Cervical Epidural Space Research Articles

Comparative analysis of contrast distribution in cervical epidural steroid injections utilizing a modified paramedian interlaminar approach with varied needle tip positions: A randomized controlledtrial.

Recent advancements in cervical interlaminar epidural steroid injections have given rise to the modified paramedian interlaminar (mPIL) approach. The objective of this study was to perform an analysis of the contrast spread pattern within the cervical epidural space, taking into account different needle tip positions in the mPIL approach. A total of 48 patients were included in the study and randomly assigned to either the medial or lateral group based on the needle tip's position in the anterior-posterior view. The primary outcome measured was the contrast flow under fluoroscopic visualization. As a secondary outcome, we analyzed the location of the needle tip position in both lateral and contralateral oblique views. Clinical effectiveness was assessed by measuring pain intensity and functional disability post-procedure. Significant disparities were noted in the ventral distribution of contrast between the medial and lateral groups. In the lateral images, needle tips in the lateral group were positioned more ventrally compared to those in the medial group. Both groups exhibited statistically significant improvements in neck and radicular pain, as well as functional status, 4 weeks after treatment, with no significant differences between them. Our results suggest that the ventral dispersion of contrast material during cervical interlaminar epidural steroid injections using the mPIL approach may vary depending on the needle tip location.

High spinal anaesthesia during local anaesthetic skin infiltration at the cervical facet joint.

Facet joint injections are generally safe to perform with a low incidence of adverse events. There are few published reports of neurological complications occurring following procedures at the facet joint or cervical epidural space. However, complications from local anaesthetic infiltration to the skin and surrounding tissue have not been reported. We report a case of transient tetraplegia after local anaesthetic infiltration to the skin in preparation for cervical facet joint injection. We discuss potential reasons for this complication and suggest practice modifications which could reduce the risk.

Short-term changes in chest CT images among individuals at low altitude after entering high-altitude environments.

To investigate the short-term changes in chest CT images of low-altitude populations after entering a high-altitude environment. Chest CT images of 3,587 people from low-altitude areas were obtained within one month of entering a high-altitude environment. Abnormal CT features and clinical symptoms were analyzed. Besides acute high-altitude pulmonary edema, the incidence of soft tissue space pneumatosis was significantly higher than that in low-altitude areas. Pneumatosis was observed in the mediastinum, cervical muscle space, abdominal cavity, and spinal cord epidural space, especially the mediastinum. In addition to acute high-altitude pulmonary edema, spontaneous mediastinal emphysema often occurs when individuals in low-altitude areas adapt to the high-altitude environment of cold, low-pressure, and hypoxia. When the gas escapes to the abdominal cavity, it is easy to be misdiagnosed as gastrointestinal perforation. It is also not uncommon for gas accumulation to escape into the epidural space of the spinal cord. The phenomenon of gas diffusion into distant tissue space and the mechanism of gas escape needs to be further studied.

Supraclavicular Artery Island Flap for Treatment of Cervical Wound Defects and Persistent Cerebrospinal Fluid Leaks: A Technical Note and Systematic Review of the Literature

BackgroundSoft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, “supraclavicular artery island flap AND spine” and “supraclavicular AND flap AND spine”. Technical NoteA 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4–C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak. Systematic Literature ReviewSeven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation. ConclusionThe SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

Ultrasound: A novel alternative technique for cervical epidural space visualization-A pilot study.

Neuraxial ultrasound (US), a newer modality, can be used for neuraxial imaging, helping in visualizing and aiding in epidural space catheterization. The aim of this study was to evaluate the efficacy of the US for cervical epidural access and to determine the failure rate and complication associated with this technique. A prospective single-arm pilot study was conducted on 21 participants. The neuraxial US image quality assessment by Ultrasound Visibility Score (UVS), epidural space depth measurement by US and by conventional loss of resistance (LOR) technique, and post-procedure epidural catheter confirmation by real-time US were the study parameters. Any procedural complications or failure rate were recorded. The Kolmogorov-Smirnov test, paired-samples t-test, and Chi-square test were used for the statistical comparison. The pre-procedural UVS by the transverse interlaminar view (x/21) was 2.81 ± 1.94 and by the oblique paramedian sagittal view was 16.66 ± 2.39 with UVS being best in the paramedian oblique sagittal view (P- value < 0.05). The comparison of depth of the epidural space identified by USG and that by the LOR technique was statistically insignificant (P = 0.83). The average puncture attempts were 1.1 ± 0.3. Post-procedure US epidural catheter confirmation score (x/3) was 1.44 ± 0.44 with either epidural space expansion or microbubbles seen or both. The pilot study has successfully demonstrated the implication of US for visualizing and aiding in epidural space catheterization. Also, the failure rate and procedural complications were drastically minimized with the help of US as compared to the traditional blind technique.

