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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Epidural Steroid Injection, Thoracic Spine
KEY FACTS
TERMINOLOGY
• Injection of glucocorticoid/long-acting anesthetic into
thoracic epidural space via interlaminar or transforaminal
approach
PROCEDURE
• Interlaminar epidural steroid injection (ESI)
○ Define margins of lamina and interlaminar space
Image-Guided Procedures
• Transforaminal ESI
○ Ensure good visualization of neural foramen on true
lateral view
• Benefit of CT
○ Improved visualization of osseous structures in severely
osteopenic patients
○ Improved visualization of pleura/medial chest cavity
POST PROCEDURE
• Expectation
(Left) Graphic shows the spinal
cord and the relationship
of vascular structures to
exiting nerve roots st.
Interlaminar epidural steroid
injection (ESI) approach is at
the junction of the lamina and
spinous process ſt. (Right)
Axial graphic demonstrates
relationship of nerve roots
and nerve root sleeve ſt to
neural foramen. Optimal
needle tip placement for
transforaminal or
interlaminar ESI is shown.
○ Improvement in pain, or cessation of pain, following
injection
• Things to do
○ Establish clinical follow-up, and have patient maintain
pain diary
○ Remind patient to expect full benefit of injection over
next 24-48 hours
OUTCOMES
• Most feared complications
○ Intraarterial injection: Spinal cord ischemia
○ Spinal cord puncture/hematoma
○ Compressive epidural hematoma
○ Pneumothorax
Normal Anatomy Normal Anatomy
450
Frontal Oblique Epidurogram Lateral Epidurogram
(Left) Oblique fluoroscopic
spot radiograph shows the
needle tip in the interlaminar
space ſt with contrast
tracking cephalad in the
thoracic epidural space .
Note the superior margin of
the lamina and spinous
process . (Right) A lateral
fluoroscopic spot radiograph
shows the needle tip
positioned within the thoracic
epidural space ſt. Contrast
is seen tracking cephalad
within the epidural space with
an amorphous appearance
characteristic of epidural
injections. Note the vertebral
compression fracture .
Epidural Steroid Injection, Thoracic Spine
TERMINOLOGY
Abbreviations
• Thoracic epidural steroid injection
Definitions
• Injection of corticosteroid/long-acting anesthetic into
thoracic epidural space via interlaminar or transforaminal
approach
PREPROCEDURE
Indications
• Thoracic radiculopathy at > 1 level
• Persistent pain following vertebroplasty/kyphoplasty
Contraindications
• Coagulopathy
• Local or systemic infection
• Allergy to injectate
Getting Started
• Things to check
○ Clinical indication
– Correlation between pain and level chosen for
injection
○ Diagnostic imaging
– Adequate epidural fat/space for needle placement
○ Laboratory
– Coagulopathy
– Infection
○ Informed consent
• Medications
○ Glucocorticoid
○ Long- and short-acting anesthetic
○ Myelography-safe iodinated contrast for fluoroscopy-
guided injection
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Prone
– Pillow placement beneath patient (kyphosis) may
improve visualization of interlaminar space
– Interlaminar: Define margins of lamina and
interlaminar space
– Transforaminal: Ensure good visualization of neural
foramen on true lateral view; triangulate trajectory
between frontal and lateral views keeping medial to
avoid lung
○ Benefit of CT
– Improved visualization of osseous structures in
severely osteopenic patients
– Improved visualization of pleura/medial chest cavity
Procedure Steps
• Procedure "time out": Verify correct patient, procedure,
and side
• Perform sterile prep and drape, local anesthetic
• Interlaminar
○ Carefully assess trajectory intermittently while advancing
needle tip to level of superior lamina
○ Very slowly advance needle under intermittent imaging
until loss of resistance is noted on plunging glass syringe
○ Once loss of resistance occurs, attach contrast tubing
