Distance to the Adult Cervical Epidural Space

Kyung-Ream Han, M.D., Chan Kim, M.D., Soo-Kyung Park, M.D., and Jin-Soo Kim, M.D.
Background and Objectives: Cervical epidural block is useful in the management of a variety of acute, chronic, and cancer-related pain syndromes involving the head, face, neck, and upper extremities. Knowledge of the depth from the skin to the cervical epidural space (DSES) may be helpful when performing cervical epidural block and may reduce the possibility of complications. We studied DSES in adults and its relationship with patient age, height, weight, and neck circumference. Methods: The study included 816 patients. Cervical epidural block was performed at the C5-6, C6-7, and C7-T1 intervertebral space by a midline approach under uoroscopic guidance. The depth to the epidural space from the skin was measured. Results: DSES at C5-6, C6-7, and C7-T1 was 4.7 0.6 cm, 5.1 0.6 cm, 5.6 0.8 cm in males and 4.0 0.6 cm, 4.6 0.6 cm, 5.0 0.6 cm in females (mean SD). Linear regression analysis revealed signicant correlations between DSES and weight, neck circumference, and body mass index. Conclusion: DSES varies with cervical intervertebral space. DSES increases as one moves caudally. The greatest DSES was noted at C7-T1 in men, and the least was at C5-6 in women. DSES had a signicant relationship with weight, neck circumference, and body mass index in both genders. Reg Anesth Pain Med 2003;28:95-97. Key Words: Analgesia, Epidural, Cervical, Depth.

ervical epidural block, while somewhat limited as an anesthetic technique, is widely used in the management of a variety of acute, chronic, and cancer-related pain syndromes involving the face, head, and upper extremities in a pain clinic.1,2 Knowledge of the depth from the skin to the epidural space (DSES) may be helpful when performing cervical epidural block and reduce the possibility of unintentional dural puncture. In an effort to provide clinically useful information for cervical epidural block procedures, we studied the DSES in 816 patients and analyzed whether there was any relationship to patient age, weight, height, neck circumference, or body mass index.

Methods
This study included 816 patients (395 males and 421 females) who received cervical epidural injection at our clinic between March 2001 and October 2001. The protocol was approved by our Clinical

From the Pain Clinic, Department of Anesthesiology, Ajou University Hospital, Suwon, Korea. Accepted for publication December 4, 2002. Reprint requests: Kyung-Ream Han, M.D., San 5 Paldal-Gu Woncheon-Dong, Suwon, Korea. E-mail: painhan@hanmir.com 2003 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/03/2802-0004$30.00/0 doi:10.1053/rapm.2003.50025

Research Committee, and written informed consent was obtained from all participants. Blocks were performed with the patient sitting on a chair, bent forward, and resting the forehead on a bed. Thus, the cervical spine was parallel to the oor, with the upper extremities hanging at the side. We marked the needle insertion point and then conrmed the c-spine level with uoroscopy. If a catheter was inserted, we visualized the level with injection of contrast medium under uoroscopic guidance after the block. Epidural block was performed at the C5-6, C6-7, and C7-T1 intervertebral spaces. A 20-gauge Touhy needle was inserted horizontally in the midline for single-shot epidural block; and an 18-gauge Touhy needle was used in patients receiving continuous techniques. The epidural space was identied by the loss of resistance technique using normal saline and conrmed by the spontaneous inow of a drop of saline placed in the needle hub. Once the epidural space was identied, the point of the needle at the skin was marked with a pen. Distance was measured in 0.1-cm intervals after the needle was removed. The circumference of the neck was measured at the level of cricoid cartilage. Height and weight were recorded. Age, weight, height, circumference of neck, and body mass index for each level of insertion were analyzed using analysis of variance (ANOVA). The analysis of correlation between

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Regional Anesthesia and Pain Medicine Vol. 28 No. 2 MarchApril 2003 Table 1. Indications for Cervical Epidural Block
Disease HNP and/or spinal stenosis Frozen shoulder Myofascial pain syndrome Postherpetic neuralgia CRPS Headache Atypical facial pain Cancer pain of head and neck No. of Patients (%) 392 (48.0) 182 (22.3) 76 (9.3) 44 (5.4) 34 (4.2) 30 (3.7) 7 (0.9) 51 (6.2)

Abbreviations: HNP, herniated nucleus pulposus; CRPS, complex regional pain syndrome.

age, weight, height, neck circumference, and body mass index for each level was performed using linear regression analysis. Results were expressed as mean SD. Statistical signicance was dened as P .01.

