Cervical Interlaminar Epidural Injection Research Articles

Comparison of pain relief of the cervical radiculopathy between high thoracic erector spinae plane block and cervical epidural injection.

The high thoracic erector spinae plane block (ESPB) has been used for the management of chronic shoulder pain or arthroscopic shoulder surgery. No study has evaluated the analgesic efficacy of ESPB in patients with cervical radiculopathy although it is a favored and easy technique compared to neuraxial block. The purpose of this study was to compare the treatment outcome of cervical radiculopathy using high thoracic ESPB or cervical interlaminar epidural injection (CEPI). This study included 82 patients with neck and arm pain who received CEPI (CEPI group) using 4 ml of 0.1% ropivacaine or high thoracic ipsilateral ESPB (ESPB group) at the T2 or T3 level using 20 ml of 0.1% ropivacaine 20 ml. The degree of pain relief and disability were assessed using an 11-point numerical scale (NRS) and neck disability index (NDI), respectively. The CEPI and ESPB groups demonstrated an equal number of patients with excellent pain relief (NRS reduction ≥ 50%). Significant reduction of NRS was found in both groups, and the effect of time was statistically significant in the groups (P < 0.001). The number of patients who showed an excellent improvement in NDI (NDI reduction ≥ 30%) was 20 (48.8%) and 22 (53.7%) in the CEPI and ESPB groups, respectively. Both the CEPI and ESPB demonstrated significant relief in neck and arm pain with improvement in disability.

Predictive factors for favorable short-term response to interlaminar epidural block for cervical radiculopathy.

We sought to identify clinical predictors of favorable short-term outcomes associated with cervical interlaminar epidural injection (CIEI). Previous studies investigating the predictive factors of CIEI efficacy have shown inconsistent results. Gaining information on the possible response determinants of CIEI is necessary for appropriate treatment selection and outcomes prediction in the treatment of cervical radiculopathy. We analyzed the clinical data of 72 patients who received fluoroscopic-guided CIEI using the paramedian approach for cervical radiculopathy to identify the predictive factors for short-term outcomes of CIEI. Demographic characteristics, history of neck surgery, diagnosis, initial numeric rating score, duration of symptoms, Douleur Neuropathique 4 (DN4) questions, painDETECT questionnaire, neck disability index, and ventral epidural spread of contrast medium were assessed. Treatment success was defined as at least a 50% reduction in the numeric rating score after CIEI and was designated as a good response. The short-term success rate of CIEI for cervical radiculopathy was 55.56%. Multivariate logistic regression analysis established that spinal stenosis (odds ratio 0.183; P = 0.012), a longer duration of > 24weeks of symptoms (odds ratio 0.206; P = 0.026), and combined positive results for the DN4 and painDETECT (odds ratio, 0.019; P = 0.008) decreased the odds ratio of a good response, 2-3weeks after CIEI. CIEI provides a significant short-term outcome in patients with cervical radiculopathy. However, CIEI efficacy may be negatively affected in patients with spinal stenosis, the presence of a chronic state, and a possible neuropathic pain component.

Does Paramedian Approach Preferentially Secure Optimal Drug Delivery Onto Ventral Epidural Space and Subsequent Superior Clinical Efficacy Over a Dorsal Midline Approach During Cervical Interlaminar Epidural Injection?

There is paucity in the literature directly comparing the clinical results between the paramedian and the midline interlaminar cervical epidural injections. To compare the proportion of ventral epidural spread of injectate and consequent clinical outcome between the paramedian and midline approach during interlaminar epidural injection in patients with axial neck and/or interscapular pain triggered from the underlying cervical spine pathologic condition. Retrospective study. Primary pain clinic and spine hospital. Two hundred and twenty-three patients with axial neck and/or interscapular pain due to cervical problem underwent interlaminar epidural injection through either a paramedian approach (PM group, n = 93) or a midline approach (ML group, n = 130). We compared the portion of ventral epidural filling, Numeric Rating Scale (NRS), and McNab criteria between both groups. The NRS and McNab criteria were also separately compared between the ventrally spread (VS) group and non-ventral spread (non-VS) group inside each PM and ML group, respectively, at 2 weeks and 10 weeks post-injection. The PM group showed a significantly higher proportion of ventral spread, successful NRS reduction, and satisfactory McNab criteria than the ML group at 10 weeks. In the PM group, the VS group showed the same results as above compared to the non-VS group. A retrospective analysis based on the relatively short-term follow-up period clinical results. The paramedian approach showed the better direct injectate transfer over the ventral epidural space and subsequently superior clinical efficacy for the patients suffering from axial neck and/or interscapular pain secondary to cervical spine problems.

