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Midline sagittal cryomicrotome section and index drawing of cervical vertebral column from C1 to C6 of a year-old male. Minimal epidural fat and veins are found in the anterior epidural space. There is no posterior epidural compartment because the dura is uniformly in contact with the ligamanta flava and lamina. From Hogan QH: Epidural anatomy examined by cryomicrotome section. Regional Anesthesia ; Reprinted with permission. Midline sagittal cryomicrotome section and drawing of cervical vertebral column of a year-old male, revealing severe degenerative disc disease at all disc levels.
Disc material has extruded into the spinal canal at levels C and C Thickening of the dura, buckling of the ligamanta flava, osteophyte formation at the vertebral body margins, and extruded disc material have resulted in cord compression and deformity with minimal cerebrospinal fluid surrounding the cord. The only posterior epidural space is at C7-T1 just visible at the right picture margin.
Direct Spinal Cord Injury Some of the opinions and information presented here are based on medical records observed by physicians serving as expert witnesses in malpractice cases that are now closed. Following are some suggestions that should help minimize the risk of serious injury: Obtain and view MRI scans prior to performing the procedure.
Disc herniation may shift the cord posteriorly and obliterate the posterior subarachnoid space. In patients with previous cervical spine surgery there may be scar formation and adherence of dura to more superficial tissues at the proposed level of injection, increasing the risk of direct needle trauma to the cord. If there is pre-existing canal stenosis and spinal cord compression, the additional pressure created by the volume of drug injected, or by the pharmacological effect of those drugs, may result in neurological injury, particularly if there is already some loss of function.
Avoid epidural needle placement above C There is typically a small amount of epidural fat in the midline posteriorly at C7-T1, creating a space between the ligamentum flavum and the dura. Midline epidural fat is minimal at C, and there is none at C and above.
Low volume cervical injections often spread upward several segments. If it is felt that steroid placement at higher levels is indicated, it may be safer to introduce an epidural catheter in the upper thoracic spine and advance it under fluoroscopy to the desired level. When possible, obtain a lateral view of the spine following needle placement prior to injecting. This is difficult at the lower cervical levels because of the superimposed shoulder joints, particularly in thick-necked patients.
The deeply sedated patient may become agitated and may move unexpectedly. Also, paresthesias may alert us to the fact that we have contacted the cord. Do not use the hanging drop technique to determine epidural needle placement, since this is not a reliable means of identifying the epidural space.
I am aware of 2 malpractice claims in which spinal cord injury was associated with failure of the hanging drop technique to indicate epidural needle entry. Ischemic Spinal Cord and Brain Injury Reports of spinal cord, brainstem, and cerebellar infarction following cervical transforaminal epidural steroid injections began to appear in the scientific literature in the early s. Following are some suggestions to reduce the risk of intraneural injection or intra-arterial embolization of particulate steroids: Following aspiration, inject contrast under live fluoroscopy.
Obtain a still image a few seconds later to insure that the dye pattern has not changed. If available, use digital subtraction. Inject dye through small extension tubing to minimize needle tip movement between dye and steroid injection.
Consider a local anesthetic test dose with minimal sedation. Look for signs of systemic symptoms and numbness and paresthesias locally. Consider the use of non-particulate steroids. This is controversial, as there is little evidence that soluble steroids have equivalent efficacy, and early studies indicated that soluble steroid preparations remain in the spinal canal only for brief periods. The arteries supplying the spinal cord do not traverse the dorsal epidural space, so the risk of injecting a radicular artery or dorsal root ganglion by this approach is minimal.
The evidence for the superiority of transforaminal epidurals is largely theoretical and is based mainly upon non-controlled case series. Make sure patients are aware of the risks associated with both types of injections. Conclusions Epidural steroid injections can be helpful for hastening recovery from radiculopathy following disc herniation and can provide temporary relief for patients with chronic radicular pain.
Geographic variation in epidural steroid injection use in medicare patients. J Bone Joint Surg Am ; Anesthesiology ; Abbasi A, Malhotra G. Pain Med ; Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine Phila Pa ; Paraplegia after intracord injection during attempted epidural steroid injection in an awake-patient. Anesth Analg ; Intramedullary injection of contrast into the cervical spinal cord during cervical myelography: a case report. Spine Phila Pa ;E A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root.
Pain ; Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Cervical and lumbar transforaminal epidural steroid injections should be performed by injecting contrast medium under real-time fluoroscopy or digital subtraction imaging, before injecting any substance that may be hazardous to the patient.
The use of digital subtraction imaging has been shown to be more effective in detecting intravascular injection than syringe aspiration alone. Cervical interlaminar epidural steroid injections are recommended to be performed at C7-T1, but preferably not higher than the C level.
The cervical epidural space is widest at the C6-T1 levels. Gaps in the ligamentum flavum are more frequent with ascending cervical levels. No cervical interlaminar epidural steroid injection should be undertaken, at any segmental level, without preprocedural review of prior imaging studies demonstrating sufficient epidural spatial dimensions for needle placement at the target level.
Particulate steroids should not be used in therapeutic cervical transforaminal injections. Injuries following nonparticulate injections were temporary, whereas paraplegias after particulate steroids were permanent. If the nerve root involved is at a higher level, i. For diagnostic injections, to help the surgeon identify the affected nerve root, pain physicians perform transforaminal injections using local anesthetic, with or without a nonparticulate dexamethasone.
A nonparticulate steroid e. There are situations in which particulate steroids could be used in the performance of lumbar transforaminal epidural steroid injections. This is because the lumbar transforaminal area is wider than in the cervical regions.
If relief from a nonparticulate steroid is of short duration, some physicians will inject a steroid containing smaller particles, either betamethasone or triamcinolone. Video Series. Pain in the Neck?