Reddy Shawn, Wu Jiang
Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington, U.S.A.
Department of Anesthesiology & Pain Medicine, Center for Pain Relief, University of Washington Medical Center, Seattle, Washington, U.S.A.
Pain Pract. 2020 Nov;20(8):919-928. doi: 10.1111/papr.12923. Epub 2020 Jul 3.
Cervical selective nerve root blocks (C-SNRBs) maintain utility for presurgical planning in patients with cervical radiculopathy. Traditional fluoroscopic or stationary computed tomography (CT)-guided methods have been associated with complications, including catastrophic neurologic insults, while ultrasound guidance has been investigated based on its theoretical advantages. Maximizing patient safety by obtaining superior anatomic and procedural details promotes the exploration for better alternative guidance.
We describe a novel approach of posterolateral (PL) extraforaminal (EF) C4 SNRB using cone beam-based CT (CBCT)/fluoroscopy, which was performed on 3 separate occasions for 1 patient with suspected right C4 radiculopathy for presurgical evaluation. CBCT/fluoroscopy uniquely provides the function of both CT and fluoroscopy using a C-arm machine. It allows precise 3-dimensional needle planning and sophisticated 2-dimensional needle guidance, while ensuring tight needle control and detailed monitoring of contrast spread.
A successful right C4 SNRB was repeatedly achieved, as evidenced by postprocedural paresthesias over the C4 dermatomal distribution and periradicular contrast spread. Additionally, the patient reported symptomatic relief (with regard to pain scores and neck range of motion), leading to cancelation of his surgical plan.
We propose the PL-EF approach as the safest protocol for C-SNRBs. When compared with fluoroscopy or CT, CBCT/fluoroscopy is an advanced imaging system that provides superior anatomic neurovascular detail, while offering precise needle control, contrast media monitoring, and easy operation in an office setting. These advanced features support it as the ideal guidance method for maximizing both the safety and efficiency of the PL-EF C-SNRB approach. However, the claimed advantages cannot be concluded without increasing its accessibility to pain specialists and conducting a prospective study with a large sample size.
颈椎选择性神经根阻滞（C-SNRB）在颈椎神经根病患者的术前规划中仍具有重要作用。传统的荧光透视或固定计算机断层扫描（CT）引导方法已出现一些并发症，包括严重的神经损伤，而超声引导因其理论优势已得到研究。通过获取更详细的解剖和操作细节来最大化患者安全性，促使人们探索更好的替代引导方法。
我们描述了一种使用基于锥束CT（CBCT）/荧光透视的新型后外侧（PL）椎间孔外（EF）C4神经根阻滞方法，该方法在3个不同时间对1例疑似右侧C4神经根病的患者进行术前评估。CBCT/荧光透视利用C形臂机器独特地提供了CT和荧光透视的功能。它允许精确的三维针道规划和复杂的二维针引导，同时确保对针的严格控制和对造影剂扩散的详细监测。
多次成功实施右侧C4神经根阻滞，术后C4皮节分布区出现感觉异常及神经根周围造影剂扩散可证明。此外，患者报告症状缓解（疼痛评分和颈部活动范围方面），导致其手术计划取消。
我们提出PL-EF方法是C-SNRB最安全的方案。与荧光透视或CT相比，CBCT/荧光透视是一种先进的成像系统，可提供更详细的解剖神经血管细节，同时在办公室环境中提供精确的针控制、造影剂监测且操作简便。这些先进特性使其成为最大化PL-EF C-SNRB方法安全性和效率的理想引导方法。然而，在疼痛专家更易使用该方法并进行大样本前瞻性研究之前，无法得出其宣称的优势结论。
