Lumbar Interlaminar Epidural Steroid Injection, Paramedian Approach

Chapter 12 Lumbar Interlaminar Epidural Steroid Injection, Paramedian Approach



Scott J. Davidoff, Michael B. Furman


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


Lumbar interlaminar epidural injections are commonly performed injections for a variety of spinal pain disorders. They are specifically indicated for radicular symptoms with or without axial pain as a result of a lumbosacral etiology. Because the injectate disperses over a larger area than a transforaminal injection, this type of injection is typically used for bilateral or multilevel symptoms.


With the approach described here, the needle is placed with the use of a trajectory view and advanced with the use of multiplanar imaging, with emphasis on safely using the lateral or contralateral oblique views to confirm depth by visualizing the spinolaminar line. Since depth is assessed with one of these “safety views,” it is not necessary to use the “step off lamina” technique. After needle tip location is confirmed with multiplanar imaging, the epidural space is accessed by advancing the needle through the ligamentum flavum with the use of the classic loss-of-resistance technique.


For patients with predominately unilateral or asymmetric pain, the injectate is aimed toward the symptomatic side.



image Trajectory View


Confirm the level (with the anteroposterior view).


The image intensifier is tilted caudally to open up the target interlaminar space and to facilitate easier entry between two adjacent laminae (Figure 12–1).


image image image

Figure 12–1 A, Fluoroscopic image of a trajectory view with the needle in position at the L5-S1 interlaminar space, toward the left. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view.


The C-arm is then obliqued approximately 5 to 10 degrees toward the more symptomatic side (i.e., the left side, in this case). This angle is used for entry, and the needle should be aimed between the laminae on either side of the space between the superior and inferior spinous processes (i.e., midline).


Because this is the trajectory view, the needle should be placed parallel to the fluoroscopic beam.



image Notes on Positioning in the Trajectory View




image With this approach, the needle tip is placed between the laminae instead of “walking off” the lamina.


image The caudal tilt is used to optimally open up the interlaminar space (and not to optimally line up the endplates).



There are typically no other radiolucent structures that are safety considerations in this trajectory view aside from advancing the needle too far ventrally. Please use the other views for needle advancement to best visualize the corresponding landmarks.



image Optimal Needle Position in Multiplanar Imaging



Optimal Needle Positioning in the Anteroposterior View (Figure 12–2)



image image image

Figure 12–2 A, Fluoroscopic anteroposterior view with ideal needle position. B, Radiopaque structures, anteroposterior view. C, Radiolucent structures, anteroposterior view.



image Notes on AP View


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Dec 23, 2015 | Posted by in INTERVENTIONAL RADIOLOGY | Comments Off on Lumbar Interlaminar Epidural Steroid Injection, Paramedian Approach

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