and inject contrast to confirm needle tip placement in
epidural space
○ Attach injectate syringe, and inject slowly
• Transforaminal
○ Carefully assess trajectory needed on biplane
fluoroscopy or CT to reach superomedial neural foramen
○ Slowly advance 22-gauge spinal needle under
intermittent imaging guidance
– Placing gentle curve 20-30° in distal needle often
facilitates placement within neural foramen
○ When approaching foramen, warn patient of possible
sudden pain in case needle contacts exiting nerve
○ When needle lies within medial neural foramen, remove
stylette, and attach air-free contrast extension tubing
○ Slowly inject contrast to confirm tracking into epidural
space
○ Obtain image to document needle tip placement
○ Attach injectate syringe, and slowly inject
Alternative Procedures/Therapies
• Radiologic
○ Selective nerve root block
• Surgical
○ Decompression
POST PROCEDURE
Expected Outcome
• Improvement in or cessation of pain following injection
Things to Do
• Help patient to sitting posture
• Establish clinical follow-up, and have patient maintain pain
diary
• Remind patient to expect full benefit of injection over next
24-48 hours
OUTCOMES
Problems
• Failure of pain relief
Complications
• Most feared complication(s)
○ Intraarterial injection: Spinal cord ischemia
○ Spinal cord puncture/hematoma
○ Pneumothorax
• Other complications
○ Bleeding, infection, nerve injury
SELECTED REFERENCES
1. Georgy BA: Interventional techniques in managing persistent pain after
vertebral augmentation procedures: a retrospective evaluation. Pain
Physician. 10(5):673-6, 2007
2. Botwin KP et al: Adverse effects of fluoroscopically guided interlaminar
thoracic epidural steroid injections. Am J Phys Med Rehabil. 85(1):14-23,
2006
Image-Guided Procedures
451
Medial Branch Block, Lumbar Spine
KEY FACTS
TERMINOLOGY
• Selective anesthesia of lumbar nerve medial branch in
diagnostic evaluation of lumbar facet joint pain
PREPROCEDURE
• Facet joint pain
○ Useful in selecting patients for medial branch
radiofrequency ablation procedure
Image-Guided Procedures
PROCEDURE
• Target: Junction of superior articular process and
transverse process
○ Medial branch is numbered along with exiting lumbar
nerve root
○ L5 medial branch innervates inferior L4/5 and superior
L5/S1 facet joint
• Patient positioning
○ Prone: Angulate C-arm such that "eye" of "Scotty dog" is
well visualized
Dorsal Ramus Medial Branch Needle Placement: Lateral View
(Left) Sagittal graphic shows
the dorsal ramus medial
branch ſt in the osseous
groove at the junction of the
superior articular process st
and transverse process ,
immediately above the
pedicle. (Right) Lateral
fluoroscopy shows an L3
needle that is superficially
located. Lateral fluoroscopy is
useful during needle
placement to ensure that bone
is reached at an appropriate
depth. Single-plane imaging is
deceptive, and care must be
taken to ensure safe needle
depth.
POST PROCEDURE
• Expectation
○ Significant reduction in facet joint pain
○ < 100% pain relief decreases likelihood of successful
rhizotomy
– Injection of superior and inferior rami essential to
effectively block nervous supply to facet joint
OUTCOMES
• Failure of pain relief
○ Incorrect level or poor needle placement
○ Facet joint may not be source of pain
• Complications
○ Intravascular injection: Spinal cord ischemia
○ Dural puncture: Cauda equina injury, meningitis
452
Needle Placement: AP View Needle Position: AP View
(Left) Oblique fluoroscopic
spot radiograph shows
successful needle placement
for L2, 3, and 5 medial branch
blocks ſt. Medial L4 needle
tip is not optimal . (Right)
Anteroposterior fluoroscopic
spot radiograph shows the
needle tips ſt at the expected
location of the right L2, L3, L4,
and L5 medial branches. Note
that the target point of L5
dorsal ramus is at the lateral
junction of the S1 superior
articular process and sacral
ala. Compare with previous
oblique view.
