Procedural Safety Guidelines for Cervical Epidural Steroid Injections: Appendix 1 - Part B
Appendix 1: Procedural Safety Guidelines for Cervical Epidural Steroid Injections - Continued ...
Rationale: If the patients symptoms are severe enough to warrant a cervical epidural injection then an evaluation of the structural pathology is justified and is required to enforce guideline #1 and guideline #3.
(7) An epidural needle of sufficient gauge to reliably feel the ligamentum flavum should be utilized.
Rationale: The relative thickness of the ligamentum flavum in the cervical epidural space can vary, depending on the angle of needle entry. It can occasionally be relatively thin, consequently returning little resistance to the advancing needle. Although there are practitioners who advocate using a 25-gauge needle, the ability to "feel" the resistance of the ligamentum flavum becomes increasingly difficult with a less than 20-gauge needle.
(8) Non-ionic contrast should be injected prior to administering corticosteroids and local anesthetic.
Rationale: If there is any resistance to the injection encountered, or if significant pain is evoked, the injection should be discontinued. The injection of nonionic contrast should be performed during real-time fluoroscopic monitoring. Contrast should remain in the epidural space post injection which will, in effect, guideline out intravascular or subarachnoid injection. Furthermore, epidural spread has a characteristic pattern that is clearly different from subcutaneous, intravascular, or subarachnoid placement.
(9) Sedation can be administered but not so much that the patient becomes unaware or nonresponsive.
Rationale: A sedating dose (e.g. 1 ml (.05 mg) Fentanyl, 1-2 mg Versed) is useful for anaesthetizing the skin and deeper tissues. The local anesthetic combined with the sedation helps prevent untoward jerking of the head during needle penetration of the ligamentum flavum. However, too much may attenuate a pain response which might indicate that the needle tip had contacted the dorsal column . Appropriate sedation, administered judiciously and incrementally, can render the patient relaxed enough to ensure the procedure is a comfortable as possible for them, while leaving them sufficiently aware to return potentially vital pain responses.
(10) The use of Depo-Medrol should be avoided.
Rationale: Ethylene glycol is a component of Depo-Medrol and is a neurotoxic substance that has been associated with chronic arachnoiditis when inadvertently injected into the subarachnoid space. On the other hand, Celestone Soluspan has been shown in animals to be "relatively innocuous" when the equivalent human dose of 12 mg is injected within the subarachnoid space.
(11) In the advent of an inadvertent dural puncture, the procedure should be abandoned immediately.
Rationale: Any substance injected into the epidural space near a prior dural puncture site will inevitable find its way into the subarachnoid space. It would be inappropriate to risk bathing a segment of the spinal cord in ethylene glycol, or any depo-corticosteroid solution.