• Reg Anesth Pain Med · Jan 2023

    Retrodural space of Okada in the posterior ligamentous complex region: clinical and anatomical findings relevant to lumbar interlaminar epidural injection.

    • Shin Hyung Kim, Tae-Hyeon Cho, Hee Jung Kim, Hyun-Jin Kwon, Hyun-Ho Kwak, Kang-Jae Shin, Yong Suk Lee, and Hun-Mu Yang.
    • Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.
    • Reg Anesth Pain Med. 2023 Jan 1; 48 (1): 222822-28.

    BackgroundThe retrodural space of Okada is a potential space posterior to the ligamentum flavum that allows communication with the bilateral facet joints. However, the actual anatomy of this space has not been clearly visualized to date. We sought to investigate the characteristics of patients showing contrast spreading to the facet joint space during epidural injection and to clarify the anatomical structures of the retrodural space and adjacent ligamentous tissues in cadaveric specimens.MethodsFluoroscopic images of patients who underwent fluoroscopy-guided lumbar interlaminar epidural injection were assessed for contrast flow to the facet joints. Patient demographics, preprocedural imaging study findings, and epidural approaches were analyzed. The anatomical study included the sectional dissection, micro-CT imaging, and histological evaluation of lumbar spine specimens from 16 embalmed cadavers.ResultsFluoroscopic images of 605 epidural injections were analyzed. Among them, 36 with inadvertent spread into the facet joints (5.9%) were identified. Multivariate analysis revealed that facet joint pathologies were significantly associated with inadvertent spread into the facet joints (OR 4.382; 95% CI 1.160 to 16.558; p=0.029). Micro-CT and histological findings consistently showed a retrodural space between the ligamentum flavum and interspinous ligament. Various anatomical communication routes in the posterior ligamentous complex leading to this space were observed in specimens with degenerative and pathological changes.ConclusionDegenerative and pathological facet joint changes were associated with a higher incidence of spread into the retrodural space during epidural injection. Our findings confirm anatomical evidence for a false loss of resistance before the needle enters the epidural space.© American Society of Regional Anesthesia & Pain Medicine 2023. No commercial re-use. See rights and permissions. Published by BMJ.

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