• Pain physician · May 2015

    Do the gaps in the ligamentum flavum in the cervical spine translate into dural punctures? An analysis of 4,396 fluoroscopic interlaminar epidural injections.

    • Laxmaiah Manchikanti, Yogesh Malla, Kimberly A Cash, and Vidyasagar Pampati.
    • Pain Management Center of Paducah, Paducah, KY; and University of Louisville, Louisville, KY.
    • Pain Physician. 2015 May 1;18(3):259-66.

    BackgroundCervical interlaminar epidural injections are performed frequently in managing chronic neck and upper extremity pain, although less commonly than lumbar interlaminar epidural injections. Recently, the US Food and Drug Administration warnings and safeguards to prevent neurologic complications. These were developed by the Multi-Society Pain Workgroup have taken center stage for all types of epidural injections, including cervical interlaminar epidural injections. The recommendations of safeguards to prevent neurologic complications after epidural steroid injections include that cervical interlaminar epidural injections must be performed utilizing fluoroscopy with anteroposterior, lateral, or oblique views with injection of contrast medium and that entry be limited to the C7-T1 epidural space or occasionally the C6-C7 with requirements for magnetic resonance imaging assessment of the epidural space.ObjectivesTo assess the incidence of dural puncture associated with fluoroscopically directed cervical interlaminar epidural injections.Study DesignA retrospective assessment of patients undergoing cervical interlaminar epidural injections from January 2013 through February 2015.SettingA private interventional pain management practice; a specialty referral center in the United States.MethodsThe data were collected for 4,396 consecutive cervical interlaminar epidural injections performed from January 2013 through February 2015. The procedures were all performed under fluoroscopic visualization under posteroanterior view with contrast medium injection with lateral view confirmation when indicated. The procedures were performed by one of 2 physicians; the dural puncture and subsequent postoperative complications with level of epidural entry were determined.Outcomes AssessmentThe outcome was assessment of dural puncture.ResultsA review of multiple manuscripts showed that defects in the ligamentum flavum may extend to as much as 100% of the population. However, it also has been shown that among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Among the 4,396 epidural injections performed at C7-T1, C6-C7, and C5-C6, 1,227 were performed at C7-T1; 1,835 were performed at C6-C7; and 1,334 were performed at C5-C6. Dural punctures were observed in 1.8% (24 procedures) at the C5-C6 level entry; 0.87% (16 procedures) at the C6-C7 level entry; and 1.71% (21 procedures) at the C7-T1 level. There was no significant difference among the entry levels. No complications or spinal cord damage or postdural puncture headache were observed.LimitationsThe limitations of this report include that it is an assessment by only 2 well experienced physicians, even though it included a relatively large number of patients.ConclusionThis study illustrates that dural puncture is equally prevalent, though very rare, irrespective of the needle entry level into the epidural space, with an overall dural puncture rate of 1.4%, with 1.8% at the C5-C6 level, 0.87% at the C6-C7 level, and 1.71% at the C7-T1 level. Based on the present literature, it appears that performing the procedure by inserting the needle into the cephalic portion of the intervertebral space rather than the caudal portion may be safer.

      Pubmed     Free full text   Copy Citation     Plaintext  

      Add institutional full text...

    Notes

     
    Knowledge, pearl, summary or comment to share?
    300 characters remaining
    help        
    You can also include formatting, links, images and footnotes in your notes
    • Simple formatting can be added to notes, such as *italics*, _underline_ or **bold**.
    • Superscript can be denoted by <sup>text</sup> and subscript <sub>text</sub>.
    • Numbered or bulleted lists can be created using either numbered lines 1. 2. 3., hyphens - or asterisks *.
    • Links can be included with: [my link to pubmed](http://pubmed.com)
    • Images can be included with: ![alt text](https://bestmedicaljournal.com/study_graph.jpg "Image Title Text")
    • For footnotes use [^1](This is a footnote.) inline.
    • Or use an inline reference [^1] to refer to a longer footnote elseweher in the document [^1]: This is a long footnote..

    hide…