• Josh Levin, David Levi, Nolan Gall, Scott Horn, and Matthew Smuck.
• Department of Orthopaedic Surgery, Stanford University, Virginia Beach, Virginia, USA.
• PM R. 2021 Mar 26.

BackgroundFew studies have evaluated the effect of final needle position on contrast flow patterns during the performance of cervical transforaminal epidural steroid injections (TFESIs).ObjectiveTo analyze fluoroscopically guided cervical TFESI contrast flow patterns based upon final needle tip position.DesignRetrospective, observational in vivo study.SettingOutpatient private practice physical medicine and rehabilitation spine clinic.ParticipantsOne hundred consecutive patients undergoing cervical TFESIs.InterventionsCervical TFESIs.Main Outcome MeasuresCategories of contrast flow patterns including epidural, intraforaminal, "sufficient to inject," and "predominantly epidural and/or intraforaminal," based upon final needle tip position.ResultsTwo independent observers reviewed images from 100 consecutive patients and classified injectate flow patterns stratified by needle tip position. The interrater reliability for all categories of interest was moderate, with kappa values from 0.61 to 0.76. More medially placed needles (middle third and lateral third of the articular pillars) resulted in higher rates of epidural contrast flow (75%; 95% confidence interval [CI]: 56%-94%; and 60%; 95% CI: 47%-73%) compared to needles placed lateral to the articular pillars (26%; 95% CI: 8%-44%), and higher rates of "predominantly epidural and/or intraforaminal" flow patterns with needles placed in the middle one third (75%; 95% CI: 56%-94%) and lateral one third of the articular pillars (47%; 95% CI: 34%-60%) compared to flow patterns when needles were placed lateral to the articular pillars (17%; 95% CI: 2%-32%). No needles were placed in the medial third of the articular pillars.ConclusionsMore medially placed needle tips result in more optimal flow patterns during cervical TFESIs. The importance of this finding is unknown as clinical outcomes were not measured.© 2021 American Academy of Physical Medicine and Rehabilitation.

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