Disclosures: Christopher Yih, DO: No financial relationships or conflicts of interest

Case Diagnosis: Moderate right L4/L5 neural foramen stenosis in a patient with C5 central cord syndrome

Case Description or Program Description: A 61-year-old man with a history of C5 AIS D central cord syndrome sustained after a MVA in 2018 presented with L4 dermatome tactile allodynia. His presentation was notable for burning pain in the setting of total body paresthesias, spasticity, and incomplete tetraplegia. The patient failed conservative treatment and was scheduled for a right L4/L5 transforaminal epidural steroid injection for moderate right L4/L5 neural foramen stenosis. The patient’s incomplete tetraplegia made transferring and positioning him on the fluoroscopy table challenging. Furthermore, due to flexion spasticity in his upper extremities, deficits in truncal stability, and decreased sensation to noxious stimuli, he was not suitable for prone positioning. Instead, he was positioned in the left lateral decubitus position while staff braced him for truncal support. The procedure was otherwise uncomplicated, and he reported over 90% pain relief at the two week follow-up.

Setting: Outpatient clinic

Assessment/Results: Right L4/L5 transforaminal epidural steroid injection for moderate right L4/L5 neural foramen stenosis with good relief.

Discussion (relevance): Typically, pronation optimizes anatomic positioning, patient stability, and fluoroscopic maneuverability in epidural injections. However, previous studies have shown that the lateral decubitus position reduces spinal deformities prior to instrumentation, increases pain relief after administering caudal epidural injections, and minimizes interference from spasticity and deficits in volitional muscle control. The lateral decubitus position allows the ipsilateral erector spinae musculature and quadratus lumborum to relax, while activating the contralateral aforementioned musculature. This creates a subtle shift and rotation of the patient’s spine, allowing the physician to access their target with more stability and ease.

Conclusions: Lateral decubitus positioning for epidural injections should be considered in patients with decreased sensory and motor function, spasticity, and truncal instability. Although further studies are needed to compare prone and lateral decubitus positioning for specific epidural procedures, available data and this case suggest that the lateral decubitus position has good utility.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2022

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/lateral-decubitus-positioning-for-fluoroscopic-epidural-steroid-injections-of-incomplete-tetraplegic-and-similar-patient-groups/