Do the Gaps in the Ligamentum Flavum in the
Cervical Spine Translate into Dural Punctures?
An Analysis of 4,396 Fluoroscopic Interlaminar
Epidural Injections
Authors: Manchikanti Laxmaiah 
Published: February 2021

Background: Cervical interlaminar epidural injections are performed frequently in managing
chronic neck and upper extremity pain, although less commonly than lumbar interlaminar epidural
injections. Recently, the US Food and Drug Administration warnings and safeguards to prevent
neurologic complications. These were developed by the Multi-Society Pain Workgroup have taken
center stage for all types of epidural injections, including cervical interlaminar epidural injections.
The recommendations of safeguards to prevent neurologic complications after epidural steroid
injections include that cervical interlaminar epidural injections must be performed utilizing
fluoroscopy with anteroposterior, lateral, or oblique views with injection of contrast medium and
that entry be limited to the C7-T1 epidural space or occasionally the C6-C7 with requirements for
magnetic resonance imaging assessment of the epidural space.
Objectives: To assess the incidence of dural puncture associated with fluoroscopically directed
cervical interlaminar epidural injections.
Study Design: A retrospective assessment of patients undergoing cervical interlaminar epidural
injections from January 2012 through February 2015.
Setting: A private interventional pain management practice; a specialty referral center in the
United States.
Methods: The data were collected for 4,396 consecutive cervical interlaminar epidural injections
performed from January 2012 through February 2015. The procedures were all performed under
fluoroscopic visualization under posteroanterior view with contrast medium injection with lateral
view confirmation when indicated. The procedures were performed by one of 2 physicians; the
dural puncture and subsequent postoperative complications with level of epidural entry were
determined.
Outcomes Assessment: The outcome was assessment of dural puncture.
Results: A review of multiple manuscripts showed that defects in the ligamentum flavum may
extend to as much as 100% of the population. However, it also has been shown that among the
levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more
frequent than in the middle or cephalic portion of the ligamentum flavum.
Among the 4,396 epidural injections performed at C7-T1, C6-C7, and C5-C6, 1,227 were
performed at C7-T1; 1,835 were performed at C6-C7; and 1,334 were performed at C5-C6. Dural
punctures were observed in 1.8% (24 procedures) at the C5-C6 level entry; 0.87% (16 procedures)
at the C6-C7 level entry; and 1.71% (21 procedures) at the C7-T1 level. There was no significant
difference among the entry levels. No complications or spinal cord damage or postdural puncture
headache were observed.
Limitations: The limitations of this report include that it is an assessment by only 2 well
experienced physicians, even though it included a relatively large number of patients Conclusion: This study illustrates that dural puncture is equally prevalent, though very rare, irrespective of the needle entry level
into the epidural space, with an overall dural puncture rate of 1.4%, with 1.8% at the C5-C6 level, 0.87% at the C6-C7 level, and
1.71% at the C7-T1 level. Based on the present literature, it appears that performing the procedure by inserting the needle into
the cephalic portion of the intervertebral space rather than the caudal portion may be safer.
Key words: Cervical interlaminar epidural injection, dural puncture, steroids, neck pain, upper extremity pain.