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Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
SECTION VI Cervical
Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach Justin J. Petrolla, S. Amir Tahaei, Kirk M. Puttlitz, Michael A. Klein, and Michael B. Furman Cervical interlaminar epidural steroid injections are indicated for radicular pain with or without axial neck pain. The interlaminar approach is well suited for delivering medication to bilateral and/or multilevel cervical sites. C7-T1 level is typically targeted since it has the largest posterior to anterior distance between the ligmantum flavum and dura/spinal cord (SC). Also, the lower cervical levels are more likely to have an intact and fused midline ligamentum flavum. Preprocedure MRI review is helpful to examine the posterior epidural space dimensions. If the posterior epidural space is minimal to nonexistent at C7-T1, choose the T1-T2 segment. After placing the needle using a trajectory view, it is advanced using multiplanar imaging, emphasizing on safety while visualizing the needle tip depth as it approaches the ventral interlaminar line (VILL) in the contralateral oblique (CLO) view and/or the spinolaminar line in the lateral view. We recommend visualizing the needle tip depth using CLO and/or lateral views rather than depending solely on the needle tip (stepping off the lamina). Typically, CLO view has better visualization than the lateral view since the shoulders frequently obstruct clear cervicothoracic region visualization in the lateral view. See Chapter 3 for more detailed CLO visualization explanation. The epidural space is accessed by advancing the needle through the ligamentum flavum using the classic loss of resistance (LOR) technique coupled with multiplanar fluoroscopic imaging and real-time contrast visualization. The final location of the needle tip should be at the midline or slightly off the midline for more unilateral or asymmetric symptoms.
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
25
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
Trajectory View (Fig. 25.1) Confirm the level with the anteroposterior (AP) view. Tilt the fluoroscope caudad. n Maximize/optimize the targeted interlaminar space radiolucency with crisp laminar edges (usually C7-T1) using caudad or cephalad tilt. n Oblique slightly (approximately 5–10 degrees) toward the symptomatic side (right side in this case). n The needle is placed directly at the midline or just ipsilateral to the midline on the painful side in the target radiolucent interlaminar space. n Because this is the trajectory view, place the needle parallel to the fluoroscopic beam. n n
Notes on Positioning in the Trajectory View Initial needle placement should be shallow in the soft tissues to avoid puncturing the dura and contacting SC. Interlaminar placement and further needle advancement can then be performed after rotating the C-arm into the lateral or CLO safety view. It is not necessary to “walk off” the lamina. n There are no consistent radiolucent safety considerations in this trajectory view. n n
Trajectory view
Trajectory view
C7 VB 1st rib T1 VB
VI
B A SC Trajectory view
SN
The needle should not be advanced too far ventrally in this view. We recommend observing the safety considerations demonstrated in other views (CLO and lateral) to visualize the corresponding landmarks.
C7 VB T1 VB 1st rib
C 402
Fig. 25.1. A, Fluoroscopic image of a trajectory view with the needle in position at the C7-T1 interlaminar space with 5 to 10 degrees of ipsilateral oblique. The needle tip is slightly to the right of the midline. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view. Note that this is not the safety view for this procedure. This image is used to emphasize the location of the spinal cord (SC).
Optimal Needle Position in Multiplanar Imaging
ptimal Needle Position O in Multiplanar Imaging We recommend a minimum of two views, including the AP view (approaching midline) and the CLO view to confirm that the tip has not respectively crossed the VILL. Optionally, use the “true” lateral to confirm that the tip has not crossed the spinolaminar line. Advance the needle tip safely toward the target only with the use of the CLO and/or “true” lateral safety view. The AP view is used to confirm laterality or midline placement but is not a safety view.
OPTIMAL NEEDLE POSITIONING IN THE AP VIEW (FIG. 25.2) The needle should ideally remain close to the midline. The needle tip may be targeted slightly off the midline for the treatment of more unilateral symptoms.
Trajectory view
Trajectory view
C7 VB 1st rib T1 VB
B A SC
SN C7 VB T1 VB
VI
Trajectory view
There are no consistent radiolucent safety considerations in this trajectory view. To avoid dural and SC contact, the needle should not be advanced too far ventrally in this view. We recommend observing the safety considerations demonstrated in other views (CLO and/or lateral) to visualize the corresponding landmarks.
