Transcript Injection
Chapter
25
Peripheral Joint , Soft Tissue & Spinal Injection
Alireza Ashraf, M.D.
Associate Professor of Physical Medicine & Rehabilitation Shiraz Medical school
1901
Cathelin -
---
epidural with cocain
1951
Hollander -
----------------------
hydrocortisone
1957
Lievre
-
----------------------------------------------------------- -----------
epidural with corticosteroid
Robecchi
&
Capra
-
--------------------
S1
Pain sources within joints :
capsule , synovium tendons , and ligaments, periosteum.
Common spine pain
: facet joint , sacroiliac joint , nerve root (spinal nerve) and intervertebral disk.
R heumatoid arthritis ,O steoarthritis S pondyloarthropathies ,G out, P seudogout ,B ursitis ,A dhesive capsulitis ,T endonitis ,A xial spine pain , S ympathetic-mediated disorders and R adiculopathy.
INJECTION MATERIALS
.
The mechanism that allows local anesthetics to provide
pain relief
is the reversible neural blockade
…
blocking
sodium channels …….
Local anesthetics
Local anesthetics can have side effects locally or systemically seizures , respiratory arrest , convulsions , confusion , death , tremor , sluggishness , twitches , drowsiness , blurred vision , incoherent speech , light-headedness , cardiac depression , malignant hypertension, and anaphylaxis.
Corticosteroid
Corticosteroids have two mechanisms:
antiinfiammatory
&
immunosuppressive
.
Corticosteroids have been utilized for treatment of musculoskeletal pain because of their antiinflammatory properties……………………………………………….
They have also been reported to have a direct membrane-stabilizing effect, which leads to decreased afferent ectopic discharges at the neural membrane…………..
There is a reversible inhibition of nociceptive C -fiber transmission with local application of corticosteroids.there has been no demonstration of A or B fiber transmission interruption………………..
Corticosteroids have a modulation effect on spinal cord……………………….
Betamethasone
,
Dexamethasone
,
Hydrocortisone
,
Methylprednisolone
,
Prednisolone
and
Triamcinolone
.
Adverse corticosteroid reactions
Skin hypopigmentation , subcutaneous fat atrophy , tendon rupture , fluid retention , flushing , hyperglycemia , change in taste , insomnia , malaise and dyspepsia ………………………………………… Systemic suppression of the adrenal glands can happen after a local injection of corticosteroids into any structure lead to a cushingoid appearance ……… Repeated injections of corticosteroids can …………….
Non-ionic contrast agents include metrizamide ( Amnipaque ), iopamidol ( Isovue ), and iohexol ( Omnipaque )……………. These are used in conjunction with injections………………..
fluoroscopy for needle tip localization in performing spinal injection procedures and some peripheral joint The use of contrast significantly reduces the risk of an unintended injection into a vascular area , blood vessel or subarachnoid space………………
The adverse effects that can result from the use of contrast agents are due to local tissue toxicity and to anaphylaxis ……………………………………………………..
Greater than 90% of adverse reactions occur within the first 15 min…………………………………………………….
other side effects : nausea , headache , and emesis …..
Pretreatment is recommended with steroids and antihistamines 12 h, and again at allergic reaction history……………….
2 h, prior to the procedure in patients with an
Gadolinium is a viable alternative for patients with contrast material allergies, and provides adequate visualization for spinal injection procedures………………………
GENERAL CONSIDERATIONS
Answer all questions. provide the patient with a clear explanation of the risks and benefits……………………………………………… Caution should always be used to avoid the risk of bleeding. Patients using should discontinue it for at least patients cannot tolerate being off aspirin, a non-selective NSAID aspirin 7 days. If can be substituted for at least the 3 days prior to any injection… Women who are pregnant or suspected to be pregnant should avoid radiation exposure from fluoroscopy ………………….
The patient is properly positioned on the procedure table before beginning the injection………………………………………………… Prepare and drape the injection site in a sterile manner with povidone-iodine ( Betadine ), chlorhexidine gluconate ( Hibiclens ), and/or isopropyl alcohol …………. Sterile gloves are worn during the injection procedure………………………………….
Gown , cap , and mask are used when performing myelography and diskography ….
Intravenous or oral antibiotics are used when performing injection procedures in patients with implanted prosthetic devices or with a history of mitral valve prolapse…….
