◊ BACKGROUND:
The purpose of this study was to evaluate epidurography contrast patterns in fluoroscopically guided cervical interlaminar epidural injections using the midline approach.

◊ METHODS:
All epidural injections were performed at the C6-7 level in the prone position. Epidurography was performed using a fixed amount of iotrolan 240 mg I/mL (1, 2, 3 mL).

◊ RESULTS:
The rate of ventral epidural spread was 56.7% in Group A (1 mL), 90% in Group B (2 mL), and 93.3% in Group C (3 mL).

◊ CONCLUSION:
Two milliliters of contrast solution can provide optimal dispersion of contrast in a ventral and longitudinal spread.

◊Reviewed by P. Rosenberg, MD, PhD,
Department of Anaesthesiology and Intensive Care Medicine
Professor of Anaesthesiology
Meilahti Hospital, Helsinki University Hospital
Finland

It is difficult to understand why this study has been accepted for publication. The hypothesis is very vague, and the study is just mentioned to have evaluated the epidural spread of contrast medium. These are further weaknesses:

1. Why would it be important to know the extent of the epidural spread of one, two or three milliliters of contrast medium injected at the C6-7 interspace, if there is no information about whether the contrast medium reached the diseased site?

2. The report is lacking any information about whether the subsequent injection (after the contrast medium) of local anesthetic and steroid had a therapeutic effect.

3. Why were patients with prior cervical surgery excluded? From a practical point of view these patients would probably be of great interest to the clinician, since another surgical operation would not be the primary option.

4. Why were patients without MRI finding excluded? Was it because a cervical epidural steroid injection in these patients was not considered indicated?

5. In the Methods section, it is mentioned that when there was no loss-of-resistance to air in the Tuohy needle, contrast medium was injected to detect the epidural space. What volume was actually injected into the epidural space? Did the amount confound the subsequent assessment of the study injection?

6. No problems or complications seemed to occur. Such an excellent record is not
very common.

7. The authors do not consider published experience from cervical epidural local anesthetic injections and the need for very small amounts (and volumes) for analgesia in the cervical and upper thoracic dermatomes.

Conclusion
This study has only little or no clinical relevance, mainly because no disease-related or therapeutic information is given.