An alternative approach to needle placement in cervicothoracic epidural injections

The use of fluoroscopy guidance together with the loss of resistance technique during epidural injections has been advocated lately; moreover, epidural injections in the absence of fluoroscopic guidance have a high rate of inaccurate needle-tip placement during the injections. However, the approach to the lower cervical and upper thoracic epidural space may be challenging due to its obscure lateral fluoroscopic views from overlying normal tissue structures. In this case, we report an alternative oblique C-arm fluoroscopy guided view approach to supplement the standard anterior-posterior and lateral fluoroscopic views to facilitate successful needle placement and precise anatomical localization of the epidural space.     

Image Guidance Technologies for Interventional Pain Procedures: Ultrasound,Fluoroscopy, and CT

Chronic pain is a common medical condition. Patients who suffer uncontrolled chronic pain may require interventions including spinal injections and various nerve blocks. Interventional procedures have evolved and improved over time since epidural injection was first introduced for low back pain and sciatica in 1901. One of the major contributors in the improvement of these interventions is the advancement of imaging guidance technologies. The utilization of image guidance has dramatically improved the accuracy and safety of these interventions. The first image guidance technology adopted by pain specialists was fluoroscopy. This was followed by CT and ultrasound. Fluoroscopy can be used to visualize bony structures of the spine. It is still the most commonly used guidance technology in spinal injections. In the recent years, ultrasound guidance has been increasingly adopted by interventionists to perform various injections. Because its ability to visualize soft tissue, vessels, and nerves, this guidance technology appears to be a better option than fluoroscopy for interventions including SGB and celiac plexus blocks, when visualization of the vessels may prevent intravascular injection. The current evidence indicates the efficacies of these interventions are similar between ultrasound guidance and fluoroscopy guidance for SGB and celiac plexus blocks. For facet injections and interlaminar epidural steroid injections, it is important to visualize bony structures in order to perform these procedures accurately and safely. It is worth noting that facet joint injections can be done under ultrasound guidance with equivalent efficacy to fluoroscopic guidance. However, obese patients may present challenge for ultrasound guidance due to its poor visualization of deep anatomical structures. Regarding transforaminal epidural steroid injections, there are limited evidence to support that ultrasound guidance technology has equivalent efficacy and less complications comparing to fluoroscopy. However, further studies are required to prove the efficacy of ultrasound-guided transforaminal epidural injections. SI joint is unique due to its multiplanar orientation, irregular joint gap, partial ankylosis, and thick dorsal and interosseous ligament. Therefore, it can be difficult to access the joint space with fluoroscopic guidance and ultrasound guidance. CT scan, with its cross-sectional images, can identify posterior joint gap, is most likely the best guidance technology for this intervention. Intercostal nerves lie in the subcostal grove close to the plural space. Significant risk of pneumothorax is associated with intercostal blocks. Ultrasound can provide visualization of ribs and pleura. Therefore, it may improve the accuracy of the injection and reduce the risk of pneumothorax. At present time, most pain specialists are familiar with fluoroscopic guidance techniques, and fluoroscopic machines are readily available in the pain clinics. In the contrast, CT guidance can only be performed in specially equipped facilities. Ultrasound machine is generally portable and inexpensive in comparison to CT scanner and fluoroscopic machine. As pain specialists continue to improve their patient care, ultrasound and CT guidance will undoubtedly be incorporated more into the pain management practice. This review is based on a paucity of clinical evidence to compare these guidance technologies; clearly, more clinical studies is needed to further elucidate the pro and cons of each guidance method for various pain management interventions.     

