interventional spine service at chi-st. francis: therapeutic and
TRANSCRIPT
Interventional Spine Service at CHI-St. Francis: Therapeutic and Diagnostic Procedures to Help Your
Patients
Dr. Nathan Murdoch, MD Heartland Radiology (GIRA)
CME presentation September 18, 2015
Disclosure
• Part owner of Grand Island Imaging Center
Objectives • Therapeutic Interventional Spine Procedures
– Epidural Steroid Injections • Cervical, Thoracic, Lumbar, Sacrum • Interlaminar versus Transforaminal
– Facet Injections – Sacroiliac Joint Injections – Intercostal injections – Kyphoplasty – Epidural Blood Patch
• Diagnostic Interventional Spine Procedures – Myelgrams – Discograms – Image guided percutaneous biopsy or disc aspiration – Lumbar Puncture (can infuse Methotrexate for Oncology patients)
Clinical Algorithm: Low Back Pain
Iannuccilli, J, et al. Interventional Spine Procedures for Management of Chronic Low Back Pain—A Primer. Semin Intervent Radiol 2013;30:307–317.
Intra-articular Facet Injection
Epidural Steroid Injections
• Diagnostic and Therapeutic – Precise anatomic delivery of pharmaceuticals
• Radicular Back Pain (nerve symptoms, good literature support)
• Axial Back Pain (limited support in literature) • Anatomy
– Interlaminar vsTransforaminal vs Caudal – Cervicothoracic, Lumbosacral
Epidural Steroid Injections
• Caudal: Least effective in literature – Least precise deposition of pharmaceutical
Johnson, B., et al. Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases. AJNR Am J Neuroradiol 20:697–705, April 1999.
Epidural Steroid Injections • Interlaminar: (Dorsal epidural space)
– With or without image guidance – Slightly more precise pharmaceutical deposition
Johnson, B., et al. Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases. AJNR Am J Neuroradiol 20:697–705, April 1999
Epidural Steroid Injections • Transforaminal (supraneural vs infraneural):
– Image guided access to ventral epidural space – Most precise pharmaceutical deposition to pain generators (disc
pathology, nerve impingements) – Diagnostic value
Johnson, B., et al. Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases. AJNR Am J Neuroradiol 20:697–705, April 1999
Epidural Steroid Injections • Evans 1930: Published “Intrasacral epidural
injection therapy in the treatment of sciatica.” – 100ml fluid injected into the sacral epidural space
diffuses throughout the spinal canal
• Barry and Kendall, 1962: Non-image guided interlaminar technique – “allow maximum concentration… at the level of
the lesion”. *Cleary, M., et al. The flow patterns of caudal epidural in upper lumbar spinal pathology. Euro Spine J. 2011. 20:804-
807. *Johnson, B., et al. Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases. AJNR Am J Neuroradiol 20:697–705, April 1999 *Barry PJ, Hume Kendall P. Corticosteroid infiltration of the extradural space. Ann Phys Med 1962;6:267–273
Importance of Image Guidance
Importance of Image Guidance
Importance of Image Guidance
How often IL ESI reaches ventral
• Imaging has helped us define how often material deposited in dorsal epidural space reaches the ventral epidural space
• IL epidural injection has unpredictable epidural spread
• Dorsal injectate reaches ventral epidural space only 47% of the time.
• Ventral epidural space thought to be location of pain generators
Weil, L, et al. Fluoroscopic Analysis of Lumbar Epidural Contrast Spread After Lumbar Interlaminar Injection. Arch Phys Med Rehabil Vol 89, March 2008.
Literature: Cervicothoracic • Both TFESI and ILESI have been reported efficacious in treating cervical
radiculitis • Prospective RCTs needed to compare techniques • ILESI reported potential complications: “dural puncture, bloating, nausea
and vomiting, vasovagal reaction, facial flushing, fever, nerve root injury, pneumocephalus, epidural hematoma, subdural hematoma, stiff neck, Cushing’s syndrome, transient paresthesias, hypotension, respiratory insufficiency, transient blindness, epidural abscess, paralysis, cord injury, and death”
• TFESI reported potential complications: “neck pain, transient increased radicular pain, nausea, vasovagal reaction, dural puncture, non-specific headache, transient lightheadedness, dyspepsia, fluid retention, transient global amnesia, vertebral artery injury, paralysis, cord infarction and cerebellar infarction, and death”
Huston, Christopher. Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review. Curr Rev Musculoskelet Med (2009) 2:30–42.
