# Could this atypical image be an unexpected combination? A visual vignette

## TL;DR

This case study highlights an unusual contrast media spread during a spinal injection procedure and emphasizes the importance of recognizing atypical images to avoid complications.

## Contribution

The paper presents a novel clinical observation of contrast media distribution during a TFESI procedure and underscores the need for physician awareness.

## Key findings

- Contrast media showed intradural spread and pulsation during the TFESI procedure.
- No neurological deficits or abnormalities were found post-procedure.
- Atypical contrast distribution patterns may indicate potential complications.

## Abstract

We report the case of a patient who underwent transforaminal epidural steroid injection (TFESI), and a combination of intradural contrast media spread and dural pulsation during the procedure.

We aimed to raise awareness of the importance of recognising atypical images in interventional pain procedures.

A 67-year-old woman presented with low back and right leg pain due to spinal stenosis. We performed right L3 TFESI with a Quincke spinal needle under the guidance of C-arm fluoroscopy. The needle placement on imaging consistent with the epidural region, but contrast distribution suggested subdural spread. When we administered contrast material again, the contrast extended and widened a little more in the cranio-caudal direction in the same region but did not disperse. Therefore, we obtained a live fluoroscopic image. The contrast media was accumulated in the same region and showed pulsatile properties in the images. We speculated that this image may be a combination of intradural spread and dural pulsation or may be due to the impact of an artery in the restricted epidural space.

We terminated the procedure.The patient exhibited no neurological deficits, and lumbar MRI and CT angiography were conducted to exclude other causes The neuroradiologist evaluated the examinations and found no abnormalities. To alleviate the persistent pain of the patient, we prescribed medical treatment.

Atypical contrast media distributions may be seen during procedures. To avoid possible complications, it is vital for physicians to have a thorough knowledge of the contrast media distribution pattern.