The injection site can be anesthetized for patient comfort with a vapocoolant spray OR anesthetic cream injection…………………. prior to
The needle is always aspirated via the syringe before the injection to avoid an intravascular or, in the case of some spinal procedures, an intrathecal injection………… Avoid injecting into a ligament, a tendon, or the periosteum .
This means repositioning the needle if there is significant resistance……………………………… Avoid needle contact with articular cartilage surfaces during joint injections …………………………………………..
The injection is given slowly , with steady pressure …………..
A dressing is applied to the injection site after the injection is completed……….
The patient is encouraged to rest the area after the injection for several days, especially if it is a major weight bearing joint…………… All patients should be driven home and should not drive for the next
…………
CONTRAINDICATIONS
Absolute contraindications Bacteremia *** Joint infection *** Cellulitis *** Skin ulcerations *** Osteomyelitis *** Infectious arthritis *** Epidural abscess pregnant patien *** Joint injections requiring fluoroscopy in the **********************
Relative contraindications
Chronic infection distant from the injection ** Allergy to the injection solution ** Latex allergy ** Diabetes mellitus ** Allergy to contrast agents for fluoroscopically ** Altered anatomy( surgery or congenital ) **
Tendons and ligaments can be ruptured if corticosteroids are injected directly into them (
this is estimated to occur in less than such cases 1%
) …………………………..
of
Patients requiring anticoagulation medication or with a known bleeding diathesis should be approached with a great deal of caution…………………………..
Coagulation parameters should be evaluated in these cases, including : prothrombin time ( INR ) and ,,,, activated partial thromboplastin time ,,,, international normalized ratio platelet level count ……
Injections should be avoided with prolonged bleeding times , an INR and a platelet count of less than 100 000 greater than per ml…….
1.2
EFFICACY
Improvement in rheumatoid synovitis has been seen to last for as long as
3
months after injecting glucocorticoids, with improvement in pain and in knee extensor strength…………………………………….
intraarticular injections of hyaluronan ( hyaluronic acid,,,,,, hyaluronate ) were more effective than placebo in reducing improving joint function osteoarthritis of the knee…………… pain from and
A small randomized controlled trial found no significant difference between intraarticular injections of methylprednisolone plus lidocaine ( lignocaine ) versus lidocaine alone was a groups at 24 for the treatment of shoulder pain, although there small improvement in pain and range of motion in both weeks……………………………….
Acromioclavicular joint
The injection is performed with the patient in the seated position with the upper limb resting comfortably……………………………….
The acromioclavicular joint is located at a depressed and soft region distal to the end of the clavicle……………………………………..
The injection site is anterior and superior to acromioclavicular joint ……………………………………… The needle is then advanced inferiorly into the joint……………..
Glenohumeral joint
The glenohumeral joint is typically injected from either an anterior or a posterior approach……………………… In the anterior approach , a needle is inserted lateral to the coracoid process while avoiding the thoracoacromial artery .The needle is then directed dorsally and medially into the joint space…………
The posterior approach by placing the patient's hand across the chest on the opposite shoulder. The needle is inserted 3 is set up cm below the posterolateral 2 aspect of the acromion. The needle is then advanced toward the coracoid process in an anterior and medial direction into the joint.
Subacromial bursa
The subacromial bursa lies above the supraspinatus tendon and under the acromion……………………………………………..
A posterolateral approach is used to place the needle into the subacromial space.The needle is inserted underneath the palpable posterolateral cornerof the acromion and advanced toward the coracoid process,which places the needle tip under the acromion………………………….
Ulnohumeral(elbow)joint
The elbow joint consists of three articulations between the humerus , ulna and radius , with the true elbow joint formed by the humerus and ulna………….
Injection of the ulnohumeral joint is accomplished from a posterolateral or posterior approach with the elbow flexed between 50 and 90°…………………..
In posterolateral approach needle is inserted in the posterolateral triangle formed by the palpable , the olecranon , lateral epicondyle and radial head ………………………………………………… The needle is directed medially away from the ulnar nerve and proximally toward the head of the radius. A lack of resistance indicates entry of the needle tip into the joint………………………………….
