Fluoroscopic Guided Thoracic/Lumbar Interlaminar Epidural Steroid Injection – Technique and Overview

Name of Procedure

• LESI or TESI – Lumbar or thoracic interlaminar epidural steroid injection

Sample Opnote

Goal

To access and then administer steroid to the lumbar epidural space.

Indications

Usually to treat degenerative disc disease or central or neural foraminal stenosis that is causing radicular symptoms into the torso or legs.

Contraindications

• Common contraindications

Anatomy

Equipment/Skills

See our disposables/equipment article for “core” supplies that are common to all procedures. Highlights below:

• Core Equipment
  • c-arm, c-arm compatible bed
• Core Disposables
  • Procedure tray. As outlined in the above link, core supplies include a pointer, syringes for subcutaneous local, syringe for injectate, drape.

• Core Skills
  • Obtain basic fluoro views of the spine
  • Steer a needle to direct it under the skin

Special items and suggested setup for this procedure (see quick guide video above for example tray prep):

1. 20g x 3.5″ Tuohy epidural needle
2. 3-5cc normal saline or air in a LOR syringe
3. steroid + 5-10cc of normal saline in a 10cc syringe as your injectate
4. 2-3cc contrast in a 3cc syringe
5. 3-5cc 1% lidocaine in a 5cc syringe with a 25g x 1.5″ hypodermic needle for subcutaneous local anesthesia.

Landmarks and Patient Positioning

Position the patient in a basic prone position so that the bottom of the c-arm can go under the table below the area of the spine that is being treated.

Technique

1. Targets vary based on clinic choice, but you can tilt the C-arm towards or away from the head to open up the target interspace as needed.
2. From here, choose an entry point on the skin, which can vary:
   1. Sometimes starting below the target interspace gives you a more “flat” trajectory which is typical of epidurals.
   2. But, since you have a C-arm as guidance if you have a large target interspace, you could start just above it and go “down the barrel” to get straight into the epidural space.
   3. Sometimes starting over the lamina just below the interspace is helpful since you can contact bone to get a gauge of depth without having to check a lateral view. Then you can walk up superiorly towards the interspace.
   4. Likewise if you are trying to “lateralize” the medication spread you can start on one side and enter the epidural space to one side. Likewise, entering paramedian to the spinous processes allows you to have less bony structures in the path of the needle.
3. Once you choose an entry point, you can localize the skin and advance the need to anesthetize the subcutaneous tissue.
   1. Usually spreading the local over a cone shaped area will allow you to anesthetize enough area for comfort but not require you to check the exact track that’s been anesthetized.
4. Remove the hypodermic needle but keep track of the entry point and the trajectory that you noted above.
5. Insert the tuohy needle (with stylet in) along the same track.
   1. You’ll enter as far as you know is safe
      1. As noted above, you can target lamina first and use an AP view to verify safety.
      2. Or you can aim straight for the epidural space and use a lateral view if you want to check depth
   1. Re-orient the needle as needed to advance to the target interspace.

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6. After getting close to the epidural space you’ll remove your stylet and advance using a continuous loss of resistance (LOR) technique.
   1. Use other cues to check your progress to stay within safe limits:
      1. If you find your advancing more than you expected based on the last image, check another image or a lateral.
      2. Check your medial-lateral orientation by physically looking at the patient and needle.
7. Once you have LOR, remove the LOR syringe, and hook up the contrast syringe
   1. Injection contrast. Live injection can help you see nice rule out vascular uptake.

8. You can also check a lateral to verify spread and position.

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9. Now simply inject the saline and steroid medication.
10. Remove the needle smoothly

Tips

1. A combination of experience, patient size and trajectory help you to determine depth. With the approaches mentioned above you usually don’t need a lateral to determine depth.
2. Tuohy needle gauge
   1. A 20g is listed in this guide but it has a much more subtle loss of resistance than an 18g, but has a lower risk of post dural puncture headache if a wet tap occurs, and might be more comfortable for patients.