Literature: Lumbosacral • Ghahreman, Ferch, Bogduk. The Efficacy of Transforaminal Injection of Steroids for the Treatment of
Lumbar Radicular Pain. Pain Medicine. 2010. 11: 1149–1168. – Prosective double-blind RCT (n=150). – TFESI pts demonstrated statistically significant pain decrease compared to sham injections, and less future surgery
• Price, et al. Cost-effectiveness and safety of epidural steroids in the management of sciatica. Health Technology Assessment 2005; Vol. 9: No. 33.
– UK National Health Service Cost Effectiveness Study – RCT between 3 unguided lumbar ESI vs placebo (n=228). – Transient improvement in pain & function at 3 weeks, no difference 6-52 weeks – Did not change need for future surgery
• Ackerman, et al. The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations. ANESTHESIA & ANALGESIA. Vol. 104, No. 5, May 2007.
– RCT comparing TFESI, ILESI & Caudal ESI for lumbar radicular pain (n=90). – “The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to
a higher incidence of steroid placement in the ventral epidural space when the TF method is used.”
• Schaufele, et al. Interlaminar Versus Transforaminal Epidural Injections For The Treatment Of Symptomatic Lumbar Intervertebral Disc Herniations. Pain Physician Vol. 9, No. 4, 2006.
– Retrospective Case Control Series, TFESI vs ILESI (n=40) – TFESI more favorable than ILESI with short term pain score and long term need for future surgery
Epidural Steroid Injections
• Cervicothoracic: – Both TFESI and ILESI have been reported efficacious in
treating cervical radiculitis – Decision on technique likely more influenced by pt
presentation • Lumbosacral:
– Literature supports TFESI more than ILESI in terms of pain reduction and surgery sparing procedure
– IL may be warranted in certain circumstances (multilevel bilateral symptoms, TF route not anatomically feasible, adjunct to TF injection when TFESI will not spread centrally)
My Cases: Epidural Steroid Injections Cervical ILESI
• 47 yo male with neck pain and right greater than left C7 radicular symptoms. MRI shows C6/7 disc bulge with bilateral NF stenosis.
• Pre-procedural pain: 9/10 • 48 hour pain: resolved
C6/7 Cervical ILESI
Dorsal Epidural Fat
C6/7 ILESI 4 procedure images
Needle Positioned Epidural Contrast Spread
Bilateral Epidural Contrast
Steroid
Circumferential Epidural Spread
Cervical TFESI
• 52 yo M with C5/6 DOC contributing to left C5/6 NFS and left C6 radiculopathy.
• Pre-procedure pain: 8/10 • Immediate Post-Procedure: 0/10 (duration
several days)
Left C5/6 TFESI Vert artery Carotid Art
Dorsal Root Gang
Spinal Cord
Left C5/6 TFESI
Lumbar ILESI
• 80 yo F with chronic low back pain, axial more than radicular. Multilevel bilateral degenerative changes and spinal stenosis on MRI.
• Pre-procedure pain: 8-9/10 • Post-procedure pain: nearly resolved @ 24hr
(duration: several weeks)
L2/3 ILESI
L2/3 ILESI
Loss of resistance, venous opacification
Needle repositioned, epidural contrast
Epidural washout & spread
Lumbar TFESI
• 38 yo M with left paracentral L5/S1 disc protrusion and extrusion.
• Low back pain and radicular left leg pain in left L5 and S1 distribution 8/10
• Immediate Post-Procedure: Pain resolved
L5/S1 disc protrusion/extrusion Sag T2
Lateral Recess, S1 nerve Neural Foramen, L5 nerve
Ax T2. NF and LR stenosis
Ax T2. Disc extrusion along S1 nerve
Sag T2
Left L5 TFESI
Lateral needle placement Contrast Injection
Neural foraminal contrast
Central, ventral epidural contrast
Left L5 TFESI
Peripheral contrast
Central, ventral epidural contrast
Left L5 TFESI
Central, ventral epidural contrast
Left L5 TFESI
Central, ventral epidural contrast
Left L5 TFESI
Central, ventral epidural contrast
Facet Syndrome
• Highly innervated synovial joints that can contribute to back and neck pain.