The feasibility of color Doppler ultrasonography for caudal epidural steroid injection

Although it entails a radiation hazard risk, the use of fluoroscopy during caudal epidural steroid injection has increased to help place the medication more accurately and allowed physicians to maximize the procedure's therapeutic success rate. To investigate the feasibility of using real-time high resolution ultrasonography for guiding the epidural needle into the caudal epidural space and to confirm any vascular intake of medication, we performed color Doppler ultrasonography while medication was being injected into the caudal epidural space of 53 patients with low back pain and sciatica. We defined the injection as being successful if unidirectional flow (observed as one dominant color) of the solution was observed with color Doppler ultrasonography through the epidural space beneath the sacrococcygeal ligament, with no flows being observed in other directions (observed as multiple colors). The correct placement of the medication was then confirmed by fluoroscopy. In 52 of the 53 subjects, the medications were successfully injected into the caudal epidural space with ultrasonography assistance. In fluoroscopy, of these 52 patients, 50 revealed correct placement of the medicine into the epidural space. In conclusion, ultrasonography may be a reliable imaging modality for caudal epidural steroid injection, and its several advantages such as its convenience and the lack of a radiation hazard, make it preferable to fluoroscopy.     

Evaluation of Epidurographic Contrast Patterns with Fluoroscopic-Guided Lumbar Interlaminar Ventral Epidural Injection

Background:   Targeted ventral epidural steroid injection with a transforaminal approach has been widely used for the treatment of nerve root inflammation and pain. Lumbar interlaminar approach is also commonly used; however, ventral epidural injection may not be obtained properly. Lumbar interlaminar ventral epidural (LIVE) injection can be achieved as the epidural catheter is placed at the ventrolateral side of the nerve root. The purpose of this study is to evaluate the contrast dispersal pattern with LIVE injection.
Methods:   Forty patients with lower back and L5 radicular pain were studied. LIVE injection was performed with an epidural catheter inserted toward the 9 o'clock position (for the right side) or 3 o'clock position (for the left side) of the pedicle, where the catheter tip was placed at the ventrolateral side of the nerve root. A total of 2 mL of contrast was injected to determine the epidurographic pattern.
Results:   With 1-mL injection, all patients showed excellent filling in the ventral epidural space of L5 nerve root. After a total of 2 mL injection, it showed rostral spread in 26/40 (65%) patients, and caudal spread in 34/40 (85%) patients. None of the patients showed intravascular injection, and no neural complications were reported.
Conclusions:   The data showed excellent spread of contrast into the nerve root and the ventral epidural space in all patients. There were no inadvertent vascular or neural complications. LIVE approach can be an alternative way to achieve targeted ventral epidural injection.     

Epidural hematoma after epidural anesthesia: a case report of non-surgical management

Neuraxial block with intraoperative intravenous (IV) heparin use is considered to be a safe technique. The risk of epidural hematoma is low as long as concomitant anti-coagulation is not used [ASRA: Neuraxial Anesthesia and Anticoagulation Consensus Statements, 1998]. We describe a patient who developed epidural hematoma under those circumstances and was successfully treated without surgical intervention.

A 75-year-old female underwent aorto-mesenteric arterial bypass for chronic mesenteric ischemia. Combined general and epidural anesthesia was used and IV heparin (total 6000 IU) was given intraoperatively. In the recovery room, aspiration of blood was noted through the epidural catheter. The next day, she developed severe back pain without sensory or motor deficit. Magnetic resonance imaging (MRI) scan revealed an epidural hematoma with spinal cord compression. Neurosurgical consultation resulted in a decision to monitor for neurological changes. She never developed a neurological deficit and was discharged from the hospital on post-operative day 7.

Our case suggests that epidural hematoma may not be uncommon phenomena in patients with neuraxial block and intraoperative IV heparin use. Implications for the decision as to which of these patients should be imaged and which should not are discussed.     

MULTIDISCIPLINARY PAIN ABSTRACTS: 5

In this study, the authors prospectively evaluated whether abnormalities at the lumbar level as diagnosed by magnetic resonance imaging (MRI) are confirmed by epiduroscopy, and assessed if targeted epidural injection of medication alleviates sciatic pain. A flexible, 0.9-mm fiberoptic endoscope was introduced through a disposable steering shaft into the caudal epidural space and advanced until the targeted spinal nerve was identified. Adhesions were mechanically mobilized under direct vision, and a mixture of 120 mg methylprednisolone acetate, 600 IU hyaluronidase, and 150 μg clonidine was applied locally. Pain scores were measured by the visual analog scale (VAS) and global subjective efficacy rating. Nineteen of 20 patients studied showed adhesions via epiduroscopy. Six patients showed concomitant signs of active root inflammation. Of 20 patients treated with a targeted epidural injection, 11 patients experienced significant pain relief at 3 months. This was maintained at 6 months for eight of the patients, at 9 months for seven of the patients, and at 12 months for seven of the patients. Mean VAS at 3 months was significantly reduced and this persisted at 12 months Epiduroscopy is of value in the diagnosis of spinal root pathology. In sciatica, adhesions unreported by MRI can be identified. Targeted epidural medication administered near the compromised spinal nerve results in substantial and prolonged pain relief.     