The
posterior approach
elbow joint involves inserting the needle in between the to the posterior olecranon and lateral epicondyle , advancing the needle until there is a loss of tissue resistance ( indicating that the needle tip is within the joint ) ………………………….
Medial and lateral epicondyle
Medial epicondylitis or elbow ', results from degenerative 'golfer's tendonosis or changes at the tendon attachment of the wrist flexor and pronator muscle groups. The elbow is positioned in abduction,with the forearm in supination.A needle is inserted at the site of tenderness along the medial epicondyle and advanced until there is contact with the periosteum.The needle is slightly withdrawn before the injection……………
Lateral epicondylitis 'tennis elbow', or is a tendonosis from repetitive wrist extension and forearm supination. The elbow is flexed to 45° and the forearm is placed in pronation. A needle is inserted at the point of tenderness along the lateral epicondyle and advanced to the periosteum………..
Olecranon bursa
Olecranon bursitis or 'draftsman's elbow ', occurs in RA, crystal arthropathies, and repetitive trauma. The needle is directed toward the olecranon bursa, which is superficial to the olecranon and external to the elbow joint ………………….
Injection of the olecranon bursa should be preceded with aspiration is a purulent discharge and no corticosteroids should be injected if there ……………….
Carpal tunnel
Injection of the carpal tunnel can be approached in ulnar or radial orientation, based on positioning relative to the palmaris longus tendon…………………………………………..
The ulnar approach is preferred during the injection. . it is less likely to injure the median nerve The wrist can be flexed to increase the prominence of the palmaris longus tendon…………….
A needle is inserted with the wrist in a neutral position at a carpal ligament. 30° angle ulnar to the palmaris longus tendon at the distal wrist crease .The needle is then advanced in a distal and radial direction underneath the transverse The needle is withdrawn if paresthesias are experienced during the insertion, and redirected within the tunnel……..
Abductor and extensor pollicis tendon
De Quervain's tenosynovitis inflammatory disorder of the wrist involving the abductor pollicis longus extensor pollicis brevis needle is placed 1cm is an tendons. The proximal to the and styloid process at a 45° angle to the forearm alongside either tendon ………… The needle is repositioned before the injection if there are any paresthesias encountered from the radial nerve during needle insertion………………………
Greater trochanter and ischial bursae
The patient is placed in the lateral decubitus position, with the affected hip upright flexed to relax the hamstrings…….. and the knees The lateral hip and inferior buttock areas are palpated for the point of greatest tenderness over the greater trochanter and the ischial tuberosity, respectively………………
For both injection procedures, the needle is inserted through the skin and advanced until contact is made with the periosteum…………………………….. The needle is then slightly withdrawn so that the tip lies within the bursa………………………
Hip joint
Intraarticular injections of the hip joint require fluoroscopic guidance and contrast enhancement, whether using a lateral or an anterior approach. Anterior approach , the patient is placed in the supine position with the lower limb in external rotation . The needle is inserted at a site just inferior to the mid trochanteric line…………………………………
The needle is inserted at a site just inferior to the mid trochanteric line. The needle is inserted …..
45° toward the femoral neck, and advanced under fluoroscopic guidance through the capsule until contact with the periosteum………………………………
Knee joint
The knee joint is the most common joint site for both injection and aspiration. There are three possible approaches: medial , lateral , and anterior . The patient is positioned supine for aspiration, with the knee fully extended or slightly flexed. The superior medial or superior lateral approaches are generally held to be the best for arthrocentesis…………….. The patella is located by palpation and is the main landmark for localizing the entry site……………………………………………
For the superior lateral approach entry site is about 1 cm superior and lateral to the patella. The skin is penetrated using a large-gauge needle directed at 45° , the and advanced under the patella toward the medial side of the joint…………………………….
The needle is advanced into the joint, while applying negative syringe pressure, until synovial fluid starts to enter the syringe. The fluid aspiration can be aided by applying pressure to the medial aspect of the joint to displace the effusion toward the direction of the needle……………………….
For the superior medial approach , needle entry is 1 cm medial to the patella………………….. superior and The needle is directed under the patella and advanced toward the opposite patella midpole, midway between the medial border of the patella and the femur………………….
The advantage of the anterior approach is greater ease of entry into knees with advanced osteoarthritis , as well as for patients who cannot fully extend their knees………………………………… The downside to this approach is a greater risk for meniscal and articular cartilage injury……………..
