joke here. This is a valuable study to the 95% of pain docs out there that have missed the boat on the need for live fluoro. There are still a ton doing blind interlaminars!

(I admit to bias since this is from my home institution)

Their study distinguishes between live and intermittent fluoro when injecting contrast, fluoro vs blind. Personally, I don't know anyone who believes intermittent fluoro while injecting the contrast gives you anything other than partial, incomplete, inadeaquate information.

Thus to me, the study seems to have taken a topic which there is uniform agreement about, and proven it. Which would be nice, were there not 100's of real questions we don't agree on where research would be useful. In a mature field, where all of the controversies had already been resolved, this would be an interesting tidbit. But in a field where the research is lacking, and we bemoan the lack of people willing to do work on really basic questions? This is indulgent.

 

[Ligament]

Personally, I don't know anyone who believes intermittent fluoro while injecting the contrast gives you anything other than partial, incomplete, inadeaquate information.

I've met a lot of such people, you'd be surprised!

 

[murphles]

Only does intermittent. He is waiting for the digital package. Smuck's point is that you don't need the technology-you need the eyes.

Sorry, Z, but most of pain medicine has not established their "duh's" and that is why we are being hounded today (in part).

 

[ampaphb]

Only does intermittent. He is waiting for the digital package. Smuck's point is that you don't need the technology-you need the eyes.

Sorry, Z, but most of pain medicine has not established their "duh's" and that is why we are being hounded today (in part).

forgive me, and this may be due to my only having worked with a few guys over time, but when you say intermittent, you don't mean intermittent fluoro for needle placement, but rather rather when injecting contrast, right?

btw, I am not certain ANYONE has said the technology is not a nice extra toy to play with, but rather that not having it is not below standard of care.