Interventional Procedures of the Spine

309 Interventional Procedures of the Spine Fernando Ruiz Santiago, MD, PhD1 Dimitrios K. Filippiadis, MD, PhD2 Alexis Kelekis, MD, PhD, EBIR2 1 Dep...
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Interventional Procedures of the Spine Fernando Ruiz Santiago, MD, PhD1 Dimitrios K. Filippiadis, MD, PhD2

Alexis Kelekis, MD, PhD, EBIR2

1 Department of Radiology, Hospital of Traumatology, Granada, Spain 2 2nd Radiology Department, University General Hospital “ATTIKON,”

Athens, Greece

Luis Guzmàn Álvarez, MD, PhD1

Address for correspondence Fernando Ruiz Santiago, MD, PhD, Department of Radiology, Hospital of Traumatology, Carretera de Jaen SN, Granada, 18013, Spain (e-mail: [email protected]).

Semin Musculoskelet Radiol 2014;18:309–317.

Abstract Keywords

► spine ► interventional radiology ► imaging guidance

Different interventional procedures performed under imaging guidance permit the diagnosis and treatment of the many causes of back pain. Sources of pain amenable to be treated include facet joints, vertebral body, intervertebral disk, and paraspinal structures including nerves and ganglion roots. These procedures may be merely diagnostic, therapeutic, or intended for both purposes. We review the main indications, advantages, and complications of these techniques.

Interventional radiology can be used to diagnose and treat many pathologic processes of the spine that may cause back pain or dysfunction. Although some procedures can be performed based on physical anatomical landmarks, it is safer and more accurate when performed under imaging guidance, mainly by fluoroscopy, computed tomography (CT), or magnetic resonance imaging (MRI). These procedures can be merely diagnostic, diagnostic and therapeutic, or only therapeutic.1 All of these techniques have to be performed under a rigorous sterile protocol. Antibiotic prophylaxis is recommended in the most complicated procedures such as vertebroplasty, thermal ablation, procedures of the intervertebral disk, and in immunosuppressed patients, even in minor interventions. Contraindications include local or systemic infection, uncorrected coagulopathy, allergy to any of the medication used, or a patient who is unwilling to provide informed consent.2 We describe them in the following order: facet joints, vertebrae and disk procedures, and general procedures (myelography, and abscess and fluid drainage).

Facet Joints Infiltrations Facet joints are frequently affected by osteoarthritis; imaging findings include joint space narrowing, intra-articular vacuum phenomenon/fluid, osteophytes, synovial cyst formation, and ligamentum flavum thickening.3 Patients complain of local paralumbar tenderness (radiating to the thigh, the iliac crest, and rarely to the groin). This pain or tenderness is usually worse when waking up from bed or trying to stand after

Issue Theme Spine; Guest Editor, Mara Epermane, MD

prolonged sitting and could be exacerbated upon pressure, hyperextension, torsion, and lateral bending of the spine. Imaging-guided infiltrations can either be combined with a conservative therapy course or solely performed as an intermediate step prior to other therapeutic options (percutaneous ablation or surgical options).2 The injectate in the vast majority of cases contains a long-acting corticosteroid mixed with a local anesthetic; sodium hyaluronate solutions or ozone have been tested as well.4,5 Facet joint infiltrations are performed under imaging guidance with a direct percutaneous posterolateral access to the articulation by means of a 22G spinal needle. Proper needle positioning is verified with contrast medium injection (►Fig. 1). Moderate evidence exists for facet joints infiltrations. However, the high success rates of the technique (59–94% immediate and 27–54% long-term pain relief) are directly related to proper patient selection.2 Furthermore, in the thoracic and lumbar spine, facet joint infiltrations can be performed as a diagnostic test(s) to verify the controlled joint as a (pain) source of back pain. The evidence for therapeutic cervical intra-articular injections is limited and lacking at the dorsal level.6 Alternative minimally invasive therapies include median nerve block, radiofrequency (RF) ablation of the medial branch nerves of the dorsal rami innervating each facet, and MRI-guided high-intensity focused ultrasound.7,8

Neurolysis Neurolysis or rhizolysis is a neurodestructive procedure intended for long-term relief of chronic pain. Permanent neurolysis can be achieved by injection of ethanol or phenol.

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI 10.1055/s-0034-1375572. ISSN 1089-7860.


