Interlaminar Epidural Injections Research Articles

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.

Cost Utility Analysis of Lumbar Interlaminar Epidural Injections in the Treatment of Lumbar Disc Herniation, Central Spinal Stenosis, and Axial or Discogenic Low Back Pain

Background: Cost utility or cost effective analysis continues to take center stage in the United States for defining and measuring the value of treatments in interventional pain management. Appropriate cost utility analysis has been performed for caudal epidural injections, percutaneous adhesiolysis, and spinal cord stimulation. However, the literature pertaining to lumbar interlaminar epidural injections is lacking, specifically in reference to cost utility analysis derived from randomized controlled trials (RCTs) with a pragmatic approach in a practical setting. Objectives: To assess the cost utility of lumbar interlaminar epidural injections in managing chronic low back and/or lower extremity pain secondary to lumbar disc herniation, spinal stenosis, and axial or discogenic low back pain. Study Design: Analysis based on 3 previously published randomized trials of effectiveness of lumbar interlaminar epidural injections assessing their role in disc herniation, spinal stenosis, and axial or discogenic pain. Setting: A contemporary, private, specialty referral interventional pain management center in the United States. Methods: Cost utility of lumbar interlaminar epidural injections with or without steroids in managing lumbar disc herniation, central spinal stenosis, and discogenic or axial low back pain was conducted with data derived from 3 RCTs that included a 2-year follow-up, with inclusion of 360 patients. The primary outcome was significant improvement defined as at least a 50% in pain reduction and disability status. Direct payment data from 2016 was utilized for 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, spinal stenosis, discogenic pain. Results: The results of 3 RCTs showed direct cost utility for one year of quality-adjusted life year (QALY) of $2,050.87 for disc herniation, $2,112.25 for axial or discogenic pain without disc herniation, and $1,773.28 for spinal stenosis, with an average cost per one year QALY of $1,976.58, with total estimated costs of $3,425, $3,527, $2,961, and $3,301 respectively. Limitations: The limitation of this cost utility analysis includes that it is a single center evaluation, even though 360 patients were included in this analysis. Further, only the costs of interventional procedures and physician visits were assessed based on the data, with extrapolation of indirect costs presenting the overall total costs. The benefits of returning to work were not assessed. Conclusion: This cost utility analysis of lumbar interlaminar epidural injections in patients nonresponsive to conservative management in the treatment of disc herniation, central spinal stenosis, and axial or discogenic low back pain in the lumbar spine shows the clinical effectiveness and cost utility of these injections of $1,976.58 for direct costs with a total cost of $3,301 per QALY.Key words: Lumbar interlaminar epidural injections, chronic low back pain, lumbar disc herniation, lumbar discogenic pain, cost utility analysis, cost effectiveness analysis, qualityadjusted life years

Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience.

Neurosurgical complications from epidural injections have rarely been reported. To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention. A prospectively maintained database of 14247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed. Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1). A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.

Role of Nonreal-time Imaging in Improving Success of Blind Interlaminar Epidural Injection for Treatment of Symptomatic Prolapsed Lumbar Intervertebral Disk

Role of Nonreal-time Imaging in Improving Success of Blind Interlaminar Epidural Injection for Treatment of Symptomatic Prolapsed Lumbar Intervertebral Disk

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

Does Trainee Involvement in Fluoroscopic Injections Affect Fluoroscopic Time, Immediate Pain Reduction, and Complication Rate?