One-year results from a randomized comparative trial of targeted steroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment of unilateral cervical radicular pain

ObjectivesThe objective of this study was to evaluate the long-term effectiveness of catheter-directed cervical interlaminar epidural steroid injection with triamcinolone compared with cervical transforaminal steroid injection with dexamethasone for the...

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives. The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations. KEY WORDS: Chronic spinal pain, interventional techniques, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural, percutaneous adhesiolysis DISCLAIMER: These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” There was no external funding in the preparation of this manuscript.

Evaluation of Contrast Flow Patterns with Cervical Interlaminar Epidural Injection: Comparison of Midline and Paramedian Approaches.

Background and objectives: The purpose of this study was to compare and to analyze contrast spread patterns between the paramedian and midline approaches to cervical interlaminar epidural injection (CIEI). Materials and Methods: We retrospectively enrolled 84 CIEI cases that had been performed for unilateral cervical spinal pain from April 2019 to April 2020. After 3 mL of contrast had been injected into the epidural space, fluoroscopic images were obtained. The CIEI was divided into a midline (Group M, n = 42) and a paramedian (Group P, n = 42) approach by anteroposterior imaging. The P Group was classified into a more medial (Group Pm, n = 26) and a more lateral (Group Pl, n = 16) group. Using ImageJ on an anteroposterior image, we assessed the grayscale brightness ratio of the ipsilateral or contralateral side of the vertebral body as well as the intervertebral disc space one level just above the needle location. We identified the dispersion of contrast into the ventral epidural space. Results: The grayscale brightness ratio was significantly higher in Group P than in Group M (p < 0.001). The incidence of ventral epidural spread in Group M was 57.1% versus 88.1% in Group P, which was significantly different (p = 0.001). Conclusions: The fluoroscopic CIEI finding in the paramedian approach predominantly showed an excellent delivery of the injectate to the ipsilateral side in comparison to the contralateral side. This showed a greater advantage in delivery toward ventral epidural space as compared to the midline approach.

Effect of low-dose lidocaine on objective upper extremity strength and immediate pain relief following cervical interlaminar epidural injections: a double-blinded randomized controlled trial

BackgroundLow-dose lidocaine is a common diluent for analgesia following cervical interlaminar epidural steroid injection (CIESI). Concerns with this practice exist. A single-arm cohort reported that 20% of patients develop postprocedural...

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Background: Chronic neck pain is reportedly considered the fourth leading cause of disability. Cervical interlaminar epidural injections are among the commonly administered nonsurgical interventions for managing chronic neck pain, secondary to disc herniation and radiculitis, spinal stenosis, or chronic neck pain of discogenic origin. Objectives: To systematically review the differences in the effectiveness of cervical epidural injections with local anesthetics with or without steroids for the management of chronic neck pain. Study Design: Systematic review and meta-analysis. Methods: A comprehensive search of the literature of randomized controlled trials (RCTs) that compared epidural injections with local anesthetic with or without steroids was performed, including a search of PubMed, EMBASE, and Cochrane databases for all years up to May 2019. Meta-analysis was done for pain relief based on the Numeric Rating Scale, functional status based on the Neck Disability Index, and opioid intake dosage. Results: Four studies met the inclusion criteria. A total of 370 patients were divided into 2 groups: the experimental group received cervical epidural injection with steroid and local anesthetic, and the control group received injection with local anesthetic only. Regrading pain relief, no significant difference was observed between both groups (weighted mean difference [WMD], –0.006; 95% confidence interval (CI), –0.275 to 0.263; P = 0.963; I2 = 0.0% at 12 months). There was also no significant difference in the improvement of the functional status (WMD, 0.159; 95% CI, –1.231 to 1.549; P = 0.823; I2 = 9.8% at 12 months). Similarly, there was no significant difference in opioid dosage (WMD, –0.093; 95% CI, –5.952 to 5.766; P = 0.975; I2 = 0.0% at 12 months). Limitations: Only a few studies on this premise were found in the literature. There was also a lack of heterogeneity of the included RCT studies. Conclusions: The addition of steroids to anesthetic injectates was not associated with better pain and functional score outcomes compared with anesthetic injectate alone in patients with chronic neck pain. Key words: Chronic neck pain, cervical radiculopathy, cervical disc disease, spinal stenosis, facet joint pathology, cervical epidural injections, steroid injections, local anesthetic injections, systematic review, meta-analysis, randomized control trial