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Fig. 1 (a) Oblique fluoroscopic view (Scottie dog projection): direct puncture in the upper part of the L5–S1 facet joint. (b) Contrast medium verifies intra-articular needle positioning. (c) Anteroposterior (AP) and (d) lateral view of the joint after puncture of the inferior recess of the joint. (e) AP fluoroscopic view of transforaminal infiltration at the lateral part of the L5–SI foramen. Contrast dispersate both in the foramen and epidural space. (f) Computed tomography of transforaminal infiltration. (g) Lateral fluoroscopic view of interlaminar epidural infiltration. Contrast medium verifies extravascular placement of the needle inside the posterior epidural space.

Controlling the distribution of the solutions injected is not easy. More controlled neurolysis can be accomplished by RF ablation under fluoroscopy or CT guidance, guaranteeing a reliable positioning of the probe.9 RF ablation is mainly used to achieve facet denervation, although it can also be used to treat root ganglions at the neural foramina to palliate or cure chronic unresolved radiculitis. Other root ganglions, such as the stellate ganglion at the cervical level, the thoracic sympathetic chain, the lumbar sympathetic chain, and the impar ganglion, can be treated to resolve painful or dystrophic syndromes (►Fig. 2). For medial branch neurolysis, the target lies at the junction between the superior articular and transverse processes. Success of medial branch neurotomy depends critically on the correct selection of patients and the use of a correct technique.10 It is indicated in patients with back pain without radiculopathy in whom a previous trial of facet joint injections or nerve block has reduced pain at least 50%.11 The evidence for continuous RF in managing chronic low back pain of facet origin is far superior to pulsed neurolysis, good for short- and long-term relief.6

Vertebrae Biopsy Biopsy is mainly indicated in diagnosing tumors, primary or metastatic, and infectious conditions. In the case of known primary tumor elsewhere, biopsy helps to confirm the metastatic nature of the vertebral lesion or to identify the presence Seminars in Musculoskeletal Radiology

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of tissue markers that may influence the choice of a specific treatment. A coaxial system allows obtaining multiple samples with only one entrance point increasing the success rate. Lesions can be approached by a transpedicular or extrapedicular way based on anatomical factors or type of imaging guidance, fluoroscopy or CT. A meta-analysis concluded that the accuracy and complication rates of spinal biopsies increased with the inner diameter of the needles.12 Accuracy, defined as the percentage between true positives plus true negatives divided by the whole sample, is > 80% in spinal lesions, superior in lytic versus blastic lesions and in metastases versus primary tumors. Success in infectious conditions may be reduced because of performing the procedure after antibiotic therapy has begun, with percentages of positive culture rates ranging from 30 to 91%13,14 (►Fig. 3).

Vertebral Augmentation Spinal augmentation is considered an interventional procedure intended to reduce pain and restore height loss due to vertebral fracture. Vertebroplasty and kyphoplasty are currently the most frequently used techniques for vertebral augmentation treatment of osteoporotic vertebral compression fractures (►Fig. 4). They are mainly indicated after failure of medical treatment when the patient has an invalidating pain or there are severe side effects due to analgesic medication. Most studies have found that both techniques lead to similar results regarding pain relief and function scores.15 Nevertheless, technical and anatomical differences

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Fig. 2 (a) Anteroposterior (b), lateral, and (c) oblique view of needle positioning for fluoroscopy-guided neurolysis of posterior branch of spinal nerves. (d) Sagittal and (e) axial view of needle positioning under computed tomography guidance. (f) Neurolysis of impar ganglion.

do exist and may influence the choice between both techniques including operator experience or preference. In addition, many other new devices have been developed to reduce the risk of cement leakage complications and to significantly restore initial vertebral height. The role of these new devices should be established after assessing the results of larger trials. According to recent randomized controlled trials, when properly indicated, vertebroplasty results in statistically significant improvement in pain and function.16,17 Some circumstances that might promote the choice of vertebroplasty as the most appropriate treatment include older age of patients and greater number of fractures to be treated because vertebroplasty is usually a quicker and less aggressive technique.18 The age of the fracture can be another important factor because height recovery is hampered in older fractures, and therefore vertebroplasty could be a better and less expensive option than kyphoplasty.19 Vertebroplasty can also restore vertebral height when there is fragment instability with intravertebral clefts, indicating nonunion of the fracture fragments. The cleft may be filled with a greater amount of cement when there is integrity of the walls of the vertebral body, without extravasations leading to loss of intravertebral pressure.20 In these cases we try to connect the cement occupying the vertebral cleft with cement inside the solid part of the vertebral body, accounting for a more stable fracture reduction and thus attempting to avoid the possibility of refracture.21 Percutaneous kyphoplasty aims for pain reduction and vertebral height restoration (with subsequent reduction of the spine’s biomechanical alterations) in patients with symp-