For injections of corticosteroids without synovial fluid aspiration, the patient is positioned as described or with 90° of knee flexion ………………………………………. The entry site for injection with the knee in the flexed position can be on either the medial or the lateral aspect of the patellar tendon…………………………….. The joint is entered inferior to the patella, using a needle directed superiorly toward the intercondylar notch…………………………………………………
.
The inferior medial approach is technically easier for injection than the lateral approach if the patient can only slightly flex the knee…………………………………………
pes anserine bursa
The pes anserine bursa is located between the medial collateral ligament and the confluence of the sartorius , gracilis , and semi-tendinosus just distal to the joint line………………………………….. tendon insertion at the proximal medial tibia A needle is inserted at the site of greatest palpable tenderness perpendicular to the tibia, and advanced until contact is made with the periosteum………………………………
prepatella bursae
The prepatellar bursa is located between the skin and the anterior surface of the patella. The needle is inserted at the midportion of the superior patellar pole ………………………….
The bursa can be significant is size from inflammation, which often allows for fluid aspiration that can be aided by direct pressure over the patella before injection…………………………………………….
ANKLE JOINT
The ankle joint is formed by the tibia and talus (tibiotalar mortise), and is not one of the more commonly injected joints………………………………………………… The main indication for injecting the ankle is for pain secondary to osteoarthritis …………………………………..
The two approaches for performing an ankle joint injection are the medial and anterior anterior lateral ……………...
The talus is palpated with the foot in the neutral position. A horizontal line can be drawn between the medial and lateral sides of the ankle, just above the malleoli……………………………………
For the anterior medial approach , a soft spot is identified medial to the anterior tibial tendon and lateral to the medial malleolus………………………………..
The needle is inserted perpendicular to the tibial joint surface and advanced slightly laterally, superiorly, and posteriorly………………………………………… The injection is then given slowly after there is a decrease in tissue resistance indicating that the needle has entered the joint…………………………………………….
The anterior lateral approach is done with the patient positioned with the foot in plantar flexion…………………….
The needle is inserted from the anterior lateral position and directed posteriorly toward the medial malleolus ……………….. The needle again is advanced until there is a drop in tissue resistance confirming entry into the joint……………..
Tarsal tunnel
The patient is placed in a lateral decubitus position with the symptomatic foot down…………………….. The posterior tibial nerve is posterior to the posterior tibialis tendon, which is identified by resisting foot inversion. The needle is inserted behind the medial malleolus posterior to the tendon,at a before the 30° angle, and advanced a few centimeters injection……………………………………………
Plantar fascia
Plantar fasciitis is the most common problem of the hind foot, with inflammation that occurs at its medial attachment to the calcaneus………………… The needle is inserted at this location perpendicular to the calcaneus, and advanced until it hits periosteum. The needle is then repositioned and advanced distal to the plantar surface of the bone, placing the needle tip superior to the plantar fascia……………………………………….
The injection is then performed in this position, which avoids the superficial fat pad, the subcutaneous tissue, and the fascia that could otherwise lead to fat pad atrophy or tissue necrosis or rupture of the fascia……………………..
Achilles (retrocalcaneal, retro-Achilles) bursae
The the retrocalcaneal bursa is located between the calcaneus and the Achilles tendon, whereas retroAchilles bursa is located between the Achilles tendon and the skin.Either of these disorders can be mistaken for Achilles tendonitis or occur in combination with Achilles tendonitis ( Haglund syndrome )…
An injection of the bursa should be considered only in severe, disabling cases after failure of conservative treatment……………………………………..
The patient is forewarned about Achilles tendon rupture as a possible side effect of the corticosteroid injection…………………………………….. To locate the area of maximum tenderness , the Achilles tendon insertion site is palpated deep, superficial, and at the tendon. The retrocalcaneal bursa is injected deep to the tendon, whereas the retroAchilles bursa is injected superficial to the tendon……………………………………………………….
Morton's neuroma
Morton's neuroma perineural fibrosis the metatarsal is actually a of the common digital nerve as it passes between heads…………………. The neuroma most commonly occurs at the distal aspect of the third metatarsal space………………..
