scholarly journals Evaluation of Contrast Flow Patterns with Cervical Interlaminar Epidural Injection: Comparison of Midline and Paramedian Approaches

Medicina ◽  
2020 ◽  
Vol 57 (1) ◽  
pp. 8
Author(s):  
Byeongcheol Lee ◽  
Sang Eun Lee ◽  
Yong Han Kim ◽  
Jae Hong Park ◽  
Ki Hwa Lee ◽  
...  
Keyword(s):  
Epidural Space ◽  
Epidural Injection ◽  
Spinal Pain ◽  
Contralateral Side ◽  
Intervertebral Disc Space ◽  
Disc Space ◽  
Lateral Group ◽  
Medial Group ◽  
Midline Approach ◽  
Interlaminar Epidural Injection

Background and objectives: The purpose of this study was to compare and to analyze contrast spread patterns between the paramedian and midline approaches to cervical interlaminar epidural injection (CIEI). Materials and Methods: We retrospectively enrolled 84 CIEI cases that had been performed for unilateral cervical spinal pain from April 2019 to April 2020. After 3 mL of contrast had been injected into the epidural space, fluoroscopic images were obtained. The CIEI was divided into a midline (Group M, n = 42) and a paramedian (Group P, n = 42) approach by anteroposterior imaging. The P Group was classified into a more medial (Group Pm, n = 26) and a more lateral (Group Pl, n = 16) group. Using ImageJ on an anteroposterior image, we assessed the grayscale brightness ratio of the ipsilateral or contralateral side of the vertebral body as well as the intervertebral disc space one level just above the needle location. We identified the dispersion of contrast into the ventral epidural space. Results: The grayscale brightness ratio was significantly higher in Group P than in Group M (p < 0.001). The incidence of ventral epidural spread in Group M was 57.1% versus 88.1% in Group P, which was significantly different (p = 0.001). Conclusions: The fluoroscopic CIEI finding in the paramedian approach predominantly showed an excellent delivery of the injectate to the ipsilateral side in comparison to the contralateral side. This showed a greater advantage in delivery toward ventral epidural space as compared to the midline approach.

scholarly journals Does Paramedian Approach Preferentially Secure Optimal Drug Delivery Onto Ventral Epidural Space and Subsequent Superior Clinical Efficacy Over a Dorsal Midline Approach During Cervical Interlaminar Epidural Injection?

2021 ◽  
Vol 24 (6) ◽  
pp. E839-E847
Keyword(s):  
Cervical Spine ◽  
Clinical Efficacy ◽  
Epidural Space ◽  
Rating Scale ◽  
Epidural Injection ◽  
Clinical Results ◽  
Numeric Rating Scale ◽  
Midline Approach ◽  
Interlaminar Epidural Injection ◽  
Numeric Rating

BACKGROUND: There is paucity in the literature directly comparing the clinical results between the paramedian and the midline interlaminar cervical epidural injections. OBJECTIVE: To compare the proportion of ventral epidural spread of injectate and consequent clinical outcome between the paramedian and midline approach during interlaminar epidural injection in patients with axial neck and/or interscapular pain triggered from the underlying cervical spine pathologic condition. STUDY DESIGN: Retrospective study. SETTING: Primary pain clinic and spine hospital. METHODS: Two hundred and twenty-three patients with axial neck and/or interscapular pain due to cervical problem underwent interlaminar epidural injection through either a paramedian approach (PM group, n = 93) or a midline approach (ML group, n = 130). We compared the portion of ventral epidural filling, Numeric Rating Scale (NRS), and McNab criteria between both groups. The NRS and McNab criteria were also separately compared between the ventrally spread (VS) group and non-ventral spread (non-VS) group inside each PM and ML group, respectively, at 2 weeks and 10 weeks post-injection. RESULTS: The PM group showed a significantly higher proportion of ventral spread, successful NRS reduction, and satisfactory McNab criteria than the ML group at 10 weeks. In the PM group, the VS group showed the same results as above compared to the non-VS group. LIMITATIONS: A retrospective analysis based on the relatively short-term follow-up period clinical results. CONCLUSIONS: The paramedian approach showed the better direct injectate transfer over the ventral epidural space and subsequently superior clinical efficacy for the patients suffering from axial neck and/or interscapular pain secondary to cervical spine problems. KEY WORDS: Cervical disease, epidural injection, interlaminar, paramedian, midline, ventral epidural spread, Numeric Rating Scale, McNab criteria

scholarly journals Comparison of Epidural Pressure Decrease Pattern According to Different Lumbar Epidural Approaches

