discussed the theoretical basis for the use of the CLO view based upon cadaveric illustration and analysis of three cases drawn from clinical practice recommending an obliquity such that the superior articular process above and below the lamina are co-aligned (around 40 degrees from the lateral in most patients), and further stated that the needle not be advanced beyond the posterior foraminal line. In this article, the obliquity was dependent upon the cross-sectional view of the lamina, and could range anywhere from 30 degrees to 60 degrees. reported the use of this view for cervical spinal cord stimulator lead placement. In a letter to the editor, Vaisman observed that at 40 degrees CLO, the tip of the needle invariably overlaps the anterior aspect of the corresponding neural foramen. Whitworth, in an observational study of 10 consecutive patients employing an angle of 30 degrees oblique from lateral view, reported successful entry into the epidural space at the posterior foraminal line. Īn image of a needle in epidural space with accompanying contrast spread appeared in a technical piece by Johnson et al. It is advocated because it lends to better visualization of the needle tip and provides a reliable radiographic landmark for the location of the posterior epidural space. Given the limitations of the lateral view, the contralateral oblique (CLO) view has been advocated for epidural needle placement, but has not been rigorously studied. Given the circumferential nature of the epidural space, the lateral view is topographically inappropriate to visualize the position of the needle tip in the epidural space. Any view that attempts to look at the relationship of the needle tip with bony landmarks must be tangential to the curvature of the epidural space at that point. In addition to the ability to accurately visualize the needle tip during epidural access, it is also critical to have a reliable radiological landmark to guide how far the needle can be safely inserted. Any last-second patient manipulation with a needle so close to the spinal cord is not desirable. The clinical success of these manipulations has not been evaluated. Various maneuvers such as adjusting the fluoroscope, caudad manipulation of the shoulders, and the swimmer's view have been suggested in order to improve the quality of needle tip imaging. Visualization of the needle tip in the lateral view in the lower cervical and cervicothoracic area is often impaired. The optimal use of fluoroscopy to meet this end has not been studied. It is clear that major cord injuries continue to occur, even with the use of fluoroscopy.Īccurate and precise visualization of the needle tip is critical to avoid trauma to the spinal cord. In the same study, it was reported that fluoroscopy was employed in 76% of the procedures that were associated with injury. In an American Society of Anesthesiologists closed claims analysis for cervical procedures from 2005 to 2008, there were 20 reported cases of direct spinal cord injury during interlaminar cervical epidural access. Despite the introduction of imaging technology, epidural interventions are not without risk. It is also likely to improve accuracy of needle placement. Fluoroscopy is now commonly used in clinical practice with the premise that it improves safety. The cervical and cervicothoracic epidural space is frequently accessed for therapeutic spine interventions such as an epidural steroid injection. Epidural (Injection Space), Fluoroscopy Introduction
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