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technique

The procedure is performed on an outpatient basis. The patient is placed prone on the CT table. A CT scan of the affected level allows precise choice of the needle pathway. For this procedure we use only CT control.

 

  • For lumbar level : The patient is placed in prone position. The entry point and the pathway are determined by CT. After local anesthesia of the skin, a 22-gauge spinal needle is placed by a posterior approach near the painful nerve root under CT control. In intracanalar infiltration, before injection of long acting steroids (cortivazol 3.75 mg) in epidural space, absence of Cerebro Spinal Fluid (CSF) is verified by aspiration. Once the needle is in the epidural space, 1.5 ml air is injected to confirm the extradural position of the needle tip. Then 2-3 ml of long acting steroids (cortivazol) solution is injected, pure or mixed with a solution of 0.5% lidocaine (2 ml). Under precise CT control, dural sac perforation is avoided. However, if the dura is perforated because of an adhesion of the dural sac to ligamentum flavum or because of a mistaken maneuver, the needle must be pulled back slightly, checked by aspiration for CSF, and if there is none, the corticosteroid solution is injected without anesthetic. During injection, the patient may experience a spontaneous recurrence of pain lasting few seconds, brought on by dural stretch.
  • For cervical level : the patient is placed in supine position head slightly turned and in hyperextension. The entry point and the pathway are determined by CT. After local anesthesia of the skin, a 22-gauge spinal needle is placed by a lateral approach near the painful nerve root under CT control. Then 2-3 ml of long acting steroid (cortivazol) solution is injected. Under precise CT control, vertebral artery injury or intra-arterial injection is avoided.

Fig 3: disk herniation


Fig 4: needle in epidural space


Fig 5: gaseous epidurography


Fig 6: steroid injection