Background: During lumbar epidural injection (LEI) using a midline approach, we might encounter
failure of identifying the epidural space owing to an equivocal or absent loss of resistance (LOR)
sensation. The reason for such absence of LOR sensation has been suggested as paucity of midline
ligamentum flavum, paravertebral muscle, and cyst in the interspinous ligament of the lumbar
spine. Despite its low specificity, LOR is the most commonly used method to identify the epidural
space.
Objectives: The purpose of this study was to analyze lumbar epidural pressure decrease patterns
and identify factors contributing to this pressure decrease.
Study Design: Prospective randomized trial.
Setting: An interventional pain management practice in South Korea.
Methods: This prospective study included 104 patients receiving LEI due to lumbar radiculopathy.
A midline or paramedian approach of LEI was determined with randomization. Among various
factors, gender, age, body mass index (BMI), and diagnosis were analyzed using a subgroup that
included 60 cases of only a paramedian approach.
Results: Grades I, II (abrupt decrease), and III (gradual decrease) were found as patterns of epidural
pressure decrease. Abrupt pressure decrease was more frequently observed in the paramedian
group (P < 0.001). Age, gender, BMI, and diagnosis did not show any significant difference in
frequencies between abrupt and gradual pressure decrease.
Limitations: We could not match LOR sensation with epidural pressure decrease shown in the
monitor.
Conclusions: This study demonstrates that abrupt pressure decrease occurs more frequently with
the paramedian approach. However, age, gender, BMI, or diagnosis did not affect the incidence of
epidural pressure decrease.
Key words: Epidural, paramedian, midline, pressure decrease