Algorithm for performing cervical epidural steroid injections with contrast spread technique

Objective: To assist pain practitioners who perform Cervical Epidural Steroid Injections (CESI) with fluoroscopy only in recognizing possible contrast medium flow scenarios and in clinical decision making based on image findings. Methods and Results: A total of 1574 CESIs with Contrast Spread Technique (CST) were performed from August 1, 2014, to June 1, 2020, in our office. Through numerous observations and discussions, we came to some realizations that broaden our understanding of the technique. This knowledge eventually led to the creation of this algorithm and the writing of this paper. Different scenarios were illustrated with images from our practice. Special attention was given to key points of the algorithm: What might be the reasoning for the needle tip appearing to be inside the epidural space, but without a confirmatory medium flow? What is the optimal C-Arm angulation with contralateral oblique fluoroscopy? How can practitioners recognize combined epidural and vascular spread? How can physicians differentiate the epidural from the subdural spread? Description of Space of Okada was included in the algorithm as CST increases its identification. The superior articular pillars line, a hypothetical radiological landmark, was introduced in pursuit of preventing serious complications. Limitations: Despite some theoretical and practical advantages, CST is not a time-proven method for epidural space recognition, loss of resistance is. Multicenter clinical trials are warranted for the exploration of its utility in clinical practice. Conclusion: The ultimate goal of any injection is the safe delivery of medication to the targeted area of pathology. Utilization of contrast media for needle depth visualization, along with a knowledgeable interpretation of the fluoroscopic images, may decrease risk, improve the quality of the procedure, and enhance both patients’ and physicians’ satisfaction with fluoroscopy-guided interlaminar epidural injections.