Transcript Fluoroscopy and CT guided injection techniques for spinal

CT Image-guided injection
techniques for
spinal pain management
Department of Radiology, Bichat Hospital,
Paris, France
Tel Aviv Medical HOSPITAL Israel
S. Bensoussan, MD, O. Silberman, MD
Spinal pain and radiculopathy
• Very common (prevalence = 5%/year)
• Most cases:
▫ Rest
▫ Physical therapy
▫ Chiropractic manipulation
▫ Percutaneous injection (under fluoroscopy control)
Silbergleit et al, Radiographics 2001
Image CT guidance for
percutaneous injections
• Improves safety, success (1)
• Indication:
▫ Resistance to conventional therapy.
▫ Resistance to steroid injection under fluoroscopy control at
the lumbar spine
▫ In first intention at the cervical and thoracic level
▫ C indication to surgery
▫ The last option before surgery
ShulmanReg anesthes
Objective
• To describe image guided techniques for spinal
pain management under CT control)
DISC HERNIATION lumbar
Materials and Methods
• 100 patients 20 – 58 y.o. disk herniation
▫ Cervical and Lumbar level
▫ Follow up AVS of 2 years 1 – 3 – 6 -12 and 24 months.
▫ 70-80% of patients didn’t undergo to surgery.
▫ 30% of this patients needed a second injection CT
control
▫ All the patients with endocanalar disc herniate were
treated in the same procedure by transligamentary
flavum pathway and foraminal pathway.
Materials and Methods
• All Suffering from refractory persistent pain as
diagnosed by above MD, despite of 1 month (at
least) of appropriate medical treatment that
included combination of analgesics, muscle
relaxants and no inflammatory drugs, combined
with physical therapy and for some of them,
after steroid injection under fluoroscopy control.
Results:
• Success: Radicular and lumbar or neck pain
relief Serious complication= 0
(Phoneinterview 48h and 15 days after
periradicular injection) AVS 0-10
• Within 2 weeks of periradicular injection most of
patients returned to their previous occupation
and full lifestyle
Results follow up after 2 years
25% No Recovery
36% Full Recovery
39% Half Recovery
Full recovery : VAS between 0 and 2
Half recovery : VAS between 3 and 6
No recovery : VAS between 7 and 10
Indication
• When there is a resistance towards conventional
medical treatment while surgical intervention is
to be recommended when neurological deficit
becomes clear (LESS THAN 10% OF DISC
HERNIATION)
• Delmer.O,Dousset.V.,(2005),in Interventional
Radiology in Pain Treatment, ch5:5056,Kastler.B Ed, Spring Verlg berlin Heidelberg
Disc herniation, mecanism
• The injury can result from a sudden strenuous
movement, trauma, or after degenerative
changes in the spine.
• This kind of injuries is very common for
professional athletes.
• The result is a herniated disc that may compress,
irritate or even permanently damage the nerve
root. The severity and level of the lumbar disc
herniation determines the type of signs and
symptoms experienced by the patient.
• Lumbar Disc herniations are seen in all age
sport…..
Technic of the procedure
• The skin entry site was marked with a surgical pen under sterile
conditions, and 2% lidocaine was used for local anesthesia.
• Three needles are introduced:
•
the 1st spinal needle is maneuvered directly adjacent to the
involved nerve root in the outer neural foramen via a posterolateral
approach,
• The 2nd needle tip is introduced into the spinal canal by the trans
yellow flavum ligamentary pathway.The needle tip is around the
endocanal disc herniation..
• The 3rd foraminal needle is introduced at the superior or lower
level of the disc herniation, considering the nerve root involved.
Transligamentary flavum approach
under ct control
▫ TARGET: epidural space between ligament flavum,
facet joint, disc herniation and symptomatic nerve
root.
▫ GOAL: to target accurately the inflammatory reaction
around the nerve root and the disc herniation
▫ PROCEDURE: Patients refered after a minimum of 1
month of adequate medical treatment, patient in a
prone position axial scan to locate target slice.
Women 25 yo dancer
Flavum
ligamentum
Left paracentral
Disc herniation
Position of the needle
left foraminal pathway
Position of the needle tip
transligamentary pathway
• Once optimal needles placements are achieved, a mixture of 7ml of
methyl prednisolone with 0.5 mL of lidocaine 2% are introduced:
2ml via the 1st and the 3rd needles each, and 3 ml by the
transligamentary pathway( 2nd needle).
• A small contrast material (0.5ml) is being injected prior to bulk
steroid injection (7ml) so that steroid diffusion would be assessed
correctly.
• The contrast injection was withheld if the patient is allergic.
• The steroid drug is slowly injected so that it infiltrates efficiently
the matrix around the nerve and the disc herniation. The needle is
slowly withdrawn with pressure held by the radiologist.
• The patients brought to the rest room for 30 min and his essential
life parameters are monitored regularly. The patient is discharged to
his home and advised to have rest for 3 days under a regime of
noninflammtory drugs and paracetamol with gastric protectors .
Paramedian posterior approach and CT guided
direct puncture from skin to the anterior aspect
of the ligamentum flavum
Male 30 yo yoga instructor
Right endocanalar L5-S1 disc herniation.
Radiculopathy . No motor deficit
• Needle tip in place
• right flavum trans
ligamentary pathway.
After contrast and steroid injection
DISK HERNIATION
cervical
Cervical nerve root injection under
Security CT control
• Cervical radiculopathy is due to an abnormal
process that involves the nerve roots
• It is caused mostly by cervical disk herniation or
uncarthrosis process in a lateral conflict.