Epidural abscess associated with intravenous drug abuse in a pregnant patient

The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.     

Ultrasound-Guided Steroid Injection for Obturator Neuralgia

▪ Abstract:   Obturator neuralgia (ON) presents with pain in the groin, medial thigh, and sometimes the medial aspect of the knee. The causes include trauma, obturator hernia, pelvic cancer, pelvic surgery, hip surgery, following pelvic fractures, endometriosis, retroperitoneal hematoma, pregnancy, and delivery. Ultrasound (US) guidance facilitates real-time imaging, identification of vascular structures, and improves patient comfort in situations where nerve stimulation can be unpleasant. This is a case report of ON successfully treated with US-guided steroid injection.
A 55-year-old man was referred to the pain clinic with groin pain and allodynia in the medial thigh and knee following a fall. He had tried multiple other therapies and none of them provided significant relief. Using a 10–5-MHz multi-frequency, 38-mm linear array transducer, the obturator nerve was scanned in both longitudinal and transverse directions. Under real-time imaging 10 mg of medroxy-progesterone in a volume of 1 mL was injected. Following the injection, a small area of the medial side of knee was still tender to light touch. A second injection was placed inferiorly and provided pain relief for more than 5 months.
This successful demonstration of US guidance in ON may further encourage US guidance in pain clinic interventions. ▪     

Sonographically guided caudal epidural steroid injections.

OBJECTIVE: Caudal epidural steroid injections are used for the symptomatic treatment of radicular lumbosacral pain syndromes, but incorrect injection placement has been recognized as a common problem with the routinely used unguided technique. We aimed to explore the use of sonography to facilitate this procedure. METHODS: In patients with clinically unreliable anatomic landmarks, high-resolution real-time sonography was used to identify those landmarks and to assist in correct needle placement. RESULTS: Sonography enabled localization of the sacral hiatus landmarks. We found this method particularly useful for guiding needle placement in patients with moderate obesity. CONCLUSIONS: Real-time sonography can facilitate caudal epidural steroid injections.     

旁正中超声实时引导在腰段硬膜外穿刺中的应用

目的 探讨旁正中超声实时引导技术在成人腰段硬膜外穿刺时的应用价值.方法 72例患者随机分为盲探穿刺组和超声实时引导组2组,每组各36例.盲探穿刺组采取传统的体表标志进针及阻力消失法确定硬膜外间隙位置,超声实时引导组采用超声采集脊柱旁正中切面超声图像,并实时引导穿刺针进行硬膜外穿刺置管.记录两组硬膜外穿刺时间、试穿次数、...     

Spinal epidural abscess

Spinal epidural abscess is an uncommon condition. Predisposing factors include spinal surgery, recent trauma, immunosuppression, a distal site of infection and intravenous drug use; however, these are not always present, as illustrated by this case report describing a patient who had repeated emergency department visits and delayed diagnosis that was ultimately confirmed via magnetic resonance imaging.     

Cranial Magnetic Resonance Imaging in Spontaneous Intracranial Hypotension after Epidural Blood Patch

▪ Abstract:   Spontaneous intracranial hypotension (SIH) is a syndrome characterized by orthostatic headache, nausea, vomiting, photophobia, and diplopia. Subdural effusion, diffuse dural enhancement, dilatation of epidural veins, and increased height of hypophysis are cranial magnetic resonance (MR) imaging findings in SIH. Epidural blood patch is reportedly one of the effective treatment options. We present the follow-up MR imaging findings in a case of SIH after a successful epidural blood patch treatment. We propose that cranial MR imaging as an objective test to evaluate the success of epidural blood patch treatment. ▪     

Ultrasound as a Screening Tool for Proceeding With Caudal Epidural Injections

Chen CP, Wong AM, Hsu C-C, Tsai W-C, Chang C-N, Lin S-C, Huang Y-C, Chang C-H, Tang SF. Ultrasound as a screening tool for proceeding with caudal epidural injections.

