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Sensory nerve fibers from the trigeminal ganglion form the spinal tract V which synapses in the spinal trigeminal nucleus (www.bioon.com/bioline/neurosci/course/face.html).
Source publication
Interlaminar cervical epidural steroid injections (ic-ESI) are safe and effective treatment options for the management of acute and chronic radiculopathy, spinal stenosis, and other causes of neck pain not responding to more conservative measures. However, the procedure inherently lends itself to possible spinal cord injury (SCI). Though reports of...
Context in source publication
Context 1
... sensory nerve fibers from the trigeminal ganglion form the spinal tract V which synapses in the spinal trigeminal nucleus (Fig. 3). From the spinal nucleus, second order neurons cross to the opposite spino-thalamic tract and are relayed to the thalamus (Fig. 4). Spinal trigeminal nucleus and spinal tract V are also associated with facial, glossopharyngeal, and vagus nerves as the sensory information conveyed by these nerves is also routed through spinal tract V and spinal trigeminal nucleus to the brain. Thus any involve- ment of the spinal nucleus can impair the sensation of the ipsilateral face. It has been proposed that the spinal trigeminal nucleus is also closely associated with the spinal accessory nerve where there is convergence of trigeminal and cervical afferents in the trigeminocervi- cal complex of brain stem (Fig. 5) ...
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Citations
... Some advocate measuring the approximate dermal-toepidural distance on an axial or sagittal cut on medical imaging. 96 However, estimates of needle depth made with MRI are consistently slightly deeper than the actual loss-of-resistance needle depth, indicating that caution should be employed when measuring this distance on MRI. 97 Epidural hematomas have been reported in several case reports, along with epidural abscesses. ...
Introduction:
Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both.
Methods:
The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized.
Results:
The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered.
Conclusions:
There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid radicular pain pulsed radiofrequency adjacent to the dorsal root ganglion may be considered.
... Depending on the height of the involved cervical spine as well as the type and volume of infusion used, direct spinal cord injury after CIESI can cause various symptoms. This may lead to irreversible consequences, such as hemiplegia and death in severe cases [7,8]. ...
... In 2014, Maddela et al. reported a case of a patient who developed hemiparesis and facial sensory loss after C5/6 interlaminar injection with sedation [8]. MRI revealed a T2-weighted high signal from C6/7 to the base of the brain immediately after the procedure. ...
... However, the mid-portion of the cervical spinal cord allows it to be positioned closer to the epidural space because of its natural bulge. Therefore, when CIESI is performed at the C6/7 level or a higher level, the likelihood of spinal cord interruption increases because of the relatively thin epidural layer compared to that of the lower cervical regions [7,8]. There could also be instances in which the loss-of-resistance (LOR) technique for identifying the epidural space during CIESI may lack specificity. ...
Background: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. Case report: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient’s PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. Conclusions: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher.
... . However, this approach could also result in serious complications, such as quadriplegia due to inadvertent intramedullary injection or spinal cord injury, even when performed under C-arm fluoroscopy [11,12]. Therefore, we aimed to identify a safe needle insertion point that can avoid cervical cord punctures as far as possible when performing cervical epidural block using the interlaminar approach under C-arm fluoroscopy. ...
... In this study, the T1 level was close to the C7 to T1 interlaminar foramen because the diameters of the spinal canal and spinal cord were measured at the upper pedicular levels. If epidural block was performed under C-arm fluoroscopy, the T1 level would be the safest injection site to reduce spinal cord injuries during cervical epidural block, as shown in previous reports [12]. Considering that the cord to canal transverse diameter ratio increases as we move to the upper cervical vertebrae, performing an epidural nerve block at levels higher than C6-7 and C7-T1 would increase the probability of spinal cord injury. ...
... like post-dural puncture headache and paresthesia [17]. All the reported cases of spinal cord injury during cervical epidural nerve block occurred under deep sedation [12,18]. Therefore, performing the procedure under arousal or under appropriate sedation is recommended so that the patient's response can be immediately confirmed during the procedure and potential injuries can be avoided or reduced. ...