Fig 1. Distribution of the distance from skin to epidural space in male patients.

Results
A total of 556 patients (277 males and 279 females) received single-shot epidural block, and 260 patients (118 males and 142 females) received continuous infusion of drug. The indications for cervical epidural block are summarized in Table 1. There were no signicant gender differences in age, weight, height, neck circumference, or body mass index between the groups (Table 2). The DSES at the C5-6, C6-7, and C7-T1 intervertebral spaces were 4.7 0.6 cm, 5.1 0.6 cm, and 5.6 0.8 cm in men (Fig 1); and 4.0 0.6 cm, 4.6 0.6 cm, and 5.0 0.6 cm in women (Fig 2). The maximum and minimum cervical epidural depth was 2.9 cm at C5-6 in a female and 7.2 cm at C7-T1 in a male patient (Figs 1 and 2). There was no signicant correlation between the DSES and age or height. There was a signicant correlation between the DSES and weight, neck circumference, and body mass index (P .01) (Table 3).

Discussion
Epidural block at the cervical, thoracic, and lumbar levels is a valuable procedure for the management of acute and chronic pain. However, the risk

of performing cervical epidural block is higher than that of lumbar epidural block. The risk of spinal cord injury is probably the most serious complication when performing cervical epidural blocks. Only physicians who are very experienced are recommended to perform cervical epidural block. Some anatomical features need to be considered when performing cervical epidural block. First, when the neck is exed, the most prominent spinous process is C7.3 Since C6 or T1 can also be prominent in thin patients,4 the distinction from C7 can be difcult. We conrmed the level of needle insertion with palpation and uoroscopic guidance. Second, because the ligmentum avum is relatively thin at the cervical region as compared with the thoracic and lumbar regions,5 loss-of-resistance may be problematic when performing cervical epidural block. A false loss-of-resistance may occur because the interspinous ligament is less developed in the cervical region than in the lumbar region.1 In order to prevent false loss-of-resistance, we conrm the spontaneous inow of a drop of saline through the needle into the epidural space (an alternative to the hanging drop method). A syringe lled with normal saline may provide better tactile feedback than air and help avoid pneumocephalus in the case of dural penetration.6 The average DSES was shallowest at the C5-C6 intervertebral space in both men and women.

Table 2. Measured and Calculated Parameters

M(C5-6) (n 105) Age (yr) Weight (kg) Height (cm) NC (cm) BMI (kg/m2) 49.0 66.7 168.3 38.3 23.3 12.6 7.1 7.5 2.5 2.1 M(C6-7) (n 162) 49.1 66.4 169.1 38.2 23.2 13.4 8.5 5.7 3.7 2.3 M(C7-T1) (n 128) 49.2 66.7 168.6 37.6 23.5 13.1 8.0 5.6 5.7 2.5 F(C5-6) (n 137) 53.6 55.3 156.6 33.3 23.0 13.7 8.1 4.8 1.8 2.6 F(C6-7) (n 164) 52.3 57.0 157.3 33.8 23.1 12.7 7.7 5.1 2.2 2.7 F(C7-T1) (n 120) 51.3 57.3 157.2 34.2 23.2 12.4 7.4 4.7 2.3 3.0

NOTE. Data are mean SD. Abbreviations: NC, neck circumference; BMI, body mass index (kg/m2); M, male; F, female.