Medial Branch Block, Lumbar Spine
TERMINOLOGY
Definitions
• Selective anesthesia of lumbar nerve medial branch in
diagnostic evaluation of lumbar facet joint pain
PREPROCEDURE
Indications
• Chronic lower back pain
• Facet joint pain
○ Useful in selecting patients for medial branch
radiofrequency ablation (RFA) procedure
Contraindications
• Allergy to injectate
• Coagulopathy
• Local or systemic infection
• Relative contraindication
○ Pregnancy
Getting Started
• Medications
○ ± corticosteroid
○ Long-acting anesthetic
○ Short-acting anesthetic
○ Iodinated contrast (myelography-safe) is optional
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Prone
– Pillow or bumper beneath patient may be useful for
stable positioning/patient comfort
– Angulate C-arm such that "eye" of "Scotty dog" is well
visualized
○ Target
– Junction of superior articular process (SAP) and
transverse process
– Medial branch is numbered along with exiting lumbar
nerve root
□ L5 medial branch innervates inferior L4/5 and
superior L5/S1 facet joint
Procedure Steps
• Procedure "time out"
○ Correct patient, procedure, side, and levels of
intervention
• Optimize C-arm angulation, 10-15° toward side of injection
• Perform sterile prep and drape
• Provide local anesthetic
• Insert 22-gauge spinal needle into subcutaneous tissue
• Advance needle under intermittent fluoroscopy
○ T12/L1-L4/L5
– Target junction of SAP and transverse process (small
osseous groove)
○ L5 dorsal ramus
– Target junction of S1 SAP and sacral ala
• When bone is reached, turn bevel down (away from neural
foramen)
○ Gently aspirate to confirm extravascular
Image-Guided Procedures
• Inject small amount of contrast
○ If desired to confirm needle tip placement/extravascular
injection
• Place needles at additional levels as indicated
• Attach injectate syringe, and inject slowly
○ Assess pain with each injection
Findings and Reporting
• Level(s) injected
• Pain scale and character before and after injection(s)
Alternative Procedures/Therapies
• Radiologic
○ Lumbar facet joint block
○ Lumbar epidural steroid injection
• Other
○ Neurolysis
– RFA
– Cryoablation
POST PROCEDURE
Expected Outcome
• Significant reduction in pain corresponding to facet joint
injected
○ < 100% pain relief decreases likelihood of successful
rhizotomy
– Injection of superior and inferior rami essential to
effectively block nervous supply to facet joint
OUTCOMES
Problems
• Failure of pain relief
○ Incorrect level or poor needle placement
○ Facet joint may not be source of pain
Complications
• Most feared complication(s)
○ Intravascular injection
– Spinal cord ischemia
○ Dural puncture
– Spinal cord or cauda equina injury
– Meningitis
• Other complications
○ Bleeding
○ Infection
○ Nerve root injury
SELECTED REFERENCES
1. Chou R et al: Nonsurgical interventional therapies for low back pain: a review
of the evidence for an American Pain Society clinical practice guideline. Spine
(Phila Pa 1976). 34(10):1078-93, 2009
2. Lee CJ et al: Intravascular injection in lumbar medial branch block: a
prospective evaluation of 1433 injections. Anesth Analg. 106(4):1274-8,
table of contents, 2008
3. Manchikanti L et al: Lumbar facet joint nerve blocks in managing chronic
facet joint pain: one-year follow-up of a randomized, double-blind controlled
trial: Clinical Trial NCT00355914. Pain Physician. 11(2):121-32, 2008
4. Verrills P et al: The incidence of intravascular penetration in medial branch
blocks: cervical, thoracic, and lumbar spines. Spine (Phila Pa 1976).
