Skeletal Radiology

, Volume 36, Issue 4, pp 301–307 | Cite as

Use of gadolinium chelate to confirm epidural needle placement in patients with an iodinated contrast reaction

  • Sanjay K. ShettyEmail author
  • Erik N. Nelson
  • Tara M. Lawrimore
  • William E. Palmer
Scientific Article



When performing epidural steroid injections for the management of chronic back pain, imaging guidance and a limited epidurogram improve accuracy of needle placement and ensure appropriate delivery of the injectate into the epidural space. We describe our experience using a gadolinium chelate as an alternative contrast agent for limited epidurography in patients with a history of an iodinated contrast reaction.


Thirty-eight of 2,067 (1.8%) epidural steroid injections performed in our department over a 25-month period (December 2003–January 2006) employed gadolinium. All injections were performed in the lumbar spine employing a paramedian interlaminar approach. Procedural notes and patient charts were reviewed to evaluate for immediate or delayed complications related to incorrect intrathecal or intravascular needle placement. A retrospective analysis of selected fluoroscopic spot images was performed to evaluate confidence of epidural needle placement; this analysis compared these spot images against those obtained from age- and gender-matched control patients in whom iodinated contrast was used to confirm needle placement.


Real-time fluoroscopic guidance permitted confident visualization of an epidurogram at the time of procedure in all 38 cases as documented in the procedural report, and no procedure resulted in a complication due to incorrect needle placement. Retrospective review of fluoroscopic spot images revealed at least moderate confidence of epidural needle placement by both readers in 29/38 cases (76.3%). Fluoroscopic spot images obtained using gadolinium yielded significantly less confidence than images obtained in control patients whose procedures were performed using iodinated contrast (P < 0.01). However, operators were sufficiently confident in needle placement based on real-time fluoroscopic images (not available in our subsequent review) to inject anesthestic in all 38 cases, despite the immediate consequences that could result from intrathecal administration. During the same time period, there were 11/2,067 (0.5%) instances of intrathecal needle placement discovered during attempted epidurography despite the use of fluoroscopy for needle guidance and reliance on loss-of-resistance technique.


Gadolinium chelate represents a safe and useful alternative contrast agent for confirmation of epidural needle placement in patients with an iodinated contrast allergy.


