Facet joint infiltrations : new safe approaches for infiltrations in the treatment of spinal conditions?

Transcription

1 Facet joint infiltrations : new safe approaches for infiltrations in the treatment of spinal conditions? Poster No.: C-2380 Congress: ECR 2015 Type: Educational Exhibit Authors: P. Brunner, E. Brunner, M. Baque-Juston, F. Soares, N Amoretti, S. Chanalet, S. Houllier, S. Belkacem, M.-Y Mourou ; Monaco/MC, Nice/FR, Mezzavia/FR Keywords: Neuroradiology peripheral nerve, CT, Technical aspects, Safety, Education and training DOI: /ecr2015/C-2380 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Learning objectives To demonstrate the value of facet infiltrations under CT-guidance for the treatment of radicular pain. To explain how to optimize such facet infiltrations at lumbar, thoracic or cervical levels, in order to reach their targets which in this case are spinal nerve roots. Page 2 of 23

3 Background Facet infiltrations are often the first minimally invasive way of treating facet joint conditions. Such approaches may also be used in epidural or foraminal infiltrations aiming to treat disco-radicular conflicts, as well as in foraminal or spinal canal stenosis avoiding epidural or foraminal spaces access. Page 3 of 23

4 Findings and procedure details How did the concept came about? Whilst performing facet joint infiltrations, a leak of contrast media (always injected first) is often seen in periarticular spaces (in the epidural area, in the ipsilateral foramen, in the spinous joint recess or sometimes in the controlateral facet joint) and exceptionally contrast leaks have been observed in the intra-thecal space (this raises other issues and limits injection of some types of corticosteroids). These "extravasations" of contrast media occur most often at the same time of intended intra-articular contrast injection. Most often, these extra-articular passages may be technically produced on purpose to obtain close contact with the targeted nerve roots. These facet joint infiltrations become therefore "transfacet infiltrations". What is the principle of this procedure and how does one do it? The usual goal of transfacet infiltration is to treat the arthropathy but we can do more... (Fig. 1,2). The principle consists of obtaining a periradicular passage by a strictly transfacet approach (Fig. 3 to 11). We don't have to puncture the inferior joint recess of this articulation but rather the midportion of the joint in this way and "catheterize" this articulation to make the approach more stable. This "catheterism" is highly facilitated by using curved needles. What can one do when the joint capsule does not give way? If the capsule doesn't rupture, some tips can help us: rotate the curved needle 180º and re-inject contrast medium; tuburlences will be different at the exit of needle's bevel and can break up the joint capsule. try to make repeated injections-aspirations of contrast medium and then of air; these " comings and goings" movements of liquid or air are going to create pressure modifications and weaken the joint capsule. catheterize the joint space more deeply and inject the contrast medium more deeply. Page 4 of 23

5 and sometimes create a direct gap on the medial part of the capsule with the needle tip. If the capsule gap can't be obtained despite all these tips, we advocate needle repositioning inside the epidural space without modifying the entry point with the benefit of first local anesthesia with a classical epidural infiltration as a result (Fig. 12 to 14). Specifics of transfacet infiltrations at cervical level: The facet joint puncture is better performed on the medial side using a pre-curved needle because when contrast medium does not go inside epidural or foraminal space, small needle rotations are required to access to the epidural space directly in close contact (Fig. 8 to 12). During transfacet infiltrations, another frequently observed trap consists of the back passage of contrast towards the spinous process, appearing immediately in the vicinity of the lateral epidural space. In this case, we have to change the procedure but without diffusion in this space. Foraminal joint recess filling can also mimick a foraminal passage and this needs a change in procedure...(fig. 12,13). Page 5 of 23

6 Images for this section: Fig. 1: Lumbar facet joint infiltration : usual goal, treat the arthropathy Page 6 of 23

7 Fig. 2: Cervical facet joint infiltration : usual goal, treat the arthropathy Page 7 of 23

8 Fig. 3: Lumbar facet joint infiltration : another purpose, treat nerve root disorder Page 8 of 23

9 Fig. 4: Lumbar facet joint infiltration : another purpose, treat nerve root disorder, the injected products are going on contact with nerve roots. : "transfacet infiltration" Page 9 of 23

10 Fig. 5: Lumbar transfacet infiltration Page 10 of 23

11 Fig. 6: Cervical transfacet infiltration Page 11 of 23

12 Fig. 7: Cervical transfacet infiltration Page 12 of 23

13 Fig. 8: Cervical facet joint infiltration :at first contrast medium diffuse only in the joint, then contrast is injected in the lateral epidural space after moving the needle to obtain an epidural infiltration. Page 13 of 23

14 Fig. 9: Right transfacet infiltration leading to a total epidural infiltration Page 14 of 23

15 Fig. 10: Left lumbar transfacet infiltration leading to a contro-lateral facet joint infiltration and an epidural infiltration Page 15 of 23

16 Fig. 11: When epidural infiltration is not feasible by using facet joint infiltration, change the orientation of the curved needle to access directly to the epidural space. Page 16 of 23

17 Fig. 12: Opacification of the facet joint objectivizes an opacification of the posterior epinous recesses and of the "foraminal" recesses Page 17 of 23

18 Fig. 13: Opacification of the facet joint objectivizes an opacification of the posterior spinous recesses and of the "foraminal" recesses (but not in the foramino-epidural space!) then direct access to epidural space is done. Page 18 of 23

19 Fig. 14: Opacification of the facet joint objectivizes an opacification of the posterior spinous recesses and of the "foraminal" recesses (but not in the foramino-epidural space!) then direct access to epidural space is done. Page 19 of 23

20 Conclusion Facet joints constitute avascular sanctuaries (like intervertebral discs) and may also offer a secure approach to infiltrations for sciatic, crural, intercostal and cervicobrachial neuralgias, by using "facet joint plus infiltrations", namely "Transfacet infiltrations". Active product injections in the joint cavity avoid exceptional vascular and neurologic complications. They may also be used as the first choice approach for periradicular spinal infiltrations and can be performed on patients under antiplatelet treatment without increased spinal canal bleeding risk. Will Transfacet infiltrations became the epicenter of the "Infiltrations World"?(Fig.19). Page 20 of 23

21 Images for this section: Fig. 19 Page 21 of 23

22 Personal information Philippe Brunner Imaging Department Princess Grace Hospital Monaco Page 22 of 23

23 References 1. Derby R et al. Complications following cervical epidural steroid injections by expert interventionnalist in Pain Physician,2004;7(4): Carette S et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N. Eng J Med,1991;325: Brunner P et al. Approaches in injections for radicular pain, the transforaminal, epidural and transfacet approaches. Diag Interv Imag,2012; 93(9): Kelekis A et al. Fluoroscopically guided infiltration of the cervical nerve root: an indirect approach through the ipsilateral facet joint. Pain Physician,2014; 17: Page 23 of 23