A Need for Unifying Digital Subtraction Angiography Guidelines in Transforaminal Epidural Steroid Injections: A Case Series

Introduction: Transforaminal epidural steroid injections (TFESI) allow steroids to be administered directly into the ventral epidural space to target the spinal nerve in patients experiencing radicular symptoms. Imaging techniques such as Digital Subtraction Angiography (DSA) are used to visualize contrast entering and spreading in the epidural space, as well as intravascularly in the case of complications. This case series shows two examples of TFESI which required significantly higher quantities of contrast to identify intravascular uptake compared to current guidelines, suggesting a need for more careful examination of current practices. Case presentation: Authors present two cases of patients with radicular symptoms who underwent TFESI with DSA. The quantity of contrast administered in these cases was twice that of standard guidelines. Conclusion: The observed two-fold increase in the amount of contrast required during DSA prompts reconsideration of existing guidelines for the precise detection of intravascular uptake using DSA during TFESI. Improving these guidelines should improve accuracy and minimize complications involving intravascular uptake during TFESI procedures.