Presentation
Left arm pain, radiating from neck. For guided injection.
Patient Data
The planning images for a left C5-6 nerve root injection, with overlying biopsy grid, were initially performed with the head in a neutral position and the left vertebral artery (VA) was identified extending into the targeted foramen. The left internal jugular vein (IJV) was deemed to be in the potential needle path, therefore the head was rotated to the right in an attempt to aid needle positioning. The final needle position was excepted in an extra-foraminal position, and iodinated contrast confirms an extra-vascular needle tip position. The steroid injectate was then administered.
Case Discussion
Achieving epidural spread of the injectate is an aim of transforminal epidural steroid injections, however, a safe target and technique is a priority. Thorough pre-procedure planning and identification of the vertebral artery must guide needle positioning and extra-foraminal injections should be used when more appropriate, in such cases where the course of the vertebral artery extends into the neural foramina. Moving the position of the head can help move certain structures out of the proposed needle path, but a turned head position can be more difficult for the patient to hold.