Diagnostic and Therapeutic Injections

Center for Diagnostic Imaging

Considering an Injection? • Imaging confirms pathology - MRI, CT, X-rays • Limited success with conservative treatment - rest - analgesics, oral steroids - physical therapy

Magnetic Resonance Imaging -MRI

Open Upright MRI • Scans performed while weight bearing • Allows for flexion and extension scans

Open Upright MRI • Scans performed while weight bearing • Allows for flexion and extension scans • Sitting

Open Upright MRI • Scans performed while weight bearing • Allows for flexion and extension scans • Sitting • Standing

Open Upright MRI • Scans performed while weight bearing • Allows for flexion and extension scans • Sitting • Standing • Recumbent

Open Upright MRI

Open-Sided MRI • Accommodates patients up to 660 lbs. • Up to twice as fast as other open scanners

Computed Tomography -CT

X-ray

What study should I order? • Decide the most likely site of pain origin – General spinal level – Specific anatomic site, if possible

What study should I order? • Decide the site – Spinal level • • • •

Cervical Thoracic Lumbar Sacral

What study should I order? • Decide the site – Anatomic site • • • •

Disc Nerve Joint Instrumentation

What study should I order? Injection procedures can be chosen according to the most likely site and cause….

Patient’s Perception of Spinal Injection

Fluoroscopic Guided Injections

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Epidural Steroid Injection (ESI) Classification • By Level • By Approach – – – –

Lumbar Cervical Thoracic Sacral

– Interlaminar – Transforaminal

Epidural Steroid Injections (ESI) • Interlaminar Approach – Regional, bilateral effects – More comfortable procedure

• Transforaminal Approach – Local, unilateral effects – More uncomfortable procedure

Epidural Steroid Injections (ESI) • Interlaminar Approach

Interlaminar Lumbar ESI • For bilateral low back & leg pain • Clinically proven, “nonspecific” injection for disc, facet, nerve root irritation • Low morbidity when properly performed

Interlaminar Lumbar ESI • For bilateral low back & leg pain • Clinically proven, “nonspecific” injection for disc, facet, nerve root irritation • Low morbidity when properly performed

Interlaminar Thoracic ESI • Interscapular pain • Posterior rib • “Nonspecific” injection for disc, facet, nerve root irritation

Interlaminar Cervical ESI • Neck and arm pain • “Nonspecific” injection for disc, facet, nerve root irritation

Epidural Steroid Injections (ESI) • Transforaminal Approach

Transforaminal Lumbar ESI • For unilateral pain • Variant of nerve block with greater injection volumes • Greater efficacy in single level disease • Increased specificity in diagnosis and treatment

Transforaminal Lumbar ESI • For unilateral pain • Variant of nerve block with greater injection volumes • Greater efficacy in single level disease • Increased specificity in diagnosis and treatment

Transforaminal Sacral ESI • For unilateral pain • Variant of nerve block with greater injection volumes • Greater efficacy in single level disease • Increased specificity in diagnosis and treatment

Epidural Steroid Injections...

… Practical Points

Technique • No special preparation • Fluoroscopic guidance improves accuracy • Contrast confirms epidural space entered • Anesthetic defines neurotome affected

Timing • Steroids exhibit maximal benefit between the first week and first month after injection • To minimize side effects, limit to only 3 injections over a 6 month period

Contraindications • Anticoagulation – Coumadin should be halted 3 days before

• Active infection – Await completion of antibiotic therapy

• Pregnancy

Side Effects • In the first days after injection patients will rarely experience – insomnia – facial redness – hiccups

• Diabetic patients need to monitor glucose - steroid may increase blood sugar levels

Rationale • Deposit slowly-released anti-inflammatory steroid directly at the irritated nerve site • Marker anesthetic inhibits nerve conduction

Efficacy • Maximal benefit between one week and one month after injection • If patients respond, 95% will do so within a week

