Ann Rehabil Med.  2011 Jun;35(3):418-426. 10.5535/arm.2011.35.3.418.

Retrodiscal Approach of Lumbar Epidural Block

• Kim C
• Moon CJ
• Choi HE
• Park Y

• KMID: 2266863
• DOI: http://doi.org/10.5535/arm.2011.35.3.418

Abstract

OBJECTIVE
To compare the technical strengths and weaknesses between retrodiscal (RD) and conventional subpedicular (SP) approaches of transforaminal epidural block (TF-EPB). METHOD: Sixty-one patients with L5 radiculopathy who planned to undergo TF-EPB were consecutively enrolled as study subjects. Subjects were randomly assigned to one of two groups. For the RD approach, the positioning of the patient and the C-arm were similar to that for lumbar discography. We compared the pattern of dye spreads, the frequency of complications during the procedures, and the effect of the pain block 2 weeks after the procedure between the two groups.
RESULTS
For the RD group (n=24), the contrast dye diffused around the L5 and S1 nerve roots in 16 cases (67%), but it diffused around only the L5 root in 27 cases (73%) in the SP group (n=37) (p<0.05). Two weeks after the procedure, the visual analogue scale (VAS) decreased by the same amount in both groups (RD group: 3.1+/-1.6, SP group: 3.2+/-2.6). Symptoms of nerve root irritation occurred in 1 case of the RD group and in 10 cases of the SD group (p<0.05).
CONCLUSION
The RD approach was as efficient as the SP approach for temporary diagnostic relief and offered considerable advantages, such as lower nerve root irritation possible lower risk of vascular injection. Thus, it could be a useful technique when a herniated disc segment is stuck or when the foraminal stenosis is severe.

Keyword

Spinal; Injection; Lumbar; Transforaminal; Retrodiscal

MeSH Terms

Constriction, Pathologic
Humans
Intervertebral Disc Displacement
Radiculopathy

Figure

• 

  Fig. 1 Schematic description for transforaminal epidural steroid injection with the retrodiscal approach versus the subpedicular approach.

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  Fig. 2 The positioning of the patient and C-arm are similar to lumbar discography. (A) The patient is placed in the prone position on a fluoroscophy table top padded to provide flattening of the lumbar lordosis. (B) The targeted disc's endplates are aligned as for discography with appropriate caudal or cranial tilt of the C-arm. (C) The beam is then rotated so that the lateral surface of the superior articular process (SAP) bisects the interspace, typically 40-45 degrees off the AP axis.

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  Fig. 3 Retrodiscal injection L5-S1. (A) In oblique view, needle tip is advanced slowly and cautiously past the SAP lateral surface. (B) The lateral radiography should also be used while advancing past the SAP to minimize the risk of the penetration, while the resistance to the needle advancement is also used as sign to stop. (C) The AP view will most often demonstrate the tip in the interpedicular line. (D) A small amount of contrast is used to confirm epidural spread.

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  Fig. 4 Subpedicular injection L5-S1. (A) In oblique view, needle tip lies directly inferior to the pedicle and inferolateral to the pars interarticularis. (B) The AP view showing the proper location of the needle at the base of pedicle. (C) The lateral radiography should also be used while the needle is advanced until the needle tip is at the posterior and superior aspect of intervertebral neural foramen. (D) A small amount of contrast is used to confirm epidural spread.

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  Fig. 5 Posteroanterior spot radiography shows contrast material has spread to L5-S1 disc through the epidural space. The AP view (A) and the lateral view (B).

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