Incidence of Unintentional Flow of Contrast into the Facet Joints During Fluoroscopy-Guided Cervical Interlaminar Epidural Injections: A Retrospective Cohort Study.

We sometimes encounter unintentional flow of contrast into the facet joints during cervical interlaminar epidural injection, which leads to false-positive epidural injection. The purposes of this study were to evaluate the rate of facet flow of contrast and to investigate various factors associated with injection into the space of Okada during fluoroscopy-guided cervical interlaminar epidural injection. Images from consecutive cases of fluoroscopy-guided cervical interlaminar epidural injection performed at a single institution between July 2015 and July 2018 were obtained and reviewed. Cases of epidural injection were classified as either facet flow or no facet flow. Multivariate logistic regression was used to identify the predictive factors of unintended injection into the Okada space. A total of 2,006 cases were included. Intra-articular flow was identified in 6.0% of cases (121/2,006). All cases of flow of contrast into the facet joints were recognized, and appropriate epidurograms were obtained during the procedures. The highest rate of unintended facet flow of the contrast (10.1%, 44/436) occurred at C5-6. Cervical interlaminar epidural injection at C5-6 and above (adjusted odds ratio [aOR] = 1.929, P = 0.001) and the paramidline approach for epidural injection (aOR = 2.427, P < 0.001) were associated with injection into the space of Okada. We detected injection into the space of Okada during fluoroscopy-guided cervical interlaminar epidural injection in 6.0% of procedures. Cervical interlaminar epidural injection at C5-6 and above and the paramidline approach for epidural injection were positive predictors of unintentional facet flow of the contrast.

Cervical Interlaminar Epidural Injections In The Treatment Of Cervical Disc Herniation, Post Surgery Syndrome, Or Discogenic Pain: Cost Utility Analysis From Randomized Trials