Objective

To study the anatomical structure of the sacral hiatus using ultrasound. Based on the sonographic images of the sacral hiatus, the feasibility of caudal epidural injection can then be assessed.

Design

Case-controlled study.

Setting

Rehabilitation outpatient clinic in a tertiary medical center.

Participants

Patients (N=47; 20 women, 27 men) with low back pain and sciatica who were to receive caudal epidural injection treatments were recruited into this study.

Interventions

Sonographic images of the sacral hiatus were obtained from all the patients. An ultrasound machine capable of examining musculoskeletal tissues with real-time linear-array ultrasound transducer was used to measure the distance between the anterior wall and posterior wall of the sacral hiatus (diameter of the sacral hiatus) and the distance between bilateral cornua.

Main Outcome Measures

Diameter of the sacral canal and distance between bilateral cornua measured in millimeters.

Results

The mean diameter of the sacral canal was measured to be 5.3±2.0mm in our recruited patients. The mean distance between bilateral cornua was measured to be 9.7±1.9mm. Caudal epidural injections failed in 7 patients. In these 7 patients, 4 had very small diameter of the sacral canal (1.6, 1.2, 1.4, and 1.5mm). In 1 man, sonographic images revealed a closed sacral hiatus (no sacral canal diameter can be measured). Two patients revealed flow of fresh blood into the syringe while checking for the escape of cerebrospinal fluid after the needles were inserted into the sacral canal. For safety reasons, steroid injections were not performed in these 2 patients.

Conclusions

Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound. Sonographic images indicating a closed sacral canal and sacral diameters ranging from 1.2 to 1.6mm may suggest a higher failure rate in caudal epidural injection.     

Left Atrial Linear Ablation to Modify the Substrate of Atrial Fibrillation Using a New Nonfluoroscopic Imaging System

Linear left atrial ablation is performed in combination with pulmonary vein (PV) isolation to improve the clinical results of atrial fibrillation (AF) ablation. These procedures require long procedures and fluoroscopic exposure. The aim of the present study was to evaluate the performance of a new, nonfluoroscopic, real-time, three-dimensional navigation system for linear ablation at the left atrial roof and mitral isthmus. The study included 44 patients (54 ± 10 years of age, 5 women) with drug-refractory AF, who underwent roof line or mitral isthmus linear ablation after 4-PV isolation. In 22 patients, ablation was performed with the navigation system (test group), and in the remainders linear ablation was performed with fluoroscopic guidance alone (control group). Conduction block was achieved in 20 patients (91%) in test group, and 21 patients (95%) in the control group (ns). Use of the navigation system was associated with a shorter fluoroscopic exposure for roof line (5.6 ± 3.0 minutes vs 8.7 ± 5.0 minutes, P < 0.05), and a trend for mitral isthmus ablation (7.8 ± 7.8 minutes vs 12.1 ± 5.9 minutes). It was also associated with a trend toward shorter procedure times for roof line (15.3 ± 8.6 minutes vs 22.9 ± 16.8 minutes) and mitral isthmus line (20.2 ± 15.8 minutes vs 32.0 ± 7.6 minutes) but no difference in duration of radiofrequency delivery. There was no procedural complication. The use of this new nonfluoroscopic imaging system was associated with a shorter fluoroscopic exposure as well as a trend toward shorter duration of linear ablation procedures for AF.     

Inadvertent discogram during epidural steroid injection: a case report

The obligatory use of fluoroscopy for placement of epidural steroids is controversial. Proponents of the use of fluoroscopy cite studies that report up to 35% rates of inaccurate placement of epidural needles without the aid of fluoroscopic imaging. This case study presents a situation in which a loss-of-resistance technique resulted in an inadvertent discogram.     

Comparison of the caudal and lumbar approaches to the epidural space. (Southampton Genera Hospital, Southampton, United Kingdom) Ann Rheum Dis 2000;59:879–882.

