Selective Cervical Nerve Root Blockade: Experience with a Safe and Reliable Technique Using an Anterolateral Approach for Needle Placement

Abstract

BACKROUND AND PURPOSE:Our aim was to evaluate the safety and clinical utility of a fluoroscopically guided anterolateral oblique approach technique for outpatient diagnostic and therapeutic selective cervical nerve root blockade (SCNRB). MATERIALS AND METHODS:During a 13-year period (1994( through February 2007, 4612 patients underwent fluoroscopically guided diagnostic and/or therapeutic extraforaminal SCNRB by using an anterior oblique approach at affiliated outpatient imaging centers. Each procedure was performed by 1 of 6 procedural radiologists, all highly experienced in and actively performing spinal injections on a full-time basis in clinical practice. All of the proceduralists were thoroughly experienced with lumbar injections before endeavoring to perform SCNRBs. Nonionic contrast was injected in nearly all patients (except isolated patients with contrast allergy), and a minimum of 2 projection filming procedures were performed to document the accuracy of needle placement and contrast dispersal before the injection of therapeutic substances. All clinically significant complications beyond skin discoloration and temporary exacerbation of symptoms were recorded. RESULTS:There were no serious neurologic complications, such as stroke, spinal cord insult, or permanent nerve root deficit. One life-threatening anaphylactic reaction occurred and was attributed to the injected materials and not the specific procedure itself. Another patient had a 3-to 4-minute grand mal seizure, from which he fully recovered within 30 minutes. There were no infections. CONCLUSION:The technique we describe for fluoroscopically guided SCNRB is a useful and safe outpatient procedure when performed by skilled and experienced proceduralists.T ransforaminal selective cervical nerve root blockade (SCNRB) is used both as a diagnostic and therapeutic procedure in patients with cervical radiculopathy. There is general agreement and support that image guidance is required for SCNRB to be performed safely and accurately.1-9 CT, 1,2,4,5 CT fluoroscopy, 7 and fluoroscopy 3,6,8,9 are all used and advocated for image guidance during performance of this procedure. Meticulous attention to needle placement with fluoroscopic guidance has proved that neurologic complications can be avoided.9 An interlaminar catheter technique for SCNRB by using fluoroscopy has also been described 10,11 and challenged 12 as an alternative to either the lateral or anterolateral approach. Devastating neurologic complications, including cerebral and spinal cord infarction, have been described with SCNRB, 13-24 resulting in some questioning the safety and appropriateness of this procedure in clinical practice. [25][26][27][28][29] We reviewed our series of 4612 cases of either 1-or 2-level (sequential) SCNRB using an antero-oblique approach performed for 13 years by 6 different procedural radiologists and found no serious irreversible neurologic complications. We describe our technique and discuss why we believe it allows us to perform this procedure safely and accurate...

Selective Cervical Nerve Root Blockade: Prospective Study of Immediate and Longer Term Complications

“…10,11 Various techniques have been described for the transforaminal or selective cervical nerve block, but there is agreement that image guidance is imperative for both accuracy and safety. 1,[12][13][14][15][16][17] Imaging techniques include CT, 14,15,18 CT fluoroscopy, 19,20 and fluoroscopy. 1,16 The advantage of CT guidance is the ability to visualize directly relevant soft-tissue structures, such as the carotid and vertebral arteries and to plan the needle trajectory accordingly.…”

“…1,[12][13][14][15][16][17] Imaging techniques include CT, 14,15,18 CT fluoroscopy, 19,20 and fluoroscopy. 1,16 The advantage of CT guidance is the ability to visualize directly relevant soft-tissue structures, such as the carotid and vertebral arteries and to plan the needle trajectory accordingly. The advantage of fluoroscopy is the ability to see contrast dispersion in real-time with a broad FOV.…”

“…1 Briefly, all procedures were performed with high-resolution C-arm fluoroscopy, with patients in a supine position. Using intermittent fluoroscopy, a 25-gauge Quinke-type spinal needle (BD Medical Systems, Franklin Lakes, NJ) was advanced to the articular pillar, lateral to the posteroinferior aspect of the neural foramen.…”

“…A recent report retrospectively reviewed all SCNRBs performed at our institution during a 13-year period. 1 In 4612 patients in whom particulate steroid solution was injected, there were 2 serious complications, both of which we believe to have been related to the steroid solution used, neither of which resulted in permanent neurologic or medical sequelae. Despite this excellent safety record, concerns about the safety of this procedure 2 voiced in the literature and reports of serious complications prompted our group to evaluate SCNRB further in a prospective manner.…”

MRI-Guided and CT-Guided Cervical Nerve Root Infiltration Therapy: A Cost Comparison

“…Tiso et al [47] therefore recommended using non-crystalloid corticosteroids for pain therapy in the cervical spine. However, in a large patient collective of 4612 patients treated within a period of 13 years, Schellhas et al were not able to identify an increased incidence of complications when using crystalloid corticosteroids [32]. A limitation of our study is that the cost evaluation was limited to cost types that could be directly allocated to individual interventions from the viewpoint of a radiological department.…”