tomatic vertebral fractures.2,22,23 Under imaging guidance and unilateral or bilateral access, working cannulas are introduced inside the vertebral body. Subsequently, a cavity is drilled and inflatable balloon bone tabs are used to elevate the vertebral end plates. Finally, the created intravertebral cavity is filled with bone cement. Recent technology developments aim to further enhance vertebroplasty and kyphoplasty techniques, improving safety and efficacy levels and the better achievement and maintenance of height restoration. Such developments include peek implant cages, nitinol endovertebral cages, polyetheretherketone implant cages, or vertebral body stents.24–26

Tumor Ablation Thermal methods for tumor treatment (RF, microwave, and cryoablation) have become important palliative resources and, in some cases, curative modalities. In the spine, close proximity to neurovascular structures may prohibit or hamper local thermal therapy. Heating > 45°C has been shown to be neurotoxic to the spinal cord and the peripheral nerves. The interposition of bone increases the insulation, but it depends on the thickness of the bone lamellae and cortex.27 Thermal insulation of neural structures by injecting room air, carbon dioxide (CO2) or glucose solution between them and the tumor may permit the procedure. Notwithstanding, temperature monitoring with a probe on the structures at risk is advocated (►Fig. 5). CT-guided radiofrequency thermal ablation (RFTA) has become the standard treatment for most osteoid osteomas including spine lessions.28 Indications for RFTA treatment are expanding and include other benign and malignant bone Seminars in Musculoskeletal Radiology

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Fig. 3 (a) Anteroposterior and (b) lateral view of coaxial transpedicular vertebral body biopsy under fluoroscopy guidance. (c) Lateral view of transpedicular access through the lower end plate inside the disk in a case of spondylodiskitis. (d) Coaxial biopsy under computed tomography guidance.

Fig. 4 (a) Many vertebrae were treated by vertebroplasty in two sessions in this patient with myeloma. (b) Sagittal short tau inversion recovery magnetic resonance imaging of a patient with acute fracture and intravertebral cleft. (c) After kyphoplasty, the cement distribution is not limited to the previously created cavities. Seminars in Musculoskeletal Radiology

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conditions such as giant cell tumors, osteoblastomas, hemangiomas, and metastasis. In this last case, most of the time it is used for palliation of pain and may be combined with vertebral cementation to strengthen the vertebral body.29 Less often, RFTA can be used in a curative intent for patients with single or oligometastases (less than three) limited in size.30 Microwave antennae are inserted within the tumor under imaging guidance. The transmitted high-frequency energy (extending  2 cm around the antenna) produces molecular movement and friction elevation, thus the temperature with coagulation necrosis is the end point result. In comparison with RFTA, microwaves create a larger ablation zone within a shorter period of time, and the ablation zone (volume and shape) is not governed by the heat-sink effect. Furthermore, no grounding pads are necessary.31–33 Technical parameters of the ablation protocol are determined by the manufacturer of the antenna aiming to kill all malignant cells with minimal surrounding tissue damage. For large size lesions, multiple antennae can be inserted to create even larger ablation zones. During cryoablation, extreme cold is applied to cause both direct cellular and vascular lethal injury to the tumor. Advantages of the technique include the visibility of the ice ball under CT imaging and the decreased perioperational pain.

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Fig. 5 (a) Osteoid osteoma of articular facet. (b) Monitoring electrode in neural foramen. Ablative electrode inside the lesion. Gas in epidural space was introduced trough the introductory cannula of the monitoring electrode. (c) Monitoring electrode in the epidural space. The lytic lesion corresponds to a breast metastasis. (d) Ablative electrode in place. (e) Vertebroplasty was performed after ablation. Epidural gas acts as heat insulator.

Disadvantages include the increased duration and cost of this technique because in most cases multiple probes must be inserted (more or less parallel and  2 cm away one from the other). Excellent imaging monitoring, rapid freezing to lethal temperature ( 40°C), slow thawing, and repetition of the same process seem to ensure safety and success.31–33 Keep in mind that any kind of hydrodissection must be avoided in cryoablation. Insulation can be achieved only with gases (air via antimicrobial filter or CO2).