1st rib
C Fig. 25.2. A, Fluoroscopic “true” AP view with the pre-loss of resistance, precontrast needle position near midline. This is a paramedian approach toward the right with the needle tip near the midline. The needle should not be advanced any further since this is not a safety view. B, Radiopaque structures, AP view. C, Radiolucent structures, AP view.
403
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
OPTIMAL NEEDLE POSITIONING IN THE CONTRALATERAL OBLIQUE VIEW (FIG. 25.3) After confirming the needle tip position in AP view, the C-arm should now be positioned in the CLO safety view. For more discussion regarding CLO, please see Chapter 3, Fig. 3.21. n Optimal needle positioning: CLO (i.e., obliqued to the opposite side of the needle tip), with the needle confirmed as being at the midline or slightly closer to the more symptomatic side. An initial starting angle will be about 60 degrees CLO. n Under the CLO view, advance the needle slowly, intermittently, or continuously checking for LOR. LOR should be encountered near the VILL. The VILL is the line that connects the posterior edge of the neuroforamen with the anterior margin of the football-shaped lamina. Note that the needle may appear to be more ventral if the tip crosses the midline to the side ipsilateral to the image intensifier.
Multiplanar view
Multiplanar view
VILL Lam SP
C5 VB C6 VB C7 VB T1 VB
B
A
VI
D Multiplanar view
SC
Safety Considerations
VILL Lam SP
C5 VB C6 VB
Safety view
Cautiously approach and traverse the VILL with a LOR technique. Avoid puncturing the dura (D) and contacting the spinal cord (SC).
C7 VB T1 VB SN
C Fig. 25.3. A, Fluoroscopic contralateral oblique view (i.e., safety view) with the pre-loss of resistance position at the ventral edge of the football-shaped lamina (Lam). The needle tip may be advanced with the loss of resistance expected at or slightly past the ventral interlaminar line (VILL). B, Radiopaque structures, contralateral oblique view. C, Radiolucent structures, contralateral oblique view.
404
Optimal Needle Position in Multiplanar Imaging
OPTIMAL NEEDLE POSITIONING IN THE LATERAL VIEW After confirming the needle tip position in AP and CLO views, the C-arm may now be positioned in the lateral safety view for further multiplanar confirmation.
PATIENT PRONE, “TRUE” LATERAL (I.E., 90 DEGREES OBLIQUE) (FIG. 25.4)
Multiplanar view
Multiplanar view
C6 VB Spinolaminar line
C7 VB T1 VB
B
A
D SC Multiplanar view
C6 VB Spinolaminar line
T1 VB
Cautiously approach and traverse the spinolaminar line with an LOR technique. Avoid puncturing the dura (D) and contacting the SC.
VI
Safety view
C7 VB
Safety Considerations
C Fig. 25.4. A, Fluoroscopic “true” lateral view (i.e., safety view) with the needle tip approaching the spinolaminar line. The loss of resistance is expected at or near the spinolaminar line. B, Radiopaque structures, “true” lateral view. C, Radiolucent structures, “true” lateral view.
405
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
OPTIMAL NEEDLE POSITIONING IN THE LATERAL SAFETY VIEW
VI
We recommend a minimum of two views, including the AP (approaching midline) and either or both of the CLO and “true” lateral views to confirm that the tip has not gone too ventral. n If the needle is advanced ventral to VILL in CLO view (or spinolaminar line in the lateral views) and LOR has not yet been encountered, then do the following: n Check the AP view to make sure that the needle tip is on the desired side and/or has not strayed too far laterally. n Re-stylet the needle to make sure that a blood clot or some other tissue substance has not occluded the needle lumen, thereby confounding the perception of LOR. n Inject contrast to see if the needle tip is indeed already in the epidural space, despite a lack of perceived LOR. n If there is a high resistance on injection or patient complaints of pain or paresthesias, it may suggest that the needle is contacting the SC or a nerve root. n Confirm position and withdraw as appropriate. n Do not inject contrast or injectate because this may precipitate clinically significant nerve or SC injury. n Do not oversedate the patient because this may hinder patient reporting of these helpful warning symptoms. n While advancing the needle via the CLO or “true” lateral safety view, we recommend intermittently switching back to the AP view to confirm the needle tip position relative to the midline. The utility of the CLO or “true” lateral is predicated upon slight ipsilateral or near midline needle tip placement. n When LOR is achieved with either of the techniques, inject contrast to confirm epidural placement.