• Facet Joint Syndrome: Signs and Symptoms – Local paraspinal tenderness – Pain with hyperextension, rotation, lateral bend,
straight leg raising – Low back stiffness (greatest in morning) – Low back, hip and thigh cramping pain (above knee)
• No Paresthesias, or radiating pain below knee Silbergleit, R, et al. Imaging-guided Injection Techniques with Fluoroscopy and CT for Spinal Pain Management. Radiographics. 2001. 21:4.
Facet Syndrome: Importance of Imaging
• Helbig and Casey described clinical criteria associated with therapeutic success of facet injections – Back pain with groin or thigh pain – Focal paraspinal tenderness – Pain with ipsilateral extension/rotation – Radiographic evidence of significant facet arthrosis
• Other studies have shown the degree of degenerative facet change on advanced imaging to correlate poorly with response to facet injection
• Quality MRI imaging excludes other source of pain
Helbig T, Casey KL. The lumbar facet syndrome. Spine 1988; 13:61– 64.
Silbergleit, R, et al. Imaging-guided Injection Techniques with Fluoroscopy and CT for Spinal Pain Management. Radiographics. 2001. 21:4.
Facet Syndrome Interventions: Systematic Literature Review
• Intra-articular Facet Injections: – Cervical: limited short-term and long-term – Lumbar: moderate short-term and long-term
• Medial Branch Blockade: – C/T/L spine: moderate short-term and long-term
• Medial Branch Neurotomy: – C & L spine: moderate short-term and long-term – Thoracic: Indeterminite
Boswell, M., et al. A Systematic Review of Therapeutic Facet Joint Interventions in Chronic Spinal Pain. Pain Physician 2007; 10:229-253.
Facet Injections
• Diagnostic and Therapeutic Value • Most important information obtained: Was
the pt’s typical pain relieved? • Standard practice to add long acting steroid
agent to short acting anesthetic • Up to 6 months pain relief
* Fenton and Czervionke. Image-Guided Spine Intervention. Saunders. 2003. Chap. 2.
* Boswell, M., et al. A Systematic Review of Therapeutic Facet Joint Interventions in Chronic Spinal Pain. Pain Physician 2007; 10:229-253.
Facet Injection
• 67 yo M with axial low back pain. MRI shows degerative facets.
• Pre-procedure pain: up to 8/10 • Post-procedure pain: 0/10
Bilat L3/4 and L4/5 facet injections
Bilat L3/4 facet injections
Left Right
Bilat L4/5 facet injections
Medial Branch Block (Facet Denervation)
• Bogduk defined medial branch of dorsal ramus of spinal nerve to innervate facet joint.
• Each facet innervated by medial branch nerve at that level, and level above
• Therefore, facet denervation involves rhizotomy at 2 levels
Silbergleit, R, et al. Imaging-guided Injection Techniques with Fluoroscopy and CT for Spinal Pain Management. Radiographics. 2001. 21:4.
Medial Branch Block • High percentage of
patients will have false positive response to Medial Branch Block
• Require 2 injections with positive response before consider rhizotomy (RFA) – Anesthetic alone or with
steroid • Positive response to
Medial Branch Block: 50-80% reduction in pain
Iannuccilli, J, et al. Interventional Spine Procedures for Management of Chronic Low Back Pain—A Primer. Semin Intervent Radiol 2013;30:307–317.
Medial Branch Radiofrequency Ablation (Facet Denervation)
• Effective when patients have shown positive response to facet injections and medial branch blocks
• Longer pain relief than intra-articular injections (1-2 years)
* Lau, P, Bogduk, N, et al. The Surgical Anatomy of Lumbar Medial Branch Neurotomy (Facet Denervation). Pain Medicine. Vol 5. No. 3. 2004.
* Fenton and Czervionke. Image-Guided Spine Intervention. Saunders. 2003. Chap. 3
SI Joint Injections
• Low back pain can be difficult to localize • Chronic LBP without radiculopathy • Diagnostic and Therapeutic value • Image-guidance essential for accurate intra-
articular needle tip placement – Only 22% intra-articular injectate with clinical
guidance alone • Immediate pain relief: 50-80% of pts • Duration of pain relief: 10 +/- 5 months
* Fenton and Czervionke. Image-Guided Spine Intervention. Saunders. 2003. Chap. 6.