BackgroundPatients have expressed concern about undergoing procedures involving trainees, even with direct attending physician supervision. Little literature has examined the effect of trainee involvement on patient outcomes. ObjectiveWe aimed to evaluate the effect of trainee involvement on patient complications, immediate pain reduction, and fluoroscopic time for different fluoroscopic injection types. DesignRetrospective review. SettingFour academic outpatient institutions with Accreditation Council for Graduate Medical Education (ACGME)−accredited residency (physical medicine and rehabilitation, or anesthesiology) or fellowship (sports medicine or pain medicine) programs from 2000 to 2015. PatientsAll patients receiving fluoroscopically guided hip (HI), sacroiliac joint (SIJI), transforaminal epidural (TFEI), and/or interlaminar epidural injections (ILEI, performed at only 1 institution). MethodsOutcome measures were examined based on the presence or absence of a trainee during the procedure. Main Outcome MeasurementsThe primary outcome was the number of immediate complications, with secondary outcomes being fluoroscopic time per injection (FTPI) and immediate numeric rating scale percentage improvement. ResultsTrainees were involved in 67.0% of all injections (N = 7,833). Complication rates or improvements in numeric rating scale scores showed no significant differences with trainee involvement for any injection type (P > .05). Trainee involvement was associated with increased FTPI for ILEIs (18.2 ± 10.1 seconds with trainees versus 15.1 ± 8.5 seconds without trainees, P < .001), but not for HIs (P = .60) or SIJIs (P = .51). Trainee involvement with TFEIs was dependent on institution for outcome with respect to FTPI (P < .001), with 28.1 ± 17.9 seconds with trainees and 32.1 ± 22.1 seconds without trainees (P = 0.51). ConclusionsThis large multicenter study of academic institutions demonstrates that trainee involvement in fluoroscopically guided injections does not affect immediate patient complications or pain improvement. Trainee involvement does not increase fluoroscopic time for most injections, although there is an institutional difference seen. This study supports the notion that appropriate trainee supervision likely does not compromise patient safety for fluoroscopically guided injections. Level of EvidenceII

Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

ObjectiveTo assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA.DesignA retrospective cohort.MethodsThe descriptive analysis of...

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines.

Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk, cessation may precipitate serious thromboembolic events. The Spine Intervention Society (SIS) and American Society of Regional Anesthesia and Pain Medicine (ASRA) put forth guidelines that dissent with regard to management of hemostatically active agents during commonly performed spinal injections. To validate an antiplatelet/anticoagulant management table based on modifications of the SIS 2013 and ASRA 2015 guidelines. Prospective descriptive study. Patients undergoing interventional spine injections from a interventional physiatrist's practice. A Modified SIS 2013-ASRA 2015 Antiplatelet & Anticoagulant (MSAAA) guideline table was devised and adopted. Patients undergoing interventional spine procedures were monitored for bleeding events. Of 4,253 injection sites, 197 (4.6%) were performed in 74 patients on antiplatelet/anticoagulants. No clinically evident bleeding events were observed in patients on antiplatelet/anticoagulant medications for lumbar transforaminal epidural (N = 90), posterior-approach facet joint (N = 62), lumbar intradiscal (N = 11), lumbar sympathetic (N = 3), and sacroiliac (N = 5) injections or in 26 radiofrequency neurotomy procedures. One in 2,026 (0.05%, 95% confidence interval = 0.00-0.31%) interlaminar epidural injections (cervical, thoracic, lumbar, and caudal) suffered epidural hematoma. This patient was not on an antiplatelet/anticoagulant drug. No patient in 191 cervicothoracic and 723 lumbar transforaminal injections experienced bleeding complications. Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.

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.

Effectiveness of Bilateral Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spinal Stenosis Patients With Neurogenic Claudication: A Case Series