406
Optimal Images
Optimal Images (Fig. 25.5) Optimal Image (Please see Table 12.1 to differentiate epidural from non-epidural flow) Contralateral oblique view: n When the needle tip is contralateral to the fluoroscope: Contrast flow should layer with a linear pattern immediately ventral to the lamina along the VILL (i.e., the line that connects the posterior edge of the neuroforamen with the anterior margin of the football-shaped lamina). Lateral view: n Contrast flow should layer immediately ventral to the bases of the spinous processes along the spinolaminar line (i.e., the line that connects the ventral edge of the spinous processes). AP view: n Contrast flow typically appears as an irregular, asymmetric cloud, possibly lateralizing to one side. n Contrast dye may outline epidural fat “bubbles.” n Contrast dye may outline exiting spinal nerves. n Contrast immediately contacts the medial pedicle. n Contrast may spread rostral and caudad for many levels; however, central stenosis may limit such spread.
Optimal
Optimal
B
A
VI
Optimal
C Fig. 25.5. A, Contralateral oblique (CLO) fluoroscopic image of a cervical interlaminar epidural steroid injection with 0.5 cc of contrast medium. B, “True” lateral fluoroscopic image of a cervical interlaminar epidural steroid injection with 0.5 cc of contrast medium. Note that the landmarks are not as well visualized as those in the CLO view. C, Anteroposterior fluoroscopic image of a cervical interlaminar epidural steroid injection with 0.5 cc of contrast medium.
407
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
Suboptimal Images (Figs. 25.6 to 25.8)
Optimal
Suboptimal
Soft tissue dye pattern
A
Optimal epidural dye pattern
B
Fig. 25.6. A, Cervical interlaminar epidural steroid injection (ESI), contralateral oblique view. The needle is located dorsal to the ventral interlaminar line (VILL). Note the posterior contrast extravasation into the dorsal soft tissue, with a striated fascial pattern. This amorphous pattern typically occurs with a false loss of resistance (LOR). B, After the needle tip was advanced ventrally toward the epidural space, a true LOR was encountered. There is now an optimal contrast pattern in the dorsal epidural space.
Suboptimal
VI
Suboptimal
A
B
Fig. 25.7. A, Cervical C6-C7 interlaminar epidural steroid injection, anteroposterior view, demonstrating communication with the space of Okada and bilateral C6-C7 Z-joints. B, Cervical interlaminar epidural steroid injection, lateral view of the same patient, demonstrating contrast extravasation in the posteriorly located space of Okada and bilateral Z-joints. Although there is some optimal flow in the epidural space, this is still a suboptimal contrast pattern.
408
Suboptimal Images
Suboptimal
Suboptimal
B
A
Fig. 25.8. A, Anteroposterior (AP) view demonstrating non-epidural contrast on either side of the spinous process (closed arrows). This is actually a “mixed” pattern with epidural flow as well (open arrow). B, Corresponding lateral view demonstrating that most of the contrast flow is dorsal to the desired epidural space and between the lamina (closed arrow), along with epidural flow (open arrow).
Suboptimal
A
Suboptimal
B
Video 25. Video of a cervical IL-ESI with inadvertent vascular injection.
References 1. Lirk P, Kolbitsch C, Putz G, et al. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology. 2003;99(6):1387–1390.
4. Furman MB, Jasper NR, Lin HW. In response to “Intricacies of the contralateral oblique view for interlaminar epidural access.” Pain Med. 2013;14(8):1267–1268.
2. Gill J, Aner M, Simopoulos T. Intricacies of the contralateral oblique view for interlaminar epidural access. Pain Med. 203;14(8):1265–1256.
