The Cervical

The cervical epidural space is more variable in size. The most consistent finding is a relatively prominent epidural space at the C7-T1 level. On sagittal magnetic resonance imaging (MRI) T1 sequencing, the epidural space is often identified by the bright signal in the epidural fat (Fig. 9). The C6-7 space is more variable and above this level the space is most frequently smaller or only a potential space. Because of this anatomic finding, ESIs are safest when performed at the C7-T1 interlaminar space. As with the lumbar approach, the superior aspect of the lamina is an important landmark, which can be seen fluo-roscopically and palpated with the needle. This landmark is more important in the cervical approach because of the close proximity of the spinal cord to the epidural space in the cervical region. As the needle is advanced from its posterior parasagittal approach toward the lamina just off midline, the superior margin is encountered and is clearly palpable. The needle is then redirected toward the midline and slightly superior to enter the epidural space. The bony margin provides an important measure of the required depth for entering the epidural space. The interlaminar ligament is often felt as well. Once the needle tip is at the laminar ridge, perpendicular fluoroscopy or steep contralateral oblique fluoroscopy is used with contrast injections to monitor the advance of the needle into the epidural space. The operator will often encounter the typical loss of resistance and see the characteristic spread of contrast as the space is entered. The loss of resistance is not as prominent in the cervical region as that of the lumbar epidural space.

Typically a 2- to 4-cc volume of steroid solution will be injected. It is generally recommended that local anesthetics not be used in the cervical injections because of the risk of subarachnoid absorption and cervical anesthesia. Although rarely reported, the author knows of cases of temporary respiratory compromise when these agents have been utilized. As can be seen with the contrast epidurogram, there will be substantial cephalad flow of the injected agents, thereby allowing treatment of the affected levels. It is important to always review correlative imaging studies prior to cervical epidural injection to guarantee adequate space at the intended injection level.

Sacral Contrast Spread

Fig. 8. Anteroposterior/lateral radiographs of needle placement for the caudal approach. The needle enters the sacral hiatus. The spread of contrast outlines the sacral epidural space and the prominent sacral dural extensions. The patient has had a laminectomy at the lumbosacral junction, making a sublaminar approach difficult at the L5-S1 level. Contrast opacifies the sacral epidural space up to the lumbosacral junction (C).

Fig. 8. Anteroposterior/lateral radiographs of needle placement for the caudal approach. The needle enters the sacral hiatus. The spread of contrast outlines the sacral epidural space and the prominent sacral dural extensions. The patient has had a laminectomy at the lumbosacral junction, making a sublaminar approach difficult at the L5-S1 level. Contrast opacifies the sacral epidural space up to the lumbosacral junction (C).

MRI of the cervical spine is generally the most useful for this pretreatment evaluation.

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