Efficacy • Best responders include those – with acute pain onset – with radicular symptoms – not taking strong analgesics

Epidural Steroid Injections • Consider ESI as another technique on the list of pain management options to control pain, especially when first line approaches fail to give satisfactory results • Remember contraindications, limitations, and potential side effects

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Dermatomes –Upper and Lower Limbs

Transforaminal Lumbar Nerve Block • Predominantly unilateral LE pain • Variant of ESI with small injection volumes • Specific for a single nerve

Transforaminal Cervical Nerve Block • Predominantly neck and arm pain • Variant of ESI with small injection volumes • Specific for a single nerve

Transforaminal Cervical Nerve Block • Predominantly neck and arm pain • Variant of ESI with small injection volumes • Specific for a single nerve

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Sacroiliac Joint Injection • Low back pain & “hip” or “groin” (referred) pain • Difficult to target joint • Often unsuspected source of back, hip, and groin pain

Sacroiliac Joint Injection

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Lumbar Facet Joint Injection • Paraspinal pain, occasionally referred to buttocks or thigh • Intra-articular injection occasionally difficult • Occasional long-term pain relief

Lumbar Facet Joint Injection • Paraspinal pain, occasionally referred to buttocks or thigh • Intra-articular injection occasionally difficult • Occasional long-term pain relief

Lumbar Facet Cyst Injection

Cervical Facet Joint Injection • Lateral neck pain • Posterior approach preferred • May be combined with facet nerve blocks

Cervical Facet Joint Injection • Lateral neck pain • Posterior approach preferred • May be combined with facet nerve blocks

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Cervical Facet Nerve Block

Cervical Facet Nerve Block • Lateral neck pain • Posterior approach preferred • Helps identify potential rhizotomy candidates

Lumbar Facet Nerve Block • Central low back pain • Primarily diagnostic • May have intermediate-term relief

Lumbar Facet Nerve Block • Central low back pain • Primarily diagnostic • May have intermediateterm relief

Lumbar Rhizotomy • For central low back pain relief after diagnostic facet nerve blocks show temporary benefit • Long term improvement in appropriately chosen patients

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Initial MRI Evaluation

Lumbar Discography • Axial low back pain • Markers: HIZ, degeneration, Modic Type I or II changes involving more than 25% of vertebral body height • Concordant pain on injection

Lumbar Discography

Cervical Discography • Axial neck pain • Different anatomy more challenging • Often excludes (rather than includes) surgery by demonstrating multiple painful levels

Common Injection Procedures • • • •

Epidural Steroid Inj. Selective Nerve Block Sacroiliac Joint Facet Joint Block

• • • •

Facet Nerve Block Rhizotomy Discography Myelography

Myelography • Contrast injected into thecal sac • Outlines spinal canal and spinal nerves • Post myelogram CT offers cross-sectional detailed images

Myelography • Alternative for patients that are nonMRI compatible • Bed rest 24 hours post procedure • Newer techniques minimize chance of spinal headache

Diagnostic and Therapeutic Injections

Center for Diagnostic Imaging

Vertebroplasty • According to the National Osteoporosis Foundation, osteoporosis causes 700,000 vertebral fractures each year • Bone tumor also possible cause of fracture • Acute trauma

Vertebroplasty • Candidates include those patients that have not responded well to rest or analgesics • Best results with early detection of compression fracture – 1 to 4 months • Stabilizes compression fracture as well as prevents further vertebral collapse

Vertebroplasty

Vertebroplasty • Bi-pedicular approach • Fluoroscopic guidance • Polymethyl Methacrylate – radiopaque bone cement • Viscosity working time 8-14 minutes

Vertebroplasty

• Compression fracture stabilized • Pain relief normally with 48 hours

Vertebroplasty

Diagnostic and Therapeutic Injections

Center for Diagnostic Imaging

Musculoskeletal Injections

Diagnostic and Therapeutic Injections

Center for Diagnostic Imaging