Optimal volume of injectate for fluoroscopy-guided cervical interlaminar epidural injection in patients with neck and upper extremity pain

Park, Jun-Young; Kim, Doo Hwan; Lee, Kunhee; Choi, Seong-Soo; Leem, Jeong-Gil

doi:10.1097/md.0000000000005206

Cited by 6 publications

(4 citation statements)

References 27 publications

(47 reference statements)

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“…Second, the volume of injectate in the parasagittal interlaminar epidural injection in the present study was decided at 6 mL arbitrarily. Although the suggested volume of injectate for epidural injection varied in a few literature reports, the optimal volume is still to be determined [35][36][37]. However, a 6 mL volume in the parasagittal approach was considered sufcient to cover the targeted spinal nerve regardless of the spinal level [38].…”

Section: Discussionmentioning

confidence: 99%

Comparison of Adjuvant Hypertonic Saline and Normal Saline for Epidural Block in Patients with Postherpetic Neuralgia: A Double-Blind, Randomized Trial

Kwon

Kim

Cho

et al. 2022

Pain Research and Management

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Background. In patients with postherpetic neuralgia (PHN), the effectiveness of epidural block and the benefits of adjuvant hypertonic saline (HS) have not been fully determined. Therefore, we investigated these issues in this study. Methods. At a tertiary medical center’s single pain clinic in Seoul, Republic of Korea, patients complaining of PHN even after 4 months of herpes zoster onset were enrolled and randomly assigned to either the HS or normal saline (NS) group. After epidural block with adjuvant HS or NS administration according to each protocol, outcomes were assessed at baseline and one and three months after the intervention. The primary outcome was pain intensity on the numerical rating scale (NRS). The secondary outcomes were the insomnia severity index (ISI), the medication quantification scale (MQS), and the global perceived effect of satisfaction (GPES). Results. Thirty-six patients (NS: 17, HS: 19) were included in the intention-to-treat analysis. The estimated pain intensity decreased in both groups at one and three months after the procedure ( P < 0.001), without a significant group difference. The estimated ISI and MQS were not significantly different at 1 month compared with baseline but significantly decreased at 3 months in each group ( P < 0.001 and P < 0.001, respectively), without group differences. In addition, there was no difference between the groups on the GPES scale at one and three months after the procedure. Conclusions. Epidural steroid injection may have the advantages of short-term pain relief, improved sleep quality, and decreased medication usage in patients with PHN. In addition, adjuvant HS administration with epidural steroid injection did not show beneficial effects in patients with PHN. Further studies are needed to clarify the potential effectiveness of HS in treating neuropathic pain such as PHN. This trial is registered with KCT0002845.

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Section: Discussionmentioning

confidence: 99%

Comparison of Adjuvant Hypertonic Saline and Normal Saline for Epidural Block in Patients with Postherpetic Neuralgia: A Double-Blind, Randomized Trial

Kwon

Kim

Cho

et al. 2022

Pain Research and Management

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“…In horses, further study is needed to determine the optimal injectate volume to reach clinically relevant anatomy (typically lower cervical region) for the treatment of lower neck and forelimb disorders as is described in people (26).…”

Section: Discussionmentioning

confidence: 99%

Cervical Epidural and Subarachnoid Catheter Placement in Standing Adult Horses

et al. 2020

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Horses underwent either cervical epidural space (CES) catheterization or subarachnoid space (SAS) catheterization while restrained in stocks, under deep sedation (detomidine and morphine) and local anesthesia (mepivacaine 2%) block. Catheters were placed under ultrasound guidance with visualization of the dura, SAS, and spinal cord between the first (C1) and second (C2) cervical vertebrae. Following sedation and sterile skin preparation, operator 1 placed under ultrasound guidance, a 6-or 8-inch Tuohy needle with the bevel oriented caudally. For CES, a 6-inch Touhy needle was used with the hanging drop technique to detect negative pressure, and operator 2 then passed the epidural catheter into the CES. For SAS, following puncture of the dura, cerebrospinal fluid (CSF) was aspirated prior to placement of the epidural catheter. Placement into either CES or SAS was confirmed with plain and contrast radiography. Catheters were wrapped for the duration of the study. CSF cytology was assessed up to every 24 h for the study period. Horses were assessed daily for signs of discomfort, neck pain, catheter insertion site swelling, or changes in behavior. A complete postmortem assessment of the spinal tissues was performed at the end of the study period (72 h). Two horses had CES catheters and five horses had SAS catheters placed successfully. All horses tolerated the catheter well for the duration of the study with no signs of discomfort. Ultrasound was essential to assist placement, and radiography confirmed the anatomical location of the catheters. CSF parameters did not change over the study period (P > 0.9). There was evidence of mild meningeal acute inflammation in one horse and hemorrhage in another consistent with mechanical trauma. Placement of an indwelling CES or SAS catheter appears to be safe, technically simple, and well tolerated in standing sedated normal horses.

