Lumbar interlaminar epidural injection
Citation, DOI, disclosures and article data
At the time the article was created Bruno Di Muzio had no recorded disclosures.View Bruno Di Muzio's current disclosures
Lumbar interlaminar epidural injections are one of some possible spinal epidural injections. For an alternative approach for the same region, please refer to the article on lumbar transforaminal epidural injections.
Typically, epidural injections are performed in patients with radicular pain who are currently not surgical candidates.
Allergy to any of the planned medications is a contraindication. Although it is possible to perform the procedure without contrast, provided consent includes the increased risk of intravascular or intradural injection.
Local or systemic infection is also a contraindication.
Diabetic patients demand caution due to the administration of steroids, but they are not contraindicated.
The patient is placed prone on the fluoroscopy table, and the lower lumbar region is exposed. Positioning a pillow under the abdomen helps to open the spinous processes and facilitates the procedure; sometimes an extra pillow is necessary.
alcohol or iodine (or both) containing skin preparation
fenestrated or chuck-drapes
22-gauge (25-gauge is an alternative), 9-10 cm (3.5 inches) spinal needle
isotonic contrast, e.g. 240 mg/mL iohexol
local anesthetic, e.g. 1% lignocaine/lidocaine
steroid, e.g. dexamethasone (non-particulate), betamethasone sodium phosphate, betamethasone acetate suspension
long-acting local anesthetic, e.g. bupivacaine
plan the procedure using, when possible, previous CT/MRI exams
after patient positioning, select the access entry and demarcate it on the skin
this technique uses a midline approach between the spinous processes aiming a path through the interspinous ligament, targeting the posterior spinous space
on the AP view, select the upper portion of the inferior spinous process as the entrance point
if the spinous processes do not allow the needle insertion in a midline approach, a parasagittal approach is an alternative
skin preparation and drapes placement
introduce the needle until it crosses the posterior margin of the facets (under lateral fluoroscopy view)
proceed with short further advancements (~1 mm) using the "air release technique" to check the resistance until the needle reaches the posterior epidural space (the injection of puffs of air outside the epidural space will cause the plunge to bounce back, this resistance ceases when the needle is inside the epidural space)
confirm the posterior epidural space with a few mL of contrast injections (optional)
inject the therapeutic mixture
2 mL of prednisolone acetate (hydrocortancyl 2.5%)
note: betamethasone is contraindicated for epidural injections
As with other epidural injections, recovery in the department for 20-30 minutes minimum is recommended, as a proportion of patients will experience transient numbness, weakness or loss of proprioception, making ambulation difficult and dangerous.
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.
- 1. Johnson B, Schellhas K, Pollei S. Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases. AJNR Am J Neuroradiol. 1999;20(4):697-705. PMC7056013 - Pubmed
- 2. J. Kevin McGraw. Interventional Radiology of the Spine. (2004) ISBN: 1588291987 - Google Books
- 3. Steven D. Waldman. Atlas of Interventional Pain Management. (2009) ISBN: 9781416099949 - Google Books
- 4. Shim E, Lee J, Lee E, Ahn J, Kang Y, Kang H. Fluoroscopically Guided Epidural Injections of the Cervical and Lumbar Spine. Radiographics. 2017;37(2):537-61. doi:10.1148/rg.2017160043 - Pubmed