Anterior spinal artery syndrome as a complication of transforaminal epidural steroid injections

Corticosteroids are commonly injected in the lumbar and cervical epidural space as a treatment for radiculitis. Historically, the epidural injections have been via an interlaminar technique but the transforaminal approach is becoming more prevalent. As the number of transforaminal procedures has increased, there have also been an increasing number of case reports of anterior spinal artery ischemic events leading to temporary and permanent neurological deficits or death. Aside from death, neurological compromise is the most feared complication of all for interventional pain physicians, and strategies to avoid the occurrence of these events are necessary. This review of complications will focus on the type and location of complications, anatomy of anterior spinal cord blood supply, description of the anterior spinal artery syndrome, discussion of potential etiologies, and suggested preventative strategies.