5. Landers MH, Dreyfus P, Bogduk N. On the geometry of fluoroscopic views of cervical epidural injections. Pain Med. 2012;13(1):58–65.
3. Furman MB, Jasper NR, Lin HW. Fluoroscopic contralateral oblique view in interlaminar interventions: a technical note. Pain Med. 2012;13(11):1389–1396.
Suggested Readings Aldrete JA, Mushin AU, Zapata JC, Ghaly R. Skin to cervical epidural space distances as read from magnetic resonance imaging films: consideration of the “hump pad.” J Clin Anesth. 1998;10(4):309–313.
Lieberman R, Dreyfuss P, Baker R. Letter to the editor: fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003;84(10):1568–1569.
Gill JS, Aner M, Nagda JV, Keel JC, Simopoulos TT. Contralateral oblique view is superior to lateral view for interlaminar cervical and cervicothoracic epidural access. Pain Med. 2015;16(1):68–80.
Strub WM, Brown TA, Ying J, Hoffmann M, Ernst RJ, Bulas RV. Translaminar cervical epidural steroid injection: short term results and factors influencing outcome. J Vasc Interv Radiol. 2007;18(9):1151–1155.
Goodman BS, Petalcorin JS, Mallempati S. Optimizing patient positioning and fluoroscopic imaging for the performance of cervical interlaminar epidural steroid injections. PM R. 2010;2(8):783–786.
Whitworth M. Puttlitz line: a rapid and reproducible fluoroscopic needle endpoint for cervical interlaminar epidural steroid injections presented at the American Academy of Pain Medicine; February 14, 2008; Orlando, FL.
409
VI
Fig. 25.9. A, Anteroposterior (AP) view of a suspected subdural injection. Note contrast flow has sharp borders as compared to typical epidural flow. B, Lateral images of suspected subdural flow. We suggest repositioning of the needle in cases of subdural flow (Courtesy of David Levi, MD). See Chapter 12, Lumbar Interlaminar ESI, for further discussion.
Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach Justin J. Petrolla, S. Amir Tahaei, Kirk M. Puttlitz, Michael A. Klein, and Michael B. Furman Cervical interlaminar epidural steroid injections are indicated for radicular pain with or without axial neck pain. The interlaminar approach is well suited for delivering medication to bilateral and/or multilevel cervical sites. C7-T1 level is typically targeted since it has the largest posterior to anterior distance between the ligmantum flavum and dura/spinal cord (SC). Also, the lower cervical levels are more likely to have an intact and fused midline ligamentum flavum. Preprocedure MRI review is helpful to examine the posterior epidural space dimensions. If the posterior epidural space is minimal to nonexistent at C7-T1, choose the T1-T2 segment. After placing the needle using a trajectory view, it is advanced using multiplanar imaging, emphasizing on safety while visualizing the needle tip depth as it approaches the ventral interlaminar line (VILL) in the contralateral oblique (CLO) view and/or the spinolaminar line in the lateral view. We recommend visualizing the needle tip depth using CLO and/or lateral views rather than depending solely on the needle tip (stepping off the lamina). Typically, CLO view has better visualization than the lateral view since the shoulders frequently obstruct clear cervicothoracic region visualization in the lateral view. See Chapter 3 for more detailed CLO visualization explanation. The epidural space is accessed by advancing the needle through the ligamentum flavum using the classic loss of resistance (LOR) technique coupled with multiplanar fluoroscopic imaging and real-time contrast visualization. The final location of the needle tip should be at the midline or slightly off the midline for more unilateral or asymmetric symptoms.