BackgroundAs our population ages, neurogenic claudication (NC) from central canal stenosis of the lumbar spine is becoming an increasingly common condition. Studies have been undertaken to assess the efficacy of caudal, interlaminar, or unilateral transforaminal epidural injections, but bilateral transforaminal epidural injections (BTESIs) have not been evaluated to date. ObjectiveTo assess the therapeutic value and long-term effects of fluoroscope-guided BTESIs in patients with NC from degenerative lumbar spinal stenosis (DLSS) of the central spinal canal. DesignCase series. SettingSingle institution spine clinic. PatientsTwenty-six adults between the ages of 40 and 90 years with a diagnosis of DLSS and a history of subacute or chronic NC. Methods/InterventionsPatients meeting inclusion criteria received fluoroscope-guided BTESI of local anesthetic and steroid at the level immediately below the most stenotic level. Patient self-reported pain level, activity level, and overall satisfaction were recorded by telephone interview at 1, 3, and 6 months after injection by an independent observer. Main Outcome MeasuresPain score and Swiss Spinal Stenosis score at baseline, 1, 3, and 6 months. ResultsOf the 22 participants eligible for analysis, 20, 19, and 18 had follow-up data available at 1, 3, and 6 months, respectively. Reduction in numeric pain scale score of at least 50% was noted in 30% of participants at 1 month, 53% at 3 months, and 44% at 6 months. Swiss Spinal Stenosis subscale scores indicated a significant reduction in the proportion of participants reporting the presence of severe pain in the back, buttocks, and legs (particularly the back or buttocks) at 1, 3, and 6 months of follow-up compared with baseline (P < .05). The proportion of participants reporting severe weakness in the legs or feet also decreased after injection and was statistically significant at 3 months of follow-up (P = .04). ConclusionsFluoroscope-guided BTESI was moderately effective in reducing pain, improving function, and achieving patient satisfaction in patients with NC from DLSS at the central spinal canal in this clinical case series. Level of EvidenceIV

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

Reliability and Accuracy of MRI Laminar Angle Measurements to Determine Intra-Procedural Contralateral Oblique View Angle for Cervical or Thoracic Interlaminar Epidural Steroid Injections.

Contralateral oblique (CLO) angle view has been a useful addition to standard views in fluoroscopically guided interlaminar epidural injections. Determination of the appropriate CLO angle is paramount in the usefulness of this technique. Using MRI laminar angle measurements as a pre-procedural guide for the intra-procedural fluoroscopic CLO angle has been proposed. The purpose of this study was to help determine if using axial MRI laminar measurements prior to a cervical or thoracic epidural steroid injection would be useful in predicting the appropriate fluoroscopic CLO angle. A retrospective review was performed for patients who underwent cervical or thoracic interlaminar injections. In the performance of interlaminar injections, the authors had routinely determined the true fluoroscopic contra-lateral oblique angle after epidural access was confirmed, for use during any potential future injections. The fluoroscopic CLO angle measurements were obtained from a chart review and compared blindly to each patient's MRI axial laminar angle measurements. 34 injections were included. Inter-rater reliability comparing the two authors' MRI angle measurements was considered fair, ICC = 0.395. Accuracy was only 57% comparing MRI laminar angle measurements to within five degrees of the true fluoroscopic CLO angle as determined during the injection procedure. Accuracy by ICC showed only fair agreement, 0.47 and 0.22, for the two authors. The findings of this study indicate fair inter-rater reliability in manual measurements of laminar angle on axial MRI images. MRI laminar angle measurements do not appear to be highly accurate in determining the appropriate fluoroscopic CLO angle.

Fluoroscopically Guided Cervical Inter-Laminar Epidural Injections: Correlation Between Degree of Spinal Stenosis and Contrast Dispersal Pattern

Objectives: Cervical inter-laminar injections at C7-T1 have been routinely performed for many years as an effective means of palliating neck pain. The purpose of this study is to measure the extent of contrast spread following C7-T1 cervical inter-laminar epidural steroid injection (CIESI), and to correlate the upper extent of contrast spread with degree of cervical spinal stenosis. Methods: We retrospectively identified 41 consecutive patients over a six months’ time frame fulfilling the following inclusion criteria: (1) Had image guided CIESI at C7-T1, (2) Had PA and oblique epidurogram pre and post procedure, (3) Had procedural notes indicating the amounts injected and (4) Had an antecedent MRI. The epidurograms were reviewed for their extent of injectate spread. MRI studies were evaluated separately and blinded to the epidurograms. For each level the degree of cervical spine narrowing was noted. We correlated the extent of contrast spread with the level of maximal cervical narrowing. Results: Maximal contrast spread was up to the skull base and down to T4-T5; minimal extent was C6-C7 to T2. We found statistically significant correlation (2-tailed Pearson correlation r= 0.867, p<0.001) between the upper-most extent of contrast spread and the lowest level of significant central canal stenosis according to pre-procedure MRI. Conclusion: Following CIESI injectate will spread up as far as the cranio-cervical junction or near the lowest level where there is moderate degenerative central stenosis.