33(6):E174-7, 2008
453
Facet Joint Injection, Lumbar Spine
KEY FACTS
TERMINOLOGY
• Injection of corticosteroid and anesthetic into lumbar facet
joint
PREPROCEDURE
• Facet joint osteoarthritis
• Synovial cyst causing neurologic symptoms
PROCEDURE
Image-Guided Procedures
• Prone
• Angle C-arm or PA fluoroscopy tube slightly toward side of
joint to be injected
○ Generally, lower 1/3 of joint is most amenable to needle
entry/injection in arthritic joint
• Ensure proper level
• Slowly inject only enough contrast to confirm that needle
tip is in joint space
• Note pain scale and pain characteristics
○ Before, during, and after injection
(Left) Axial NECT shows the
needle tip ſt at the
superolateral margin of the
right L4/5 facet joint. Note
that the needle is nearly
within the plane of the image
and that the needle tip casts a
dark artifact . (Right)
Oblique fluoroscopic
radiograph shows a 22-gauge
spinal needle passing between
adjacent articular facets st
into the right L4/5 facet joint
ſt. Correlation with lateral
imaging is helpful in
determining depth. A "pop" is
felt upon penetration of the
joint capsule.
• Synovial cyst therapeutic rupture
○ May require significant injection pressure
○ See sudden spread of contrast into epidural space
OUTCOMES
• Failure to alleviate pain
○ Wrong level injected
○ Injection extraarticular
○ Facet joint not source of pain
○ May require multilevel injections
• Most feared complications
○ Thecal sac puncture, cord injury, meningitis
• Other complications
○ Nerve root injury, bleeding, infection
CT Facet Injection Needle Positioning: Frontal Oblique View
454
(Left) Fluoroscopic spot
radiograph obtained during
lumbar facet joint injection
shows contrast about the
joint; particularly note linear
craniocaudal extension of
contrast ſt, which is
characteristic of an
intraarticular injection. (Right)
AP fluoroscopic spot
radiograph shows contrast
opacification within the facet
joint extending caudally into a
focal collection consistent
with a synovial cyst ſt.
Mixed Intra-/Extraarticular Injection: AP
Oblique View
Contrast Injection: Facet Joint and
Synovial Cyst
Facet Joint Injection, Lumbar Spine
TERMINOLOGY
Abbreviations
• Facet joint injection (FJI)
Definitions
• Injection of corticosteroid ± anesthetic into lumbar facet
joint
PREPROCEDURE
Indications
• Facet joint osteoarthritis
• Synovial cyst causing neurologic symptoms
Contraindications
• Local or systemic infection
• Coagulopathy
• Allergy to injectate
Getting Started
• Things to check
○ Imaging of facet joint for pathology and anatomic
relationships
○ Informed consent
○ Laboratory: Coagulation parameters
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Prone
– Angle C-arm or PA fluoroscopy tube slightly toward
side of joint to be injected
– May need slight cranial angulation as well to optimize
joint visualization
– Generally, lower 1/3 of joint is most amenable to
needle entry/injection in arthritic joint
□ Inferior recess may be only accessible site for
injection in severely arthritic joint
Procedure Steps
• Ensure correct spine level for injection
• Target lower 1/3 of joint space
○ Often, arthritic joints will have redundancy inferiorly,
creating more accessible joint space
• Perform sterile prep and drape
• Apply local anesthetic
• Place spinal needle into subcutaneous tissue, and confirm
trajectory with imaging
• Advance until bone is reached or feel needle advance into
joint space
• If reach bone, "walk" needle into joint
• Attach preloaded contrast tubing and syringe
• Slowly inject only enough contrast to confirm needle tip in
joint space
• Remix and attach injectate syringe
• Slowly inject
• Note patient's symptoms during and immediately following
injection
• Synovial cyst therapeutic rupture
○ Same steps as FJI
Image-Guided Procedures