Background: Neck pain is one of the major conditions attributing to overall disability in the United States. There have been multiple publications assessing clinical and cost effectiveness of multiple modalities of interventions in managing chronic neck pain. Even then, the literature has been considered sparse in relation to cervical interlaminar epidural injections in managing chronic neck pain. In contrast, cost utility studies of lumbar interlaminar injections, caudal epidural injections, cervical and lumbar facet joint nerve blocks, percutaneous adhesiolysis demonstrated costs of less than $3,500 for quality-adjusted life year (QALY). Objectives: To assess the cost utility of cervical interlaminar epidural injections in managing chronic neck and/or upper extremity pain secondary to cervical disc herniation, post-surgery syndrome in neck, and axial or discogenic neck pain. Study Design: Analysis based on 3 previously published randomized trials of the effectiveness of cervical interlaminar epidural injections assessing their role in disc herniation, cervical post-surgery syndrome, and axial or discogenic pain. Setting: A contemporary, private, specialty referral interventional pain management center in the United States. Methods: Cost utility of cervical interlaminar epidural injections with or without steroids in managing cervical disc herniation, cervical post-surgery syndrome, and cervical discogenic or axial neck back pain was conducted with data derived from 3 randomized controlled trials (RCTs) that included a 2-year follow-up, with inclusion of 356 patients. The primary outcome was significant improvement defined as at least 50% in pain reduction and disability status. Direct payment data from all carriers from 2018 was utilized for the assessment of procedural costs. Overall costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 to accommodate for indirect payments respectively for disc herniation, discogenic pain, and cervical post-surgery syndrome. Results: The results of the 3 RCTs showed direct cost utility for one year of QALY of $2,412.31 for axial or discogenic pain without disc herniation, $2,081.07 for disc herniation, and $2,309.20 for post surgery syndrome, with an average cost per one year QALY of $2,267.57, with total estimated overall costs with addition of indirect costs of $3,475.38, $4,028.55, $3,856.36, and $3,785.89 respectively. Limitations: The limitation of this cost utility analysis includes that it is a single center evaluation. Indirect costs were extrapolated. Conclusion: This cost utility analysis of cervical interlaminar epidural injections in patients nonresponsive to conservative management in the treatment of disc herniation, post surgery syndrome and axial or discogenic neck pain shows $2,267.57 for direct costs with a total cost of $3,785.89 per QALY. Key words: Cervical interlaminar epidural injections, chronic neck pain, cervical disc herniation, cervical discogenic pain, post surgery syndrome, cost utility analysis, cost effectiveness analysis, quality-adjusted life years

A Prospective Comparison of CT-Epidurogram Between Th1-Transforaminal Epidural Injection and Th1/2-Parasagittal Interlaminar Epidural Injection for Cervical Upper Limb Pain

Background: Cervical epidural injections for treating neck and upper limb pain are performed by 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertent intravascular injection have been reported with the use of cervical transforaminal epidural steroid injection through the anterior-lateral approach. Despite international practical guidelines that have been proposed, cervical transforaminal epidural injection is still less recommended than cervical interlaminar epidural injection. Objectives: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1- TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that of Th1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristics of Th1-TFEI. Study Design: This research involved a prospective study of 30 patients receiving both Th1-TFEI and Th1/2-pILEI. Methods: Thirty patients with unilateral upper limb pain were enrolled for this prospective study. Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy, and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics, presence of Horner’s syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse events were investigated. Results: Patients included 15 men and 15 women and included 24 cases of cervical spine disease and 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of “Th1 root filling” (100%), “ventral spread” (70.0%), and “lateral limitation” (26.7%) compared to the Th1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reaching approximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximately up to C4. The 2 groups showed significant differences in cephalad spread. Horner’s syndrome appeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEI group at 17.2%. The presence of Horner’s syndrome showed significant correlations with “ventral spread” and “spread up to C6.” There were no significant differences in NRS-11 improvement and changes in circulatory dynamics between the groups. There were no major complications. Limitations: The components of injectate were standardized; however, the needle gauge numbers were varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size was small; therefore, multivariate analysis was not possible. Conclusions: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on the injection side, and there was better dorsal spread – although ventral spread was small. Contrarily, Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephalad spread was limited. We expected the addition of a sympathetic block effect suggested by the Horner’s syndrome as well as the merits of the ventral spread. However, short-term clinical effects were equal to those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and to increase the number of cases to enable evaluation of clinical effectiveness.Key words: Epidural, cervical, transforaminal, interlaminar, fluoroscopy, CT-epidurogram, dorsal, ventral, cephalad, Horner’s syndrome

Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome.

