Hanyang Med Rev.  2011 May;31(2):90-102. 10.7599/hmr.2011.31.2.90.

Lumbar Ventral Epidural Approach

• Shim JC

• KMID: 2168185
• DOI: http://doi.org/10.7599/hmr.2011.31.2.90

Abstract

The utilization of transforaminal epidural steroid injections (TFESIs), an elective diagnostic and therapeutic spinal procedure, has risen dramatically over the past decade. The transforaminal technique uses a needle that approaches the posterolateral aspect of the intervertebral foramen. Despite the superiority of the transforaminal route, transforaminal blocks have been associated with devastating neurological complications, particularly paraplegia. Since the radiological target advocated for transforaminal injections matches the superoanterior portion of the foramen, it comes as no surprise that this approach renders radiculomedullary arteries vulnerable to injury. The author uses retrograde interlaminar ventral epidural steroid injection with catheters to obtain a theoretically advantageous placement of epidural corticosteroid. Epidurography of such injections does demonstrate that this approach more frequently achieves coverage of both the putative disc source of nerve irritation and of the affected segmental nerve.

Keyword

Epidural; Infarct; Nerve block; Spinal cord

MeSH Terms

Arteries
Catheters
Needles
Nerve Block
Paraplegia
Spinal Cord

Figure

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  Fig. 1 Fluoroscopic lateral image of a ventral epidural space with contrast media spreading. Ventral epidural space is narrow at the disc level (black arrow) compared with supraoraminal level (white arrow).

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  Fig. 2 Fluoroscopic image (antero-posterior view) of epidural steroid injection of the right S1 root. Arrow, intraforaminal and epidural portion of the exiting nerve root.

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  Fig. 3 Radiographs of 57-year-old woman with radiating pain to left buttock and lower leg in L4 dermatome. MR image (not shown) revealed left paracentral L3/4 disc herniation with compression of left L4 nerve root. Pars interarticularis TFESI was performed at L4 neural foramen. (A) Antero-posterior view with contrast media spreading to L3/4 disc through the epidural space. (B) Lateral view showing needle tip in posterior aspect of the L4/5 neural foramen.

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  Fig. 4 CT images showing the path of catheter at sagittal view (A, B) and coronal view (C, D). Black arrow heads indicate the localization of catheter tip.

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  Fig. 5 CT axial view at S1 level showing the path of catheter. The catheter was advanced through the space between dural sac and left S1. The catheter tip (black arrow head) is located at the ventrocaudal aspect of left S1 nerve root.

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  Fig. 6 Fluoroscopic antero-posterior (A) and lateral (B) image of left L5, S1 RLIVESI. The catheter was placed in the ventrocaudal aspect of exiting nerve root in antero-posterior view (white arrow head). Note that the contrast media spreads through the ventral epidural space at the L5 level (black arrow head) in lateral view. Contrast media filling defect was observed at the L5S1 disc level due to left posterolateral disc extrusion (white arrow head).

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