What is the role of fluoroscopy in the administration of cervical epidural blocks (CEBs) for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

Fluoroscopy is recommended to aid in needle placement. With the patient in a supine position on the fluoroscopy table, the patient's head is turned slightly away from the side of the injection so that the fluoroscopy beam is rotated to an anterior oblique position to allow the best visualization of the target neural foramina at its largest diameter. The fluoroscopy beam may need to be moved caudally to allow better visualization of the targeted neural foramina, which occurs when the fluoroscopic beam is parallel with the affected nerve root.

The skin is prepared with antiseptic solution and with a LA to produce a skin wheal. The skin wheal is placed at a point overlying the posterior aspect of the foramen just over the tip of the superior articular process at the level below the affected neural foramen. This point is approximately one third of the distance from the most posterior-inferior aspect of the foramen.

A 25-gauge, 2-inch needle is placed through the previously anesthetized area and advanced until the tip rests against the superior articular process just posterior to the targeted neural foramen. The physician should be concerned with failure to impinge on bone because such a failure may indicate that the needle has passed through the foramen and into the substance of the spinal cord. Of course, correct bony placement should be achieved and identified using AP and lateral fluoroscopic views to verify the needle's position within the neural foramen and not past the midpoint of the posterior column composed of the facet joints.

When satisfactory needle position is confirmed, the needle bevel is medially oriented, and 0.2-0.4 mL of contrast medium is gently injected under active fluoroscopy. Contrast flow into the epidural space and distally along the affected nerve root sheath. The injected contrast should be immediately stopped if the patient complains of pain from the injection. If placement and epidural contrast flow suggests that the needle is properly placed, then injection of 6 mg of betamethasone or a solution of 20-40 mg of methylprednisolone or 20-40 mg of triamcinolone are combined with 0.5-1.5 mL of 2-4% of preservative-free lidocaine is slowly injected; this is terminated if the patient describes pain. [19]


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