Price C M, Rogers P D, Prosser A S, Arden N K
Department of Pain Management, Portsmouth Hospitals NHS Trust, UK.
Ann Rheum Dis. 2000 Nov;59(11):879-82. doi: 10.1136/ard.59.11.879.
To investigate the accuracy of placement of epidural injections using the lumbar and caudal approaches. To identify which factors, if any, predicted successful placement.
200 consecutive patients referred to a pain clinic for an epidural injection of steroid were randomly allocated to one of two groups. Group L had a lumbar approach to the epidural space and group C a caudal approach to the epidural space. Both groups then had epidurography performed using Omnipaque and an image intensifier to determine the position of the needle.
Body mass index (BMI), grade of operator, and route of injection were predictors of a successful placement. 93% of lumbar and 64% of caudal epidural injections were correctly placed (p< 0.001). 97% of lumbar and 85% of caudal epidural injections clinically thought to be correctly placed were confirmed radiographically. For epidural injections where the clinical impression was "maybe", 91% of lumbar injections, but only 45% of caudal injections were correctly placed. Obesity was associated with a reduced chance of successful placement (odds ratio (OR) 0.34 (95% confidence interval (CI) 0.17 to 0.72) BMI >30 v BMI <30). A more senior grade of operator was associated with a reduced chance of successful placement (OR 0.16 (95% CI 0.03 to 0.89) consultant v other). However, small numbers may have accounted for the latter result.
The weight of the patient and intended approach need to be considered when deciding the method used to enter the epidural space. In the non-obese patient, lumbar epidural injections can be accurately placed without x ray screening, but caudal epidural injections, to be placed accurately, require x ray screening no matter what the weight of the patient.
研究采用腰椎和骶管入路进行硬膜外注射的穿刺准确性。确定是否有预测穿刺成功的因素。
连续200例因硬膜外注射类固醇而转诊至疼痛门诊的患者被随机分为两组。L组采用腰椎入路进入硬膜外腔，C组采用骶管入路进入硬膜外腔。然后两组均使用欧乃派克和影像增强器进行硬膜外造影，以确定穿刺针的位置。
体重指数（BMI）、操作者级别和注射入路是穿刺成功的预测因素。93%的腰椎硬膜外注射和64%的骶管硬膜外注射穿刺位置正确（p<0.001）。临床上认为穿刺位置正确的97%的腰椎硬膜外注射和85%的骶管硬膜外注射经影像学证实。对于临床印象为“可能正确”的硬膜外注射，91%的腰椎注射穿刺位置正确，但只有45%的骶管注射穿刺位置正确。肥胖与穿刺成功几率降低相关（优势比（OR）0.34（95%置信区间（CI）0.17至0.72），BMI>30对比BMI<30）。级别更高的操作者与穿刺成功几率降低相关（OR 0.16（95%CI 0.03至0.89），顾问医生对比其他医生）。然而，样本量较小可能导致了后一结果。
在决定进入硬膜外腔的方法时，需要考虑患者体重和预期入路。对于非肥胖患者，腰椎硬膜外注射无需X线透视即可准确穿刺到位，但骶管硬膜外注射，无论患者体重如何，要准确穿刺均需X线透视。