BackgroundNeck and back pain are leading sources of disability placing substantial burden on health care systems. Surgical interventions in managing chronic neck pain secondary to various disorders continue to increase. Even though surgical interventions are effective, a significant proportion of patients continue to have symptomatology and develop cervical post-surgery syndrome. This study was performed to know the effectiveness of cervical interlaminar epidural injections with or without steroids.MethodsThe effectiveness of fluoroscopic cervical interlaminar epidural injections in post-surgery syndrome was evaluated in a randomized, active controlled trial. The study population included 116 patients assigned to 2 groups. Group 1 received cervical interlaminar epidural injections with local anesthetic alone and Group 2 received injection with local anesthetic and steroids. The main outcomes were defined as significant improvement (greater than 50%) of pain relief using the numeric rating scale and/or functional status improvement using the Neck Disability Index (NDI).ResultsBoth groups had similar results with significant improvement (≥ 50% pain relief and functional status improvement) in 69% of the patients in Group I, whereas, in Group II, 71% of the patients showed significant improvement at the end of 2 years. During a 2-year period, the average number of procedures was 5 to 6, with an average of approximately 12 weeks of significant improvement per procedure.ConclusionsFluoroscopic cervical interlaminar epidural injections administered in cervical post-surgery syndrome using local anesthetic, regardless of the use of steroids, may be effective in approximately 70% of the patients at 2-year follow-up.

Acute Epidural Hematoma Following a Cervical Epidural Injection in a Patient without Bleeding Risk

An acute epidural hematoma following a cervical interlaminar epidural injections is rare, but when it occurs, it can be associated with devastating complications if appropriate corrective action is not taken. Surgical decompression or conservative management has been proposed in managing acute epidural hematoma, based on the progression of symptomatology with neurologic dysfunction. We report a case of a cervical epidural hematoma in a healthy 43-year-old functioning female patient without overt risk factors for procedural hemorrhagic complications including baseline coagulopathy, baseline dysfunction, and intake of anticoagulants. There were no technical difficulties in performing the procedure. The patient developed symptomatology consisting of neck pain, left upper extremity pain, weakness in the left lower extremity, and inability to urinate following the cervical interlaminar epidural. Unbeknownst to the provider, who had performed the epidural injection, the patient presented to the local emergency room and underwent a workup to rule out cardiac etiologies for her symptoms. The patient was also given ketorolac intravenously for neck pain. The provider who performed the epidural injection was informed 18 hours post-procedure. The patient had progressive symptomatology with neurological dysfunction including weakness and numbness. The provider suspected an epidural hematoma. As a result, an emergent magnetic resonance imaging (MRI) was performed, which showed a significant collection of blood within the epidural space, which clinically required surgical decompression. Subsequently, surgical decompression was carried out with full recovery of neurologic function. Issues in managing an acute epidural hematoma are related to avoidance of drugs increasing hemorrhagic complications and rapid diagnosis with appropriate therapy, with shared decision making. These hematomas can be managed conservatively or with surgery. Nonsurgical management is influenced by the initial neurological presentation and spontaneous recovery or at least lack of progression of the deficit. After reasonable monitoring, if stable status is absent and neurological dysfunction is increasing, then surgical decompression is recommended. Key words: Cervical epidural injection, cervical epidural hematoma, bleeding risk factors, surgical decompression, nonsurgical management, ketorolac

NEEDLE TIP DEPTH ASSESSMENT ON FORAMINAL OBLIQUE FLUOROSCOPIC VIEWS DURING CERVICAL RADIOFREQUENCY NEUROTOMY. A TECHNICAL NOTE

Background: Precise needle tip visualization using fluoroscopy is critical to avoid injury to nearby neurovascular structures during cervical radiofrequency neurotomy (RFN). The contralateral oblique (CLO) view has been shown to be superior to the lateral view for needle tip visualization during cervical interlaminar epidural injection (CESI). It has been demonstrated that increasing the angle of obliquity during CESI causes the needle tip to appear to move dorsal and superficial on contralateral oblique views. Needle tip visualization for cervical RFN has been described using a foraminal oblique (FO) view, but the technique and effect of angle on needle tip depth have not been studied. Objective: To analyze how the needle tip depth changes with varying oblique angles of FO views during cervical RFN. Methods: Fluoroscopic views during cervical RFN between lateral and 50 degrees FO in a single subject were analyzed. Results: The needle tip appears to move ventral and deeper with increasing angle of obliquity with respect to the lamina. Conclusion: Contrary to the phenomenon noticed with contralateral oblique views in CESI, in this case the needle tip appears to move ventral and deeper with increasing angle of obliquity on foraminal oblique views during cervical RFN. It becomes crucial for practitioners to understand that during cervical RFN, with inadequate foraminal oblique angle, needle tip looks artificially superficial, which in turn may cause one to advance the needle to a dangerous depth. Limitation: This is an observational study in a single subject; hence further larger studies are needed to confirm the findings in this technical report. Key words: contralateral oblique, needle depth assessment, cervical radiofrequency neurotomy, cervical radiofrequency ablation, foraminal oblique, fluoroscopy views, fluoroscopy angles