Background:
Cervical epidural block could cause spinal cord injury if the epidural needle is over-inserted and punctures the spinal cord. However, if the proportion of the spinal cord in the epidural space can be determined under C-arm fluoroscopy, a safe entry point for the epidural needle can be established.
Methods:
We retrospectively evaluated the imaging data of 100 patients (50 men and 50 women) who underwent both cervical computed tomography (CT) and cervical magnetic resonance imaging (MRI) at our hospital. We measured the diameters of the spinal canal and spinal cord from the 3rd cervical vertebra to the 1st thoracic vertebra (T1) at each level by using the patients' cervical CT and MR images. The spinal cord and spinal canal diameters were measured in the transverse plane of cervical MR and CT images, respectively.
Results:
The spinal cord to spinal canal diameter ratio was the highest at the 4th and 5th cervical vertebrae (0.64 ± 0.07) and the lowest at T1 (0.55 ± 0.06, 99% confidence interval : 0.535 - 0.565).
Conclusions:
Our findings suggest that the cord to canal transverse diameter ratio could be used as a reference to reduce direct spinal cord injuries during cervical epidural block under C-arm fluoroscopy. In the C-arm fluoroscopic image, if an imaginary line connecting the left and right innermost lines of the pedicles of T1 is drawn and if the needle is inserted into the outer one-fifth of the left and right sides, the risk of puncturing the spinal cord would be relatively reduced.
... It is worth noting this patient received sedation and was unable to communicate during the procedure. In addition, MRI revealed severe degenerative disc disease with close proximity of spinal cord and lamina at C5-C6 level [18]. [10] Prospective 790 3 vasovagal syncope, 2 dural puncture headaches Catchlove [4] Retrospective 141 6 hypotension Shulman [12] Retrospective 202 Minor complications (headache, facial flushing) in 17% of injections Goel [13] Prospective 65 11 headache, 14 insomnia, 14 facial flushing, 14 increased temperature, 4 increased pain Bose reported a rare case that a CESI at the C6-C7 level was performed under fluoroscopic guidance in a surgery center with a 20-gauge Touhy needle. ...
... Reviewing MRI or CT prior to injections, the level of injection should be selected appropriately [18]. Any level devoid of epidural signal should be avoided. ...
... The approximate dermal to epidural distance can be measured on an axial or sagittal cut to approximate needle depth to serve as a guide [18]. 3. Careful judgment should be exercised in limiting the volume of injectate and speed at which it is administered. ...
Purpose of review:
Cervical interlaminar epidural steroid injection is a common intervention in the management of cervical radiculitis. Given the large number of injections done annually, it is important to assess the potential complications associated with this procedure.
Recent findings:
Based on current published studies, the overall complication rate varies. The vast majority are minor complications. However, this review also identified potentially catastrophic complications following cervical interlaminar epidural steroid injections. Based upon our review, cervical epidural steroid injection is considered a safe intervention. Nevertheless, catastrophic complications such as spinal cord injuries from needle placement, infections, and epidural hematoma can occur. It is prudent to take appropriate measures to minimize these complications.
... This relative discrepancy may be due to the attention cervical transforaminal epidural steroid injections (CTFESI) received after multiple reports of serious neurologic complications such as motor complete tetraparesis, stroke, and death [2][3][4][5][6][7]. That said, CILESI also carry the risk of paralysis [8][9][10][11][12][13][14]. The aim of this article is to describe the cases of serious neurologic complications due to CILESI, safety techniques to mitigate the risks of these, and lastly cover the other more common but less severe complications associated with these injections. ...
... MRI revealed increased T2 signal from C6 to 7 to the base of the brain. At follow-up, the patient had partial but incomplete improvement in right upper and lower extremity strength [14]. ...
