Korean J Pain.  2022 Jul;35(3):345-352. 10.3344/kjp.2022.35.3.345.

Relationship between needle depth for lumbar transforaminal epidural injection and patients’ height and weight using magnetic resonance imaging

• John H
• Sohn K
• Kim JH

• KMID: 2530990
• DOI: http://doi.org/10.3344/kjp.2022.35.3.345

Abstract

Background
Optimal needle depth in transforaminal epidural injection (TFEI) is determined by body measurements and is influenced by the needle entry angle. Physician can choose the appropriate needle length and perform the procedure more effectively if depth is predicted in advance.
Methods
This retrospective study included patients with lumbosacral pain from a single university hospital. The skin depth from the target point was measured using magnetic resonance imaging transverse images. The depth was measured bilaterally for L4 and L5 TFEIs at 15°, 20°, and 25° oblique angles from the spinous process.
Results
A total of 4,632 measurements of 386 patients were included. The lengths of the left and right TFEI at the same level and oblique angle were assessed, and no statistical differences were identified. Therefore, linear regression analysis was performed for bilateral L4 and L5 TFEIs. The R-squared values of height and weight combined were higher than the height, weight, and body mass index (BMI). The following equation was established: Depth (mm) = a – b (height, cm) + c (weight, kg). Based on the equation, maximal BMI capable with a 23G, 3.5-inch, Quincke-type point spinal needle was presented for three different angles (15°, 20°, and 25°) at lumbar levels L4 and L5.
Conclusions
The maximal BMI that derived from the formulated equation is listed on the table, which can help in preparations for morbid obesity. If a patient has bigger BMI than the one in the table, the clinician should prepare longer needle than the usual spinal needle.

Keyword

Body Mass Index; Epidural Space; Injections; Epidural; Low Back Pain; Lumbosacral Region; Magnetic Resonance Imaging; Obesity; Morbid; Regression Analysis

Figure

• 

  Fig. 1 A virtual dotted line vertically crosses the pedicle of lumbar vertebra 4, which is the needle target point of left L4 transforaminal epidural injection.

• 

  Fig. 2 (A) For measurement of left L4 transforaminal epidural injection, move the transverse plane slightly upward as shown to check the L3/4 facet point. Then, draw a virtual line at the center of the upper material entrenchment of the facet joint (dotted line). (B) The sagittal plane image of magnetic resonance imaging. The transverse plane image of (A) is where the yellow line is located.

• 

  Fig. 3 (A) Lower the transverse plane to a view directly below the pedicle of the lumbar 4 vertebra body and measure the length (red arrow) from skin to the contact point (arrow tip) of the vertebral body and the imaginary line (dotted line). (B) The sagittal plane image of magnetic resonance imaging. The transverse plane image of (A) is where the yellow line is located.

• 

  Fig. 4 (A) Measurement of length of L4 transforaminal epidural injection at 15° was performed. (B) The sagittal plane image of magnetic resonance imaging. The transverse plane image of (A) is where the yellow line is located.

• 

  Fig. 5 Estimated needle depth based on body mass index (BMI) is shown on the graph at three different angles (15°, 20°, and 25°) at lumbar levels L4 and L5.

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  Fig. 6 Minimal weight ranges for injection with a 88.9 mm spinal needle at three different angles (15°, 20°, and 25°) at lumbar levels L4 and L5. The needle depth for transforaminal epidural injection is positively correlated with weight and height. A 3.5-inch (88.9 mm) needle will suffice for patients with weight lighter than the weight of the corresponding height on the x-axis of the graph, while a longer than 3.5-inch needle will be required for patients with weight heavier than the weight of the corresponding height on the x-axis of the graph.

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