Role of Nonreal-time Imaging in Improving Success of Blind Interlaminar Epidural Injection for Treatment of Symptomatic Prolapsed Lumbar Intervertebral Disk
Ajit S Naorem, Jugindro S Ningthoujam, Kunjabasi Wangjam, Rajkumar Rajesh Singh
Citation Information :
Naorem AS, Ningthoujam JS, Wangjam K, Singh RR. Role of Nonreal-time Imaging in Improving Success of Blind Interlaminar Epidural Injection for Treatment of Symptomatic Prolapsed Lumbar Intervertebral Disk. Indian J Phy Med Rehab 2019; 30 (1):7-11.
Objective: To see effectiveness of measurements in plain roentgenograms of lumbosacral (LS) spine to guide needle placement into the epidural space.
Setting: Department of Physical Medicine and Rehabilitation.
Design: Cross-sectional study.
Materials and methods: A total of 56 consecutive diagnosed prolapsed intervertebral disk (PIVD) patients attending PMR OPD were enrolled. Length of the spinous process and skin thickness were measured using a caliper, which were converted to centimeter by using a calibration bar in a digital X-ray of the LS spine. A 22G Quincke needle was advanced to the expected depth given by digital X-ray measurement. One milliliter of Iohexol dye was injected, and the position of the needle was checked by C-arm X-ray. Two milliliters of methyl prednisolone acetate were injected into the space.
Main outcome measures: Depth measured by using digital X-ray and length of the spinal needle from the epidural space to the skin by C-arm X-ray in centimeters.
Results: Out of 56 subjects, 46 (73.1%) completed the treatment program. A needle was placed at proper depth in 36 cases by using X-ray measurement, giving success rate of 87.8%. Depth of the epidural space from the skin (mean 3.82 ±0.74 cm) as measured from X-ray and actual measurement confirmed by fluoroscopy (mean 3.96 ± 0.81 cm) were compared using the Pearson's correlation coefficient (=0.86).
Conclusion: Measurement of depth of the epidural space using plain X-ray of the LS spine improves the success rate of blind midline interlaminar epidural steroid injection (MILESI) from around 50–87.8%. This method of nonreal-time imaging is cost-effective in developing countries where C-arm X-ray facilities are not available.
Bressler HB, Keyes WJ, Rochon PA, et al. The prevalence of low back pain in the elderly. A systemic review of the literature. Spine 1999;24(17):1813–1819. DOI: 10.1097/00007632-199909010-00011.
Verhaak PF, Kerssens JJ, Dekker J, et al. Prevalence of chronic benign pain disorder among adults: a review of the literature. Pain 1998;77(3):231–239. DOI: 10.1016/S0304-3959(98)00117-1.
Ricci JA, Stewart WF, Chee E, et al. Back pain exacerbations and lost productive time costs in United States workers. Spine 2006;31(26):3052–3060. DOI: 10.1097/01.brs.0000249521.61813.aa.
Slipman CW, Shin CH, Patel RK, et al. Etiologies of failed back surgery syndrome. Pain Med 2002;3(3):200–214. DOI: 10.1046/j.1526-4637.2002.02033.x.
Manchikanti L, Singh V, Pampati V, et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001;4(4):308–316.
Qaseem A, Wilt Timothy J, McLean Robert M, et al. Noninvasive treatments for acute, subacute and chronic low back pain: a clinical guidelines from the american college of physicians. Annals Org 2017;166(7):514–530. DOI: 10.7326/M16-2367.
Abdi S, Datta S, Trescot AM, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007;10(1):185–212.
Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the medicare population: 1994 to 2001. Spine 2007;32(16):1754–1760. DOI: 10.1097/BRS.0b013e3180b9f96e.
Gharibo CG, Varlotta GP, Rhame EE, et al. Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Physician 2011;14(6):499–511. ISSN 1533-3159.
Koes BW, Scholten RJ, Mens JM, et al. Efficacy of epidural steroid injections for low back pain and sciatica: a systematic review of randomized clinical trials. Pain 1995;63(3):279–288. DOI: 10.1016/0304-3959(95)00124-7.
Koes BW, Scholten RJ, Mens JMA, et al. Epidural steroid injections for low back pain and sciatica: an updated systematic review of randomized clinical trials. Pain Digest 1999;9:241–247.
Staal JB, de Bie R, de Vet HC, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev 2008(3):CD001824. DOI: 10.1002/14651858.CD001824.pub3.
Burn JM, Guyer PB, Langdon L. The spread of solutions injected into the epidural space: a study using epidurograms in patients with lumbosciatic syndrome. Br J Anaesth 1973;45(4):338–345. DOI: 10.1093/bja/45.4.338.
Bartynski WS, Grahovac SZ, Rothfus WE. Incorrect needle position during lumbar epidural steroid administration: inaccuracy of loss of air pressure resistance and requirement of fluoroscopy and epidurography during needle insertion. Am J Neuroradiol 2005; 26(3):502–505.
Manchikanti L, Bakhit CE, Pakanati RR, et al. Fluoroscopy is medically necessary for the performance of epidural steroid. Anesth Analg 1999;89(5):1330–1331. DOI: 10.1097/00000539-199911000-00063.
Botwin KP, Natalicchio J, Hanna A. Fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician 2004;7(1):77–80.
Weil L, Frauwirth NH, Amirdelfan K, et al. Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection. Arch Phys Med Rehabil 2008;89(3):413–416. DOI: 10.1016/j.apmr.2007.08.161.
Fredman B, Nun MB, Zohar E, et al. Epidural steroids for treating “failed backsurgery syndrome”: is fluoroscopy really necessary? Anesth Analg 1999;88:367–372.
Bogduk N. Epidural steroids for low back pain and sciatica. Pain Digest 1999;9:226–227.
Gharries H. Is ultrasound guide spine injection safe? J Anes Criti Care Open Access 2018;10(4):131–138.
Gupta R, Singh S, Kaur S, et al. Correlation between Epidurographic contrast flow patterns and clinical effectiveness in chronic lumbar discogenic radicular pain treated with epidural steroid injections via different approaches. Korean J Pain 2014;27(4):353–359. DOI: 10.3344/kjp.2014.27.4.353.
Milligan KR, Cramp P, Schatz L, et al. The effect of patient position and obesity on the spread of epidural analgesia. Int J Obstet Anesth 1993;2(3):134–136. DOI: 10.1016/0959-289X(93)90005-3.
Norris MC, Dewan DM. Effect of gravity on the spread of extradural anaesthesia for caesarian section. Br J Anaesth 1987;59(3):338–341. DOI: 10.1093/bja/59.3.338.