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Table 3. Correlation Coefcient Between Age, Weight, Height, NC, BMI, and Cervical Epidural Depth
M(C5-6) (n 105) Age (yr) BW (kg) Ht (cm) NC (cm) BMI (kg/m2) .110 .567* .141 .636* .553* M(C6-7) (n 162) .101 .487* .071 .535* .426* M(C7-T1) (n 128) .198 .431* .062 .523* .536* F(C5-6) (n 137) .040 .483* .042 .495* .426* F(C6-7) (n 164) .177 .459* .149 .504* .404* F(C7-T1) (n 120) .190 .450* .058 .617* .478*

Abbreviations: BW, body weight; Ht, height; NC, neck circumference; BMI, body mass index (kg/m2). *Statistical signicance for P .01 was noted.

Depth increased as the level moved caudal (was lower). Aldrete et al.7 measured the depth from the skin to inner line of ligamentum avum at C6-7, C7-T1, T1-2, and T2-3 intervertebral spaces in 100 American patients with magnetic resonance imaging. The greatest DSES was noted at the C6-7 and C7-T1 levels, with a mean of 5.7 cm; then decreased to a mean of 5.4 cm at the T1-2, and 4.7 cm at the T2-3 intevertebral spaces. This may be due to the presence of fatty tissue along the lower cervical and upper thoracic areas. For epidural block, because a Touhy needle is positioned in the epidural space past the ligametum avum, the measured depth might be greater than that measured using magnetic resonance imaging. Swelling from local anesthetic skin inltration may also increase the depth measured from skin to the epidural space. Our study involved Korean subjects, while Aldrete et al.7 studied American subjects, which could also inuence measurements. Among the complications of the cervical epidural block, the incidence of the unintentional dural puncture is reported to be less than 0.5% when performed by experienced physicians.1,8 When a local anesthetic is injected without verifying whether a dural puncture has occurred, there is a danger not only of total spinal anesthesia, but also of spinal cord injury,1,8 thus, extreme caution is required when performing the procedure. For lumbar epidural block, the shallower the depth from

the skin to the epidural space, the higher the risk of dural pucture.3 In patients with a 2 to 4 cm depth to the lumbar epidural space, the incidence of dural puncture is 3 times higher than in patients with a 4 to 6 cm epidural depth.3 In the present study, the minimum epidural depth at the cervical region was 3.8 cm for men and 2.9 cm for women. We believe that in order to reduce the risk of dural puncture in the cervical region, the needle for skin inltration should not be inserted deeper than 2.5 cm. Our study shows that DSES correlates with weight, body mass index, and neck circumference. The DSES is thus related to the subcutaneous tissue mass as is the case for the lumbar epidural space. In conclusion, the average depth from the skin to the cervical epidural space is least at the C5-C6 intervertebral space in both men and women, and the depth increases as the level moves caudal. It is advisable, when performing cervical epidural block, to consider the weight and neck circumference of the patient. The needle for skin inltration should not be inserted 2.5 cm.

References
1. Waldman SD. Interventional Pain Management. 2nd ed. Philadelphia, PA: Saunders; 2001:373-381. 2. Shylman M, Nimmagadda U, Valenta A. Cervical epidural steroid injection for pain cervical spine origin. Anesthesiology 1984;61:A233. 3. Sutton DN, Linter SPK. Depth of extradural space and dural puncture. Anaesthesia 1991;46:97-98. 4. Stonelake PS, Burwell RG, Webb JK. Variation in vertebral levels of the vertebra prominens and sacral dimples in subjects with scoliosis. J Anat 1988;159:165-172. 5. Cousins MJ, Bridenbaugh PO: Neural Blockade in Clinical Anesthesia and Management of Pain. 3rd ed. Philadelphia, PA: Lippincott-Raven; 1998:249. 6. Lucas DN, Kennedy A, Dob DP. Dural puncture and iatrogenic pneumocephalus with subsequent transverse myelitis in a parturient. Can J Anaesth 2000;47:1103-1106. 7. Aldrete JA, Mushin AU, Zapata JC, Ghaly R. Skin to cervical epidural space distance as read from magnetic resonance imaging lms: Consideration of the hump pad. J Clin Anesth 1998;10:309-313. 8. Waldman SD. Cervical steroid epidural nerve blocksA prospective study of 790 consecutive blocks. Reg Anesth Pain Med 1984;11:149-152.

Fig 2. Distribution of the distance from skin to epidural space in female patients.