Incidence of Inadvertent Dural Puncture During CT Fluoroscopy-Guided Interlaminar Epidural Corticosteroid Injections in the Cervical Spine: An Analysis of 974 Cases.

The objective of this study is to determine the rate of inadvertent dural puncture during CT fluoroscopy-guided cervical interlaminar epidural corticosteroid injection. In addition, in a subanalysis, we aim to assess the rate of inadvertent dural puncture superior to C5-C6 occurring during interlaminar epidural corticosteroid injection using CT fluoroscopy guidance because such injections are not performed using conventional fluoroscopy. Images obtained from consecutive CT fluoroscopy-guided cervical interlaminar epidural corticosteroid injections conducted from November 2009 to November 2015 were reviewed. The following information was recorded: the presence of inadvertent dural puncture, the level of the cervical interlaminar space, approach laterality (left or right), anteroposterior spinal canal diameter, and the presence of a trainee. Two-tailed Fisher exact tests were used for assessment of categoric variables, and t tests were used for continuous variables. A total of 974 cervical interlaminar epidural corticosteroid injections were identified in 728 patients. Inadvertent dural punctures were identified in association with 1.4% (14/974) of these injections; all punctures were recognized during the procedure. Needle placements were performed at every cervical level (C1-C2 through C7-T1). The highest rate of dural puncture (2.8%) occurred at C5-C6. No dural punctures occurred superior to C5-C6 (16.6% of cases). The complication rate was 0.4%. Only greater anteroposterior spinal canal diameter was associated with increased dural puncture rates (p = 0.049). CT fluoroscopy-guided cervical interlaminar epidural corticosteroid injections were performed at all levels throughout the cervical spine. A very low complication rate and a minimal rate of inadvertent dural puncture were noted, similar to previously reported rates for conventional fluoroscopy-guided injections limited to the lower cervical spine only.

Response to Letter: Optimal Angle of Contralateral Oblique View in Cervical Interlaminar Epidural Injection: Safety or Precision?

Response to Letter: Optimal Angle of Contralateral Oblique View in Cervical Interlaminar Epidural Injection: Safety or Precision?

TWO CASES OF ACUTE EPIDURAL HEMATOMA FORMATION AFTER CERVICAL INTERLAMINAR EPIDURAL STEROID INJECTIONS

Cervical interlaminar epidural injections are rarely associated with epidural hematoma resulting in surgical decompression. Multiple strategies in the prevention of epidural hematoma after cervical epidural injections are based on cessation of therapy in patients with bleeding disorders on antiplatelet therapy, fi sh oil, and multiple other drugs. Multiple guidelines from organizations across the globe have recommended continuation of nonsteroidal anti-infl ammatory drugs (NSAIDs) and low dose aspirin. Guidelines also have recommended to continue or cessation of antithrombotic agent therapy based on risk benefi t ratio, due to associated risks of thrombotic events with interventional techniques or other surgeries with discontinuation of antiplatelet therapy. We report 2 cases of cervical epidural hematoma requiring surgical decompression, without residual dysfunction. The fi rst case was in a 41-year-old Caucasian woman with controlled hypertension; however, with no drug therapy contributing to bleeding and 2 uneventful cervical interlaminar epidural injections, the patient developed a cervical epidural hematoma after the third procedure which was performed uneventfully. She developed rapid paralysis and underwent surgical decompression without residual dysfunction. The second case involved a cervical epidural injection resulting in a cervical epidural hematoma. This patient was on 81 mg of aspirin and was continued with therapy. Surgical decompression was carried out with no residual dysfunction. This patient also received Toradol for pain control in the recovery room which may have exacerbated the epidural hematoma. These 2 case reports illustrate that cervical epidural hematoma is a rare, but fatal occurrence associated with cervical epidural injections. Appropriate patient selection with constant vigilance on post operative course and follow-up treatment with surgical intervention or conservative management is crucial. It is also crucial to understand the role of loss of resistance technique with air only which may complicate the closed space phenomenon of cord compression and post procedure pain at the injection site which is different from the pain ever experienced by the patient with the previous injections. Key words: Interventional techniques, cervical epidural injections, cervical epidural hematoma, bleeding disorders, aspirin, antithrombotic agents, Ketoralac