Unilateral neurostimulation-assisted cervical epidural anesthesia for upper limb surgeries—a case series

BackgroundThe role of neurostimulation-aided cervical epidural anesthesia (CEA) in shoulder surgery has been described in the literature. The use of nerve stimulators and the infusion of local anesthetic (LA) in the cervical epidural space has also been mentioned. Epidural needle rotation prior to insertion of the catheter is not described, and it is not clear if general anesthesia was administered in these cases.Case presentationIn this case series, we performed CEA at the level of C7-T1 in 12 patients undergoing various surgeries on the proximal open shoulder and mid humerus after informed consent. Ipsilateral motor responses elicited by continuous electrical stimulation were used to identify lateralization of the epidural catheter tip. The placement of catheters was confirmed under an intraoperative image intensifier. Using the median approach at the level of C7-T1, an ipsilateral twitch was noted in all patients. Neurostimulation persisted with an advancement of stimulating catheter 3–4 cm in the cervical epidural space in all patients. A cervical radiograph confirmed the placement of an ipsilateral catheter and contrast injection there upon revealing the spread of the LA agent. All patients had successful awake shoulder and mid-humerus surgeries under sole cervical epidural anesthesia as evidenced by the absence of pain response at the surgical incision.ConclusionsIpsilateral CEA can be offered for unilateral upper limb surgeries. Low volumes of LA can be injected after precise placement of the tip of the catheter corresponding to the level of surgical incision.

Prediction of the Cervical Epidural Space Depth from the Skin Using Cervical X-Ray, During Cervical Epidural Block with Paramedian Approach.

The purpose of this study is to compare the actual needle depth measured during cervical epidural block (CEB) with the predicted needle depth measured through a cervical flexion x-ray image at the paramedian approach. The study was conducted based on the medical records of patients who underwent CEB at the pain clinic of Haeundae Paik Hospital. The actual needle distance (AD) was recorded after each successful CEB. The distance from the spinolaminar line to the skin, predicted median depth (PMD), was measured using lateral x-ray images. The medial to lateral distance (MLD), which is the distance from the midline of the spine to the needle insertion point, was measured using anteroposterior (AP) x-rays. The predicted paramedian depth (PPD) was calculated using the Pythagorean formula. The PMD represents the expected depth of the median approach, while the PPD represents the expected depth of the paramedian approach. The PMD, PPD, and AD were compared with each other. Concordance correlation coefficient (CCC) and Bland-Altman analysis were obtained for PMD and PPD. The CCC value of PMD was measured as 0.829, and the CCC value of PPD was measured as 0.830. In the Bland-Altman analysis, PPD was measured at -0.13 ± 8.37 mm, and PMD was measured at 1.29 ± 8.38 mm. When performing CEB through the paramedian approach, the depth can be predicted using a cervical flexion x-ray. At this time, the PMD can also be used to predict the depth during the paramedian approach.

ID: 216501 Subdural Contrast Spread in the Contralateral Oblique View During Epidural Steroid Injection

Introduction/Description: For accessing the cervical epidural space, the contralateral oblique (CLO) view under fluoroscopy at 50 degrees (CLO50) has been described as a safe and effective view for obtaining epidural access with some studies suggesting it is superior to the lateral and anteroposterior (AP) views for correct needle tip placement [1]. Because false loss of resistance can still occur using this approach, contrast medium needs to be injected prior to medication administration to ensure correct placement. It is important to recognize spread patterns within the meningeal layers to distinguish between proper placement into the epidural space and unintended spread into the subdural or intrathecal space.

Identification of cervical epidural space: A comparison study between contrast spread and loss of resistance techniques.

Early epidural space identification is critical to the efficacy and safety of cervical epidural steroid injections (CESI). Currently, the accepted method for epidural space recognition is the loss of resistance technique (LORT). I hypothesized that the contrast spread technique might recognize epidural space concurrently with or sooner than LORT and that smaller needles might be employed with the fluoroscopy only method but not with LORT. To test my hypotheses, I conducted a comparison study. The study participants were patients from my practice with a clinical diagnosis of cervical radiculitis divided into two groups of 20 each, who underwent CESI with either an 18 G or a 25 G Tuohy needle. All CESIs were performed utilizing the fluoroscopy only method. Then, LOR was tested using an Epidrum device that was observed for 30 s; if the Epidrum deflated, the result was positive. LOR was positive in 12 out of 20 patients in the 18 G group and 2 out of 20 in the 25 G group. The 95% confidence interval test for proportion revealed a statistically significantly lower rate for epidural space detection by LORT in both groups: [0.385, 0.815] in the 18 G and [-0.031, 0.231] in the 25 G group. Statistical significance of the difference between groups in LOR accuracy rate (60% vs. 10%) was confirmed by z-test for independent proportions: z = 3.31 (p < 0.001), Cohen's h = 1.13. Fluoroscopy only method might be a safer alternative to LORT as it employs a different concept, might recognize epidural space sooner, and favors smaller needles. NCT05260294.