2020 ◽  
Vol 2;23 (4;2) ◽  
pp. E202-E210
Author(s):  
Jihee Hong
Keyword(s):  
Epidural Space ◽  
Management Practice ◽  
Epidural Injection ◽  
Epidural Pressure ◽  
Abrupt Decrease ◽  
Interspinous Ligament ◽  
Pressure Decrease ◽  
Significant Difference ◽  
Key Words Epidural ◽  
Midline Approach

Background: During lumbar epidural injection (LEI) using a midline approach, we might encounter failure of identifying the epidural space owing to an equivocal or absent loss of resistance (LOR) sensation. The reason for such absence of LOR sensation has been suggested as paucity of midline ligamentum flavum, paravertebral muscle, and cyst in the interspinous ligament of the lumbar spine. Despite its low specificity, LOR is the most commonly used method to identify the epidural space. Objectives: The purpose of this study was to analyze lumbar epidural pressure decrease patterns and identify factors contributing to this pressure decrease. Study Design: Prospective randomized trial. Setting: An interventional pain management practice in South Korea. Methods: This prospective study included 104 patients receiving LEI due to lumbar radiculopathy. A midline or paramedian approach of LEI was determined with randomization. Among various factors, gender, age, body mass index (BMI), and diagnosis were analyzed using a subgroup that included 60 cases of only a paramedian approach. Results: Grades I, II (abrupt decrease), and III (gradual decrease) were found as patterns of epidural pressure decrease. Abrupt pressure decrease was more frequently observed in the paramedian group (P < 0.001). Age, gender, BMI, and diagnosis did not show any significant difference in frequencies between abrupt and gradual pressure decrease. Limitations: We could not match LOR sensation with epidural pressure decrease shown in the monitor. Conclusions: This study demonstrates that abrupt pressure decrease occurs more frequently with the paramedian approach. However, age, gender, BMI, or diagnosis did not affect the incidence of epidural pressure decrease. Key words: Epidural, paramedian, midline, pressure decrease

Intervertebral Disc Infection after Lumbar Chemonucleolysis: Report of a Case

Neurosurgery ◽  
1986 ◽  
Vol 18 (5) ◽  
pp. 616-621 ◽  
Author(s):  
Evan H. Zeiger ◽  
Edward J. Zampella
Keyword(s):  
Intervertebral Disc ◽  
Spinal Pain ◽  
Intervertebral Disc Space ◽  
Disc Space ◽  
Differential Cell Count ◽  
Paravertebral Muscle ◽  
Space Infection ◽  
Objective Evidence ◽  
Differential Cell ◽  
Bone Scans

Abstract Intervertebral disc space infection can be a serious and disabling complication of any procedure that affords entry for bacteria into the susceptible disc space. Most disc space infections occur after cervical or lumbar laminectomies. Discitis has been reported after myelography, lumbar puncture, paravertebral injection, and obstetrical epidural anesthesia. A case of septic discitis occurring after intradiscal therapy with chymopapain is presented. Patients who return for evaluation of recurrent spinal pain after chemonucleolysis, especially those with paravertebral muscle spasm, should be evaluated for the possibility of disc space infection by obtaining an erythrocyte sedimentation rate, peripheral white count, differential cell count, and plain roentgenograms. Radionuclide bone scans, although not specific, may provide further objective evidence leading to the diagnosis of an intervertebral disc space infection.

scholarly journals Anatomical Flow Pattern of Contrast in Lumbar Epidural Space: A Human Study with a Midline vs. Parasagittal Interlaminar Approach under Fluoroscopy

2015 ◽  
Vol 18;4 (4;18) ◽  
pp. 317-324
Author(s):  
Morteza Kazempour Kazempour
Keyword(s):  
Back Pain ◽  
Study Design ◽  
Epidural Space ◽  
Rating Scale ◽  
Human Study ◽  
Epidural Injection ◽  
Epidural Injections ◽  
Interlaminar Approach ◽  
Number Of Patients ◽  
Midline Approach

