Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance

BACKGROUND AND PURPOSE

Inadvertent intrafacet injection can occur during interlaminar epidural steroid injection, resulting in a false-positive loss of resistance and nontarget injection of medication. The purpose of this investigation was to compare the observed rates of this phenomenon during lumbar interlaminar epidural steroid injection performed by using conventional fluoroscopic and CT fluoroscopic guidance.

MATERIALS AND METHODS

We retrospectively reviewed 349 lumbar interlaminar epidural steroid injections performed by using conventional fluoroscopy or CT fluoroscopic guidance to determine the observed rates of inadvertent intrafacet injection with each technique. Cases of inadvertent intrafacet injection were classified as either recognized or unrecognized by the proceduralist at the time of the procedure. Multivariate logistic regression was used to determine the independent effect of imaging guidance technique, age, and sex.

RESULTS

The rate of inadvertent intrafacet injection was observed to be 7.5% in the CT fluoroscopic group and 0.75% in the conventional fluoroscopy group. All 16 cases identified from CT fluoroscopic procedures were recognized during the procedure; the single case identified from conventional fluoroscopy procedures was not recognized prospectively. The type of imaging guidance showed a statistically significant effect on the detection of the phenomenon (OR for conventional fluoroscopy versus CT fluoroscopy = 0.10, P = .03) that was independent of differences in age or sex.

CONCLUSIONS

Inadvertent intrafacet injection is identified during CT fluoroscopic-guided interlaminar epidural steroid injection at a rate that is 10-fold greater than the same procedure performed under conventional fluoroscopy guidance.

Direct BCG vaccination in Burundi, Dahomey and Mauritania. A study of local complications

Until recently it was believed that BCG vaccine given to persons strongly sensitive to tuberculin would cause local complications detrimental to health. In mass BCG campaigns, therefore, the accepted practice has been to give a tuberculin test before vaccination in order to exclude tuberculin reactors from vaccination. This two-step procedure not only is costly but considerably reduces the campaign coverage.Recent investigations indicate that direct BCG vaccination-i.e., vaccination without previous tuberculin testing-does not produce unpleasant local reactions to any great extent. This procedure might therefore be adopted in countries with limited financial resources. The present study was designed to investigate the frequency of large local reactions resulting from direct BCG vaccination under campaign conditions in Africa, where there is a pressing need to economize available resources.The accelerated vaccination reactions observed in persons who reacted strongly to tuberculin were no larger than the tuberculin reactions that they would have experienced in a traditional campaign using a low-dose tuberculin test for pre-vaccination screening. These accelerated reactions quickly diminished, and after four weeks they were practically the same size in both reactors and non-reactors. The incidence of axillary lymph-node enlargement was also the same in reactors and non-reactors. It was therefore concluded that local vaccination reactions would not occur to an extent that might render direct BCG vaccination unacceptable, even in a mass vaccination campaign.