SI joint anatomy
• 2 part articulation between sacrum and ilium – Synovial lined cartilaginous joint
• Inferior ½ to 2/3 of joint
– Fibrous articulation
• Obliquity of joint varies along its course, and among individuals
• Innervation of SI joint from dorsal rami of S1-4 nerve roots
* Fenton and Czervionke. Image-Guided Spine Intervention. Saunders. 2003. Chap. 6.
SI joint injection
• 41 yo F with right SI joint pain clinically.
Right SI joint injection
Synovial irregularity, could indicate synovitis.
Intercostal Nerve Block
• 85 yo F with 8-9/10 left rib pain after spell of coughing. CR and CT show emphysema, otherwise negative.
• Pre-procedure pain: 8-9/10 • Post-procedure pain: 3/10 • 24-hr post procedure pain: 0/10
Intercostal Nerve Block
No left rib fractures
Left 4-7 Intercostal Nerve Block
Kyphoplasty • Vertebral Compression
Fractures • Definition: “a fracture
causing loss of height of the vertebral body either by trauma or by pathology; it occurs most commonly in thoracic and lumbar spines. A common sequela of osteoporosis.”
Image courtesy of Medtronic, Inc.
Stedman’ Concise Medical Dictionary For The Health Professions. 4th Edition. LWW. Philadelphia. 2001. Page 209.
Quality of Life Impairment
• ADL’s limited: 24.6% • Difficulty standing > 2hr: 46.9% • Difficulty bending: 21.9% • Difficulty transitioning in/out of auto: 39.5% • Difficulty putting on socks: 27.2% • Reaching over head: 29.0%
Tosteson et al. Impact of Hip and Vertebral Fractures on Quality-Adjusted Life Years, Osteoporosis International. 2001. 12:1042-49.
Increased Mortality Rate with VCF • FIT trial (Fracture
Intervention Trial) • 6459 postmenopausal
females, age 55-81, with low BMD
• 907 pts with symptomatic fracture
• 3.8 year follow up • 6-fold mortality increase
with hip fx • 9-fold mortality increase
with spine fx – Deaths/1000 person years
Cauley, J, et al. Risk of Mortality Following Clinical Fractures. Osteoporosis International. August 2000, Volume 11, Issue 7, pp 556-561
Patient Demographics
• Osteoporosis (84%) – Age related – Medication side-effect – Systemic Illness
• Pathologic fractures (11%) – Primary or Metastatic tumor
• Trauma in Non-Osteoporotic Pts. (5%) • Gender
– Female (69%) – Male (31%)
Layton, Thielen, Koch, Luetmer, Lane, Wald & Kallmes. Vertebroplasty, First 1000 Levels of a Single Center: Evaluation of the Outcomes and Complications. AJNR. 28: 683-89. April 2007.
VCF Treatment Algorithm
Brunton et al. Vertebral Compression Fractures in Primary Care. Journal of Family Practice. Sep., 2005. 781-88.
MRI Helpful?
Very Important
VCF Imaging Workup
• Radiographs • MRI • CT • Nuclear Medicine Bone Scan
Radiographs, with comparison
12/27/13 01/15/14
MRI
* Statistically significant difference in clinical response favoring patients with bone marrow edema (BME) on pretreatment MR imaging over patients without BME.
Voormolen, M, et al. Pain Response in the First Trimester after Percutaneous Vertebroplasty in Patients with Osteoporotic Vertebral Compression Fractures with or without Bone Marrow Edema. AJNR Am J Neuroradiol 2006;27:1579-85.
T8
T12
Sag T1 Sag T2 Sag STIR
Edema
Edema
Fluid Filled Fracture Cleft
MRI
*This retrospective review identified a trend toward better outcomes 6 to 12 months after treatment when compared with individuals whose treated levels did not demonstrate clefts.
Lane, JI, Timothy P. Maus, John T. Wald, et al. Intravertebral Clefts Opacified during Vertebroplasty: Pathogenesis, Technical Implications, and Prognostic Significance. AJNR Am J Neuroradiol 2002;23:1642-46.
CT with Bone Scan
*This retrospective paper demonstrated that increased activity identified by bone scintigraphy is highly predictive of a positive clinical response to percutaneous vertebroplasty.