A needle is passed through the dorsal surface of the foot and advanced about pad………………… 1 cm proximal to the metatarsal web space. The needle is advanced deep enough to place the tip at the level of the neuroma, while at the same time avoiding the plantar fat
SPINAL INJECTION TECHNIQUES
Indications
R adiculopathy****************** SI joint************************ F acet joint********************* E pidurography****************** D iskography******************** M yelography******************** S ympathetic procedures*******
EPIDUROGRAPHY
.
Epidurography is utilized during epidural procedures to determine proper needle placement and to avoid intravascular or intrathecal injections………………………………….
MYELOGRAPHY
Myelography is a diagnostic procedure commonly combined with computed tomography (CT) for the evaluation of spinal pathology, including::::::::::::::::::::::: disk herniations , stenosis , tumors , infection ……………………………………
DISKOGRAPHY
Diskography is a procedure used to identify whether or not an intervertebral disk(s) is generating axial spine pain in the cervical, thoracic, or lumbar regions… Diskography is recommended after there has been no response to conservative treatment and traditional diagnostic modalities, such as (MRI), CT, myelography and EDX are unremarkable or not diagnostic……………..
Diskography is also used for surgical planning when considering an intradiskal procedure, such as intradiskal electrothermal therapy * fusion ***************************** artificial disk replacement *********
complications
I ntravascular or subarachnoid **** A llergic reaction ***************** A naphylactic reaction ************ V asovagal syncope ************** D ural puncture ******************* S pinal headache ***************** E pidural abscess ***************** E pidural
ALLERGY ------------- ANAPHYLAXY
Allergic or anaphylactic reactions can occur from either corticosteroids or radio-logic contrast material…………………………. Typically, contrast allergies occur at the time of the injections, and can quickly progress to an anaphylactic reaction with respiratory compromise………………..
Corticosteroid allergic the chest area. reactions are often delayed by up to a week, and present as an intense hot, erythematous flushing involving the neck, face, and occasionally Corticosteroid anaphylactic reactions often occur within 2-6 h after the injection……………………………………………… While there is concern regarding respiratory compromise, there have been no reported fatalities…………………………….
VASOVAGAL EPISODES
Vasovagal episodes can occur with any type of injection procedure, whether it is a joint injection or a spinal procedure, due to the noxious stimulation effect from the needle. Patients typically become diaphoretic , hypotensive , and bradycardic ……………………………………… Treatment is primarily supportive, including fluids and oxygen by removing the needle…….
, but begins with getting rid of the noxious stimulation
DURAL PUNCTURES
Dural punctures have a low reported incidence………………………………………….. Headaches resulting from dural puncture have been reported to range from 7.5% to 75%..................................... The use of smaller gauge needles with conical noncutting tips has been associated with fewer episodes of headaches………………………………………… Dural puncture headaches can occur 1-2 days after a translaminar or transforaminal epidural……………………….
SUBARACHNOID --------- INTRAVASCULAR INJECTION A subarachnoid or intravascular anesthetic injection can lead to periorbital numbness , disorientation , light headedness , nystagmus , tinnitus , complete sensory or motor block , muscle twitching , respiratory depression , and seizures ……………………. The risk of complications from intrathecal and intravascular injections of local anesthetic is proportional to the injected volume………………………
EPIDURAL ABSCESS
An epidural abscess is rare from an injection, and is more common with the use of an indwelling catheter …………………………………… . Patients with an abscess present with severe back pain , fever , and chills ………………………………………..
EPIDURAL HEMATOMA
The risk of epidural hematoma increases with anticoagulation but is rare in the presence of normal clotting factors……………………………………………… A hematoma can potentially lead to caudal equina compression in the lumbar spine, or cord compression in the cervical and thoracic spine………….. The presence of spinal stenosis increases this compression risk………….
Epidurals should be avoided in patients with a platelet count less than
100 000
less than per ml and a spinal canal midsagittal diameter 12 mm………………………
Complications of transforaminal epidural steroid injections (TFESIs)
Infection ************************* Allergic reaction ****************** Bleeding *************************
Injury to the radicular artery, particularly the artery of Adamkiewicz result of (lower thoracic and upper lumbar levels), or other collateral arteries within the foramen is believed to occur as a spasm , puncture , thrombosis , or embolization by corticosteroid particulate matter.
.