Background: Epidural injections for managing chronic back pain are one of the most commonly performed interventions; however, controversy continues regarding the most effective method of epidural injections. A ventral distribution of epidural injected drug plays a significant role in its effectiveness. Objective: To determine the distribution of a drug in the epidural space after parasagital and midline epidural injection. Setting: Academic hospital. Study Design: In randomized double-blind clinical trial, patients with a diagnosis of low back pain (LBP) and unilateral lumbosacral radicular pains were randomized to receive drug through either parasagital or midline approach. Methods: Patients were assessed for anterior epidural spread of contrast under fluoroscopy in anteroposterior and lateral views. After epidural space confirmation, triamcinolone (80 mg) plus bupivacain was injected and patients were followed up for 2 weeks. Results: Fifty-six patients enrolled in the study. Successful infiltration of the drug into the ventral epidural space was successfully achieved in 75% of cases in the parasagital group but in only 25% of the cases in using a midline approach. Effective pain relief (numeric rating scale [NRS] < 3) was observed in 76.5% of patients in the parasagital group and 24.5% of patients in the midline group (P = 0.001) at 2 weeks. Number of patients with improved disability (measured by Oswestry Disability Index [ODI] < 20%) was significantly higher in the parasagital group (78%) compared to the midline group (26%) at 2 weeks (P = 0.002). Limitations: The results of the current study should be interpreted in relation to the study design and future studies should include larger patient numbers and longer follow-up time. However, the results are consistent with previous studies. Conclusion: Parasagital epidural injection showed higher infiltration of the drug to the ventral epidural space compared to the midline approach. The higher infiltration of the ventral epidural space provides better improvement of clinical disability and pain in the parasagital group. Key words: Epidural, midline, parasagital, ventral distribution, disc herniation

Intervertebral disc space cyst simulating a recurrent herniated nucleus pulposus

1988 ◽  
Vol 69 (1) ◽  
pp. 137-139 ◽  
Author(s):  
Jordan C. Grabel ◽  
Raphael Davis ◽  
Rosario Zappulla
Keyword(s):  
Intervertebral Disc ◽  
Preoperative Diagnosis ◽  
Relevant Literature ◽  
Radicular Pain ◽  
Lumbar Region ◽  
Intervertebral Disc Space ◽  
Disc Space ◽  
Content Type ◽  
Herniated Nucleus Pulposus ◽  
Fine Print

✓ The case presented is of a patient with an intervertebral disc space cyst producing recurrent radicular pain following microdiscectomy in the lumbar region. Difficulties with the preoperative diagnosis of this and other recurrent radicular syndromes are discussed, and a review of the relevant literature is presented.

scholarly journals Proposed Ionizing Radiation Doses of 3711 Fluoroscopy-Guided Epidural Injections

2021 ◽  
Author(s):  
Rekib Sacaklidir ◽  
Ekim Can Ozturk ◽  
Savas Sencan ◽  
Osman Hakan Gunduz
Keyword(s):  
Ionizing Radiation ◽  
Imaging Techniques ◽  
Epidural Injection ◽  
Critical Issue ◽  
University Hospital ◽  
Epidural Injections ◽  
Epidural Steroid Injections ◽  
Dose Levels ◽  
Interlaminar Epidural Injection ◽  
Caudal Epidural

Background: Since fluoroscopy-guided interventional therapies grew significantly in recent years, exposure to ionizing radiation (IR) either for patient or medical staff became a critical issue. IR exposure varies according to the physicians’ experience, patients’ body mass index (BMI), imaging techniques and type of the procedure performed. The purpose of this study is to calculate the reference IR doses for fluoroscopy-guided epidural injections per procedure and BMI to provide reference doses for potential use in future dose reduction strategies. Methods: A retrospectively, evaluation of patients who received epidural steroid injections between January 2015 and December 2020 in a university hospital interventional pain management center, was performed. This observational study was conducted with patients aged  18 who underwent 3711 epidural injections including cervical interlaminar, lumbar interlaminar, lumbar transforaminal and caudal approaches. Provided IR doses for each patient were also divided by patients’ BMI to obtain dose per BMI. Results: The highest IR dose per procedure was found in caudal epidural injection with 0.218 mGy m2 and lowest dose was in cervical interlaminar epidural injection with 0.057 mGy m2. The IR dose per procedure was 0.123 mGy m2 for lumbar transforaminal and 0.191 mGy m2 for lumbar interlaminar epidural injection. Caudal epidural injection had also the highest IR dose per BMI which was 0.00749 and cervical interlaminar epidural injection had the lowest radiation dose per BMI which was 0.00214. Conclusions: We proposed reference IR dose levels of four approaches of epidural injections obtained from 3711 injections performed in a university hospital pain medicine clinic. BMI of patients were taken into account with the dose levels of injections given per BMI. Multicenter research with standardized techniques will assure more reliable reference levels which will guide pain physicians to self-assess their own levels of radiation exposure.

