Jatinder S. Gill

Contralateral Oblique View is Superior to Lateral View for Interlaminar Cervical and Cervicothoracic Epidural Access

OBJECTIVE The purpose of this study was to compare the reliability of the lateral fluoroscopic view and several contralateral oblique (CLO) views at different angles in visualizing and accurately predicting the position of the needle tip at the point of access in the posterior cervical and cervicothoracic epidural space. DESIGN After the epidural space was accessed but before confirmation with contrast fluoroscopy, we prospectively obtained fluoroscopic images at eight different angles. Subsequent contrast injection confirmed epidural spread. Needle tip visualization and location of needle relative to bony landmarks were analyzed. RESULTS The needle tip was clearly visualized in all CLO projections in all 24 subjects. CLO view at 50 degrees and at obliquity measured on magnetic resonance imaging (MRI) images provided the most consistent needle tip location. In these views, the epidural space was accessed at or just beyond the ventral laminar margin at the ventral interlaminar line or within the proximal half of the predefined CLO area in all patients. The needle tip was poorly visualized in the lateral view and the location of the needle tip was less well defined and independent of the needle location in the anteroposterior (AP) view. CONCLUSIONS This study provides evidence that during cervical and cervicothoracic epidural access, the CLO view at 50 degrees and at MRI-measured obliquity is superior to the lateral view for the purpose of needle tip visualization and in providing a consistent landmark for accessing the epidural space. This article also introduces the concept of zones to describe needle position in the cervical and cervicothoracic spine in AP, lateral, and oblique views.

Intricacies of the Contralateral Oblique View for Interlaminar Epidural Access

To the Editor, Furman and colleagues present a good overview of the contralateral oblique view when performing interventions via the posterior epidural space ⇓. Indeed, this view is superior to the lateral view in visualizing the needle tip and may improve overall safety especially with cervical interventions. Ambiguity, however, remains about the appropriate angle and the distance the needle needs to be advanced beyond the ventral interlaminar line (VILL) before the epidural space is accessed. In this letter we would like to highlight these inconsistencies and look at the relationship of the angle used in the contralateral oblique view to the location of the needle tip. Furthermore, we would like to comment on the so-called “spinolaminar” line mentioned by Furman and colleagues. The degree of obliquity when employing the contralateral oblique view is of paramount importance. Final needle tip position in this view is a function of the …

Cervical Epidural Contrast Spread Patterns in Fluoroscopic Antero-Posterior, Lateral, and Contralateral Oblique View: A Three-Dimensional Analysis

Objective To describe and to analyze cervical epidural contrast patterns seen in antero-posterior (AP), contralateral oblique (CLO), and lateral view. To identify factors that might help in predicting contrast distribution pattern and extent. Method Spread of contrast in the cervical epidural space was prospectively studied in AP, lateral, and three CLO views. Results CLO view showed contrast spread of variable thickness with its posterior margin overlying the ventral interlaminar line (VILL). In the lateral view, the spread was also of variable thickness, but the posterior margin of the contrast lay on the spinolaminar line in only 10 of 24 patients. Ventral contrast spread was not visualized in any patient. In the AP view, bilateral spread was seen in 14 of 24 subjects, and nerve root spread was seen in 16 of 24 subjects. No association of the pattern of spread or dispersion was seen to patient age, volume injected, or needle location. Conclusions The CLO view provides a consistent radiological landmark for the posterior margin of contrast in the dorsal epidural space; the lateral view fails to provide such a consistent landmark. The thickness of the spread is variable, both in the CLO and in the lateral view. Thick spread extending into the foramen in the CLO view and over the articular pillars in the lateral view is frequent and should not be misconstrued as subdural or intrathecal spread. In contradistinction to previous studies, true ventral spread was not seen in any patient. When using low volumes, contrast spread is independent of patient age, volume injected, or needle tip location in the AP view.

Contralateral Oblique View Is Superior to the Lateral View for Lumbar Epidural Access

OBJECTIVE The purpose of this study was to perform a comparative analysis of the contralateral oblique (CLO) view and the lateral view for lumbar interlaminar epidural access. DESIGN After the epidural space was accessed, fluoroscopic images at eight different angles (antero-posterior view, multiple CLO, and lateral view) were prospectively obtained. Visualization and location of needle tip relative to bony landmarks were analyzed. The epidural location of the needle was subsequently confirmed by contrast injection and analysis in multiple views. RESULTS Visualization of the needle tip and the relevant radiologic landmarks was superior in the CLO view. The needle tip location in the epidural space was most consistent at a CLO angle of 45°. CONCLUSION This study shows that the CLO view for lumbar interlaminar epidural access offers clear advantages over the lateral view on many clinically important grounds: the needle tip visualization is better, the important radiological landmarks are better visualized, and the needle tip when placed in the epidural space presents a more precise relationship to these landmarks. All of these differences were highly significant. Thus, when using this view, the needle may be directly placed in very close vicinity to the epidural space and true loss of resistance expected soon thereafter. In addition, this view provides the ability to plot the cranio-caudad needle trajectory. The combination of these factors is likely to improve the ease and efficiency of epidural access. The crisp visualization of the final moments of epidural access could also translate to improved safety and accuracy. In light of this, it is suggested that a CLO view at 45° be considered the preferred view for gauging needle depth during interlaminar lumbar epidural access.