Epidural Spine Spinal Gadolinium Injections 


  1. 1.
    Cahana A, Mavrocordatos P, Geurts JW, Groen GJ. Do minimally invasive procedures have a place in the treatment of chronic low back pain? Expert Rev Neurother. 2004;4(3):479–90, May.PubMedCrossRefGoogle Scholar
  2. 2.
    Lievre CA, Boaro G. Treatment of radicular pain by cortisone administered through direct peridural route. Minerva Ortop. 1957;8(11):566–70, Nov.PubMedGoogle Scholar
  3. 3.
    Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in management of lumbar nerve root compression. Br Med J. 1973;2(5867):635–7, Jun 16.PubMedCrossRefGoogle Scholar
  4. 4.
    Mehta M, Salmon N. Extradural block. Confirmation of the injection site by X-ray monitoring. Anaesthesia. 1985;40(10):1009–12, Oct.PubMedCrossRefGoogle Scholar
  5. 5.
    el-Khoury GY, Ehara S, Weinstein JN, Montgomery WJ, Kathol MH. Epidural steroid injection: a procedure ideally performed with fluoroscopic control. Radiology. 1988;168(2):554–7, Aug.PubMedGoogle Scholar
  6. 6.
    Johnson BA, Schellhas KP, Pollei SR. Epidurography and therapeutic epidural injections: technical considerations and experience with 5334 cases. AJNR Am J Neuroradiol. 1999;20(4):697–705, Apr.PubMedGoogle Scholar
  7. 7.
    Spinosa DJ, Kaufmann JA, Hartwell GD. Gadolinium chelates in angiography and interventional radiology: a useful alternative to iodinated contrast media for angiography. Radiology. 2002;223(2):319–25; discussion 26–7, May.PubMedGoogle Scholar
  8. 8.
    Henson JW, Nogueira RG, Covarrubias DJ, Gonzalez RG, Lev MH. Gadolinium-enhanced CT angiography of the circle of Willis and neck. AJNR Am J Neuroradiol. 2004;25(6):969–72, Jun–Jul.PubMedGoogle Scholar
  9. 9.
    Falco FJ, Rubbani M. Visualization of spinal injection procedures using gadolinium contrast. Spine. 2003;28(23):E496–8, Dec 1.PubMedCrossRefGoogle Scholar
  10. 10.
    Safriel Y, Ali M, Hayt M, Ang R. Gadolinium use in spine procedures for patients with allergy to iodinated contrast-experience of 127 procedures. AJNR Am J Neuroradiol. 2006;27(6):1194–7, Jun–Jul.PubMedGoogle Scholar
  11. 11.
    Brown FW. Management of diskogenic pain using epidural and intrathecal steroids. Clin Orthop Relat Res. 1977;(129):72–8, Nov–Dec.PubMedGoogle Scholar
  12. 12.
    Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336(23):1634–40, Jun 5.PubMedCrossRefGoogle Scholar
  13. 13.
    Cuckler JM, Bernini PA, Wiesel SW, Booth RE, Jr., Rothman RH, Pickens GT. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am. 1985;67(1):63–6, Jan.PubMedGoogle Scholar
  14. 14.
    Watts RW, Silagy CA. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care. 1995;23(5):564–9, Oct.PubMedGoogle Scholar
  15. 15.
    Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain. 1995;63(3):279–88, Dec.PubMedCrossRefGoogle Scholar
  16. 16.
    Samanta A, Samanta J. Is epidural injection of steroids effective for low back pain? BMJ. 2004;328(7455):1509–10, Jun 26.PubMedCrossRefGoogle Scholar
  17. 17.
    Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol. 1991;12(5):1003–7, Sep–Oct.PubMedGoogle Scholar
  18. 18.
    Fredman B, Zohar E, Ben Nun M, Iraqi R, Jedeikin R, Gepstein R. The effect of repeated epidural sympathetic nerve block on “failed back surgery syndrome” associated chronic low back pain. J Clin Anesth. 1999;11(1):46–51, Feb.PubMedCrossRefGoogle Scholar
  19. 19.
    Fitzgibbon DR, Posner KL, Domino KB, Caplan RA, Lee LA, Cheney FW. Chronic pain management: American Society of Anesthesiologists Closed Claims Project. Anesthesiology. 2004;100(1):98–105, Jan.PubMedCrossRefGoogle Scholar
  20. 20.
    Nelson DA. Dangers from intraspinal steroid injections. Arch Neurol. 1990;47(3):255, Mar.PubMedGoogle Scholar
  21. 21.
    McNeill MJ, Thorburn J. Cannulation of the epidural space. A comparison of 18- and 16-gauge needles. Anaesthesia. 1988;43(2):154–5, Feb.PubMedCrossRefGoogle Scholar
  22. 22.
    Johnson A, Ryan MD, Roche J. Depo-Medrol and myelographic arachnoiditis. Med J Aust. 1991;155(1):18–20, Jul 1.PubMedGoogle Scholar
  23. 23.
    American College of Radiology. Adverse reactions to gadolinium-based contrast media. Manual on contrast media, 5th edn. Reston, VA: American College of Radiology; 2004 p 41–3.Google Scholar
  24. 24.
    Tali ET, Ercan N, Krumina G, Rudwan M, Mironov A, Zeng QY, et al. Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: results of a multicenter study. Invest Radiol. 2002;37(3):152–9, Mar.PubMedCrossRefGoogle Scholar
  25. 25.
    Nyman U, Elmstahl B, Leander P, Nilsson M, Golman K, Almen T. Are gadolinium-based contrast media really safer than iodinated media for digital subtraction angiography in patients with azotemia? Radiology. 2002;223(2):311–8; discussion 28–9, May.PubMedGoogle Scholar

Copyright information

© ISS 2006

Authors and Affiliations

  • Sanjay K. Shetty
    • 1
    • 2
    Email author
  • Erik N. Nelson
    • 1
  • Tara M. Lawrimore
    • 1
  • William E. Palmer
    • 1
  1. 1.Division of Musculoskeletal Radiology, Department of RadiologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of RadiologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA

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