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“…Subsequently, a mixture of 2 mL of corticosteroid (betamethasone 6 mg/mL; Celestone Soluspan, Schering, Kenilworth, NJ) and 3 mL of contrast material was injected. It is established that larger volumes of contrast agent result in farther extent of spread throughout the epidural space (12)(13)(14)19,20). However, we chose 3 mL of contrast material because we felt it best reflected the volumes of medication typically delivered in clinical practice and because it was the most common volume previously examined in the planar fluoroscopy literature (11,12,14,21,22).…”

Section: Procedural Details and Ct Techniquementioning

confidence: 99%

“…Therefore, previous studies (9-14) have used planar fluoroscopic images to analyze the extent of spread of contrast agent during the CILESI epidurography as a surrogate for medication spread. These studies (9)(10)(11)(12)14) reported a wide range of rates of spread to the VES (range, 0%-93.3%). This wide variance may be because planar imaging cannot directly image contrast agent flow within the VES, which limits assessment.…”

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confidence: 99%

Cross-sectional CT Assessment of the Extent of Injectate Spread at CT Fluoroscopy–guided Cervical Epidural Interlaminar Steroid Injections

et al. 2019

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Background: Previous studies analyzed contrast agent spread during cervical interlaminar epidural steroid injections (CILESIs) by using planar fluoroscopy and reported wide variance of the rate of spread to the ventral epidural space (VES). Cross-sectional CT allows for direct viewing of contrast agent in the VES, providing improved spread assessment and thereby informing needle placement decisions when targeting pain generators. Purpose: To determine the extent of injectate spread at CT fluoroscopy-guided CILESI, with particular attention to the VES and bilateral neuroforamina, by using cross-sectional CT. Materials and Methods: This study reviewed 83 consecutive CT fluoroscopy-guided CILESIs at which a postprocedural cervical spine CT was performed (June 2016 to December 2017). All procedures used the same injectate (2 mL corticosteroid, 3 mL contrast agent). Postprocedural CT scans were reviewed for the presence of contrast within the VES, dorsal epidural space, ipsilateral neuroforamen, and contralateral neuroforamen in every cervical interlaminar level. Descriptive data are presented as frequencies or means. McNemar tests or hierarchical logistic models were used to assess associations between covariates and contrast agent spread to particular locations. Results: The study cohort included 73 individual patients (59% women; 43 of 73) (mean patient age, 57.6 years 6 11.5 [standard deviation]). Mean number of levels of cranial spread were 0.6 level for VES, 1.9 levels for contralateral neuroforamen, 2.1 levels for ipsilateral neuroforamen, and 3 levels for dorsal epidural space. No VES spread in any level was found with 35% (29 of 83) of injections. VES spread was more likely to occur in the level of needle placement (43%; 36 of 83) than in other interlaminar levels (19.5%; 97 of 498; P , .001). Spread was more likely to occur in the neuroforamen ipsilateral to the needle approach compared with contralateral (P , .001). Conclusion: Cervical interlaminar epidural steroid injections have injectate spreads with a mean of less than one level cranially in the ventral epidural space (VES) and approximately two levels in the neuroforamen. VES spread occurs more frequently at the level of needle placement and within the ipsilateral neuroforamen.

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Optimal volume of injectate for fluoroscopy-guided cervical interlaminar epidural injection in patients with neck and upper extremity pain

Cited by 6 publications

References 27 publications

Comparison of Adjuvant Hypertonic Saline and Normal Saline for Epidural Block in Patients with Postherpetic Neuralgia: A Double-Blind, Randomized Trial

Comparison of Adjuvant Hypertonic Saline and Normal Saline for Epidural Block in Patients with Postherpetic Neuralgia: A Double-Blind, Randomized Trial

Cervical Epidural and Subarachnoid Catheter Placement in Standing Adult Horses

Cross-sectional CT Assessment of the Extent of Injectate Spread at CT Fluoroscopy–guided Cervical Epidural Interlaminar Steroid Injections

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