Treatment of Chronic Refractory Neuropathic Pelvic Pain with High Frequency 10 Kilohertz Spinal Cord Stimulation

Chronic neuropathic pelvic pain remains a recalcitrant problem in the field of pain management. Case series on application of 10 kHz spinal cord stimulation is presented. High frequency stimulation can improve chronic neuropathic pain states that are known to be mediated at the conus medullaris and offers another avenue for the treatment of these patients.

The Incidence and Management of Postdural Puncture Headache in Patients Undergoing Percutaneous Lead Placement for Spinal Cord Stimulation

Spinal cord stimulation (SCS) is rapidly expanding therapy for the treatment of refractory neuropathic pain. Although technical issues such as battery life and lead migration have been well studied and improved, little is known about the incidence and management of inadvertent dural puncture and consequent headache.

A Brief History of the Opioid Epidemic and Strategies for Pain Medicine

The opioid epidemic has resulted from myriad causes and will not be solved by any simple solution. Consequent to a staggering increase in opioid-related deaths in the USA, various governmental inputs and stakeholder strategies have been proposed and implemented with varying success. This article summarizes the history of opioid use and explores the causes for the present day epidemic. Recent trends in opioid-related data demonstrate an almost fourfold increase in overdose deaths from 1999 to 2008. Tragically, opioids claimed over 64,000 lives just last year. Some solutions have undergone legislation, including the limitation of numbers of opioids postsurgery, as well as growing national prevalence of enhanced recovery after surgery protocols which focus on reduced postoperative opioid consumption and shortened hospital stays. Stricter prescribing practices and prescription monitoring programs have been instituted in the recent past. Improvement in abuse deterrent strategies which is a major focus of the Food and Drug Administration (FDA) for all opioid preparations will likely play an important role by increasing the safety of these medications. Future potential strategies such as additional legislative policies, public awareness, and physician education are also detailed in this review.

The Long-Term Durability of Multilumen Concentric Percutaneous Spinal Cord Stimulator Leads

Lead fracture is a well‐known complication of cylindrical spinal cord stimulator leads. In order to reduce this complication, anchor design and techniques have been modified, but internal lead design has received little attention.

High Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Complex Regional Pain Syndrome: A Case Series of Patients with or without Previous Spinal Cord Stimulator Implantation

High‐frequency spinal cord stimulation at 10 kHz (HF10‐SCS) has been demonstrated to provide enhanced and durable pain relief in patients with chronic back and radiating leg pain. Patients with pain related to complex regional pain syndrome (CRPS) in the chronic stages are commonly challenging to treat and often receive traditional spinal cord stimulation (SCS). Very little information is currently available about the therapeutic outcomes following application of high‐frequency stimulation in this cohort of patients.

Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review

Objective To determine the risks of continuing or ceasing anticoagulant or antiplatelet medications prior to image-guided procedures for spine pain. Design Systematic review of the literature with comprehensive analysis of the published data. Interventions Following a search of the literature for studies pertaining to spine pain interventions in patients on anticoagulant medication, seven reviewers appraised the studies identified and assessed the quality of evidence presented. Outcome Measures Evidence was sought regarding risks associated with either continuing or ceasing anticoagulant and antiplatelet medication in patients having image-guided interventional spine procedures. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system. Results From a source of 120 potentially relevant articles, 14 provided applicable evidence. Procedures involving interlaminar access carry a nonzero risk of hemorrhagic complications, regardless of whether anticoagulants are ceased or continued. For other procedures, hemorrhagic complications have not been reported, and case series indicate that they are safe when performed in patients who continue anticoagulants. Three articles reported the adverse effects of ceasing anticoagulants, with serious consequences, including death. Conclusions Other than for interlaminar procedures, the evidence does not support the view that anticoagulant and antiplatelet medication must be ceased before image-guided spine pain procedures. Meanwhile, the evidence shows that ceasing anticoagulants carries a risk of serious consequences, including death. Guidelines on the use of anticoagulants should reflect these opposing bodies of evidence.