• The symptoms of cervical radiculopathy are neck
and brachial-radicular pain, motor weackness or
paresthesia , in 80-100 % of patients.
Cervical nerve root injection under
Security CT control versus fluoroscopy
• Foraminal cervical nerve root injection in patients who
have persistent radicular pain without motor deficit, and
should be performed only under CT guidance because of
the presence of the vertebral artery.
• CT guidance the once safety option (1) for cervical pain
management because of the lack of visualization of the
vessels and nerve root under fluoroscopy control
(1)Complications of Cervical Selective Nerve Root Blocks Performed with Fluoroscopic Guidance
Marc A. Wallace1, Melanie B. Fukui1, Robert L. Williams1, Andrew Ku1 and Parviz Baghai2
Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA 2005
Cervical nerve root injection under
Security CT control
• The diagnosis of cervical radiculopathy was
etablished by both the referring physicians and
the interventional radiologist.
• Radiographics, CT scan and MRI examinations
performed to determine the causal lesions ,and
exclude an anatomic variant, especially for
vascular and bone structures.
• Pregnant women and patients with cervical
myelopathy,malignancy, inflammatories
deasease, coagulation disturbances,or a history
of severe corticosteroid side effects were
excluded;
Foraminal Selective Nerve root steroid
injection
Male patient, 36 y.o.
Left C6 radiculopathy
Vertebral artery
(contrast)
C5-C6: small left postero-lateral disk herniation
MRI Axial ,Sag FSE T2
• W. 29 yo Right cervico brachial radiculopathy.
No motor deficit.
Axial MRI
T2. C5-C6
Sagital MRI
T2
Left postero-lateral disc herniation
Before needle injection
THE FACET joint :
The safe stopping point
Because its situation is
always posterior to the
vertebral artery.
After needle injection
Follow up 5 years
No underwent to surgery
One procedure was
performed
CYST FACET JOINT
Cyst injection
Male patient, 50 years old
Left L5 radiculopathy
Left L5 nerve root
compression by a
left lumbar facet cyst
MRI, FSE T2w
L4-L5
Cyst injection
Transarticular route
Cyst rupture
2 PROCEDURES WERE PERFORMED
FOLLOW UP 4 YEARS : NO UNDERWENT TO SURGERY
NERVE ROOT CALCIFICATION
Nerve root steroid injection
Male patient,
35 y.o. golf player
After bad
movement
Left back thoracic
Pain.
T9-T10
calcification
Needle positioning
Avoid pleural space !
(needle medial and
posterior).
Intra-discal
and right nerve root
calcifications
Needle in place
Control after 3 injections
(one year after)
Steroid injection
Post operative complications
Fibrosis Post laminectomy
bilateral unremetting
radiculopathy(spinal stenosis)
Fibrosis and Left building disc after
laminectomy
Discussion
• Cervical and lumbar radiculopathy treated non
surgically / ideal outcomes in 80-90% (1)
• Surgery/ unremitting pain; progressive
weackness or cervical myelopathy.(2)
• cervical foraminal injections with antero-lateral
approach under CT control
• Ellenberg Arch Phys Med Rehab 1994
CT Guidance helps avoiding:
• surgery in many cases (cervical thoracic and
lumbar disc herniation, cyst facet joint)1,2,3
• complications usually due to lack of precision
when using conventional fluoroscopy for
guidance;
• anaesthesia and sedation: most of the
procedures are performed without any type of
anaesthesia.
1-RSNA 2005 CT GUIDED TECHNICS for chronic cervico-brachialgia
2-AJNR Mars2004 Open study on Percutaneus Periradicular Foraminal steroid Infiltration
under CT control in 30 patients
3-CARDIOVASCULAR AND INTERVENTIONAL radiology :CT-Guided Epidural/perineural Injections in Painful Disorders of the
lumbar Spine
CT advantages
• Accuracy
• Safety (Preventing of harming delicate anatomic
structures).
• More accuracy under CT control between 30 to
40% than under fluoroscopy control.1
• The possibility to approach the endocanalar
lesions by trans ligamentary
pathway.
Conclusion
• CT -guidance increases the precision of the
procedure and help confirm needle placement.
• Periradicular corticosteroid injections under
CTimage-guided, complementarity step before
more invasive treatment
• an alternative to surgery.
Results
Intra-articular injection C1-C2
• Female patient, 70 years old, PR.
• Cervical pain++
Arthropathy C1-C2.
• Arthrogram and injection of 2mL of corticosteroid
Patient #6: Before vertebroplasty
Male patient, 75 year old, prostate cancer
L2 metastasis
PAIN ++ resistant to morphine and radiotherapy
Before vertebroplasty
Left pedicule
FRONTAL
SAGITAL
Right pedicule
FRONTAL
Fluoroscopy control post
vertebroplasty
Frontal view.
Sagital view
CT control post vertebroplasty
No epidural or paravertebral opacification is observed
Sagital view
Material and Method
• CT guidance:
▫ Nerve root injection
 (cervical, thoracic, lumbar)
▫ Cyst facet joint injection
• Fluoroscopy guidance
▫ Vertebroplasty
▫ Nerve root injection : lumbar spine.
Foraminal Injection. Fluoroscopy control.
•
•
•
•
•
Male patient, 40 years old,right S1 radiculopathy.
Axial MRI: L5-S1:right postero-lateral disk herniation.
Injection of 2mL of hydrocortisone.
Pain relief after 24 hours.
Following at 2 years: no underwent at surgery.