This complication might be reduced or eliminated by inserting needles into the posterior portion of the foramen, while avoiding injections in the presence of significant foraminal stenosis , using blunt tip needles , and injecting with non-particulate corticosteroids...............................
Complications from cervical facet injection
Vertebral artery puncture *************************** Motor and sensory block **************************** Phrenic and recurrent laryngeal nerve paralysis ***** Spinal cord trauma ********************************** Spinal anesthesia *********************************** Dural puncture ************************************** Intravascular injection ****************************** Chemical meningitis ******************************** Hematoma formation ******************************* Pneumothorax ************************************** Infection *******************************************
complications of SIJ injection
Posterior leakage of contrast into the dorsal sacral foramina,can affect the nearby neural structures such as L5 & lumbosacral plexus** Trauma to the sciatic nerve ****** Infection ************************* Adverse drug reactions ***********
complications from stellate ganglion blocks
Pneumothorax ******************* * central nervous system toxicity *** low blood pressure **************** phrenic nerve block *************** brachial plexus block ************* blockage of recurrent laryngeal ***
This procedure is rarely performed bilaterally, because of the risk of blocking the phrenic and recurrent laryngeal nerve………….
Complications from lumbar sympathetic blocks
lumbar plexus block ************** renal injection ******************** genitofemoral neuralgia *********** Hypotension ********************* * postdural puncture headache ***** spinal block **********************
complication from a myelogram
Postdural puncture headache the most common complication from a myelogram……………………….
is
Epidural hemorrhage is a reported complication of myelography……………….
Spinal cord puncture is another potentially serious complication when cervical myelography is performed with a lateral Cl, C2 approach……………………..
This risk can be eliminated by using a lumbar puncture to instill contrast for a cervical myelography………………………….
complications from diskography
diskitis , nerve root injury , bleeding , allergic reaction , subarachnoid puncture , soft tissue infection and chemical meningitis ……………………………………… The incidence of diskitis can be reduced with meticulous aseptic technique prophylactic antibiotics and , two-needle technique…………………………………………..
EFFICACY
.
The largest number of epidural outcome studies has been reported for cervical lumbar epidural steroid injections followed by epidural steroid injections………………………………….
There are no published randomized studies for thoracic epidural steroid injections…………..
The evidence for strong caudal epidurals is for short-term relief and for long-term relief……………… moderate The findings for are moderate limited interlaminar epidurals for short-term relief and for long-term relief of symptoms.
The results for TFESIs are strong for both short- and long-term relief…………..
There is a 10-30% prevalence of sacroiliac joint dysfunction as the cause of low back pain.There are no definitive historical, physical examination, or diagnostic findings that are specific for sacroiliac joint pain…………………………… Only 22% of sacroiliac joint injections are successfully performed without fluoroscopic guidance ………………………..
Epidurography
to confirm is an integral part of performing interlaminar and transforaminal steroid injections. Epidurography is used needle placement in the epidural space prior to instilling therapeutic agents and to avoid intravascular or intrathecal injection…………………………………… .
Epidurography is also used to evaluate the status of the
epidural space
patient………… , such as in the postoperative spine
Myelography
is a diagnostic imaging study in which radiopaque contrast material is injected into the intrathecal space under direct fluoroscopic observation. Multiple x-rays are obtained after contrast injection to evaluate specific areas of the spinal canal……………..
Myelography is helpful (particularly when combined with CT) in the evaluation of intrathecal pathology, such as
tumors ***************************
arachnoiditis ********************* disk pathology ******************* nerve root compression ********** spinal stenosis *******************
Myelography with flexion and extension views allows for a dynamic spine evaluation under fluoroscopy that is not possible with MRI or CT…………………………… Myelography is also used when MRI or CT are inconclusive………….
Diskography
has demonstrated a 60% prevalence of diskogenic neck pain in the post-traumatic chronic neck pain population…………………………………..
Diskography has detected a prevalence of diskogenic pain in patients with 6 months of chronic low back pain who have had an otherwise unremarkable diagnostic workup including imaging studies …………………..
40% ,
Cervical thoracic lumbar ******************** epidural injection
Interlaminar approach
Imaging studies (MRI or CT) of the cervical and thoracic spine are recommended to evaluate any possible compromise to the epidural space prior to performing an interlaminar epidural injection at the cervical , thoracic , and upper lumbar levels……………………………. The same applies to mid and lower lumbar levels in the postoperative patient……………………………………………….
