Introduction Epidural steroid injections and epidural blood patches commonly involve the injection of a small amount of radiocontrast media under fluoroscopy to properly identify the target tissue or anatomic space and prevent off-target or intravascular delivery of therapeutic or diagnostic drugs. Iodinated low osmolar non-ionic contrast media is the standard preparation used as it is considered safe and cost-effective, but gadolinium-based preparations have been used as an alternative for patients with an ‘iodine’-related or radiocontrast media allergy label to prevent hypersensitivity reactions. The risk of neurotoxic events when gadolinium is inadvertently injected into the intrathecal space has been reported in recent years, raising concerns when gadolinium-based contrast media is used in lieu of iodinated low osmolar non-ionic contrast media.
Methods A retrospective review was conducted of patients who received gadolinium-based contrast media for procedures with risk of inadvertent intrathecal access from January 1, 2019 to May 1, 2022. Information on patient demographics, allergy label information, and procedure description was documented for all patients who received gadolinium-based contrast media for axial spine procedures (including epidural steroid injections, epidural blood patch procedures, and selective nerve root blocks), and all side effects reported within 1 month of the procedure were recorded. Saved fluoroscopy images of all procedures for which there was concern for possible gadolinium-based contrast media-related side effect were reviewed for evidence of inadvertent intrathecal gadolinium-based contrast media administration. Descriptive statistical analysis was performed using REDCap and IBM SPSS Statistics V.28.
Results We identified 508 patients who received gadolinium-based contrast media during a fluoroscopically guided axial spine procedure. These patients underwent 697 epidural procedures and 23 patients were identified as experiencing an adverse event that could be consistent with possible, probable, or clear signs of exposure to intrathecal gadolinium. Our calculated adverse event rate was 3.3%. Ten patients required additional medical evaluation or treatment.
Discussion Almost all patients in our cohort had an allergy label on their chart that guided the provider to switch to gadolinium-based contrast media, but most were incomplete, ill-defined, or related to allergy to iodine but not iodinated contrast media. Such practice is not recommended based on current guidelines. The current study raises concern regarding the use of gadolinium-based contrast media in axial spine procedures, with the risk of potential severe adverse events, without evidence-based need for avoiding iodinated contrast media.
- drug-related side effects and adverse reactions
- spinal injections
- multimodal imaging
- pain management
- chronic pain
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
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Presented at ASRA Pain Medicine Annual Pain Medicine Meeting, November 17, 2022, Orlando, Florida, USA.
Contributors CH and AH-C conceived the present idea. AH-C, JE, DAP, CH and AG-E agreed upon the research protocol. AH-C, TA-L, JK, LF-P-d-M and DY performed the retrospective chart review according to study inclusion criteria. AH-C developed the first draft. CH, JE and DAP provided intensive revisions to the first draft. AG-E, TA-L, JK, LF-P-d-M and DY provided additional edits to the final submission. CH supervised the findings of this work and serves as its guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests AH-C received a travel stipend from ASRA to present the poster describing this research at the 2022 Annual Meeting. DAP is the President of ASRA Pain Medicine and has received consulting fees from Avanos, Boston Scientific, Nevro, SI Bone and Medtronic. Pain Diagnostics and Interventional Care has received research support from Avanos, Boston Scientific, Medtronic, Abbott, Nevro and Stimgenics. CH has received funding from Nevro in support of research, unrelated to this work, paid to her institution.
Provenance and peer review Not commissioned; externally peer reviewed.