Efficacy of Platelet Rich Plasma via Lumbar Epidural Route in Chronic Prolapsed Intervertebral Disc Patients-A Pilot Study.

Lumbar radiculopathy is a major health problem often treated by surgery or guided lumbar epidural steroids for pain relief. We have used Platelet Rich Plasma (PRP) a novel therapeutic tool of autologous nature that has emerged strongly in recent years to treat patients of prolapsed intervertebral disc. To evaluate the efficacy of PRP via interlaminar epidural route in treatment of pain in patients with prolapsed inter vertebral disc. Ten patients were injected with five ml of autologous platelet rich plasma under fluoroscopic guidance via interlaminar lumbar epidural injection into area of affected nerve root. They were followed using VAS (Visual Analogue Scale), SLRT (Straight Leg Raising Test) and MODQ (Modified Oswestry Disability Questionnaire) for clinical improvement. Patients who had received epidural injections of autologous PRP showed improvements in their scores of evaluation tools. Improvement was sustained during the 3 month study period and was not associated with any complications. Autologous PRP can be considered as a good alternative to epidural steroids and surgery in management of patients with chronic prolapsed intervertebral disc.

Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis

Background: Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic spinal pain have yielded conflicting results. Objective: To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic spinal pain. Study Design: A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain. Methods: In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. Results: A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar spinal stenosis. The evidence is Level II for cervical spinal stenosis management with an interlaminar approach The evidence is Level II for axial or discogenic pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level II in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level II with cervical interlaminar epidural injections. Limitations: Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. Conclusion: This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic spinal conditions. Key words: Chronic pain, spinal pain, epidural injections, local anesthetic, steroids, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections

Epidural Ahesiolysis Provides Misinformation

The manuscript by Hsu et al (1) published in Anes-thesia & Analgesia described factors associated with the treatment outcome of epidural lysis of adhesions. This analysis which they called the largest and the first of its nature, misses many important manuscripts and pro-vides misinformation. It appears that authors may have misunderstood the epidural adhesiolysis procedure. The total number of patients included over a period of 4 years from 2 centers is rather small (N=104), with an attempt to obtain too many variables. The outcomes at a glance show that only 50% of the patients reported a positive outcome in the short-term.There have been multiple randomized, double-blind, controlled trials performed in post surgery syn-drome and spinal stenosis (2-7). Further, authors have based their entire description on an outdated, old, sys-tematic review published in 2007 (8). Since then updat-ed systematic reviews have been published in 2009 and 2012 (9,10), as well as with updated guidelines (11,12).Authors also have described a procedure with a noncatheter technique and one with a catheter tech-nique. Both procedures are incomplete and do not de-scribe adhesiolysis. Percutaneous adhesiolysis is indicated after the failure of caudal or interlaminar epidural injections. Caudal epidural injections have been well studied in post lumbar surgery syndrome with significant im-provement in 59% with local anesthetic and 58% with steroids in well selected patients (13) and approximatey 50% of patients with central spinal stenosis with caudal (14) and over 80% with lumbar interlaminar (15,16). Among the patients failing to respond to epidural in-jections, Manchikanti et al have illustrated significant improvement in post surgery syndrome and central spi-nal stenosis patients at the end of 2 years with repeat procedures as medically necessary, in 71% of patients with central stenosis (6) and 82% of patients with post surgery syndrome (4).Laxmaiah Manchikanti, MD Clinical Professor of Anesthesiology and Perioperative MedicineUniversity of LouisvilleLouisville, KentuckyMedical DirectorPain Management Center of Paducah2831 Lone Oak RoadPaducah, KY 42003E-mail: drlm@thepainmd.com Ramsin Benyamin, MDMillennium Pain Center1015 S. MercerBloomington, IL 61701E-mail: ramsinbenyamin@yahoo.comStandiford Helm II, MDThe Helm Center for Pain Management Center 24902 Moulton ParkwaySuite 200Laguna Hills, CA 92637E-mail: drhelm@thehelmcenter.comJoshua A. Hirsch, MDChief: NeuroInterventional Spine ServiceVice Chief: Interventional CareMassachusetts General Hospital Associate Professor of RadiologyHarvard Medical SchoolBoston, MAE-mail: HIrsch@snisonline.org

