Ligamentum Flavum Rupture by Epidural Injection Using Ultrasound with SMI Method.

The loss of resistance (LOR) method has been used exclusively to identify epidural space. It is difficult to find the epidural space without the risk of dural puncture. Various devices have been developed to improve the accuracy of the LOR method; however, no method has overcome the problems completely. Therefore, we devised a ligamentum flavum rupture method (LFRM) in which the needle tip is placed only on the ligamentum flavum during the epidural injection, and the injection pressure is used to rupture the ligamentum flavum and spread the drug into the epidural space. We confirmed the accuracy of this method using ultrasound with superb microvascular imaging (SMI) to visualize the epidural space. Here, we report two cases of 63-year-old and 90-year-old males. The 63-year-old patient presented with severe pain in his right buttock that extended to the posterior lower leg. The 90-year-old patient presented with intermittent claudication every 10 min. LFRM was performed, and SMI was used to confirm that the parenteral solution had spread into the epidural space. Our results indicate that LFRM can be used for interlaminar lumbar epidural steroid injections.