Maynard, AS, Mary E. Jensen, Patricia A. Schweickert, William F. Marx, John G. Short, and David F. Kallmes. Value of Bone Scan Imaging in Predicting Pain Relief from Percutaneous Vertebroplasty in Osteoporotic Vertebral Fractures. AJNR Am J Neuroradiol 2000;21:1807-12.
L2 L2
L2
Contraindications
• Asymptomatic VB compression fractures • Patient improving with medical therapy • Ongoing local or systemic infection • Retropulsed bone fragment resulting in
myelopathy or symptoms • Spinal canal compromise secondary to tumor
resulting in myelopathy • Uncorrectable coagulopathy • Allergy to bone cement
Kandarpa, K. Handbook of Interventional Radiologic Procedures. 4th Ed. LWW. Philadelphia. 2011. Pages 627-32.
Quality Imaging & Interpretation Matters! Good Clinical Exam Matters!
Sag T1 Sag T2 Sag STIR
Ax T2
MRI images obtained at outside facility
Quality Imaging & Interpretation Matters! Good Clinical Exam Matters!
• Low tesla open MRI: Interpretation: “mild spinal canal narrowing” – I recognized severe canal compromise, with cord
compression – I was suspicious of underling myelopathic changes not
detected by low tesla open MRI • My clinical exam: Patient with new and
progressing lower extremity and bladder neurologic symptoms.
• I called clinician. Case was cancelled. Patient undergoes RT.
FREE (Fracture Reduction Evaluation)
Boonen, et al. Balloon Kyphoplasty for the Treatment of Acute Vertebral Compression Fractures: 2-Year Results From a Randomized Trial. J of Bone and Mineral Research. 26:7. July, 2011. 1627-37.
FREE Study
• Prospective, randomized non-blinded trial comparing kyphoplasty with non-surgical therapy for treatment of acute VCF. – Feb. 2003-Dec. 2005 – 21 centers in 8 countries – 24 month follow up
• 300 pts enrolled (1279 screened, 232 @ 24 mo) – 149 kyphoplasty (120 @ 24 mo) – 151 non-surgical therapy (112 @ 24 mo)
• Standard practices (analgesics, bed rest, bracing, PT, walking aids, Calcium, Vit. D, antiresorptive or anabolic agents)
FREE Study
• Inclusion Criteria – Adults with 1-3 acute VCF from T5-L5 – Bone Marrow Edema on MRI – ≥ 15% vertebral height loss – Local investigator determined “painful” – VAS pain score ≥ 4/10 – Pain ≤ 3 months
FREE Study
FREE Study
FREE Study
FREE Study
* Kyphoplasty patients had 136 fewer limited activity days compared with Non-surgical management control patients.
Impact on Patient Mortality
Edidin, A, et al. Mortality Risk for Operated and Nonoperated Vertebral Fracture Patients in the Medicare Population. JBMR. Vol. 26, No. 7, July 2011, pp 1617–1626.
Impact on Mortality
• 100% U.S. Medicare Data Set from 2005-2008 • 858, 978 VCF patients identified • 119,253 Kyphoplasty patients • 63,693 Vertebroplasty patients • 4 year assessment • Survival determined by Kaplan-Meier
Impact on Mortality
• Percutaneous Cement Augmentation (Vertebroplasty & Kyphoplasty) associated with increased survival compared with non-operated patients
• Kyphoplasty associated with increased survival compared with vertebroplasty
MZ, 88 yo Female
• 1 month history of acute “1000/10” mid-back pain standing from sitting position
• “Takes my breath away”, “every breath hurts” • Activities of Daily Living limited
– “Walking is impossible” – Unable to complete physical therapy b/c pain
• Narcotics make her nauseated. Tylenol not working.