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
25
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
Trajectory View (Fig. 25.1) Confirm the level with the anteroposterior (AP) view. Tilt the fluoroscope caudad. n Maximize/optimize the targeted interlaminar space radiolucency with crisp laminar edges (usually C7-T1) using caudad or cephalad tilt. n Oblique slightly (approximately 5–10 degrees) toward the symptomatic side (right side in this case). n The needle is placed directly at the midline or just ipsilateral to the midline on the painful side in the target radiolucent interlaminar space. n Because this is the trajectory view, place the needle parallel to the fluoroscopic beam. n n
Notes on Positioning in the Trajectory View Initial needle placement should be shallow in the soft tissues to avoid puncturing the dura and contacting SC. Interlaminar placement and further needle advancement can then be performed after rotating the C-arm into the lateral or CLO safety view. It is not necessary to “walk off” the lamina. n There are no consistent radiolucent safety considerations in this trajectory view. n n
Trajectory view
Trajectory view
C7 VB 1st rib T1 VB
VI
B A SC Trajectory view
SN
The needle should not be advanced too far ventrally in this view. We recommend observing the safety considerations demonstrated in other views (CLO and lateral) to visualize the corresponding landmarks.
C7 VB T1 VB 1st rib
C 402
Fig. 25.1. A, Fluoroscopic image of a trajectory view with the needle in position at the C7-T1 interlaminar space with 5 to 10 degrees of ipsilateral oblique. The needle tip is slightly to the right of the midline. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view. Note that this is not the safety view for this procedure. This image is used to emphasize the location of the spinal cord (SC).
Optimal Needle Position in Multiplanar Imaging
ptimal Needle Position O in Multiplanar Imaging We recommend a minimum of two views, including the AP view (approaching midline) and the CLO view to confirm that the tip has not respectively crossed the VILL. Optionally, use the “true” lateral to confirm that the tip has not crossed the spinolaminar line. Advance the needle tip safely toward the target only with the use of the CLO and/or “true” lateral safety view. The AP view is used to confirm laterality or midline placement but is not a safety view.
OPTIMAL NEEDLE POSITIONING IN THE AP VIEW (FIG. 25.2) The needle should ideally remain close to the midline. The needle tip may be targeted slightly off the midline for the treatment of more unilateral symptoms.
Trajectory view
Trajectory view
C7 VB 1st rib T1 VB
B A SC
SN C7 VB T1 VB
VI
Trajectory view
There are no consistent radiolucent safety considerations in this trajectory view. To avoid dural and SC contact, the needle should not be advanced too far ventrally in this view. We recommend observing the safety considerations demonstrated in other views (CLO and/or lateral) to visualize the corresponding landmarks.
1st rib
C Fig. 25.2. A, Fluoroscopic “true” AP view with the pre-loss of resistance, precontrast needle position near midline. This is a paramedian approach toward the right with the needle tip near the midline. The needle should not be advanced any further since this is not a safety view. B, Radiopaque structures, AP view. C, Radiolucent structures, AP view.
403
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
OPTIMAL NEEDLE POSITIONING IN THE CONTRALATERAL OBLIQUE VIEW (FIG. 25.3) After confirming the needle tip position in AP view, the C-arm should now be positioned in the CLO safety view. For more discussion regarding CLO, please see Chapter 3, Fig. 3.21. n Optimal needle positioning: CLO (i.e., obliqued to the opposite side of the needle tip), with the needle confirmed as being at the midline or slightly closer to the more symptomatic side. An initial starting angle will be about 60 degrees CLO. n Under the CLO view, advance the needle slowly, intermittently, or continuously checking for LOR. LOR should be encountered near the VILL. The VILL is the line that connects the posterior edge of the neuroforamen with the anterior margin of the football-shaped lamina. Note that the needle may appear to be more ventral if the tip crosses the midline to the side ipsilateral to the image intensifier.
Multiplanar view
Multiplanar view
VILL Lam SP
C5 VB C6 VB C7 VB T1 VB
B
A
VI
D Multiplanar view
SC
Safety Considerations
VILL Lam SP
C5 VB C6 VB
Safety view
Cautiously approach and traverse the VILL with a LOR technique. Avoid puncturing the dura (D) and contacting the spinal cord (SC).
C7 VB T1 VB SN
C Fig. 25.3. A, Fluoroscopic contralateral oblique view (i.e., safety view) with the pre-loss of resistance position at the ventral edge of the football-shaped lamina (Lam). The needle tip may be advanced with the loss of resistance expected at or slightly past the ventral interlaminar line (VILL). B, Radiopaque structures, contralateral oblique view. C, Radiolucent structures, contralateral oblique view.