Do the Gaps in the Ligamentum Flavum in the Cervical Spine Translate into Dural Punctures? An Analysis of 4,396 Fluoroscopic Interlaminar Epidural Injections

Background: Cervical interlaminar epidural injections are performed frequently in managing chronic neck and upper extremity pain, although less commonly than lumbar interlaminar epidural injections. Recently, the US Food and Drug Administration warnings and safeguards to prevent neurologic complications. These were developed by the Multi-Society Pain Workgroup have taken center stage for all types of epidural injections, including cervical interlaminar epidural injections. The recommendations of safeguards to prevent neurologic complications after epidural steroid injections include that cervical interlaminar epidural injections must be performed utilizing fluoroscopy with anteroposterior, lateral, or oblique views with injection of contrast medium and that entry be limited to the C7-T1 epidural space or occasionally the C6-C7 with requirements for magnetic resonance imaging assessment of the epidural space. Objectives: To assess the incidence of dural puncture associated with fluoroscopically directed cervical interlaminar epidural injections. Study Design: A retrospective assessment of patients undergoing cervical interlaminar epidural injections from January 2012 through February 2015. Setting: A private interventional pain management practice; a specialty referral center in the United States. Methods: The data were collected for 4,396 consecutive cervical interlaminar epidural injections performed from January 2012 through February 2015. The procedures were all performed under fluoroscopic visualization under posteroanterior view with contrast medium injection with lateral view confirmation when indicated. The procedures were performed by one of 2 physicians; the dural puncture and subsequent postoperative complications with level of epidural entry were determined. Outcomes Assessment: The outcome was assessment of dural puncture. Results: A review of multiple manuscripts showed that defects in the ligamentum flavum may extend to as much as 100% of the population. However, it also has been shown that among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Among the 4,396 epidural injections performed at C7-T1, C6-C7, and C5-C6, 1,227 were performed at C7-T1; 1,835 were performed at C6-C7; and 1,334 were performed at C5-C6. Dural punctures were observed in 1.8% (24 procedures) at the C5-C6 level entry; 0.87% (16 procedures) at the C6-C7 level entry; and 1.71% (21 procedures) at the C7-T1 level. There was no significant difference among the entry levels. No complications or spinal cord damage or postdural puncture headache were observed. Limitations: The limitations of this report include that it is an assessment by only 2 well experienced physicians, even though it included a relatively large number of patients Conclusion: This study illustrates that dural puncture is equally prevalent, though very rare, irrespective of the needle entry level into the epidural space, with an overall dural puncture rate of 1.4%, with 1.8% at the C5-C6 level, 0.87% at the C6-C7 level, and 1.71% at the C7-T1 level. Based on the present literature, it appears that performing the procedure by inserting the needle into the cephalic portion of the intervertebral space rather than the caudal portion may be safer. Key words: Cervical interlaminar epidural injection, dural puncture, steroids, neck pain, upper extremity pain.

The air shady sign (air epidurogram)

Interlaminar epidural injections with loss of resistance and fluoroscopic guidance are one of the most commonly performed procedures in interventional spine care [1].