Cervical interlaminar epidural steroid injection
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Cervical interlaminar epidural steroid injections (ILESIs) are used to inject steroids in the epidural space and around the exiting nerve roots and are one of the two main spinal epidural injections; the other is cervical transforaminal epidural injections.
Typically performed in patients with radicular arm pain who are wishing to avoid surgery and/ or may not be surgical candidates.
actively taking anti-coagulation
anaphylaxis to contrast medium/ injectate
unable to remain still
recent previous steroid injection
Relevant imaging should be reviewed and details of the patient confirmed. The patient should have an opportunity to discuss the risks and benefits and consent obtained.
Driving is not advised as a local anesthetic is included in the epidural injectate. The reasons include an inability to perform an emergency procedure and be in safe control of a vehicle.
The patient should be comfortable and placed prone on the fluoroscopy table, with the posterior neck and thorax exposed. A pillow or specially designed brace is usually placed under the chest and a towel under the forehead making the patient more comfortable during the procedure.
alcohol or iodine (or both) containing skin preparation
fenestrated or chuck-drapes
needles e.g. 22-gauge Tuohy
short extension tubing
syringes e.g. x3 10mL, 5mL
isotonic contrast, e.g. 240 mg/mL iohexol
local anesthetic, e.g. 1% lidocaine
long-acting local anesthetic, e.g. bupivacaine
plan the procedure using, when possible, previous CT/MRI exams
after patient positioning, select the needle entry and demarcate it on the skin
on a true AP identify the level to be approached (e.g. C6/7 or C7/T1)
mark the point located halfway down from the superior endplate of the inferior vertebral body (e.g. C7 when accessing C6/7) and halfway between the spinal process and the pedicle
skin preparation and drapes placement
introduce the needle and angle it towards the midline
rotate the image 45-55 degrees contralaterally and then progress the needle under fluoroscopy view, ~1 mm at a time, and verify with a small amount of contrast until reaching the posterior epidural space
confirm the posterior epidural space with a few mL of contrast injection
inject the therapeutic mixture
prednisolone acetate (hydrocortancyl 2.5%) - 2mL
note: betamethasone is contraindicated for epidural injections
As with other epidural injections, recovery in the department for 20-30 minutes minimum is recommended.
As with all epidural spinal injections, care should be taken to confirm
extradural location - to avoid intradural injection with resultant adhesive arachnoiditis.
intravascular location - to avoid spinal cord infarction
A low-pressure headache can also result from dural puncture (subarachnoid tap).
Post-procedure infection is rare.