This study investigated the accuracy of placement of epidural injections using the lumbar and caudal approaches and to identify which factors, if any, predicted successful placement. Two-hundred consecutive patients referred to a pain clinic for an epidural injection of steroid were randomly allocated to one of two groups. Group L had a lumbar approach to the epidural space and Group C, a caudal approach to the epidural space. Both groups then had epidurography preformed using Omnipaque and an image intensifier to determine the position of the needle. Body mass index (BMI), grade of operator, and route of injection were predictors of a successful placement. Ninety-three percent of lumbar and 64% of caudal epidural injections were correctly placed. Ninety-sevent percent of lumbar and 85% of caudal epidural injections clinically thought to be correctly placed were confirmed radiographically. For epidural injections where the clinical impression was “maybe,” 91% of lumbar injections, but only 45% of caudal injections were correctly placed. Obesity was associated with a reduced chance of successful placement. A more senior grade of operator was associated with a reduced chance of successful placement. However, small numbers may have accounted for the latter result. Conclude that the weight of the patient and intended approach need to be considered when deciding the method used to enter the epidural space. In the nonobese patient, lumbar epidural injections can be accurately placed without x-ray screening, but caudal epidural injections, to be placed accurately, require x-ray screening no matter what the weight of the patient. Comment by Gabor B. Racz, M.D. The study compared lumbar epidural versus caudal epidural injections by 14 experienced anesthesiologists. The success rate for the lumbar epidural were higher so long as the patient was not obese and was significantly lower for the caudal placement. A reflection of the British system, the more senior consultants had a lower success rate than the registrar grade practitioners, reflecting the bulk of the pain work being done by the less experienced practitioner. The overall problem with the assessment is the fact that they did not standardize the injections deeming, individual experience to be the best for that individual which may or may not be so. The recommendations, however, are appropriate in recommending fluoroscopy in the caudal approach as well as the more difficult obese patient. Nevertheless, the paper reflects the lack of understanding of the current trend that the target site is not necessarily just epidural space but the ventral and lateral epidural space where most of the pathology is occurring and simple access to the spinal canal does not assure appropriate delivery of medication to the site where the most benefit can be obtained. There was no attempt by the authors to evaluate the outcome of the injections. Rather they discussed the nonstandardized delivery of steroids as verified by fluoroscopy and occasionally fluoroscopy in a nonstandardized manner.     

Descriptive Cadaveric Study Comparing the Accuracy of Ultrasound Versus Fluoroscopic Guidance for First Sacral Transforaminal Injections: A Comparison Study

Background

Ultrasound is rarely used for guiding lumbosacral epidural steroid injections due to its technical limitations. For example, sonographic imaging lacks the ability to confirm epidural spread and identify vascular uptake. The perceived risk that these limitations pose to human subjects has precluded any large scale clinical trials to date.

可视化荧光成像技术的胸部外科应用

可视化荧光成像是一种新兴的外科辅助技术，近年来被广泛应用于多个外科领域。荧光染料具有实时可视化成像特性，可以显示患者的肿瘤、血供、淋巴、神经等不同解剖结构，从而提高手术的准确性和术后恢复，并可能由此改变手术方法。针对胸部疾病，可视化荧光成像技术在肺结节检出定位，肿瘤切缘和残留识别，胸腔镜手术中肺段间平面识别，预防食管切除术后吻合口瘘，辨认术中胸导管和治疗术后乳糜漏，绘制前哨淋巴结等方面具有良好的临床指导意义。为了评估在不同手术场景下对荧光引导的不同需求，我们分别阐述了成像技术和荧光剂的临床前研究和临床应用进展，至此标志着可视化荧光成像技术的日趋成熟，以及在胸部外科中广泛的应用前景。      

Optimized guidance of percutaneous edge-to edge repair of the mitral valve using real-time 3-D transesophageal echocardiography

Background  

Percutaneous edge-to-edge repair with the MitraClip device has been shown to allow effective treatment of mitral regurgitation. It is mainly guided by transesophageal echocardiography while fluoroscopic guidance is of less importance. The impact of real-time three-dimensional transesophageal echocardiography (RT 3-D TEE) for guidance of this complex interventional procedure has not been evaluated.