Contralateral Oblique View During Cervical Epidural Access May Prevent Injury

A fluoroscopy-guided, contralateral oblique (CLO) visualization of needle tips reduced the risk of dural puncture or spinal cord injury during cervical epidural access with a paramedian approach. It also decreased the incidence of false loss of resistance (LOR), according to findings from a prospective, observational study published in Regional Anesthesia and Pain Medicine.

Researchers identified 393 patients with cervical radicular pain scheduled to undergo cervical epidural interlaminar injection between 2021 and 2022. Patients had a median age of 57 (IQR, 48-65) years, a BMI of 24.4 (IQR, 22.0-26.5) kg/m², and 55.2% were men.

Safety and risk for dural puncture were evaluated among individuals who received fluoroscopy-guided epidural access using the CLO view at 50° plus or minus 5°.

Overall, 9.4% of patients received a catheter insertion, 85.0% had an approach at C6 to C7, and 48.6% received a right-side needle insertion. The epidural was performed by staff (48.9%), fellows (40.5%), and residents (10.7%).

Most of the procedures were successful at first pass (85.0%) and all achieved final success (100%). No instances of dural puncture or spinal cord injury occurred.

The average needling time was 133.8 (SD, 74.9%) seconds; moreover, 8.1% of procedures had a false-positive LOR, and 2.0% had a false-negative LOR.

After LOR was obtained, the fluoroscopic view indicated that most needle tips were in O zone 0 (44%) or O zone 1 (45.9%) in the CLO view. In the anteroposterior (AP) view, most needle tips were in zone 2 (70.2%). When the needle tip was in AP zone 0, all needle tips were in O zone 2 (44.4%) or 3 (55.6%), whereas when they were in AP zone 1, most were in O zone 1 (60.0%). When in AP zone 2, most were in O zone 0 (56.0%) or 1 (42.2%), and when in AP zone 3, half were in O zone 1 (58.1%).

Overall, the intraprocedural complication rate was 3.9% and the postprocedural complication rate was 6.6%. The most common intraprocedural complication was intravascular entry (3.1%) and the most common postprocedural complications were mild dizziness (3.3%) and headache (1.5%).

Study limitations included the variance in the clinicians’ level of expertise as well as the difference in protocol across the institution. In addition, there may be a lack of generalizability as the study only evaluated an Asian population with a relatively low BMI.

“In fluoroscopy-guided cervical epidural access with the paramedian approach, the CLO view at 50°±5° can be clinically useful to prevent aberrant needle placement, which may lead to serious complications such as dural puncture or spinal cord injury, and to reduce false LOR,” the authors noted. “Notably, it is recommended that the needle tip is finally located in the medial half area of the lamina on the AP view to obtain the optimal advantages of the CLO view.” they concluded.