Transvenous Approaches to the Vertebral‐Venous Plexus for Endovascular Treatment of Cervical Epidural Arteriovenous Fistulas: Anatomy and Technique

Background Spinal epidural arteriovenous fistulas (seAVF) are a rare subset of vascular lesions that are most commonly found in the cervical levels. Unlike spinal dural AVF, seAVF are typically supplied by multiple arteries, including direct branches from the vertebral artery, which increases the risk of nontarget embolization using a transarterial endovascular approach. In these cases, transvenous embolization may be a preferable option, but accessing the cervical epidural venous space, also termed the internal vertebral venous plexus, can be challenging and requires advanced foreknowledge of cervical venous channels. Methods The authors review salient neurovascular anatomy and present 2 techniques for endovascular access of the cervical epidural space to treat seAVF. Results The physiology and structure of the cervical internal vertebral venous plexus is briefly reviewed. Next, the authors describe 2 complementary methods for transvenous access to the cervical internal vertebral venous plexus via the jugular vein (cranial‐caudal) and the vertebral vein (caudal‐cranial). The first approach involves retrograde microcatheterization via the jugular bulb and condylar veins. The second approach involves direct antegrade approach via the vertebral vein, arising from the brachiocephalic vein. Both approaches enable stable catheter positioning for coil embolization at remote cervical levels to treat a wide spectrum of seAVF. Conclusions Accessing the cervical epidural venous space is technically demanding and requires effective planning and knowledge of relevant spinal venous anatomy. These techniques are important tools for safe and effective endovascular treatment of seAVF.

Cervical Epidural and Subarachnoid Catheter Placement in Standing Adult Horses.

Horses underwent either cervical epidural space (CES) catheterization or subarachnoid space (SAS) catheterization while restrained in stocks, under deep sedation (detomidine and morphine) and local anesthesia (mepivacaine 2%) block. Catheters were placed under ultrasound guidance with visualization of the dura, SAS, and spinal cord between the first (C1) and second (C2) cervical vertebrae. Following sedation and sterile skin preparation, operator 1 placed under ultrasound guidance, a 6- or 8-inch Tuohy needle with the bevel oriented caudally. For CES, a 6-inch Touhy needle was used with the hanging drop technique to detect negative pressure, and operator 2 then passed the epidural catheter into the CES. For SAS, following puncture of the dura, cerebrospinal fluid (CSF) was aspirated prior to placement of the epidural catheter. Placement into either CES or SAS was confirmed with plain and contrast radiography. Catheters were wrapped for the duration of the study. CSF cytology was assessed up to every 24 h for the study period. Horses were assessed daily for signs of discomfort, neck pain, catheter insertion site swelling, or changes in behavior. A complete postmortem assessment of the spinal tissues was performed at the end of the study period (72 h). Two horses had CES catheters and five horses had SAS catheters placed successfully. All horses tolerated the catheter well for the duration of the study with no signs of discomfort. Ultrasound was essential to assist placement, and radiography confirmed the anatomical location of the catheters. CSF parameters did not change over the study period (P > 0.9). There was evidence of mild meningeal acute inflammation in one horse and hemorrhage in another consistent with mechanical trauma. Placement of an indwelling CES or SAS catheter appears to be safe, technically simple, and well tolerated in standing sedated normal horses.

Cervical Ultrasound Utilization in Selective Cervical Nerve Root Injection for the Treatment of Cervical Radicular Pain: a Review

This paper aims to review the available literature addressing the safety, accuracy, and efficacy of ultrasound-guided injections for cervical radicular pain. Ultrasound-guided injections remain a “partially blind technique” due to the inability to visualize relevant structures and the distribution of injectate. There remains a need for adequately powered studies evaluating the safety, accuracy, and effectiveness of ultrasound-guided steroid injections in the cervical spine. Fluoroscopy remains the best evidence-based image-guidance modality for injections into the cervical epidural space to treat cervical radicular pain. If ultrasound guidance is planned for treatment of cervical radicular pain, the authors recommend concomitant use of fluoroscopy guidance. Given the risk of inaccurate needle placement, physicians should retain fluoroscopic images prior to contrast injection to document the proper vertebral segment and final needle tip position. As epidural flow cannot be fully visualized with ultrasound, it is recommended to use fluoroscopy and, if needed, digital subtraction imaging to confirm the absence of intravascular injection. At a minimum, images should be saved post-contrast injection to document epidural flow.

