image-guided spine procedures for relief of severe

28
ASSR 2007 Image-guided Spine Procedures for Relief of Severe Lower Back Pain: A Guide to Epidural Steroid Injection, Facet Joint Injection, and Selective Nerve Root Block. PETER H TAKEYAMA MD HENRY WANG MD PhD SVEN EKHOLM MD PhD P-L WESTESSON MD DDS PhD University of Rochester, Rochester, NY Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 1 of 28

Upload: hoangnhan

Post on 06-Feb-2017

217 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

Image-guided Spine Procedures for Relief of Severe Lower Back Pain:

A Guide to Epidural Steroid Injection, Facet Joint

Injection, and Selective Nerve Root Block.

PETER H TAKEYAMA MD HENRY WANG MD PhD

SVEN EKHOLM MD PhD P-L WESTESSON MD DDS PhD

University of Rochester, Rochester, NY

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 1 of 28

Page 2: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 Outline I.! Introduction II.! Objectives III.!Anatomy IV.!Patient

evaluation V.! Procedures VI.!Conclusion

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 2 of 28

Page 3: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 I. Introduction •! Back pain is a major problem in the United States

with countless emergency room visits every year.

•! The emotional, physical, and healthcare costs are tremendous.

•! Image-guided spine procedures can be successful in diagnosing and relieving the source of severe back pain.

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 3 of 28

Page 4: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

II. Objectives This educational poster will illustrate key learning points of epidural steroid injection, facet joint injection, and lumbar nerve root block.

•!Basic relevant anatomy •! Indications •!General procedure

principles •!Possible complications

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 4 of 28

Page 5: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

III. Anatomy – Lumbar SpinePlain film

Pedicle

Neural foramen

Superior endplate

Inferior endplate

Facet joint

Pars interarticularis

Intervertebral disc

Pedicle

Spinous process

Facet joint

Lamina

Pars interarticularis

Pedicle

Inferior articular process

Superior articular process

Transverse process

Interlaminar space

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 5 of 28

Page 6: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

III. Anatomy – Lumbar SpineCT

Facet joint

Transverse process

Intervertebral disc

Neural foramen

Facet joint Spinous process

Superior articular process

Inferior articular process

Vertebral body Vertebral body

Pedicle

Ligamentum flavum

Psoas

Lamina Spinal canal

Exiting nerve

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 6 of 28

Page 7: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

III. Anatomy – Lumbar SpineMRI

T1 T1 T2

Intervertebral disc

Anterior longitudinal ligament

Vertebral body

Epidural fat

Spinous process

Supraspinous ligament

Interspinous ligament

Neural foramen

Ligamentum flavum

Facet joint

Nerve root

Dorsal Dural margin

Superior endplate

Inferior endplate

Conus medullaris

Nucleus pulposus

Annulus fibrosus

CSF

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 7 of 28

Page 8: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

III. Anatomy – Lumbar SpineMRI

T2

Intervertebral disc

Neural foramen

Spinous process

Exiting nerve

Facet joint

Transverse process

Superior articular process

Inferior articular process

Vertebral body

Pedicle

Ligamentum flavum

Vertebral body Psoas

Lamina

Thecal sac with cauda equina

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 8 of 28

Page 9: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

•!History including duration and nature of pain •!Physical exam •!Review imaging studies,

findings must correlate with pain •!Explain risks, benefits, and

possible complications •! Informed consent

IV. Patient evaluation All patients are evaluated by the neuroradiologist prior to procedure.

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 9 of 28

Page 10: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 V. Procedures

1.!Epidural injections

2.!Facet joint injections

3.!Lumbar nerve root block

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 10 of 28

Page 11: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

1. Epidural injectionsIndications and Rationale •! Commonly performed for symptoms of •! Herniated disc •! Spinal stenosis •! Refractory back pain of uncertain etiology

•! Decrease inflammation and swelling of nerve root •! Relieve pain and break pain cycle •! Allow patients to return to their usual activities •! May help delay or avoid more invasive surgical

procedures

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 11 of 28

Page 12: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 1. Epidural injections