404
Optimal Needle Position in Multiplanar Imaging
OPTIMAL NEEDLE POSITIONING IN THE LATERAL VIEW After confirming the needle tip position in AP and CLO views, the C-arm may now be positioned in the lateral safety view for further multiplanar confirmation.
PATIENT PRONE, “TRUE” LATERAL (I.E., 90 DEGREES OBLIQUE) (FIG. 25.4)
Multiplanar view
Multiplanar view
C6 VB Spinolaminar line
C7 VB T1 VB
B
A
D SC Multiplanar view
C6 VB Spinolaminar line
T1 VB
Cautiously approach and traverse the spinolaminar line with an LOR technique. Avoid puncturing the dura (D) and contacting the SC.
VI
Safety view
C7 VB
Safety Considerations
C Fig. 25.4. A, Fluoroscopic “true” lateral view (i.e., safety view) with the needle tip approaching the spinolaminar line. The loss of resistance is expected at or near the spinolaminar line. B, Radiopaque structures, “true” lateral view. C, Radiolucent structures, “true” lateral view.
405
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
OPTIMAL NEEDLE POSITIONING IN THE LATERAL SAFETY VIEW
VI
We recommend a minimum of two views, including the AP (approaching midline) and either or both of the CLO and “true” lateral views to confirm that the tip has not gone too ventral. n If the needle is advanced ventral to VILL in CLO view (or spinolaminar line in the lateral views) and LOR has not yet been encountered, then do the following: n Check the AP view to make sure that the needle tip is on the desired side and/or has not strayed too far laterally. n Re-stylet the needle to make sure that a blood clot or some other tissue substance has not occluded the needle lumen, thereby confounding the perception of LOR. n Inject contrast to see if the needle tip is indeed already in the epidural space, despite a lack of perceived LOR. n If there is a high resistance on injection or patient complaints of pain or paresthesias, it may suggest that the needle is contacting the SC or a nerve root. n Confirm position and withdraw as appropriate. n Do not inject contrast or injectate because this may precipitate clinically significant nerve or SC injury. n Do not oversedate the patient because this may hinder patient reporting of these helpful warning symptoms. n While advancing the needle via the CLO or “true” lateral safety view, we recommend intermittently switching back to the AP view to confirm the needle tip position relative to the midline. The utility of the CLO or “true” lateral is predicated upon slight ipsilateral or near midline needle tip placement. n When LOR is achieved with either of the techniques, inject contrast to confirm epidural placement.
406
Optimal Images
Optimal Images (Fig. 25.5) Optimal Image (Please see Table 12.1 to differentiate epidural from non-epidural flow) Contralateral oblique view: n When the needle tip is contralateral to the fluoroscope: Contrast flow should layer with a linear pattern immediately ventral to the lamina along the VILL (i.e., the line that connects the posterior edge of the neuroforamen with the anterior margin of the football-shaped lamina). Lateral view: n Contrast flow should layer immediately ventral to the bases of the spinous processes along the spinolaminar line (i.e., the line that connects the ventral edge of the spinous processes). AP view: n Contrast flow typically appears as an irregular, asymmetric cloud, possibly lateralizing to one side. n Contrast dye may outline epidural fat “bubbles.” n Contrast dye may outline exiting spinal nerves. n Contrast immediately contacts the medial pedicle. n Contrast may spread rostral and caudad for many levels; however, central stenosis may limit such spread.
Optimal
Optimal
B
A
VI
Optimal
C Fig. 25.5. A, Contralateral oblique (CLO) fluoroscopic image of a cervical interlaminar epidural steroid injection with 0.5 cc of contrast medium. B, “True” lateral fluoroscopic image of a cervical interlaminar epidural steroid injection with 0.5 cc of contrast medium. Note that the landmarks are not as well visualized as those in the CLO view. C, Anteroposterior fluoroscopic image of a cervical interlaminar epidural steroid injection with 0.5 cc of contrast medium.
