Introduction

Epidural lysis of adhesions is a procedure used to treat axial and radicular spine pain. This chapter describes the cervical technique and steps to avoid complications.

Anatomy

The spinal epidural space lies within the spinal canal from the foramen magnum to the sacral hiatus. The posterior epidural space is bounded by the ligament flavum posteriorly and the dura mater anteriorly. The epidural space contains veins and fat as well as segmental arteries. The epidural space extends laterally into the neural foramina. The epidural space may be compartmentalized by attachment of the dura mater to the ligamentum flavum lamina or other structures. A negative pressure is produced in the epidural space by the pressure gradient associated with inspiration. Most of the arteries lie in the more anterior part of the foramen.

The ligamentum flavum in the cervical epidural space is inconsistent so the loss of resistance technique is less reliable compared to the lumbar levels especially superior to the 6th cervical level [1].

A large epidural venous plexus is present at the cervico-thoracic junction, but cervical epidural procedures are performed at this level to avoid risk of dural puncture at mid-cervical spinal cord level. Cervical neural foramina increase in size with cervical flexion and decrease with extension.

The posterior longitudinal ligament is highly innervated and is a source of spine pain [2]. The procedures for cervical lysis of adhesions have been described in detail elsewhere and much of the text and images are reproduced herein [3].

Indications

• Chronic neck pain of 3–6 months duration and failed conservative treatment options
  
• Neck pain with or without radiculopathy
  
• Radiating upper extremity pain with provocative Lasegue’s test
  
• Failed neck surgery syndrome
  
• Radiographic evidence of pathology such as spondylosis
  
• Spinal stenosis
  
• Osteophyte and radiculopathy
  
• Lateral recess stenosis and radiculopathy
  
• Disc herniation and radiculopathy
  
• Spondylosis and radiculopathy, (MRI, CT)
  
• Radiculopathy due to epidural fibrosis (on enhanced MRI)
  
• Discogenic neck pain and neck spasm
  
• Faded stimulation from neuromodulator (SCS, spinal narcotics)
  
• 18 years of age or older (no specific contraindication by age).

Contraindications

• Spinal instability
  
• Spinal cord syrinx
  
• Local infection, unresolved spinal infection
  
• Chronic infection
  
• History of gastrointestinal (GI) bleeding or ulcers
  
• Substance use disorder and/or uncontrolled major depression or psychiatric disorders
  
• Arachnoiditis
  
• Arterio-venous malformation
  
• History of adverse reaction to local anesthetic, steroids, contrast or other injected medications

• Uncontrolled or acute medical illnesses
  
• The use of anti-platelet medications or anticoagulants (laboratory measurements for bleeding and clotting to be in the normal range following discontinuation for appropriate duration)
  
• Pregnant or lactating women.

Technique

The goal of the procedure is to inject therapeutic medications at the site of pathology. The site of pathology is determined by history, physical exam, and imaging studies, including epidurography. Epidurography is performed by injecting myelogram-grade radiopaque contrast into the epidural space to demonstrate areas of epidural adhesions that do not fill with contrast normally. A specialized catheter is used to penetrate the adhesion area of the epidural space so that injections will open the space and allow delivery of therapeutic medications. Following catheter placement into the scar area, additional contrast is used to open the epidural space and neural foramina. Following this, local anesthetic is injected to provide analgesia and to test for subdural blockade. Hyaluronidase is usually injected to facilitate spreading of injected medications. Hypertonic saline is injected to reduce swelling and provide long-term analgesia.

Cervical Interlaminar Epidural RX-2™ Coudé® Needle and Catheter Placement

The patient is placed in the prone position, with a pillow under the their chest, no head rest and arms at the side with the shoulders relaxed anteriorly, the C-arm is rotated into the cephalad direction compensating for the patient’s spinal kyphosis helping to optimize and enlarge the C7–T1 interlaminar target site.

The C7–T1 interspace is used to avoid superior cervical levels where the ligamentum flavum is incomplete and also to avoid large venous plexuses at T1–T2.