PREVALENCE OF EPIDURAL HEMATOMA FOLLOWING CERVICAL EPIDURAL INJECTIONS IN INTERVENTIONAL PAIN MANAGEMENT SETTINGS: LITERATURE REVIEW WITH TWO CASE REPORTS

Epidural injections are performed frequently in managing chronic neck pain secondary to disc herniation, spinal stenosis, discogenic pain, and post cervical surgery syndrome. Major risks and devastating complications have been reported with cervical transforaminal epidural injections. Cervical interlaminar epidural injections have been considered as safe and effective in managing chronic spinal pain of multiple origins. Epidural hematoma is one of the rare complications. Efforts at prevention of cervical epidural hematoma have focused on avoidance of the procedures or cessation of therapy in patients with bleeding disorders, on antiplatelet therapy, fi sh oil, and multiple other drugs. The guidelines from multiple organizations have provided variable recommendations regarding the need to stop nonsteroidal anti-infl ammatory drugs (NSAIDs) including low dose aspirin and antithrombotic agents. The risks of thrombotic events have been reported to be higher than of bleeding during surgery or interventional techniques with discontinuation of antiplatelet therapy. We looked at a 16 year span of cervical interlaminar epidural injections (2000 through 2015), performed in a single facility during which time there were two epidural hematomas. The fi rst patient was managed conservatively while the second patient required surgical intervention. Both patients recovered without residual complications. During the same period, 2 cases of cardiovascular events were reported in our practice associated with the cessation of antithrombotic therapy. They also recovered without residual complications. Nevertheless, rapid diagnosis is crucial as manifested by increased or unusual axial pain at the site of injection which is often different from patient’s previous experience. Two cases provided a prevalence rate of 0.0085% (2/23,552) over 16 years at this facility. Based on occurrence of the year, the prevalence was one of 2,604 cases, or 0.03%, in 2012 and one of 2,287 cases, or 0.04%, in 2015. This provides a prevalence rate of 0.085 per 10,000 procedures. Even though complications are extremely rare, it is essential to weigh the risk benefi t ratio of these procedures and select the patients with extreme caution and perform the procedures with diligence. Key words: Interventional techniques, bleeding disorders, aspirin, antithrombotic agents, cervical epidural injection, cervical epidural hematoma

Optimal volume of injectate for fluoroscopy-guided cervical interlaminar epidural injection in patients with neck and upper extremity pain

There is no study of optimal volume of contrast medium to use in cervical interlaminar epidural injections (CIEIs) for appropriate spread to target lesions. To determine optimal volume of contrast medium to use in CIEIs. We analyzed the records of 80 patients who had undergone CIEIs. Patients were divided into 3 groups according to the amount of contrast: 3, 4.5, and 6 mL. The spread of medium to the target level was analyzed. Numerical rating scale data were also analyzed. The dye had spread to a point above the target level in 15 (78.9%), 22 (84.6%), and 32 (91.4%) patients in groups 1 to 3, respectively. The dye reached both sides in 14 (73.7%), 18 (69.2%), and 23 (65.7%) patients, and reached the ventral epidural space in 15 (78.9%), 22 (84.6%), and 30 (85.7%) patients, respectively. There were no significant differences of contrast spread among the groups. There were no significant differences in the numerical rating scale scores among the groups during the 3 months. When performing CIEIs, 3 mL medication is sufficient volume for the treatment of neck and upper-extremity pain induced by lower cervical degenerative disease.

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