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Paraplegia following thoracic and lumbar transforaminal epidural steroid injections: how relevant is physician negligence?
  1. Rinoo V Shah
  1. Correspondence to Dr R V Shah, Department of Anesthesiology, Guthrie Clinic-Big Flats, 31 Arnot Road, Horseheads, NY 14845, USA; rinoo_shah{at}

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Neurointerventionalists place mechanical devices inside thrombosed arteries on awake patients to treat stroke, place metal wires and coils inside ruptured aneurysms, and inject permanent embolic agents into cerebral areas immediately adjacent to normal cortex. Procedural complications are rightfully the bane of any proceduralist's existence; however, it is likely true that even the most careful, well trained practitioner will inevitably have treatments that have bad results. Catastrophic complications following elective outpatient procedures are particularly troubling. Paralysis following thoracolumbar transforaminal epidural steroid injections (TFESI), a commonly performed therapeutic intervention, is such a complication. Adjudication of this complication is often emotionally charged and opinion based. Is there a constructive way to examine the role of physician negligence to act as a counterweight to expert opinion? This commentary discusses objective means to evaluate the role of physician negligence.

Thoracolumbar TFESIs are commonly performed anterior, superior, and lateral to the exiting spinal nerve, a region referred to as the ‘safe’ triangle. Unfortunately, this traditional approach has been associated with paraplegia.1 Early cases created a knowledge void wherein causality was debated and physician negligence feted as the culprit.2 These catastrophic events are now thought to stem from an iatrogenic injury to a radiculomedullary vessel.1 This commentary examines the role of physician negligence: is the traditional TFESI approach—the physician's decision to choose this technique—the culprit; or is the physician's skill—in performing the technique—the culprit?.1 ,3


The artery of Adamkiewicz or arteria radicularis magna (ARM) originates from T9 to T11 in 75% of patients. Less commonly, the origin is as high as T5 and as low as L5. There is a left-sided (69–85%) greater than right-sided (15–31%) predilection.1 ,4 The ARM may be duplicated, ipsilaterally (two adjacent foramina) or bilaterally.4 ,5 Cadaveric estimates suggest that the ARM has a …

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  • Contributors RVS was solely responsible for the conception and design, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.