Predicting Epidural Space Spread Using Ultrasound Color Doppler Imaging in Interlaminar Epidural Steroid Injection: A Prospective Observational Study

Abstract

Background: While the use of fluoroscopy-guided transforaminal epidural steroid injection (TFESI) to help spread the injectate toward the ventral side has increased, this procedure has a radiation risk. Recently, ultrasound has been widely used in the medical field; among ultrasound methods, color Doppler is useful for predicting the direction of the injectate.

Objective: This study describes a novel technique employing color Doppler to help predict epidural space spread in interlaminar epidural steroid injection (ILESI).

Study design: Prospective observational study.

Setting: The study took place at a single pain clinic within a medical center in Jeonju, Republic of Korea.

Methods: We enrolled 35 patients scheduled for lumbar epidural steroid injection (ESI). Ultrasound-guided epidural lateral parasagittal interlaminar injection was performed and real-time images using color Doppler were recorded during injections of 5 mL of 0.1% ropivacaine containing contrast dye with dexamethasone 5 mg (1 mL). Fluoroscopy-guided TFESI was performed if it was difficult to perform the procedure based on ultrasound images.

Results: The analysis included 30 images from 30 patients. The observed sensitivity, specificity, positive predictive value, and negative predictive values of the ultrasound color Doppler were 100%, 89.5%, 84.6%, and 100%, respectively. The agreement with ultrasound color Doppler was 93.3%.

Limitations: The sample size was relatively small.

Conclusion: The main advantage of ultrasound-guided ILESI is the lack of radiation exposure and contrast medium requirement. Color Doppler may be a reliable imaging modality to predict epidural space spread during ultrasound-guided ILESI. It is worth predicting the spread in the anterior epidural space (AES) by first attempting ultrasound-guided ESI. If the injectate has not spread to the AES, fluoroscopy-guided TFESI may be a good option after confirming improvement of the patient's symptoms.

Keywords: Doppler; epidural; intervertebral disc displacement; spinal stenosis; ultrasonography; Injections.