Method to Reduce the False-Positive Rate of Loss of Resistance in the Cervical Epidural Region

Abstract

Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.

Analysis of epidural waveform for cervical epidural steroid injections confirmed with fluoroscopy

“…This study demonstrated the incidence of false LOR as 29.5% which is similar to previous results performed in cervical area, [ 1 , 5 ] and higher than the results of lumbar area. [ 1 ]…”

“…To reduce the false LOR, various methods including the use of contrast medium or epidrum to detect LOR have been studied. [ 5 , 6 ] We suggest that EPWA might be more valuable if it is applied to CESI which shows high false LOR rate and one adjunctive method to reduce the failure of CESI.…”

“…[ 1 , 3 , 4 ] The false positive rate of the lumbar and cervical area was reported to be 8.3% ∼ 17% and 30% ∼ 68%, respectively. [ 1 , 5 , 6 ] If the false positive rate is high, repeated attempts of epidural steroid injection (ESI) are required, with additional discomfort or pain to the patient.…”

“…In this reliability study, we chose the cervical epidural space, which is reported to have a high false LOR [ 1 , 5 , 6 ] and which has never been studied related to the reliability of EPWA.…”

Fluoroscopically Guided Epidural Injections of the Cervical and Lumbar Spine

“…The paramidline approach is preferred when a midline approach is difficult, as in cases with ossification of the supraspinous ligament or Baastrup disease. The loss of resistance as the needle traverses the ligamentum flavum, which indicates that the needle is in the epidural space, can be unreliable, compared with use of test injections of contrast material (55,(63)(64)(65). A test injection of contrast material would result in a vertical semilunar-shaped contrast agent deposit along the spinolaminar line on the lateral view and a thick ipsilateral contrast agent shadow along the medial margin of the upper and lower pedicles and the exciting nerve sheath on the AP view (Fig 6a-6c).…”