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Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(24)00018-9
10.1016/j.inpm.2024.100398
100398
Letters to the Editor
An essential rule; Do not proceed without seeing needle depth
Ozler Sinem drsinemozler@gmail.com
⁎
Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
Sencan Savas
Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
Kokar Serdar
Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
Gunduz Osman Hakan
Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
⁎ Corresponding author. Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey. drsinemozler@gmail.com
06 3 2024
3 2024
06 3 2024
3 1 10039825 1 2024
19 2 2024
19 2 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords

Fluoroscopy
Cervical
Epidural interlaminar injection
Pain medicine
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pmcDear Editor,

We have read the article “Iatrogenic Cervical Spine Cord Injury After Interlaminar Cervical Epidural Injection” by Chabra et al. [1] with great interest. Significantly, the article mentions the cord injury, which is a catastrophic complication of cervical epidural steroid injections. As the author says, there were certainly predisposing factors, such as anterior cervical discectomy and fusion surgery history, anatomic patterns precluding loss of resistance, repetitive microtrauma of posterior vertebral ligaments, and narrow cervical epidural space, that led to spinal cord injury in this case. It is significant for us, interventional pain practitioners, that the article highlights these factors that may offer important clinical implications in the treatment of chronic cervicalgia. Above all these predisposing factors, we get sight of a major inaccuracy in the injection technique. It appears that, during the first needle attempt, the cervical epidural interlaminar injection was advanced only in the anteroposterior view, and the loss of resistance technique was used without taking the contralateral oblique view. Subsequently, after the patient experienced paresthesia, the needle was withdrawn and then reinserted for a second attempt. We believe that the cord injury occurred at this first needle attempt.

This case report illustrates the danger of the classic technique that is still taught, namely to contact the lamina as a measure of the depth, rather than obtaining an early depth view to determine safe needle tip location. The superior laminar margin may not always be accurately visualized and cannot be relied upon, as is demonstrated by this case. In order to avoid cord injury, it is recommended that, after confirming that the needle is in the midline or paramedian line in the AP view, the needle should be advanced under the contralateral oblique view or lateral view as a safety precaution. The needle depth must be observed under a contralateral oblique view [2,3]. After approaching the ligamentum flavum, the loss of resistance technique should be applied [4]. The AP view should be used only for being coaxial; the needle should not be advanced to deeper structures in this view [5]. In our opinion, this sequence should be the primary consideration. Although multiple predisposing factors may cause cord injury, cervical interlaminar epidural procedures should not be proceeded with without observing the needle depth.

Author disclosures

None of the authors have potential conflicts of interest to be disclosed.

No funding was received.

Declaration of Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Chabra R. Maung C. Pazionis T. Habibi B. Iatrogenic cervical spinal cord injury after interlaminar cervical epidural injection Interventional Pain Medicine 2 4 Dec. 2023 100288 10.1016/j.inpm.2023.100288
2 Ozturk E.C. Sacaklidir R. Sencan S. Ertan G. Gunduz O.H. The impact of contrast spread patterns to clinical outcomes of cervical interlaminar epidural steroid injection: an observational study Turk Neurosurg 33 6 2023
3 Gill J.S. Aner M. Jyotsna N. Keel J.C. Simopoulos T.T. Contralateral oblique view is superior to lateral view for interlaminar cervical and cervicothoracic epidural access Pain Med 16 1 2015 68 80 25220833
4 House L.M.L. Barrette K. Mattie R. McCormick Z.L. Cervical epidural steroid injection: techniques and evidence Phys Med Rehabil Clin 29 1 Feb. 01, 2018 1 17 10.1016/j.pmr.2017.08.001 W.B. Saunders
5 Furman M.B. Atlas of image-guided spinal procedures e-book 2017 Elsevier Health Sciences
