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Assessing the Agreement Between Radiologic and Clinical Measurements of Lumbar and Cervical Epidural Depths in Patients Undergoing Prone Interlaminar Epidural Steroid Injection
背景与目的
临床上，通常采用荧光镜引导硬膜外类固醇注射（ESI）治疗根性疼痛，但如果未精确定位，则可能导致不良事件的发生。术前准确的评估从皮肤到硬膜外腔的距离则能够降低ESI不良反应的发生风险。我们假设术前磁共振成像（MRI）测量的皮肤到硬膜外腔的距离与后正中入路行ESI时穿刺针到达硬膜外腔的距离一致。本研究探讨了颈椎或腰椎行ESI过程中穿刺阻力消失（LOR）时达到的最终穿刺深度与术前颈椎和腰椎MRI测量的从硬膜外腔前后边界到皮肤的距离之间的关系。
方 法
回顾性分析了2013年6月1日至2015年6月1日间门诊慢性疼痛接受俯卧位ESI治疗患者的手术记录单，MRI结果及人口统计学资料。收集了以下数据：体重指数（BMI），年龄，性别，ESI的椎间水平和LOR深度。然后，我们测量了MRI上皮肤表面到黄韧带（黄韧带深度[LFD]）和硬脊膜（硬膜深度[DD]）前边缘的距离。共纳入335名患者，分别分为以下亚组：年龄≥65岁，年龄<65岁；BMI≥30kg / m2（肥胖），BMI <30 kg / m2（非肥胖）；男性和女性。然后进行二次分析，以比较LOR深度和DD之间的一致性以及每个患者亚组中LOR深度和LFD之间的一致性。使用内部相关系数（ICC）和Bland-Altman图来评估DD或LFD与LOR深度之间的一致性。
结 果
分析了335例ESI的数据，其中包括147例颈椎和188例腰椎ESI患者。 所有腰椎和颈椎穿刺病例中，LOR深度和LFD之间的一致性评估数值ICC值分别为0.88（95％[CI]，0.85-0.91）和0.72（95％[CI]，0.64-0.79），LOR深度和DD之间一致性的评估数值ICC值分别为0.86（95％[CI]，0.82-0.89）和0.69（95％[CI]，0.60-0.77）。
结 论
本研究评估了MRI测量硬膜外深度与临床测量结果之间的一致性。术前MRI测量的 从皮肤到黄韧带的前边缘的距离代表硬膜外腔后侧的厚度，与从皮肤到硬脊膜或硬膜外腔最前部的距离相比，前者与LOR达到深度的一致性更强。这些结果需要进一步的分析和细化才能支持临床应用。
原始文献摘要
Jones, J.H., et al., Assessing the Agreement Between Radiologic and Clinical Measurements of Lumbar and Cervical Epidural Depths in Patients Undergoing Prone Interlaminar Epidural Steroid Injection. Anesth Analg, 2017. 124(5): 1678-1685.
BACKGROUND: Fluoroscopy-guided epidural steroid injection (ESI) commonly is performed to treat radicular pain yet can lead to adverse events if the needle is not advanced with precision. Accurate preoperative assessment of the distance from the skin to the epidural space holds the potential for reducing the risks of adverse effects from ESI. It was hypothesized that the distance from the skin to the epidural space as measured on preoperative magnetic resonance imaging (MRI) would agree with the distance traveled by a Tuohy needle to reach the epidural space during midline, interlaminar ESI. This study compared the final needle depth measurement at the point of loss of resistance (LOR) from cervical or lumbar ESI to the distance from the skin to the anterior and posterior borders of the epidural space on the associated cervical and lumbar preoperative MRI.
METHODS:This retrospective chart review analyzed the procedure notes, MRI, and demographic data of patients who received a prone, interlaminar ESI at an outpatient chronic pain clinic between June 1, 2013, and June 1, 2015. The following data were collected: body mass index (BMI), age, sex, intervertebral level of the ESI, and LOR depth. We then measured the distance from the skin surface to the anterior border of the ligamentum flavum(ligamentum flavum depth [LFD]) and dura (dura depth [DD]) on MRI. A total of 335 patients were categorized into the following patient subgroups: age ≥65 years, age <65 years, BMI ≥30 kg/m2 (obese), BMI <30 kg/m2 (nonobese), male, and female. Secondary analyses were then performed to compare the agreement between LOR depth and DD with that between LOR depth and LFD within each patient subgroup. Intraclass correlation coefficient (ICC) and Bland-Altman plot were used to assess the agreement between DD or LFD and LOR depth.
RESULTS:Data from 335 ESIs were analyzed, including 147 cervical ESIs and 188 lumbar ESIs. Estimated ICC values for the agreement between LOR depth and LFD for all lumbar and cervical measurements were 0.88 (95% confidence interval [CI], 0.85–0.91) and 0.72 (95% CI, 0.64–0.79), respectively. Estimated ICC values for the agreement between LOR depth and DD for all lumbar and cervical measurements were 0.86 (95% CI, 0.82–0.89) and 0.69 (95% CI, 0.60-0.77), respectively.
CONCLUSIONS：This study assessed the agreement between MRI-derived measurements of epidural depth and those determined clinically. MRI-derived measurements from the skin to the anterior border of the ligamentum flavum, which represents the most posterior aspect of the epidural space, revealed stronger agreement with LOR depths than did measurements to the dura or the most anterior aspect of the epidural space. These results require further analysis and refinement before supporting clinical application.
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