Preparation •! Prone position on fluoroscopy suite table •! Sterile preparation of lower back and drapes •! 1% buffered lidocaine for skin local anesthesia •! 22-gauge Tuohy needle with Medallion syringe and tubing •! Syringes for local anesthetic, contrast, and steroid •! Mixture of 2-3 cc of 0.5% Marcaine and 80 mg of Kenalog •! Conscious sedation not necessary. IV midazolam and fentanyl can

be given if required

Contraindications •! Coagulopathy. Patient should discontinue anticoagulative

medication (coumadin). Check INR, PT, PTT. •! Allergy to contrast. Procedure can be modified and performed

without contrast. •! Contraindication to steroids use (ulcers, active infection)

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 12 of 28

Page 13: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

1. Epidural injections

Anatomy •! Epidural space bordered by

dural sac, ligamentum flavum, and vertebral bodies

Procedure •! Needle is advanced to the

appropriate level lamina under fluoroscopy, just touching the periosteum adjacent to interlaminar space

•! Needle is withdrawn a few millimeters and “walked” carefully past the lamina medially

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 13 of 28

Page 14: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 1. Epidural injections

Procedure (continued) •! Stylet removed and connected to

Medallion syringe containing air •! Needle is slowly advanced while

tapping syringe plunger until loss of resistance

•! Needle is connected to contrast (Omnipaque 180) via tubing and slowly injected

•! Contrast rapidly advances confirming placement in epidural space

•! Spot image is obtained •! Mixture of Marcaine and Kenalog is

injected into epidural space

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 14 of 28

Page 15: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 1. Epidural injectionsComplications •! Bleeding •! Infection •! Placement of needle into subarachnoid space •! Injury to vessel or nerve •! Contrast reaction •! Vasovagal reaction •! Non-response to therapy

Post Procedure •! Monitoring of vital signs •! Home care instructions for potential complications, ie. Infection •! Initial pain reduction from local anesthetic •! Steroid effects may gradually take effect after 1-2 day delay •! May require repeat series of injections for optimal effect

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 15 of 28

Page 16: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 2. Facet injections

Indications and Rationale •! Commonly performed for spinal facet

syndrome, inflammation of facet joints •! Symptoms are variable and diagnosis

can be a challenge •! Pain can be overlying affected joints, or

may be referred •! Innervation of facet joints by medial

branch of dorsal rami of spinal nerves •! Facet injections can be both diagnostic

and therapeutic

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 16 of 28

Page 17: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 2. Facet injectionsContraindications •! Coagulopathy. Patient should discontinue anticoagulative

medication (coumadin). Check INR, PT, PTT. •! Allergy to contrast. Procedure can be modified and performed

without contrast. •! Contraindication to steroids use (ulcers, active infection)

Preparation •! Prone position on fluoroscopy suite or CT table •! Sterile preparation of lower back and drapes •! 1% buffered lidocaine for skin local anesthesia •! 25 gauge (or 22 gauge) 3.5 to 5 inch needle (longer if obese) •! Syringes for local anesthetic, contrast, and steroid •! Mixture of 2-3 cc of 0.5% Marcaine and 80 mg of Kenalog •! Conscious sedation not necessary. IV midazolam and fentanyl can

be given if required Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 17 of 28

Page 18: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 2. Facet injectionsAnatomy •! Facet joints are synovial joints with joint capsule, articular cartilage

and synovium •! Osseous components include the superior articulating process

from the caudal spinal segment and inferior articulating process from the rostral spinal segment

•! Innervation from medial branch of the dorsal ramus of spinal nerve from the corresponding level and variably from a level above and below

Dorsal ramus of spinal nerve

Medial branch of dorsal ramus

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 18 of 28

Page 19: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 2. Facet injections

Procedure •! Needle insertion at appropriate

level with small incremental advances under fluoroscopy or CT guidance

•! Confirm placement of needle in joint with contrast

•! Spot image is obtained •! Mixture of Marcaine and Kenalog is

injected into facet joint space •! Where equipment is available,

pulsed radiofrequency ablation can be performed on medial branch of dorsal ramus

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 19 of 28

Page 20: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 2. Facet injections

Complications •! Bleeding •! Infection •! Injury to vessel or nerve •! Contrast reaction •! Vasovagal reaction •! Non-response to therapy

