Cervical and Lumbar Epidural Injections


Executive Summary

  • General indications for ESI include herniated disk disease with or without radicular pain, spinal stenosis, axial low back pain, and post–lumbar surgery syndrome.
  • With an interlaminar ESI, a single line and a well-defined or smudged convexity along the spinolaminar line on the lateral view suggest that the needle tip is positioned correctly in the epidural space. On the AP view, contrast agent dispersion with drug injection may outline exiting spinal nerves.
  • With a transforaminal ESI, if the needle tip is in the true epidural space, a test dose of contrast agent will flow upward (occasionally downward) along the medial margin of the pedicles and along the exiting nerve.
  • With an intradural injection, contrast material rapidly disperses and accumulates at the ventral portion of the spinal canal, forming a cerebrospinal fluid–contrast agent level (dorsal cerebrospinal fluid and ventral contrast material) because of the patient’s prone position. The AP view demonstrates a symmetric distribution of contrast material, similar to that seen at myelography.
  • At imaging, intraepineural injection manifests as two thin lines resembling a so-called tram track, with a subtle feathery appearance inside the nerve root and sharp outlines.
  • Source

Very Useful tabular Data


Imaging Neurologic Conditions in Pregnant Patients

Executive Summary:

  • Neurological symptoms may be exacerbations of existing problems (MS, seizure); initial manifestation of neurological disorder (tumor, stroke) or issue unique to pregnancy (eclampsia, postpartum cerebral angiopathy, Sheehan syndrome and lymphocytic adenohypophysitis.
  • ACR Guidance on safe MRI practices states pregnant patients should undergo MRI only if the information cannot be obtained any other way.
  • Autoimmune hypophysitis is a rare chronic inflammatory disorder of the pituitary stalk and gland.  It is classified by involved portions of the gland.
  • Spontaneous or postinstrumentation intracranial hypotension.
  • Source Paper

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Corticosteroid Choice In Epidural Injection

Executive Summary

  • Major decision branch point is particulate (DepoMedrol, Kenalog, Celestone) versus non-particulate (Decadron).
  • Serious complications have been documented with particulate steroids AND nonparticulate steroids.
  • Studies have not demonstrated the superiority of particulate or non-particulate steroid in terms of efficacy (specifically in Cervical TFESI).
  • Lumbar TFESI studies lacked statistical significance between groups using particulate and non-particulate steroids.
  • Digital subtraction should be used in transforaminal injections if available to maximize identification of aberrant or variant arterial anatomy.
  • Source Paper

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A Guide to Diagnosing Peripheral Arterial Disease

Executive Summary

  • In PAD, the level of the lesion is grouped into three categories: aortoiliac, femoropopliteal, and tibiopedal/crural.
  • An ABI less than 0.90 is diagnostic for PAD in patients with claudication or other signs of ischemia, with 95% sensitivity and 100% specificity.
  • A proximal-to-distal decrease in sequential pressures greater than 20 mm Hg or a decrease in segmental-brachial index greater than 0.15 indicates occlusive disease and correlates with the level of the lesion.
  • A normal lower extremity arterial Doppler velocity tracing is triphasic, with a sharp upstroke and peaked systolic component, an early diastolic component with reversal of flow, and a late diastolic component with forward flow. A biphasic signal is considered abnormal if there is a clear transition from triphasic signal along the vascular tree. Monophasic waveforms are always considered abnormal.
  • Abnormal PVR findings include decreased amplitude, a flat peak, and an absent dicrotic notch.
  • In symptomatic patients with normal or borderline ABI at rest, an exercise ABI should be performed. The sensitivity for the detection of PAD may be increased with postexercise measurements.
  • Source Paper
  • Handy Reference (Angiologist)

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Lumbar Disc Nomenclature 2.0


A number of highly relevant changes in reporting nomenclature.  Some things have not changed, such as the term herniation which is a general category of disc disruption and really should only be used in the vaguest possible sense, such as in the impression “Multiple disc herniations detailed at each level above”.

More importantly, the clarification of locations of protrusions, extrusions, and sequestrations (image on the right). Adoption of standard nomenclature puts the radiologist and surgeon on the same page and eliminates the ambiguity inherent in non-standard reporting.

Adoption of standard nomenclature puts the radiologist and surgeon on the same page and eliminates the ambiguity inherent in non-standard reporting.

Other minor changes such as the replacement of the term “annular tear” with “annular fissure” attempt to remove etiology from the report and focus on accurate description.

On a related note, I am eager to see the results of the LIRE trial which has the potential to help clinicians understand the frequency of abnormal MRI findings.

Google Drive Link to Full Article

MDCT of Pelvic Ring Disruptions


Good review of signs of rotational instability in pelvic fractures and Tile Classification

Tile Classification:


Tile classification 


  • A: stable
    • A1: fracture not involving the ring (avulsion or iliac wing fracture)
    • A2: stable or minimally displaced fracture of the ring
    • A3: transverse sacral fracture (Denis zone III sacral fracture)
  • B – rotationally unstable, vertically stable
    • B1: open book injury (external rotation)
    • B2: lateral compression injury (internal rotation)
      • B2-1: with anterior ring rotation/displacement through ipsilateral rami
      • B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
    • B3: bilateral
  • C – rotationally and vertically unstable
    • C1: unilateral
      • C1-1: iliac fracture
      • C1-2: sacroiliac fracture-dislocation
      • C1-3: sacral fracture
    • C2: bilateral with one side type B and one side type C
    • C3: bilateral with both sides type C