Yair Safriel MBBCh, Presenter: Nothing to Disclose

Olga Alex Lopatina MD, Abstract Co-Author: Nothing to Disclose

Cervical interlaminar epidural steroid injections (CIESI) can generally be safely performed at C7-T1 or, rarely at C6-7. This is due to the small epidural space and the subsequent danger of intrathecal injection above that. Yet in many patients it is difficult or impossible to visualize the small needles used on lateral fluoroscopy due to shoulders and other tissues. To overcome this limitation, we evaluated the safety and utility of an oblique fluoroscopically guided technique for outpatient CIESI that obviates the need for lateral fluoroscopy.

172 patients underwent fluoroscopically guided CIESI using a posterior oblique approach. The patients were placed prone with a support under the forehead or chest so as to ensure that the neck was either neutral or slightly flexed. The C-arm was then rotated approximately 5 degrees towards the operator and approximately 5 degrees caudate. A trajectory leading to the apex of the interlaminar space was marked on the skin. A needle was then advanced under fluoroscopic control and its progress monitored in the AP projection and in a projection approximately 25 degrees from midline obliqued away from the operator. Once the needle tip was near the spinolaminar line, test injections with radio-opaque contrast were performed until epidural opcification obtained. Midline needle placement was also documented on the AP projection. Epidurography was performed on all patients. All clinically significant complications other than skin discoloration or temporary local symptoms related to needle passage were recorded.

There were no cases where the injectate was either outside the epidural space or intrathecal. There were no immediate complications. All patients were discharged uneventfully without delayed reported complications. All patients had needle tip imaged at all times in two planes without the need for lateral fluoroscopy. 25G Quinke needles were used in 78 cases, 22G Quinke needles in 4 cases and 22G Whitacre needles in 90 cases. There were 165 C7-T1 procedures, five C6-7 procedures and one each at C5-6 and T1-T2.

The oblique CIESI approach described is safe & reliable and is now routinely used in the authors practice.

This technique allows safe & reliable needle placement in the epidural space in patients of all sizes without added time or risk. It will allow many more patients to successfully undergo CIESI.

Safriel, Y, Lopatina, O, Oblique Approach to Cervical Interlaminar Epidural Steroid Injections: Experience in 172 Patients with a Safe and Reliable Technique.  Radiological Society of North America 2008 Scientific Assembly and Annual Meeting, February 18 - February 20, 2008 ,Chicago IL. http://archive.rsna.org/2008/6009646.html