How are interlaminar cervical epidural blocks (CEBs) administered 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

Performance of a interlaminar CEB can be performed with the patient sitting or horizontally in a lateral or prone position. Regardless of the operator's experience, this procedure is best performed with fluoroscopic guidance. In most cases, the patient is placed in an optimal flexed cervical spine posture stabilized with enough resistance to prevent movement of the head during the procedure.

The skin is prepared with an antiseptic solution and the operator places the middle and index fingers on each side of the spinous processes at C5-6 or C6-7 spinal levels. The midline of the selected interspace is identified by palpating the spinous processes above and below where midline needle entry is intended. LA, such as lidocaine, may be used, to mark the intended site of skin entry. See image below

Typical placements for cervical, thoracic, and lum Typical placements for cervical, thoracic, and lumbar interlaminar epidural steroid injections.

As much as 1 mL of a short acting anesthetic (eg, lidocaine) is used to infiltrate the skin and subcutaneous tissues, as well as both the supraspinous, and interspinous ligaments. Physicians are advised to insert a 25-gauge, 2-inch needle exactly into the targeted midline. Some physicians prefer to use a longer, larger, blunter needle, such as a 3.5-inch, 18-gauge or 20-gauge Hustead needle.

After the LA has been given time to anesthetize the area, a right-hand dominant physician holds the needle firmly at the hub with the left thumb and index finger. Then the palm of the left hand is placed firmly against the patient’s neck, so that the left hand acts as a unit to stabilize, protect, and control the needle’s trajectory and its metered ingress from any unexpected patient or physician activity.

The needle is then advanced with the left hand, which is braced against the neck with the needle hub held tightly between the left thumb and forefinger The operator uses the right hand to monitor resistance through a syringe containing air or preservative free normal saline. With constant pressure applied to the plunger of the syringe through light pressure applied by the right thumb, the needle and syringe are advanced in a slow and deliberate manner. As the bevel passes through the ligament flavum and enters the epidural space, a sudden loss of resistance that the operator appreciates; the plunger can then be effortlessly depressed under minimal, if any, pressure through the right thumb.

Needle position within the epidural space can be checked by using fluoroscopic verification and by repeating the loss of resistance maneuver. The cervical epidural space should accept 0.5-1 mL of air or sterile preservative free saline without significant resistance. The force required to depress the plunger should not exceed that which is necessary to overcome the resistance of the needle. Any significant pain or sudden increase in resistance during the injection suggests incorrect needle placement.

The physician should stop the injection and assess the position of the needle using fluoroscopy. If the needle remains satisfactorily placed and loss of resistance within the epidural space is confirmed without additional patient report of pain, gentle aspiration is checked to assure that the needle is not positioned in the subarachnoid space or that it’s not intravascular. If cerebrospinal fluid (CSF) is aspirated, the operator can repeat the block attempt at a different interspace. If aspiration of blood occurs, the needle should be tightly rotated and the aspiration test should be repeated. If the aspiration of blood continues, the procedure should be aborted due to the danger of developing an epidural hematoma and possibly neurological compromise. [19]

If the operator is confident that the needle is correctly placed in the midline of the epidural space, then injection of as much as 5-7 mL of solution can be performed. For diagnostic and prognostic blocks, 1% preservative-free lidocaine is a reasonable choice. For therapeutic blocks, 0.25% preservative-free bupivacaine combined with 40-80 mg of methylprednisolone is commonly recommended.

In some cases, this procedure is repeated on a daily basis or every other day when treating acute painful disorders. Repeat treatments are performed in cases whereby temporary pain reduction is indicated for the management of acute pain Some randomized studies have demonstrated both short-term (< 6 wk) and long-term (≥6 wk) pain relief from CEBs. [22, 23]

When the cervical epidural route is chosen for the administration of opioids, 0.5 mg of preservative-free morphine sulfate is a reasonable initial dose in patients who can tolerate opioids. More lipid-soluble opioids such as fentanyl must be delivered by continuous infusion via cervical epidural catheter.

Cervical epidural injections by interlaminar approach are usually considered safe and effective; however, the patient should undergo this procedure without anesthesia, so that appropriate feedback can be provided to the physician operator.


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