Diversifying the Approach to Fluoroscopic Guided Thoracic Epidural Steroid Injections in Patients with Complex Surgical Factors

Veronica Takougang, MD, MS, Melanie Russell, MD, Lady Christine Ong Sio, MD, Laura DeVita, MD

Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH

 

Introduction: 

Thoracic epidural steroid injections

(TESIs) are utilized for the treatment of

disc herniation, post-surgical spine

syndrome, spinal stenosis and post-

thoracotomy pain syndrome. The

standard procedural approach for a

TESI is in the prone position.

Successful epidural steroid injections

(ESIs) are a cost-effective option for

patients to achieve pain relief, restore

function, and return to physical therapy

when indicated. Complex surgical

factors can be a contraindication to

TESI placement due to limitations in

patient positioning.

 

Objectives:

• Identify appropriate indications for TESI

placement based on a patient’s medical

and surgical history and severity of

symptoms.

• Discuss how complex surgical factors

can lead to limitations in patient

positioning for steroid injections.

• Emphasize the importance of

diversifying one’s approach to the

current standard of care of ESIs to

ensure appropriate patient access.

Case Description:

4-year-old male with a past medical history significant for coronary artery disease status-post

CABG, degenerative disc disease and radiculopathy who presented for a T6-T7 ESI. Patient’s

surgical course was complicated by a nonunion closed sternal plating along the fifth, sixth, and

seventh ribs. Conventional TESI administration in the prone position was precluded due to the

patient’s mobile chest plate and inability to lie flat. We broadened our approach to traditional

positioning and utilized fluoroscopic guidance to perform the TESI in the seated position with

constant communication between our X-ray technician and the pain physician. Once in the

seated position, the lateral foraminal space between T6-7 was identified under fluoroscopic

guidance and local anesthesia was administered. By manipulating the C-Arm around the

patient, we were able to achieve precise needle placement and medication delivery. The

epidural space was accessed using the loss of resistance technique, and 1mL of contrast was

administered in the epidural space with excellent spread from T5-8 space bilaterally. The steroid

was administered with no complications and the patient was discharged home in good condition.

 

Discussion:

ESIs remain an effective option to

managing chronic radicular pain of various

etiologies and often bypass the need for

operative management. To date, there is a

paucity of literature exploring fluoroscopic-

guided ESI placement in the seated

position. There is strong evidence showing

the loss of resistance technique when

performed blindly may not be sufficient for

ensuring needle placement. The use of

epidurography improves the accuracy of

both needle placement and medication

delivery. Our case serves as an example

of how expanding upon the current

standard of care for ESI can continue to

ensure appropriate patient access to these

interventions despite limitations as it

relates to patient positioning.

 

References:

Helm Ii S, Harmon PC, Noe C, Calodney AK, Abd-Elsayed A, Knezevic NN, Racz GB.

Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy

and Safety. Pain Physician. 2021 Jan;24(S1):S209-S232. PMID: 33492919.

 

Kaye AD, Manchikanti L, Abdi S, Atluri S, Bakshi S, Benyamin R, Boswell MV, Buenaventura R,

Candido KD, Cordner HJ, Datta S, Doulatram G, Gharibo CG, Grami V, Gupta S, Jha S, Kaplan

ED, Malla Y, Mann DP, Nampiaparampil DE, Racz G, Raj P, Rana MV, Sharma ML, Singh V,

Soin A, Staats PS, Vallejo R, Wargo BW, Hirsch JA. Efficacy of Epidural Injections in Managing

Chronic Spinal Pain: A Best Evidence Synthesis. Pain Physician. 2015 Nov;18(6):E939-1004.

PMID: 26606031.

Benyamin RM, Wang VC, Vallejo R, Singh V, Helm Ii S. A systematic evaluation of thoracic

interlaminar epidural injections. Pain Physician. 2012 Jul-Aug;15(4):E497-514. PMID:

22828696.

 

Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in

cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine (Phila Pa

1976). 2002 Mar 1;27(5):509-14. doi: 10.1097/00007632-200203010-00011. PMID: 11880836.