The patient is positioned prone on the fluoroscopy table ……………………………… The entry level for the typically at the C7-T1 cervical spine is level………………..
At the site of pathology and lumbar for the thoracic spine………………………………. Epidural injections are avoided at sites of previous posterior spine surgery, due to the obliteration of the epidural space and the subsequent increased risk of intrathecal penetration……………………..
An epidural needle is advanced through the skin using a paramedian approach under intermittent fluoroscopy until contact is made with the lamina The needle is 'walked off' the laminar edge on to the ligamentum flavum ……………………………………. A 2-3cc volume of non-ionic contrast is slowly injected under fluoroscopy after negative aspiration to produce an epidurogram to confirm appropriate needle placement…………………………... A 1-cc test dose of lidocaine (lignocaine) is injected, after which the anesthetic and corticosteroid solution is slowly injected into the epidural space………………………………………………….
Transforaminal approach
The patient is positioned in the supine position for a cervical TFESI, and the C arm or the patient is positioned obliquely until there is a clear view of the foramen…………………………………..
The patient is positioned in the prone position for a thoracic or lumbar TFESI, and the C arm or the patient is positioned obliquely until the tip of the ipsilateral subjacent superior articular process divides the pedicle in half.
At least 0.5 cc of non-ionic contrast is injected under fluoroscopy……………………………… Syringes are exchanged for the anesthetic and steroid mixture…..
The solution is slowly injected after a negative 1-cc test dose……
Caudal injection
A spinal needle penetrates the skin at a space….
45° angle between the sacral cornu, and is advanced until it contacts the sacrum. The needle is slightly withdrawn and advanced at a shallow 10° ligament into the epidural angle through the sacrococcygeal
After negative aspiration, contrast is injected under fluoroscopy into the epidural space, followed by the injectate solution………………………..
Sacroiliac joint injection technique
The needle pierces the posterior sacroiliac ligament and then enters the joint at the hyperlucent area………………………………………….
. Contrast is injected after negative aspiration to produce an arthrogram to confirm needle tip placement………………………………… .
Myelography injection technique
The patient is placed table elevated 5-10 prone on the fluoroscopy table, with the head of the °…………………………… The skin and subcutaneous tissue are anesthetized with 1% lidocaine (lignocaine)………………………………………. A spinal needle is placed midline at the L2, L3 level to ensure the introduction of contrast above the L3 vertebral level.
The spinal needle is advanced under fluoroscopy……………………… There is resistance as the needle enters the ligamentum flavum , which decreases as it passes through the ligament into the subarachnoid space……………………
The needle tip bevel is turned cephalad, and there is flow of CSF after removing the stylet………………………………………….. If there is no CSF flow, a lateral radiographic view is recommended to check the needle depth……………………… If the needle depth is correct, the patient is asked to perform Valsalva's maneuver , which inevitably leads to flow of CSF through the needle……………
Approximately 18-20 cc of contrast is injected to complete the myelogram, after which x-rays are obtained, including anteroposterior, lateral, oblique, flexion and extension views ……….
A CT scan is performed afterward to complement the myelogram …………………………… …
For cervical and thoracic myelography, the contrast is injected in the same manner into the lumbar subarachnoid space. The patient is then placed into Trendelenburg's position to allow for flow of contrast into the cervical and thoracic areas………………………………………………….. Care is taken to avoid contrast flow into the foramen magnum……………………………. CT and regular x-rays are performed after the myelogram injection………………………..
Routine postmyelography instructions include head elevation at 30-45° above the horizontal plane for 12-24 h and oral fluids……………..
Diskography injection
Intravenous antibiotics and light intravenous sedation are given to the patient prior to starting the procedure………………..
Intradiskal antibiotics can be given as an alternative or in addition to the intravenous antibiotics for prevention of disk infection…………………………..
The patient is positioned in a modified lateral decubitus position when performing thoracic and lumbar diskography, with the symptomatic side down………………
The needles are then placed into the disks from the asymptomatic side…………………
Although the needle site entry for cervical diskography can be performed with the same methodology, this is not as critical, because the needles are being placed through the anterior portion of the neck…………………………….. In addition, needle insertion from the left side carries a greater risk of esophageal puncture………………………