The Bromage grip should be used for needle advancement. This grip includes bracing the knuckles of the non-dominant hand against the patient’s back or neck. The needle is advanced with the fingers so that, if the patient moves toward the needle, the hand and the needle also move so that the needle does not penetrate deeper. The direction-depth-direction (3-D) technique is used to avoid subdural needle placement. AP and lateral fluoroscopic images are used in an alternating fashion to advance the needle. Following local anesthetic injection, the RX-2 Coudé needle is introduced with the tip facing antero-medially. Using a paramedian approach allows smooth passage of the RX Coudé needle to the midpoint of the interlaminar space. The point of entry is slightly medial to the pedicle at the level below the chosen interspace. Orient the needle tip medially while crossing the interspace. Curving the needle medially crossing the interspace, rotate the needle tip down inferiorly and bony contact is made with the lamina aiming toward the midpoint. When the tip of the needle crosses the proximal end of the T1 lamina, the C-arm is rotated to the lateral view. The spinolaminar line can be seen on lateral fluoroscopic imaging. The ligamentum flavum is in direct extension between the straight lines. Rotate the needle anteriorly and advance to the ligamentum flavum. The needle is rotated so that the tip is now parallel with the ligamentum flavum. The needle is advanced to be in line with the “straight line”. The straight line is the enhanced bony outline of the bony cortex of the inside and the outsides of the bifurcating lamina. The ligamentum flavum should be penetrated in the midline. The stylet should be removed and a (LOR) syringe is attached to the hub of the needle. The needle is advanced with the “loss of resistance” technique until a loss of resistance is felt which indicates entry into the epidural space. With this technique, the plane of the needle bevel tip is parallel to the plane of the dura, reducing the chance of penetration. Small volumes of contrast injection can confirm epidural placement on lateral and AP view. The RX-2 Coudé needle features an additional threaded interlocking blunt stylet that protrudes a short distance beyond the RX needle tip. At this point, the second stylet is placed (Figure 22.1).

This allows the rotation of the curved needle toward the direction of the area where the catheter needs to be directed. The blunt tip safely pushes the dura away. In this configuration, redirection (or rotation) of the needle tip is possible. Any needle directional rotation may cut the dura and lead to CSF leak and spinal headache. After the RX-2 Coudé needle has been rotated in the direction of the target, remove the extended blunt stylet. It is important to make a one-half inch 15° bend in the catheter for optimum steering ability. Insert the catheter into the RX2 needle that will safely place the catheter parallel to the dura. Following the RX2 Coudé entry into the epidural space, the soft-tipped catheter is placed for a short 1/4”–1/3-inch distance beyond the tip of the needle to push the dura away. This allows the rotation of the needle toward the intended target. When the RX-2 Coudé needle is rotated in the direction of the target, the catheter is placed parallel to the dura. The RX-2 Coudé Needle should always point in the direction of the target. The incorrect needle orientation is shown in Figure 22.2.

After rotation, the catheter becomes easier to direct and parallel to the plane of the dura. The C-Arm is rotated to the anterior–posterior position. The catheter tip is placed toward the target. Bacterial filters are recommended in all instances when more than one-time injection is used or the catheter is left in place for a prolonged period. Any time there is a disconnection of the catheter and the connector, the system should be removed from the patient to prevent infection.

Catheter Tape-down Technique

• Place suture and tie loose loop
  
• Wrap around catheter two times and tie surgical knot
  
• Apply antibiotic ointment around skin entry and place two-split 2 × 2-in gauze to keep antibiotic in place
  
• Apply adhesive i.e., tincture of benzoin around gauze
  
• Place one loop on catheter and transparent dressing i.e., opsite
  
• Connect bacterial filter and four pieces of sweat-resistant hypofix tape (Figure 22.3).

Equipment Options

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Complications of Opiate Therapy Complications of Obturator Nerve Block Complications of Cervical Discography Complications of Intradiscal Therapeutic Procedures Complications of Percutaneous Cordotomy Complications of Stellate Ganglion Block (SGB)