Chapter 29 Cervical Interlaminar Epidural Steroid Injection, Paramedian Approach

Note: Please see page ii for a list of anatomical terms/abbreviations used in this book.

Cervical interlaminar epidural steroid injections are indicated for radicular symptoms (i.e., shoulder, arm, and hand symptomatology) with or without axial neck pain. The size of the cervical epidural space is relatively small; therefore, the interlaminar approach is well suited to allow injectate to reach bilateral and multilevel pathology.

With the approach described in this chapter, the needle is placed with the use of a trajectory view. It is then advanced using multiplanar imaging, with an emphasis on safety that results from the use of the lateral and/or contralateral oblique views⁶ to confirm needle depth as the spinolaminar line and epidural space are approached. Because it is common for the patient’s shoulders to obscure the needle image in the lateral view, the 60-degree contralateral oblique view may be the only view available for safely identifying needle depth by visualizing the line. If the needle tip is midline, the oblique may be in either direction (i.e., right or left.) When the lateral or contralateral oblique view is used to assess depth, one need not “step off” of the lamina, as is often recommended.

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. In addition, 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. The loss-of-resistance (LOR) technique may be nearly impossible to use for some patients in whom the ligamentum flavum has not fused, and it must be coupled with the safety view to mitigate the risks of this procedure. The final location of the needle tip should be midline or slightly off midline ipsilaterally for more unilateral symptoms.

The epidural space is accessed by advancing the needle through the ligamentum flavum using the classic LOR technique. 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; ultimately, however, the feel of the LOR technique coupled with multiplanar fluoroscopic imaging and real-time contrast visualization are needed for safe epidural access.

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.

Trajectory View (Figure 29–1)

Figure 29–1 A, Fluoroscopic image of a trajectory view with the needle in position at the C7-T1 interlaminar space with 5 to 10 degrees of ipsilateral oblique and the needle near midline. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view. Note that this is not the safety view for this procedure. These images are used to emphasize the location of the spinal cord.

The needle should not be advanced too far ventrally. We recommend observing the safety considerations demonstrated in other views (lateral and contralateral oblique). There are no consistent radiolucent safety considerations in this trajectory view.

Notes on Positioning in the Trajectory View

Initial needle placement should be shallow in the soft tissues to avoid puncturing the dura and contacting the spinal cord. Needle depth can then be confirmed by rotating into the lateral or contralateral oblique safety view.

Confirm the level (with the anteroposterior [AP] view).

Tilt the fluoroscope.

Maximize the radiolucent size of the targeted interlaminar space (usually C7-T1) with the use of a caudad tilt.

Oblique slightly to symptomatic side about 5 to 10 degrees.

The needle is placed directly midline or just ipsilateral to midline on the painful side in the target radiolucent interlaminar space.

Place the needle parallel to the fluoroscopic beam.

Optimal Needle Position in Multiplanar Imaging

We recommend a minimum of two views, including the AP view (approaching midline) and either or both of the “true” lateral and contralateral oblique views to confirm that the tip has not crossed the spinolaminar line.

The needle must remain close to midline (this should be confirmed with the AP view) to reduce the risk of a false or no LOR if the ligamentum flavum has not fully fused. In addition, when the needle tip is not midline, it will need to be advanced more ventrally and laterally as a result of the tubular shape of the dura, and it may not have as distinct of a LOR. The tip may be placed slightly off midline ipsilaterally for the treatment of more unilateral symptoms.

To safely advance the needle, the C-arm should now be positioned in the lateral safety or contralateral oblique safety view.

Optimal Needle Positioning in the AP View (Figure 29–2)

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