Post Procedure •! Monitoring of vital signs •! Home care instructions for potential complications, ie. Infection •! Initial pain reduction from local anesthetic •! Steroid effects may gradually take effect after 1-2 day delay •! May require repeat series of injections for optimal effect

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 20 of 28

Page 21: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 3. Lumbar nerve root block

Indications and Rationale •! For diagnosis of radicular pain when

etiology is uncertain •! For therapeutic block of spinal nerve

causing radicular pain following successful diagnosis

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 21 of 28

Page 22: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 3. Lumbar nerve root blockContraindications •! Coagulopathy. Patient should discontinue anticoagulative

medication (coumadin). Check INR, PT, PTT. •! Allergy to contrast. Procedure can be modified and performed

without contrast. •! Contraindication to steroids use (ulcers, active infection) Preparation •! Prone position on fluoroscopy suite or CT table •! Sterile preparation of lower back and drapes •! 1% buffered lidocaine for skin local anesthesia •! 25 gauge (or 22 gauge) 3.5 to 5 inch needle (longer if obese) •! Syringes for local anesthetic, contrast, and steroid •! Mixture of 2-3 cc of 0.5% Marcaine and 80 mg of Kenalog •! Conscious sedation not necessary. IV midazolam and fentanyl can

be given if required Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 22 of 28

Page 23: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 3. Lumbar nerve root block

Anatomy •! Nerve root exit the neural foramen in the lumbar region inferior to

adjacent pedicle •! Ganglion is located in the lateral aspect of neural foramen •! Postganglionic portion of lumbar exiting nerve root tracks

anteroinferiorly under the mid transverse process the level below

Procedure (Lumbar Postganglionic) •! Superior aspect of mid transverse process is

targeted inferior to level of desired nerve root •! Needle insertion with small incremental

advances under fluoroscopy or CT guidance

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 23 of 28

Page 24: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 3. Lumbar nerve root blockProcedure (continued)

•! Paresthesia felt by patient when needle is at the target nerve

•! Confirm placement of needle by nerve root with contrast

•! Spot image is obtained •! For diagnostic block, 2-3 cc of 1% lidocaine is

injected •! For therapeutic block, mixture of Marcaine and

Kenalog is injected

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 24 of 28

Page 25: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 3. Lumbar nerve root blockProcedure (Lumbar Periganglionic) •! For periganglionic block (transforaminal

epidural injection), neural foramen is targeted •! Needle insertion with small incremental

advances under fluoroscopy or CT guidance •! Needle is directed to the neural foramen at the

rostral pedicle •! Confirm placement of needle by nerve root with

contrast, frequently contrast will extend into epidural space

•! Spot image is obtained •! For diagnostic block, 2-3 cc of 1% lidocaine is

given •! For therapeutic block, mixture of Marcaine and

Kenalog is injected

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 25 of 28

Page 26: Image-guided Spine Procedures for Relief of Severe

ASSR 2007 3. Lumbar nerve root block

Complications •! Bleeding •! Infection •! Injury to vessel or nerve •! Contrast reaction •! Vasovagal reaction •! Non-response to therapy Post Procedure •! Monitoring of vital signs •! Home care instructions for potential complications, ie. Infection •! Initial pain reduction from local anesthetic •! Steroid effects may gradually take effect after 1-2 day delay

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 26 of 28

Page 27: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

VI. Conclusion•! Back pain is a major problem requiring

countless emergency room visits •! Significant physical, emotional, and

healthcare costs •! Image-guided spine procedures can

diagnose and relieve severe back pain •! Image-guided spine procedures can

help delay or avoid more invasive surgical procedures •!Many patients have improvement in

quality of life

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 27 of 28

Page 28: Image-guided Spine Procedures for Relief of Severe

ASSR 2007

References Brown D. Atlas of Regional Anesthesia. 2nd Ed. Saunders 1999. Williams A and Murtagh FR. Handbook of Diagnostic and Therapeutic

Spine Procedures. Mosby 2002. Amirsys StatDX website. http://my.statdx.com

AcknowledgementsSome of the images were adapted from the University of Rochester Neuroradiology website. http://www.urmc.rochester.edu/radiology/ Thanks to Margaret Kowaluk for PowerPoint slide design and arrangement.

Presentation material is for education purposes only. All rights reserved. ©2007 URMC Radiology Page 28 of 28