Cervical epidural steroid injection

dr A Sugeng Wibisono, SpAn ,FIPM,FIPP

Epidural space
 It is bounded cranially by the
foramen magnum
 Caudally the sacrococcygeal
ligament
 these structures allow drugs
injected into the cervical
epidural space to travel
beyond the injection site as
the epidural space is
contiguous from the foramen
magnum to the
sacrococcygeal membrane
Epidural space
 Anteriorly by the post
longitudinal ligament
 Laterally by the vertebral
pedicles , nerve root
 Posterior both lig flavum &
vertebral lamina
 Shallowest anteriorly
where the dura may fuse
with the posterior long.
Ligament
 Deepest posteriorly
 Epidural space
(dorsal, ventral, lateral)

Contents
– Fat,
– Veins,
– Arteries,
– Lymphatics
 Cervical epidural space size (mm)

MRI (Aldrete, et. al.)

– Anterior is 1 mm
– Increases with
flexion
– Decreases with
extension
– Decreases laterally
C6-7 3
C7-T1 4
T1-2 5
T2-3 4
 Ligamentum flavum
• The ligamenta flava connect the lamina from one
vertebra to the next. Also, they attach from the facet
joint capsule to where the lamina fuses to form
spinous processes
• It is relatively thin in the cervical region and becomes
thicker farther caudad, closer to the lumbar spine
• This fact has direct clinical implications in that the loss
of resistance felt during cervical epidural nerve block
is more subtle than it is in the lumbar or lower
thoracic region.
 Ligamentum flavum- Dura
• The distance between the ligamentum flavum and
dura is greatest at the C2 interspace, measuring 5.0-
6.0 mm in adults.
• At C7 ,because of the enlargement of the cervical
spinal cord, the distance from the ligamentum
flavum and dura is only 1.5-2.0 mm
• Flexion of the neck moves this cervical enlargement
more cephalad, resulting in widening of the epidural
space to 3.0-4.0 mm at the C7 -TI interspace.
Ligamentum flavum Midline gaps

●
Lirk, et. al., Anesthesiology 2003
 al, Anesthesiology 2003
Midline gaps

Midline gaps of 1.0 ± 0.3 mm in size

• Th1–Th2: 21%
• C3–C4: 66% • Th2–Th3: 11%
• C4–C5: 58% • Th3–Th4: 4%
• C5–C6: 74% • Th4–Th5: 2%
• C6–C7: 64%
• Th5–Th6: 2%
• C7–T1: 51%
 Entry point
• Entry point at the C7-T1 level is typically
selected for several reasons.
– It has the largest epidural space relative to the
dura and spinal cord in the cervical spine, thereby
allowing more room to work.
– the cervical ligamentum flavum can fail to fuse,
thus potentially leaving gaps at all cervical levels;
however, lower failure rates have been found at
the lower levels.
 Image guidance with
contrast enhancement

 Increased precision
 Increased safety
 Increased comfort
 Better outcomes
 Better science
 New procedures

11
It is not just bones!

•Soft tissues
•Blood vessels
•Nerves
•Spinal Cord
•Radiation exposure

“There are no safe zones”

 Access epidural space
• The epidural space is accessed by advancing the needle through
the ligamentum flavum using the classic LOR or transforaminal
technique
• LOR technique may be nearly impossible to use for some patients
in whom the ligamentum flavum has not fused and and it must be
coupled with the safety view to mitigate the risks of this procedure
• It should be noted that multiplanar fluoroscopic imaging allows
the physician to safely approach the epidural space without
puncturing the dura or touching the spinal cord;
• The feel of the LOR technique coupled with multiplanar
fluoroscopic imaging and realtime contrast visualization are
needed for safe epidural access.
 Access epidural space
• For patients with predominately unilateral or
asymmetric pain, a paramedian approach is
used. In these cases, the injectate flow is
aimed toward the symptomatic side.
• The final location of the needle tip should be
midline or slightly off midline ipsilaterally for
more unilateral symptoms
 Access epidural space
• Because it is common for the patient
shoulders to obscure the needle image in the
lateral view, the 50-60 degrees contralateral
oblique view may be the only view available for
safely identifying needle depth by visualizing
the line.
• When the lateral or contralateral oblique view
is used to assess depth, one need not “step
off” of the lamina, as is often recommended.
Lateral view
Lateral view
Contra lateral oblique
MEASURED
 Contralateral oblique view
50-60 *

Spinolaminar line
the line that connects the posterior edge of the neuroforamen
with the anterior margin of the football-shaped lamina
 AP 30* 40* 45*

50* MEASURED LATERAL LATERAL

AP 30*
45* MEASURED
 Indications
• Cervical radicular pain syndromes
– disk herniation,
– central or foraminal cervical spinal stenosis, and
– spondylolisthesis.
– cervical spondylosis
– postlaminectomy syndrome due to cervical discectomy;
• Complex regional pain syndrome of the upper extremity;
• Acute and subacute postherpetic neuralgia in the cervical
and upper extremity region
• The entry level of the epidural space should be inferior to
the level of stenosis whether a single shot or catheter
technique is used.
 EBM
• The evidence is good for cervical interlaminar
epidural injections for cervical disc herniation
or radiculitis;
• The evidence is fair for axial or discogenic
pain, spinal stenosis, and post cervical surgery
syndrome

