1 Department of Radiology, University of Utah Health Sciences Center, 30N 1900E, Rm #1A71, Salt Lake City, UT 84132.
2 Department of Radiology & Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN.
AJR Am J Roentgenol. 2017 Oct;209(4):895-903. doi: 10.2214/AJR.17.18111. Epub 2017 Aug 10.
There is a paucity of evidence-based literature regarding the advantages and disadvantages of the interlaminar approach and needle bevel orientation for performing a lumbar interlaminar epidural steroid injection (ESI). The purpose of this study was to determine if superior versus inferior lamina approach, needle bevel tip orientation, or both may predispose to inadvertent nonepidural penetration during lumbar interlaminar ESI.
A prospective study was performed of patients with low back pain with or without radicular pain or neurogenic claudication referred for lumbar interlaminar ESI. Two hundred eleven patients were randomized by interlaminar approach (superior vs inferior) and bevel tip orientation (cranial vs caudal). Lumbar interlaminar ESI was performed by six interventionalists of varying levels of experience using fluoroscopic guidance with curved tip epidural needles, using loss-of-resistance technique and confirmation with contrast opacification. Exact Poisson regression was used to model the study outcome.
Two hundred twenty-one lumbar interlaminar ESIs were performed on 211 patients, randomized to a superior (n = 121) or inferior lamina approach (n = 100) and to a cranial (n = 103) or caudal (n = 118) orientation of the bevel tip. Epidural needle placement was confirmed in 96.4% (n = 213) of cases. Nonepidural needle placement was most commonly associated with superior lamina approach and caudal bevel tip orientation, which was marginally significant (adjusted risk ratio, 6.88; 95% CI, 0.93-∞; p = 0.059).
Inadvertent nonepidural needle penetration during fluoroscopically guided lumbar interlaminar ESI appears to be affected by approach, with superior lamina approach and caudal bevel tip orientation being the least favorable technique.
关于行腰椎间硬膜外类固醇注射（ESI）时使用的经皮入路和针尖斜面方向的优缺点，目前仅有少量基于证据的文献。本研究旨在确定上、下椎板入路、针尖斜面尖端方向，或者两者是否会导致腰椎间硬膜外注射时无意中穿透硬膜外腔。
对因腰痛伴或不伴根性痛或神经源性跛行而接受腰椎间硬膜外注射的患者进行前瞻性研究。211 例患者按经皮入路（上或下）和针尖斜面尖端方向（头或尾）随机分组。6 名介入放射医师在透视引导下使用带弯曲针尖的硬膜外针进行腰椎间硬膜外注射，采用阻力损失技术，并通过对比显影确认。使用精确泊松回归对研究结果进行建模。
211 例患者共行 221 例腰椎间硬膜外注射，随机分为上椎板入路（n = 121）或下椎板入路（n = 100）和针尖斜面头侧（n = 103）或尾侧（n = 118）方向。96.4%（n = 213）的病例确认了硬膜外针的位置。最常见的非硬膜外针位置与上椎板入路和尾侧针尖斜面尖端方向相关，这具有边缘显著性（调整风险比，6.88；95%置信区间，0.93-∞；p = 0.059）。
在透视引导下进行腰椎间硬膜外注射时，无意中穿透硬膜外腔似乎与入路有关，上椎板入路和尾侧针尖斜面尖端方向是最不利的技术。