407
Chapter 25 Cervical Interlaminar Epidural Steroid Injection—Paramedian Approach
Suboptimal Images (Figs. 25.6 to 25.8)
Optimal
Suboptimal
Soft tissue dye pattern
A
Optimal epidural dye pattern
B
Fig. 25.6. A, Cervical interlaminar epidural steroid injection (ESI), contralateral oblique view. The needle is located dorsal to the ventral interlaminar line (VILL). Note the posterior contrast extravasation into the dorsal soft tissue, with a striated fascial pattern. This amorphous pattern typically occurs with a false loss of resistance (LOR). B, After the needle tip was advanced ventrally toward the epidural space, a true LOR was encountered. There is now an optimal contrast pattern in the dorsal epidural space.
Suboptimal
VI
Suboptimal
A
B
Fig. 25.7. A, Cervical C6-C7 interlaminar epidural steroid injection, anteroposterior view, demonstrating communication with the space of Okada and bilateral C6-C7 Z-joints. B, Cervical interlaminar epidural steroid injection, lateral view of the same patient, demonstrating contrast extravasation in the posteriorly located space of Okada and bilateral Z-joints. Although there is some optimal flow in the epidural space, this is still a suboptimal contrast pattern.
408
Suboptimal Images
Suboptimal
Suboptimal
B
A
Fig. 25.8. A, Anteroposterior (AP) view demonstrating non-epidural contrast on either side of the spinous process (closed arrows). This is actually a “mixed” pattern with epidural flow as well (open arrow). B, Corresponding lateral view demonstrating that most of the contrast flow is dorsal to the desired epidural space and between the lamina (closed arrow), along with epidural flow (open arrow).
Suboptimal
A
Suboptimal
B
Video 25. Video of a cervical IL-ESI with inadvertent vascular injection.
References 1. Lirk P, Kolbitsch C, Putz G, et al. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology. 2003;99(6):1387–1390.
4. Furman MB, Jasper NR, Lin HW. In response to “Intricacies of the contralateral oblique view for interlaminar epidural access.” Pain Med. 2013;14(8):1267–1268.
2. Gill J, Aner M, Simopoulos T. Intricacies of the contralateral oblique view for interlaminar epidural access. Pain Med. 203;14(8):1265–1256.
5. Landers MH, Dreyfus P, Bogduk N. On the geometry of fluoroscopic views of cervical epidural injections. Pain Med. 2012;13(1):58–65.
3. Furman MB, Jasper NR, Lin HW. Fluoroscopic contralateral oblique view in interlaminar interventions: a technical note. Pain Med. 2012;13(11):1389–1396.
Suggested Readings Aldrete JA, Mushin AU, Zapata JC, Ghaly R. Skin to cervical epidural space distances as read from magnetic resonance imaging films: consideration of the “hump pad.” J Clin Anesth. 1998;10(4):309–313.
Lieberman R, Dreyfuss P, Baker R. Letter to the editor: fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003;84(10):1568–1569.
Gill JS, Aner M, Nagda JV, Keel JC, Simopoulos TT. Contralateral oblique view is superior to lateral view for interlaminar cervical and cervicothoracic epidural access. Pain Med. 2015;16(1):68–80.
Strub WM, Brown TA, Ying J, Hoffmann M, Ernst RJ, Bulas RV. Translaminar cervical epidural steroid injection: short term results and factors influencing outcome. J Vasc Interv Radiol. 2007;18(9):1151–1155.
Goodman BS, Petalcorin JS, Mallempati S. Optimizing patient positioning and fluoroscopic imaging for the performance of cervical interlaminar epidural steroid injections. PM R. 2010;2(8):783–786.
Whitworth M. Puttlitz line: a rapid and reproducible fluoroscopic needle endpoint for cervical interlaminar epidural steroid injections presented at the American Academy of Pain Medicine; February 14, 2008; Orlando, FL.
409
VI
Fig. 25.9. A, Anteroposterior (AP) view of a suspected subdural injection. Note contrast flow has sharp borders as compared to typical epidural flow. B, Lateral images of suspected subdural flow. We suggest repositioning of the needle in cases of subdural flow (Courtesy of David Levi, MD). See Chapter 12, Lumbar Interlaminar ESI, for further discussion.