IPM Guidelines Pain Physician: April 2013; 16:S49-S283

 Contraindications
• local infection;
• coagulopathy;
• vital function instability;
• psychopathologies.
 PREPARATION OF PATIENT
• Physical Examination
– Examine the area for local infection and the ability
to flex the cervical spine. The ability to assume
and maintain the position for the procedure is
important.
• Imaging Studies
– Plain films comprise a minimum in order to rule
out bone destruction from tumor,
spondylolisthesis with instability, or other proces.
 PREPARATION OF PATIENT
– CT or magnetic resonance imaging (MRI) studies,
are frequently helpful in determining the level of
likely symptomatology.
• Informed Consent
– Written informed consent, which includes risks of
paralysis, pain, numbness, bowel, bladder or
sexual dysfunction, bleeding, and infection, needs
to be obtained.
 Cervical interlaminar epidural block approach

• The procedure of the cervical interlaminar

epidural block can be performed in three
positions:
– sitting, (Blind with LOR, not recommended)
– lateral,
– prone
 Step 1. Prepare the patient before the procedure

• The type of analgesia or sedation needs to be

ascertained before performance of the procedure.
• If placement of an epidural catheter for cervical
neuroplasty is planned, the patient needs to be able
to respond to the stimulation test.
• Intravenous fentanyl, midazolam, and/or propofol
may be used judiciously for the patient’s comfort.
 Step 2. Position and monitor the patient
1. Place the patient in the prone position on the table. Support
the abdomen and thorax with pillows, tmake the patient
comfortable.
2. Pull the shoulders down to obtain a better view of the
cervical vertebra.
3. An intravenous cannula is inserted for medication injections.
4. Monitoring of vital signs is mandatory.
5. Oxygen is provided by nasal cannula.
6. The area for needle entry is prepared in a sterile fashion.
7. The position of the head and neck is stabilized on the table
Prone position with C-arm in posteroanterior
view for the cervical interlaminar approach
 Step 3. Equipment and drugs for the technique

• 1½ inch, 25 gauge needle (for the infiltration

of the skin);
• 5 ml syringe (for local anesthetic solution);
• 2 ml empty syringe (for aspiration test);
• 18 or 20 gauge, 3½ inch Tuohy
• 1% lidocaine for skin infiltration and for
diagnostic injections.
• Steroid
 Step 4. Visualization
• Place the C-arm in a
postero-anterior
position.
• Identify the midpoint
of the intervertebral
space at the C7–T1
level.
 Step 5. Direction of the needle

1. Infiltrate the skin with local anesthetic.

2. Advance the needle toward the
intervertebral space.
 Step 6. Depth of the needle
• Position the C-arm laterally and advance the
needle with the loss of resistance technique .
• The needle is gently pushed toward the
entrance to the cervical epidural space in the
lateral fluoroscopic view or contralateral
oblique view.
• The “loss of resistance technique” and multi
planar views are used to identify the epidural
space.
 Step 7. Confirming in epidural space

• Once entering the epidural space and

confirming the correct needle position
• After negative aspiration of blood or
cerebrospinal fluid, inject 2 ml of contrast
material;
• Look for a “straight” line view in lateral vision
Step 8. Cervical interlaminar epidural block

• Once the needle is placed correctly in the

cervical epidural space one can inject
– 5 ml of either 1% lidocaine for diagnostic block or
– dexamethasone or equivalent with or without a
low concentration of local anesthetic.
Paramedian technique
Transforaminal approach
Transforaminal approach
 Complications
• Inadvertent dural puncture
• Inadvertent subdural puncture
– Injection of a very small amount of contrast
material will appear like a thin straight line at
multiple levels. Unlike in the subarachnoid space,
contrast material does not disappear.
– total spinal block but may take a long time, i.e. as
long as 20 minutes.
 Complications

• Spinal cord injury

– immediate injury to the spinal cord
– delayed injury by causing an epidural hematoma
or abscess
– The patient may not feel pain or paresthesia when
the needle contacts the spinal cord. They may feel
pain only if the needle contacts the sensory fibers
within the meninges.
– Quadriplegia
 Complications

• Epidural hematoma
– Bleeding of the vessels within the epidural space
may give rise to signs and symptoms of epidural
compression but maybe delayed by hours,
days,and/ or weeks.
– If severe pain, paresthesia, and loss of strength in
the upper extremities develop within hours or
days, one should use the protocol for epidural
hematoma
 Complications
• Inadvertent puncture of vertebral artery
– the needle is directed more paramedially
• Infarct due to particulate steroid
– A particulate steroid suspension (e.g.
triamcinolone) injected into a vertebral or
radicular artery may cause an infarct in the brain
stem or spinal cord.