• Acutely point tender on palpation over T9 • Initial X-rays at clinic office “negative”
Large FOV Sag T2
Acute T9 VCFX
Thoracic Spine MRI, SFMC Grand Island, NE
Old compression fx
Degenerative changes
Sag T1 Sag T2 Sag STIR
Edema
Edema
Fluid Filled Fracture Cleft
Minimal Posterior Retropulsion
T9 Kyphoplasty, Bone Access Needle Advanced
Co-Axial Manual Drill Advanced
Co-Axial Balloon Inflated
Coaxial Filler Needle, Cement Injected
Needles Removed
Fracture Cleft Filled
Post-Procedure Clinical Results
• Pre-Procedural pain: “1000/10”, “every breath hurts”
• Immediate post-procedure pain score (still on table): “0/10”, “you must have a magic wand”
• 2-hr post procedure pain score: 0/10. – Patient up walking halls with physical therapist,
smiling. – “Boy, I’m sure glad I met you Dr. Murdoch”
Spontaneous Intracranial Hypotension Secondary to Nerve Root Sleeve Diverticulum
• Clinical: Postural Headache • Imaging:
– Brain MRI with contrast: features of CSF hypotension
– CT myelogram: Nerve Root Sleeve Diverticulum • Commonly at Cervical/Thoracic junction
• Treatment: – CT guided epidural blood patch directed toward
leak or NRSD
Kranz, J, Gray, L, et al. CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol. May, 2011. 32:832–38.
CT-guided Epidural Blood Patch (NRSD)
• 8 patients referred for treatment, with post-procedural imaging
• 7 of 8 had nerve root sheath diverticuli • Symptom duration: 11.5 months (average) • 3 of 8: previous non-targeted epidural blood
patches • All pts demonstrated resolution of postural HA • All treated patients demonstrated resolution of
MRI findings of CSF hypotension Kranz, J, Gray, L, et al. CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol. May, 2011. 32:832–38
CT guided Epidural Blood Patch
• 65 yo M with severe postural headaches, 9/10 upright and 2/10 laying down. Imaging evidence of pachymeningeal enhancement, subdural collections, concerning for possible spontaneous CSF hypotension. No trauma. Multilevel nerve root sheath diverticulum in spine on CT myelogram.
• Post-procedural pain: 0/10 • 4 month follow-up: 0/10
Pre-procedural, September 2014
Ax T2 FLAIR Ax T1 post-contrast Cor T1 post-contrast
CT Myelogram, looking for CSF leak
• Multiple Nerve Root Sheath Diverticuli
C7/T1 L2/3 L3/4
CT guided multi-level Epidural Blood Patch
C7/T1 L2/3
Follow-up MRI 7 months later
Sep, 2014
April, 2015
*Resolution of SD collections, pachymeningeal enhancement, and postural HA
Interventional Spine: Diagnostic
Lumbar CT Myelogram
Cervical Puncture CT Myelogram
Cervical Puncture CT Myelogram
Cervical Puncture CT Myelogram
Discogenic Pain: Discogram
• Contrast injected into disc nucleus pulposus • Clinical Diagnostic Response: assess pain
response with injection • Imaging Diagnostic Value: fluoroscopic and post-
procedural CT imaging. • Discography more sensitive in detecting internal
disc disruption than MRI • Variable clinical utility in terms of clinical decision
making. • Discogenic pain difficult to treat effectively.
* Fenton and Czervionke. Image-Guided Spine Intervention. Saunders. 2003. Chap. 9.
Discogram
• 39 yo F with prior L4/5 Fusion and PL stabilization. Severe persistent low back pain, presumed discogenic etiology based on MRI and clinical assessment
• Discogram ordered for preoperative planning
MRI- L3/4 annular disc tear above fusion
Sag STIR
Fluoro 1mL each 2mL each 2mL & 2.5mL
CT
L2/3 L3/4
Disc Bx and Aspiration
• 61 yo F with extreme LBP
Fluoro
Culture Positive for bacteria.
Flouro Guided Disc aspiration and VB biopsy
• 90 yo male with low back pain • MRI: Compression Fx at L1 (unchanged), VB
edema at L1 and L2, abnormal L1/2 and L2/3 disc signal
• Bone Scan: L1/2 abnormal uptake • Elevated PSA • Elevated CRP (and increasing) • Anticoagulated • Kyphoplasty requested
Disc Aspiration and VB bx
2013 Sag T1 2013 Sag STIR 2015 Sag T1 2015 Sag STIR
L1 L1 L1
L1
Disc Aspiration and VB bx
L1 and L2 increased radiotracer activity
L1/2 Disc Aspiration
Disc aspiration and VB bx
L2 VB bx L1 VB bone bx
CT guided T10 VB bone lesion biopsy
• 76 yo F with hx of smoking, multiple lung nodules and bone lesions, all hypermetabolic on PET-CT.