○ Alternate approach is interlaminar puncture of cyst
– CT guidance suggested for translaminar approach
○ Patient will often feel "pop" with cyst rupture
– May require significant injection pressure
– Can be quite painful for patient
○ Interventionalist will see sudden spread of contrast into
epidural space with cyst rupture
Alternative Procedures/Therapies
• Radiologic
○ Medial branch block
○ Epidural steroid injection
○ Percutaneous facet joint fusion
POST PROCEDURE
Expected Outcome
• Improved pain symptoms
Things to Do
• Help patient from procedure table
• Establish follow-up
• Remind patient to keep pain diary until next clinic
appointment
Things to Avoid
• Strenuous activity for remainder of day
• Bathing for 48 hours
OUTCOMES
Problems
• Failure to alleviate pain
○ Technical failure
– Wrong level injected
– Injection extraarticular
○ Clinical failure
– Facet joint not source of pain
□ May require multilevel injections
– Multifactorial pain
Complications
• Most feared complication(s)
○ Thecal sac puncture
– Cord injury
– Meningitis
– Cerebrospinal fluid leak
• Other complications
○ Bleeding
○ Infection
○ Nerve injury
SELECTED REFERENCES
1. Datta S et al: Systematic assessment of diagnostic accuracy and therapeutic
utility of lumbar facet joint interventions. Pain Physician. 12(2):437-60, 2009
2. Martha JF et al: Outcome of percutaneous rupture of lumbar synovial cysts:
a case series of 101 patients. Spine J. 9(11):899-904, 2009
455
Selective Nerve Root Block, Lumbar Spine
KEY FACTS
TERMINOLOGY
• Selective corticosteroid and long-acting anesthetic injection
of lumbar nerve root at level of neural foramen
PREPROCEDURE
• Imaging
○ Single or multilevel involvement
PROCEDURE
Image-Guided Procedures
• Carefully determine correct level(s) for injection
○ Nerve root exits below pedicle of same numbered
vertebral body
• 2 approaches for lumbar selective nerve root block
○ Angle C-arm toward side to be injected and target
beneath pedicle/"eye" of "Scotty dog"
○ Using AP projection, mark skin 6-8 cm lateral to neural
foramen and determine trajectory to foramen
• Assess pain score/reproduction of pain before, during, and
after injection
(Left) Sagittal T1-weighted
MR shows hyperintense fat st
in the neural foramina
surrounding the lumbar nerve
roots. The nerve root is
located superiorly ſt, like
thoracic nerves. Cervical
nerves are located inferiorly.
(Right) AP spot radiograph
shows the needle tip deep
within the neural foramen
beneath the central aspect of
the pedicle ſt with contrast
within the left L5 neural
foramen as well as a large
volume of contrast extending
into the right dorsolateral
epidural space from the L4-S1
levels st.
• Findings and reporting
○ Pain before, during, and after injection
○ Was pain reproduced by procedure?
○ Level(s) injected including injectate volume and
medications injected
POST PROCEDURE
• Expectation
○ Significant reduction in pain following injection (may take
48-72 hours)
OUTCOMES
• Most feared complications
○ Dural puncture (spinal cord injury, meningitis, CSF leak)
○ Vascular injury/intravascular injection (spinal cord
ischemia)
• Problems
○ Failure of pain relief
○ Vasovagal reaction
Anatomy Intraforaminal and Epidural Injection
456
Needle Placement: Oblique View Intraforaminal and Epidural Injection
(Left) Oblique "Scotty dog"
view of the lumbar spine
allows targeting of the neural
foramen beneath the
pedicle/"eye" ſt, and then
advance the needle parallel to
the imaging beam .
Intermittent lateral imaging is
essential to determine needle
depth. (Right) AP image from
another patient shows the
expected linear appearance of
contrast tracking along the
exiting lumbar nerve root ſt.
In addition, there is contrast
extending slightly above the
neural foramen, medial to the
pedicle, into the epidural
space .