Novel Technique for Insertion of Cervical Spinal Cord Stimulator Percutaneous Leads: Technical Note and Institutional Experience

Cervical spinal cord stimulation is a safe and effective treatment for chronic axial neck pain and upper limb neuropathic pain. We report our novel institutional experience with performing cervical spinal cord stimulation trials with patients placed in an upright sitting position. This allows easy access to the cervical epidural space and has the added benefit of unobstructed access to the airway. We retrospectively reviewed data for patients who had undergone cervical spinal cord stimulation trial procedures in an upright, sitting position at the Vanderbilt University Medical Center. Demographic information including age, gender, preoperative diagnosis, progression to permanent implant after a successful trial, and operative time in minutes was collected. A detailed description of the technique for implantation of cervical spinal cord stimulator trial leads in an upright sitting position is described. A total of 29 patients were implanted; 16 (55%) were female. Mean operative time was 78 minutes from incision to closing. The majority of patients (25/29; 86%) had successful trials and proceeded to permanent implant. No complications occurred, and the procedure was well tolerated by all patients. Cervical spinal cord stimulation trials performed in an upright, sitting position allow for easy epidural access and an unobstructed airway with reasonable setup time.

Differences in Epidural Pathology between Cervical and Thoracolumbar Intervertebral Disk Extrusions in Dogs.

BackgroundAlthough the basic pathophysiology is the same in both cervical and thoracolumbar intervertebral disk (IVD) extrusions, there are considerable clinical differences that have only been partially explained.Hypothesis/ObjectivesThe epidural inflammatory response differs between cervical and thoracolumbar IVD extrusions.AnimalsFifty‐five dogs with cervical and 80 dogs with thoracolumbar IVD extrusions.MethodsClinical data and histopathologic variables were investigated. Associations between severity of epidural inflammation and clinical and pathologic variables, impact of chondrodystrophic phenotype, and localization (cervical versus thoracolumbar) were evaluated statistically.ResultsDogs with cervical IVD extrusion were significantly older (P < 0.001), had less severe and longer duration of neurologic signs (both P < 0.001), were more painful (P = 0.038), and had a better outcome (P = 0.005) than dogs with a thoracolumbar IVD extrusion. On histopathology, cervical epidural material had less severe calcification (P = 0.002) and inflammation (P < 0.001). No significant differences regarding chondrodystrophic phenotype were found.Conclusion and Clinical ImportanceThere was significantly less intensive inflammatory response in the cervical epidural space. This observation correlated positively with less nucleus pulposus calcification in cervical extrusions indicating biochemical, metabolic, and biomechanical differences between the 2 locations, which remain to be characterized in future studies.

Prediction of midline depth from skin to cervical epidural space by lateral cervical spine X-ray

Prediction of midline depth from skin to cervical epidural space by lateral cervical spine X-ray

Cervical Epidural Contrast Spread Patterns in Fluoroscopic Antero-Posterior, Lateral, and Contralateral Oblique View: A Three-Dimensional Analysis.

To describe and to analyze cervical epidural contrast patterns seen in antero-posterior (AP), contralateral oblique (CLO), and lateral view. To identify factors that might help in predicting contrast distribution pattern and extent. Spread of contrast in the cervical epidural space was prospectively studied in AP, lateral, and three CLO views. CLO view showed contrast spread of variable thickness with its posterior margin overlying the ventral interlaminar line (VILL). In the lateral view, the spread was also of variable thickness, but the posterior margin of the contrast lay on the spinolaminar line in only 10 of 24 patients. Ventral contrast spread was not visualized in any patient. In the AP view, bilateral spread was seen in 14 of 24 subjects, and nerve root spread was seen in 16 of 24 subjects. No association of the pattern of spread or dispersion was seen to patient age, volume injected, or needle location. The CLO view provides a consistent radiological landmark for the posterior margin of contrast in the dorsal epidural space; the lateral view fails to provide such a consistent landmark. The thickness of the spread is variable, both in the CLO and in the lateral view. Thick spread extending into the foramen in the CLO view and over the articular pillars in the lateral view is frequent and should not be misconstrued as subdural or intrathecal spread. In contradistinction to previous studies, true ventral spread was not seen in any patient. When using low volumes, contrast spread is independent of patient age, volume injected, or needle tip location in the AP view.