Intervertebral Disks Epidural Infiltrations The epidural space can be approached via interlaminar, transforaminal, or caudal (through the sacro-coccygeal hiatus) access (►Fig. 1). Infiltrations with a mixture of a longacting corticosteroid and a local anesthetic can be delivered by means of a 22G spinal needle and can be performed via any of the accesses just mentioned; ozone infiltrations are reserved for transforaminal access.2,34 Specifically for the cervical spine, it is preferable not to use a local anesthetic but a mix of a corticosteroid with saline solution to avoid inadvertent nerve anesthetization.2 Sterile technique is a prerequisite. Indications include radiculalgia without neurologic deficit, postoperative patients with recurrent pain, equivocal neurologic examinations, and spinal nerve root compression or inflammation. Imaging guidance and contrast medium use ensure accurate needle positioning, increase safety, and the technical and clinical efficacy of the infiltration. Concerning transforaminal infiltrations, the needle should be positioned in the lower and most lateral part of

the foramen to avoid nerve or vascular puncture.35 Furthermore, in the thoracic and lumbar spine, transforaminal infiltrations can be performed as diagnostic tests to verify the controlled nerve root as the pain source of back pain or neuralgia. Caudal infiltrations require larger volumes of injectate.2

Intervertebral Disk Therapies Intervertebral disk decompression techniques are minimally invasive outpatient procedures for the treatment of disk herniation. Under imaging guidance and via a percutaneous approach, a trocar is inserted in the nucleus pulposus of the disk (►Fig. 6). Through this trocar a variety of thermal, chemical, or mechanical decompression devices are introduced inside the nucleus pulposus, with very little disruption of the surrounding tissues, assuring its partial removal2,36 (►Table 1). During the 1970s, the Hijikata theory and experimental studies by Asher and Choy provided the rationale for these techniques. According to these studies, removal of a small nuclear volume results in a significant decrease of intradiskal pressure and at the same time creates space for the herniation to implode inward. Mechanical decompression is achieved by means of mechanical high rotation per minute devices (with spiral tips or metallic wires/laminae that promote disk removal), by pneumatically or water-driven suction-cutting probes or by herniotomes.2,36,37 Thermal decompression is achieved by laser fiber, plasma energy electrode, and RF coil/electrode. The latter technique is the only one during which the coil is deployed not at the nucleus pulposus but at the annulus fibrosus aiming for the destruction of nerve Seminars in Musculoskeletal Radiology

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Fig. 6 Fluoroscopy-guided mechanical decompression using a high rotation per minute device with metallic laminae. (a) Lateral fluoroscopic projection: Final needle position should be toward the anterior third of the disk at midway between the end plates. (b) Anteroposterior fluoroscopic projection: Final needle position should be toward the midline at midway between the end plates. (c, d) Lateral fluoroscopic projection: A high rotation per minute device with metallic laminae is coaxially advanced inside the disk through the placed trocar.

Table 1 Percutaneous minimally invasive imaging-guided intervertebral disk decompression and regeneration techniques Decompression type



Mechanical decompression

Automated percutaneous lumbar diskectomy

Pneumatically driven suction-cutting probe

Percutaneous disk decompression

Mechanical high rotation per minute device with spiral tips or metallic laminae or water-driven suction cutting probe

Percutaneous diskectomy

Herniotome extracts hernia or portion of the hernia to decrease pressure on the nerve root

Percutaneous laser decompression

Laser energy vaporizes a small volume of nucleus pulposus

Intradiskal electrothermal therapy

Flexible thermal resistive coil (electrode or catheter) coagulates the disk tissue with radiant heat

Intervertebral disk nucleoplasty

Bipolar radiofrequency energy causes molecular dissociation and dissolves nuclear material


Gelified ethanol causes dehydration of nucleus pulposus

Ozone therapy

Ozone’s chemical properties and the reaction of hydroxyl radical with carbohydrates and amino acids leads to breakdown of nucleus pulposus

Hydrogel, platelet-rich plasma, and stem cell therapy

Aim: intervertebral disk regeneration

Thermal decompression

Chemical decompression

Biomaterial implantation

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Interventional Procedures of the Spine endings. Chemical decompression is achieved by means of alcohol gel (DiscoGel) or ozone intradiskal injection, which causes dehydration and breakdown of the nucleus pulposus.2,36 Lately there is a trend for biomaterial implantation (hydrogel, platelet-rich plasma, and stem cell therapy) aiming for intervertebral disk regeneration.38,39 Indications for percutaneous decompressive disk therapies include the presence of symptomatic (refractory to 4–6 weeks of a conservative therapy course) intervertebral disk herniation occupying less than a third of the spinal canal as confirmed by MRI. Presence of sequestration is an absolute contraindication.2,36 The mean success rate for all decompression techniques is  85%.2,36,37 Comparison of mechanical decompression techniques with conservative therapies shows a statistically significant improvement of the symptoms and longerlasting outcomes concerning pain reduction and mobility improvement.40 The mean complications rate is < 0.5% (clinically significant). The most common potential complication (0.24% per patient and 0.091% per disk per patient) is infection (spondylodiskitis) with the exception of thermal decompression techniques in which sterile inflammation of vertebral end plates due to damage during the session may complicate 2.5% of cases.2,36 Rare complications include material failure, allergic reaction, reflex sympathetic dystrophy, puncture of thecal sac, hemorrhage, and neurologic injury, pneumothorax, and vasovagal reactions.