scholarly journals Contrast Flow Selectivity During Transforaminal Lumbosacral Epidural Steroid Injections

2008 ◽  
Vol 6;11 (12;6) ◽  
pp. 855-861
Author(s):  
Michael B. Furman
Keyword(s):  
Epidural Space ◽  
Nerve Root ◽  
Lumbar Disc ◽  
Human Study ◽  
Contralateral Side ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Needle Position ◽  
Epidural Steroid ◽  
Contrast Flow

Background: Lumbosacral transforaminal epidural steroid injections (LS-TFESIs) are an accepted procedure used in the comprehensive, conservative care for lumbar disc pathology and/or spinal stenosis induced low back pain with a radicular component. Historically, the terminology used to describe the transforaminal technique of instilling medications into the epidural space and/or exiting structures has varied. These procedures have also been referred to as either diagnostic or therapeutic selective nerve root blocks (SNRBs). Although this procedure is typically used to “selectively” treat isolated pathology, the “SNRB” terminology suggests that one can selectively diagnose or treat a specific nerve root as a pain generator by anesthetizing or blocking it. It has been recently demonstrated that L4 and L5 SNRBs are often non-“selective” by investigating the extent of epidural contrast flow patterns after injecting 1.0 mL of contrast. Our study attempts to identify the minimum injectate volume at which LS-TFESIs may still be considered “selective” with no injectate extending to either the adjacent (superior and/or inferior) levels or to the contralateral side. Objective: Quantitatively evaluate contrast flow level selectivity noted during fluoroscopically guided lumbosacral transforaminal epidural steroid injections (LS-TFESIs). Study Design: Prospective, nonrandomized, observational human study. Methods: Thirty patients (female = 10, male = 20) undergoing LS-TFESIs were investigated. After confirming appropriate spinal needle position with biplanar imaging, 4.0 mL of nonionic contrast was slowly injected. Fluoroscopic images were recorded at 0.5 mL increments. These biplanar contrast flow images were evaluated to determine which 0.5 mL volume increment was no longer specific for the injected level. In particular, we documented when contrast extended either to a superior or inferior spinal segment or crossed the midline spine to the contralateral side. Results: After injecting 0.5 mL of contrast, 30% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.0 mL of contrast, 67% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.5 mL of contrast, 87% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 2.5 mL of contrast, 90% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. Conclusions: Diagnostic LS-TFESI or SNRB blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes exceeding 0.5mL. Injectate volumes greater than 0.5mL are consistently non-selective and cannot be used reliably for diagnostic block procedures in the epidural space. Key words: Epidural steroid injections, selective nerve root block, transforaminal, contrast flow

Albert Dereymaeker and Joseph Cyriel Mulier’s description of anterior cervical discectomy with fusion in 1955

2018 ◽  
Vol 28 (4) ◽  
pp. 395-400 ◽  
Author(s):  
Ronald H. M. A. Bartels ◽  
Jan Goffin
Keyword(s):  
French Literature ◽  
Case Series ◽  
Anterior Cervical Discectomy ◽  
Subsequent Paper ◽  
Intervertebral Disc Space ◽  
Disc Space ◽  
Iliac Crest Graft ◽  
Cervical Discectomy ◽  
Time Period

Anterior cervical discectomy with fusion (ACDF) is a very well-known and often-performed procedure in the practice of spine surgeons. The earliest descriptions of the technique have always been attributed to Cloward, Smith, and Robinson. However, in the French literature, this procedure was also described by others during the exact same time period (in the 1950s).At a meeting in Paris in 1955, Belgians Albert Dereymaeker and Joseph Cyriel Mulier, a neurosurgeon and an orthopedic surgeon, respectively, described the technique that involved an anterior cervical discectomy and the placement of an iliac crest graft in the intervertebral disc space. In 1956, a summary of their oral presentation was published, and a subsequent paper—an illustrated description of the technique and the details of a larger case series with a 3.5-year follow-up period—followed in 1958.The list of authors who first described ACDF should be completed by adding Dereymaeker’s and Mulier’s names. They made an important contribution to the practice of spinal surgery that was not generally known because they published in French.

Sign in / Sign up

Export Citation Format

Share Document