False Loss of Resistance in Cervical Epidural Injection: The Loss of Resistance Technique Compared with the Epidrum Guidance in Locating Epidural Space

Background: Epidural block failures can occur due to a misleading loss of resistance (LOR) signal. Objective: This study was designed to evaluate the false LOR rate and to determine whether the Epidrum, which is an LOR device for identifying the epidural space, improves the ability to find the epidural space during cervical epidural injection compared the LOR technique. Study Design: A randomized, single-blind trial. Setting: Single academic medical center. Methods: A total of 150 patients undergoing cervical interlaminar epidural injections at C7-T1 were randomized to receive either the LOR technique with a syringe (group C) or the Epidrum guidance (group E). Fluoroscopic images were used to confirm the accuracy of the needle placement within the epidural space. The rate of misleading epidural signals and adverse effects were recorded and analyzed. Results: The false LOR rate was 74.7% for group C, 62.7% for group E, and 68.7% overall. The incidence of false LOR was not significantly different between the 2 groups. Also, the success rate and the rate of true epidural signals were similar between the 2 groups. Limitations: The Epidrum cannot be used to confirm whether the needle has entered the vascular space without fluoroscopy. Conclusions: In this study, we did not find any difference in accuracy between the Epidrum and the LOR technique with a syringe for detecting the cervical epidural space. The overall higher false LOR rate suggests that the combined use of fluoroscopy and LOR technique with a syringe or the Epidrum is necessary to increase the rate of finding the true cervical epidural space. Clinical Trials registration: KCT0001333 Key words: Cervical epidural injection, epidural space, Epidrum, false positive, false negative, loss of resistance

Severe Scapular Pain Following Unintentional Cervical Epidural Air Injection

This a unique case of severe scapular pain following unintentional epidural space air injection during epidural steroid injection. A 70-year-old woman presented for a fluoroscopically guided C7-T1 interlaminar epidural steroid injection. Three injection attempts were made using the loss of resistance with air technique. On the first attempt the epidural space was entered, but contrast injection showed that the needle was intravenous. On the second attempt an equivocal loss of resistance with air was perceived and 5 mL of air was lost from the syringe. The needle was withdrawn and redirected, and upon the third needle passage the contrast injection showed appropriate epidural space filling up to the C4-5 level. Injection of betamethasone mixed in lidocaine was initially uneventful. However, 20 minutes post-injection the patient experienced sudden sharp and continuous pain along the medial edge of the scapula. After failing to respond to multiple intravascular analgesics, the patient was transferred to the emergency room. Her pain subsided completely following an intravenous diazepam injection. Cervical spine computerized tomography showed obvious air in the posterior epidural space from C4-5 to C6-7 as well as outside the spinal canal from (C4-T2). Having recovered fully, she was discharged the following morning. In reviewing the procedure, the equivocal loss of resistance on the second passage was actually a true loss of resistance to epidural space and air was unintentionally injected. Surprisingly, severe scapular pain resulted in a delayed manner after the steroid solution was injected. The authors theorize that unintentional prefilling of the epidural space with air prior to the injection of the subsequent steroid mixture added sufficient pressure to the epidural space to cause right-sided C4 nerve root stretching/entrapment and ensuing radicular pain to the right scapular border. The subsequent intravenous diazepam provided cervical muscle relaxation and facilitated foramina passage of air out of the spinal canal. This case demonstrates that under certain conditions entry of air into cervical epidural space can lead to unexpected, albeit temporary, neurological symptoms. Key Words: Pheumorrhacis, cervical, epidural, steroid, complication, pain, radiucular, air

Salmonella Epidural Abscess in a Patient With Rheumatoid Arthritis Treated With Tocilizumab

A 59-year-old woman with a 23-year history of rheumatoid arthritis and treated with tocilizumab for the previous 6 months was referred to the neurosurgery service with neck pain and upper extremity paresthesias. Magnetic resonance imaging of the cervical spine showed an epidural abscess with associated vertebral osteomyelitis. Culture of a computed tomography–guided aspirate from the abscess grew Salmonella enteridis as did cultures from a subsequent surgical debridement with C4-5 vertebrectomies and C3-6 fusion. The patient subsequently recalled a diarrheal illness associated with consumption of tomatoes purchased from a farmers' market approximately 3 weeks before the onset of her symptoms. We postulate that, during that illness, she had transient Salmonella bacteremia with seeding of the cervical epidural space.

Method to Reduce the False-Positive Rate of Loss of Resistance in the Cervical Epidural Region.

Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.