Selective Nerve Root Block, Lumbar Spine
TERMINOLOGY
Abbreviations
• Selective nerve root block (SNRB), epidural steroid injection
(ESI)
Definitions
• Selective corticosteroid and long-acting anesthetic injection
of lumbar nerve root at level of neural foramen
PREPROCEDURE
Indications
• Lumbar radiculopathy
○ Lumbar osteoarthritis
○ Posttraumatic osteoarthritis
Contraindications
• Coagulopathy
• Local or systemic infection
• Severe allergy to components of injectate
• Relative
○ Pregnancy, iodinated contrast allergy, recent live virus
vaccination
Getting Started
• Things to check
○ Preprocedure imaging
– Look for causative lesion and single or multilevel
involvement
○ Laboratory data
– Signs of infection or coagulopathy
○ Informed consent
• Medications
○ Corticosteroid
○ Long-acting anesthetic
○ Short-acting (local) anesthetic
○ Myelography-safe iodinated contrast
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Prone
– 2 approaches for lumbar SNRB
□ Angle C-arm toward side to be injected and target
foramen beneath pedicle/"eye" of "Scotty dog"
□ Use anteroposterior projection and mark skin 6-8
cm lateral to neural foramen
Procedure Steps
• Procedural "time out"
○ Verify correct patient, side of injection, and procedure to
be performed
• Carefully determine correct level(s) for injection
• Mark skin at appropriate level and perform sterile prep and
drape
• Anchor 22-gauge spinal needle and check trajectory with
AP and lateral fluoroscopy
• Carefully advance needle under intermittent frontal and
lateral fluoroscopy until foramen or bone is reached
Image-Guided Procedures
• Remove stylette, observe hub for blood, then attach
contrast syringe/tubing
• Aspirate gently, then inject myelography-safe contrast
○ Watch for vascular enhancement and adjust needle tip if
necessary
○ Should see contrast track along nerve root
• Remove contrast tubing then mix and attach injectate
syringe
• Slowly inject, noting patient pain and whether characteristic
pain is reproduced
• Remove needle and obtain hemostasis
Findings and Reporting
• Pain before, during, and after injection
○ Was pain reproduced by procedure?
• Level(s) injected including injectate volume and
medications injected
○ SNRB ± transforaminal ESI
POST PROCEDURE
Expected Outcome
• Significant reduction in pain following injection
○ May experience worsening of pain between local
anesthetic wearing off and corticosteroid taking effect
(48-72 hours)
Things to Do
• Remind patient to keep pain diary until next clinic visit
Things to Avoid
• Bathing for 48-72 hours
OUTCOMES
Problems
• Failure of pain relief
○ Improper needle placement/extraforaminal injection
○ Improper level injected
• Vasovagal reaction
Complications
• Most feared complication(s)
○ Dural puncture (spinal cord injury, meningitis, CSF leak)
○ Vascular injury/intravascular injection (spinal cord
ischemia)
• Other complications
○ Bleeding, nerve root injury, infection
SELECTED REFERENCES
1. Boezaart AP et al: Paravertebral block: cervical, thoracic, lumbar, and sacral.
Curr Opin Anaesthesiol. 22(5):637-43, 2009
2. Eckel TS et al: Epidural steroid injections and selective nerve root blocks.
Tech Vasc Interv Radiol. 12(1):11-21, 2009
3. Manchikanti L et al: Comprehensive review of neurophysiologic basis and
diagnostic interventions in managing chronic spinal pain. Pain Physician.
12(4):E71-120, 2009
4. Roberts ST et al: Efficacy of lumbosacral transforaminal epidural steroid
injections: a systematic review. PM R. 1(7):657-68, 2009
457
Epidural Steroid Injection, Lumbar Spine
KEY FACTS
TERMINOLOGY
• Corticosteroid/anesthetic injection into lumbar epidural
space via interlaminar, transforaminal, or caudal approach
PREPROCEDURE
• Indications
○ Lumbar radiculopathy
○ Residual pain following vertebroplasty/kyphoplasty
Image-Guided Procedures
• Things to check
○ Prior imaging: Adequate epidural space (especially
important in postoperative back!)
• Avoid interlaminar approach in patient with severe canal
stenosis without identifiable epidural space on
preprocedure imaging
• Literature supports use of nonparticulate steroid
(dexamethasone) to minimize possibility of small vessel
vascular embolization
Severe Central Canal Stenosis Needle Placement: Interlaminar ESI
(Left) Sagittal T1WI MR shows
severe central canal stenosis
ſt at each disc level due to
disc bulge/osteophyte and
posterior ligamentous laxity.