• Percutaneous T10 VB lesion bx
Lung and Bone lesions
CT guided T10 VB biopsy
Pathology: Lung CA primary
Works Cited 1. Ackerman, et al. The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations. ANESTHESIA & ANALGESIA. Vol.
104, No. 5, May 2007. 2. Barr, et al. Position Statement on Percutaneous Vertebral Augmentation, A Consensus Statement… JVIR. 2014. 25: 171-181. 3. Barry PJ, Hume Kendall P. Corticosteroid infiltration of the extradural space. Ann Phys Med 1962;6:267–273 4. Berenson, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in
patients with cancer: a multicentre, randomized controlled trial. (CAFÉ Study) Lancet Oncol. 2011 Mar;12(3):225-35. 5. Boonen, et al. Balloon Kyphoplasty for the Treatment of Acute Vertebral Compression Fractures: 2-Year Results From a Randomized Trial. J of
Bone and Mineral Research. 26:7. July, 2011. 1627-37. 6. Boswell, M., et al. A Systematic Review of Therapeutic Facet Joint Interventions in Chronic Spinal Pain. Pain Physician 2007; 10:229-253 7. Brunton et al. Vertebral Compression Fractures in Primary Care. Journal of Family Practice. Sep., 2005. 781-88. 8. Burge, R, et al. Incidence and Economic Burden of Osteoporosis-Related Fractures in the United States, 2005–2025 Journal of Bone and Mineral
Research. Volume 22, Issue 3, pages 465-475, 4 DEC 2006 9. Calmels, V., J.-N. Vallée, M. Rose, and J. Chiras. Osteoblastic and Mixed Spinal Metastases: Evaluation of the Analgesic Efficacy of Percutaneous
Vertebroplasty. AJNR Am J Neuroradiol 2007;28:570-74 10. Cauley, J, et al. Risk of Mortality Following Clinical Fractures. Osteoporosis International. August 2000, Volume 11, Issue 7, pp 556-561. 11. Cleary, M., et al. The flow patterns of caudal epidural in upper lumbar spinal pathology. Euro Spine J. 2011. 20:804-807. 12. Eck, et al. Comparison of Vertebroplasty and Balloon Kyphoplasty for Treatment of VCFs: a Meta-analysis of the Literature. Spine J. 2008 May-
Jun;8(3):488-97 13. Edidin, A, et al. Mortality Risk for Operated and Nonoperated Vertebral Fracture Patients in the Medicare Population. JBMR. Vol. 26, No. 7, July
2011, pp 1617–1626. 14. Fenton and Czervionke. Image-Guided Spine Intervention. Saunders. 2003. 15. Garfin, et al. Kyphoplasty and Vertebroplasty for the Treatment of Painful Osteoporotic Compression Fractures. SPINE. 26:14. 2001. 1511-15. 16. Ghahreman, Ferch, Bogduk. The Efficacy of Transforaminal Injection of Steroids for the Treatment of Lumbar Radicular Pain. Pain Medicine.
2010. 11: 1149–1168. 17. Helbig T, Casey KL. The lumbar facet syndrome. Spine 1988; 13:61– 64 18. Huston, Christopher. Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review.
Curr Rev Musculoskelet Med (2009) 2:30–42. 19. Iannuccilli, J, et al. Interventional Spine Procedures for Management of Chronic Low Back Pain—A Primer. Semin Intervent Radiol 2013;30:307–
317. 20. Jenson, M, Evans, Mathis, Kallmes, Cloft, Dion. Percutaneous Polymethylmethacrylate Vertebroplasty in the Treatment of Osteoporotic Vertebral
Body Compression Fractures: Technical Aspects. AJNR. 18:1897-1904. Nov. 1997.
21. Johnson, B., et al. Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases. AJNR Am J Neuroradiol 20:697–705, April 1999.
22. Kallmes, D, et al. A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures. NEJM. 361;6 nejm.org. 8/6/2009. 23. Kandarpa, K. Handbook of Interventional Radiologic Procedures. 4th Ed. LWW. Philadelphia. 2011. Pages 627-32. 24. Klazen, C, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label
randomized trial. Lancet. Pu Online Aug. 10, 2010. 25. Knavel, E., K.R. Thielen, and D.F. Kallmes. Vertebroplasty for the Treatment of Traumatic Nonosteoporotic Compression Fractures . AJNR Am J
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