Transcript Image guided epidural for Back Pain
Dr. Amr Abdelfatah M.D.
Dep. of Anesthesia, Intensive Care medicine & Pain Management Ain Shams University, EGYPT [email protected]
Interventional Injections Interventional Implants
Interlaminar Epidural Transforaminal Epidural Caudal (sacral ) Epidural
LOR to identify lumbar epidural space, was too superficial in 17% of cases. Inconsistent LOR in Adhesions & fibrosis (Mehta M, Salmon N. Anaesthesia. .
1985 , 1012 – 40:1009 1985). Fluoro.: Reduces technical failures & difficulties with ESI up to 60%. (Manchikanti L, et al Anesth Analg 89:1330–1331, 1999) .
◦ ◦ ◦ Blind caudal for ESI : 48% incorrect by trainee 15 % experienced hands 9.2% i.v. injection. (Renfrew DL, et al. Am J Neuroradiol .
1991 , 1007 – 12:1003 Fluoro.: 91% - 97% success on first attempt on caudal ESI ) (Stitz M, et al. Spine, 1999 , 1376 – 24:1371 ).
◦ ◦ ◦ Blind Cervical ESIs: 53% false LOR on 1 st trail unilateral spread in 51% ventral spread in 28% (Stojanovic MP, et al. Spine 2002 , 514 – 27:509 ) Better viewing for contrast spread.
Needle and pathology location
Success rate increased in BMI > 30 vs. BMI <30 (Price CM, et al: Ann Rheum Dis 882 – 59:879 ; 2000 ) Previous back surgery and fixation
Tissue irritation and inflammation HNP Nerve root irritation (Lumbosacral radiculopathy) Previous back surgery Post spinal fixation Spinal canal stenosis. Spondylolisthesis & degerative disc disease !!
Interlaminar vs Transforaminal Injections ?!
Rhee and colleagues: ◦ TFESI: 46% reduction in pain score 10% required surgery. ◦ Interlaminar injections: 19% reduction in pain score 25% required surgery. (Rhee Jm, et al.
J Bone Joint Surg Am. 2006)
Improvement was 70% of pt. in TFESI compared to 45% in interlaminar group. (Schaufele MK; et al: Pain physician , 2006) 5 yrs follow up post-TFESI : (81%) studied population didn’t approach for surgery (Riew KD et al. .
J Bone Joint Surg Am . 2006 ).
Depositing steroids in the anterior epidural space as only 28% ventral epidural spread of dye with interlaminar route (Stojanovic MP, et al. Spine, 2002).
Systematic review on TFESI confirmed its efficacy over interlaminar approach.
(Buenaventura RM, et al.
Pain Physician. Jan-Feb 2009 )
Clark C. Smith, MD,* Thomas Booker, MD,§ Michael K. Schaufele, MD,*† and P. Weiss, MS‡ Departments of *Rehabilitation Medicine, †Orthopedics and ‡Biostatistics, Emory University, Atlanta, Georgia; §Crystal Run Healthcare LLP, Middletown, New York, USA Conclusions. In the current study, neither transforaminal nor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions when compared with each other.
Artery of Adamkiewicz (supplies lumbosacral enlargement ) Radicular artery close to DRG @ sup.& middle portion of the foramen.
Risk of paraplegia esp. with particulate steroids Dexamethasone and betamethasone are better choices, particles <50 µm (Christopher WA review: Current Rev. Musculoskelet Med 2009).
emerging lumbar nerve root at the intervertebral foramen anterior to the , together with the ascending anterior and posterior nerve root branches (neural branches) of the lumbar artery. Reprinted with permission from Crock et al. The blood supply of the vertebral column and spinal cord Fig. 3. Course of artery of Adamkiewicz (red) and its feeding in man. RR Donnelly & Sons, Chicago, 1977 (32).
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P A
Safe Triangle
anterior-superior Kambin’s Triangle Post. Inferior
Paraplegia Following Image-Guided Transforaminal Lumbar Spine Epidural Steroid Injection: Two Case Reports @ University of Florida College of Medicine (David J, et al. Pain Medicine, 10: 1389–1394) So Image & contrast prior to injection
0.2 LAO 0.00 CRA AP projection
L4 L5
Scotty Dog
20-30 degree lateral projection
L4 L5 Spinal 22G
L4 L5 Lat. projection
Omnipaq contrast in Ant. Epidural Space
Anteroposterior fluoroscopic view showing the Omnipaq outlining the nerve root and diffusing through the intervertebral foramina into the epidural space
Anteroposterior fluoroscopic view showing the Omnipaq outlining the nerve root and diffusing into the intervertebral foramina into the epidural space
Anteroposterior fluoroscopic view showing the Omnipaq outlining the nerve root and diffusing into the intervertebral foramina into the epidural space
previous laminectomy Post-Spine fixation Dural Adhesion & fibrosis (LOR) Epidural in high BMI Normal epidurogram
Faulty Subcut. Injection Correct Needle placement
Dr. Gabor Racz scar tissue entrapping nerves Flex tip & Steering end L.A + Steroids hyaluronidases 3%, 7%, 10 % NaCl RACZ Catheter
RACZ cath. Through Tuohy needle Touhy needle through Sacral hiatus
◦ ◦ ◦ Hypertonic saline injected into the SCF cardiac arrhythmias Myelopathy Paralysis & loss of sphincter control So Image & contrast prior to injection Cord compression, hematoma, bleeding, infection, dural puncture.
A Retained Racz® Catheter Fragment After Epidural adhesolysis : Implications During Magnetic Resonance Imaging.
(William J. Perkins, et al. Anesth Analg 2003;96:1717–9)
Melzack and Wall gate control theory in 1965 Pulsed electrical stimulation for the dorsal column (large fibers stim. can signal hyperalgesia ?!) Neurochemical alteration ◦ ◦ ◦ ◦ Non-pharmacological method Failed back surgery Neuropathic pain , CRPS Ischemic limb Intractable anginal pain In the epidural space since 1967.
Image guided for cord level determination.
Dermatomal level representation in the dorsal columns is higher than the corresponding vertebral level (e.g. sciatic pain around T9-11).
Kunnumpurath S, et al. Journal of Clinical Monitoring and Computing, (2009) 23, 333-339.
Image guided Epidural Lead seated at desired spinal level
AP projection Prone position
Neurostimulator leads: (left to right) percutaneous type to paddle type
T9 T10 T11 T12
Depends on proper pt. selection Fluoroscopic guidance is a must for proper visualization of exact spinal level Reported “success” rates (generally defined as a minimum of 50% pain relief ) vary from 12 to 88% at follow- ups of 0.5–8 years.
Image-guided spine procedures provide physiological information not available from diagnostic imaging studies. Real-time observation during contrast injection Assess for vascular opacification reduce jeopardizing radicular vessels . CT and MRI are additional modalities.
Image-guided spine injection procedures are ◦ minimally invasive ◦ performed on an outpatient basis Perfection = ◦ extensive training ◦ imaging equipment safety ◦ familiarity with image-based anatomy.
Dr. Amr Abdelfatah M.D.