Percutaneous Diskography Lindblom (1944) and Wise-Weiford (1951) are some of the pioneers of diskography.41,42 Percutaneous provocative diskography is a minimally invasive diagnostic technique used for the evaluation of diskogenic pain. After major refining of the technique and its indications, provocative diskography is used today as a diagnostic imaging-guided procedure.43 During diskography a needle is placed percutaneously inside the intervertebral disk and contrast medium is injected into the nucleus pulposus (►Fig. 7).

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Diskography shows if there is a direct correlation between the patient’s usual pain and the intervertebral disk’s morphology. This is evidenced first by the pain that might be triggered by the injection of the contrast medium into the intervertebral disk and second by the assessment of the disk’s morphology evidenced in fluoroscopy and/or CT. Noninvasive imaging studies (X-rays, CT, MRI) neither reproduce the patient’s clinical syndrome nor characterize a disk as symptomatic or not. Percutaneous disk manometry is an alternative to classic diskography during which a disk manometer is used for the administration of a mixture injection at a steady rate and at the same time for recording the mixture volume and the intradiskal pressures, thus producing a P-V curve. This information seems to be valuable for the assessment of biomechanical integrity of the end plate–intervertebral disk complex and for proper patient selection in case of subsequent therapeutic approaches.44 Indications for provocative diskography/disk manometry include patients with cervicobrachialgia, sciatica with or without lumbago, and herniation presence confirmed by MRI.2,45 The access to the disk is the same as in decompression techniques.

Intervertebral Disk Biopsy Sampling from the intervertebral disk is indicated for cultures in cases of suspected or proved spondylodiskitis, to identify the microorganism causing the infection and provide proper therapy.46 The access to the intervertebral disk of interest is the same as in diskography or decompression techniques. Alternative approaches include a transpedicular one aiming to reach the disk through the vertebral end plate (►Fig. 3). Antibiotic prophylaxis is useless whenever spondylodiskitis is suspected.

Myelography Myelography today is reserved for patients who are not compatible with MRI (e.g., pacemaker, neurostimulator,

Fig. 7 Diskography. (a) Lateral fluoroscopic projection: Final needle position should be toward the anterior third of the disk midway between the end plates. (b) Lateral view showing “cotton ball” appearance of a normal intervertebral disk in L4–L5 and radial tear (arrow) in L5–S1 disk. Seminars in Musculoskeletal Radiology

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Fig. 8 (a) Lateral fluoroscopic projection of myelography. (b) Needle positioning in computed tomography (CT) myelography. (c) Percutaneous psoas abscess drainage under CT guidance.

claustrophobia, etc.), for cases where MRI is not available, for postoperative patients where metal artifacts are expected to reduce the diagnostic quality, in depicting suspected leakage of cerebrospinal fluid (CSF), or for the study of traumatic injuries of the cervical nerve roots.47,48 CT myelography is able to detect any leakage of contrast-enhanced CSF and compression of neural structures (►Fig. 8). Additional indications include equivocal MRI findings that require further evaluation or a need for dynamically assessing instability or stenosis (and dynamic or tilting MRI is not available). The most common complication is postpuncture headache, which is directly related to the diameter of the used needle. Rarer complications include seizures, nausea, and/or vomiting, bleeding, infection, arachnoiditis, and nerve root injury.47,49

Abscess and Fluid Drainage Sometimes spine infections lead to abscess formation amenable to percutaneous drainage. These collections may be located at epidural, paraspinal, or prevertebral spaces, or spread along muscles, mainly psoas and iliac muscle (►Fig. 8). Percutaneous drainage under CT guidance of the fluid content may be curative and complementary to medical therapy. Success can be hampered in chronic tuberculous abscess because of the existence of a thickened wall that does not collapse spontaneously. After failure of percutaneous drainage, surgical debridement is warranted.50

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Seminars in Musculoskeletal Radiology

Vol. 18

No. 3/2014


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