... Risk Mitigation for Aberrant Needle Placement A number of considerations can be made to minimize the risk of intrathecal or intraparenchymal needle placement. The first three cases highlight two of these safety techniques, wherein sedated patients underwent C5-6 CILESI [13,14]. First is consideration of the natural bulge in the mid portion of the cervical spinal cord, which places the spinal cord in even closer proximity to the epidural space and further reduces the margin of error. ...
Purpose of Review
The purpose of this review is to describe cases of serious neurologic complications due to cervical interlaminar epidural steroid injection, safety techniques to mitigate the risks of these, and briefly cover other more common but less severe complications.
Recent Findings
The most common complications reported in the largest available cohort of epidural steroid injections include increased pain, steroid side effects, and vasovagal reaction without any cases of serious neurologic complications being captured.
Summary
The risk of neurologic damage due to aberrant needle location or space occupying lesions is very small, though not zero even if ideal technique is used. Proper utilization of risk mitigation techniques can further reduce the risk of these rare but serious complications.
... Although CILESIs are commonly used procedures in the diagnosis and treatment of painful disorders of the cervical spine [10], they have been associated with complications, such as nonpositional headache, facial flushing, vasovagal episodes, and increased axial neck pain. Additionally, major complications, such as epidural hematoma, subdural hematoma, permanent spinal cord injury, and death, can occur during the procedure [11,12]. To improve patient safety, many clinicians recommend performing the procedure under fluoroscopic guidance [4,[13][14][15]. ...
Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (
P
=
0.012
). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.
Objectives
Trans-foraminal epidural injections have been used successfully to aid in the management of cervicobrachialagia. The aim of this study was to assess the cross sectional area of the vertebral artery during transforaminal cervical nerve root injections (TFCNRI) when the head is typically rotated and to compare with the neutral position cross sectional area. We hypothesize that head rotation does not lead to a change of vertebral artery calibre at the neural foramen, thus this technique can be performed relatively safely during TFCNRI.
Material and Methods
A pilot study involving a retrospective review of 16 computed tomography guided TFNRI was performed and cross sectional area of vertebral artery with head tilted and head in neutral position was performed.
Results
There was no correlation between the degree of head rotation and change in the area of the ipsilateral or contralateral vertebral artery.
Conclusion
We suggest that head can safely be rotated to varied degrees while performing TFCNRI.
Epidural steroid injections (ESIs) are used to manage radicular pain in patients with spinal degenerative disk disease, spinal stenosis, and disk herniations. Although rare, devastating neurological complications and death have been reported after cervical transforaminal epidural steroid injections (CTESIs). Knowledge of the anatomy of the cervical spine, careful review of the available images, the use of the appropriate technique, disciplined and accurate imaging while performing the procedure, and continuous patient monitoring are mandatory while performing these injections. A low threshold for aborting the procedure should be considered if persistent venous runoff or vertebral artery outline is observed on plain fluoroscopy and digital subtraction angiography (DSA). Procedures should be aborted immediately if evidence of rapid vascular runoff ascending toward the vertebral artery or directed medially toward radicular arteries providing blood supply to the spinal cord is observed. CTESIs should always be performed by physicians who have had specific training, have proven experience with interventional pain management techniques, and are able to manage eventual complications.
Epidural steroid injections are widely used as a medical intervention for the treatment of radicular pain from disc herniation. Iatrogenic spinal cord injuries after epidural steroid injections are rare, but catastrophic and devastating events have been reported in the literature. Clinical precautions should be implemented to identify individuals who are at high risk for neurologic injury, and measures should be taken to improve patient safety.
Serious neurologic complications following cervical transforaminal epidural steroid injections (CTFESI) and cervical interlaminar epidural steroid injections (CILESI) have been reported. For CILESI, this is caused by aberrant needle placement or space-occupying lesions, such as hematoma or abscess. For CTFESI, this is caused by embolic infarct when inadvertent intra-arterial injection of particulate steroids has occurred. Multiple safety techniques are used to mitigate the risk of these serious complications. The most common adverse events that occur following CTFESI or CILESI are procedural-related pain, steroid side effects, and vasovagal reactions, which are relatively minor and self-limited.