Note the epidural fat at
levels above surgery. (Right)
AP fluoroscopic image
obtained during lumbar
epidural steroid injection (ESI)
shows anatomic landmarks
and well-defined interlaminar
space . Note the spinous
process st and cortex of
laminae above and below ſt.
PROCEDURE
• Interlaminar epidural steroid injection (ESI)
○ Target superior lamina near midline
• Transforaminal ESI
○ Target superomedial neural foramen
• Caudal ESI
○ Target sacral hiatus at midline, and consider catheter
placement in patients requiring higher lumbar level
injections
POST PROCEDURE
• Expectations
○ Reproduction of pain with needle placement/injection
○ Significant improvement in pain after injection
OUTCOMES
• Most feared complications
○ Intravascular injection/spinal cord ischemia
○ Spinal cord puncture
458
Transforaminal ESI Contrast Spread in Dorsal Epidural Space
(Left) AP view obtained in this
patient undergoing right L1/2
transforaminal ESI shows
contrast ſt spreading medial
to the pedicle and cephalad
within the lumbar epidural
space. (Right) The lateral view
provides additional
confirmation that contrast is
predominantly spreading
within the dorsal epidural
space and is noted to
extend readily in a cephalad
direction.
Epidural Steroid Injection, Lumbar Spine
TERMINOLOGY
Abbreviations
• Epidural steroid injection (ESI)
Definitions
• Corticosteroid/anesthetic injection into lumbar epidural
space via interlaminar or transforaminal approach
PREPROCEDURE
Indications
• Lumbar radiculopathy
○ Degenerative disc disease
○ Posttraumatic
Contraindications
• Coagulopathy
• Allergy to injectate
• Local or systemic infection
• Relative contraindications
○ Iodinated contrast allergy, pregnancy, active hepatitis
Getting Started
• Things to check
○ Laboratory data
– Coagulation studies as indicated for patients
undergoing anticoagulation therapy
□ Prothrombin time, activated partial thromboplastin
time, international normalized ratio, platelet count
• Equipment list
○ Interlaminar ESI
– Glass syringe with preservative-free saline ("loss of
resistance" technique)
– 18- to 22-gauge Tuohy or Whitacre needle
○ Transforaminal ESI
– 22-gauge spinal needle
○ Caudal ESI
– 18- to 22-gauge Tuohy or Whitacre needle
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Prone
Procedure Steps
• Steroid: Literature supports use of nonparticulate steroid
(dexamethasone) to minimize possibility of small vessel
vascular embolization
○ No strong literature support for better efficacy of
particulate or Depo preparations
• Interlaminar
○ Target superior lamina near midline
○ Carefully "walk" off lamina superiorly, then attach glass
syringe
○ Very carefully advance needle until loss of resistance
occurs with glass syringe plunging
• Transforaminal
○ Target superomedial neural foramen
○ Slowly advance adjacent to exiting nerve root
• Caudal
Image-Guided Procedures
○ Sacral hiatus/canal
○ Advance Tuohy needle through canal to epidural space
using "loss of resistance" technique
– If contrast does not opacify high enough into lumbar
canal, consider use of catheter or vascular sheath
□ Exchange needle over 0.035 wire, and navigate
sheath or catheter over wire to desired level under
fluoroscopic guidance
• Document needle placement with imaging
• Attach injectate, and slowly inject
Findings and Reporting
• Document level, amount of pain before and after
procedure
POST PROCEDURE
Expected Outcome
• Reproduction of pain with needle placement/injection
• Improvement in pain after injection
Things to Avoid
• Interlaminar approach in patient with severe canal stenosis
without identifiable epidural space on preprocedure
imaging
OUTCOMES
Problems
• Incorrect level injected/failure of pain relief
• Vasovagal reaction
Complications
• Most feared complication(s)
○ Intravascular injection
– Spinal cord ischemia
○ Spinal cord puncture
SELECTED REFERENCES
1. Dietrich TJ et al: Particulate versus non-particulate steroids for lumbar
transforaminal or interlaminar epidural steroid injections: an update. Skeletal
Radiol. 44(2):149-55, 2015
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