1. 2022;25;E349-E356Predicting Epidural Space Spread Using Ultrasound Color Doppler Imaging in Interlaminar Epidural Steroid Injection: A Prospective Observational Study
   Observational Study
   Yeon Ju Kim, MD, Hyungtae Kim, MD, PhD, Ha-Jung Kim, MD, PhD, Won Uk Koh, MD, PhD, Jiyoung Kim, MD, and Young-Jin Ro, MD, PhD.

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.

KEY WORDS: Injections, epidural, intervertebral disc displacement, spinal stenosis, ultrasonography, Doppler