MEDICAL HISTORY CHIRO PHYSICAL

Transcription

1 Overview of Spinal Injection Procedures Blake A. Johnson, MD, FACR 1 PATIENT MANAGEMENT EVALUATION TREATMENT P.T. MEDICAL CHIRO S SURGICAL Effective treatment requires a precise diagnosis! HISTORY PHYSICAL IMAGING S DX FUSION / LAMINECTOMY / ETC. 2 SPINAL S ADVANCED IMAGING CLINICAL UTILITY: Diagnostic Identify pain source Therapeutic Provide pain relief Guide subsequent intervention 3 Evaluate degenerative disease Exclude neoplasm, infection Assess for stenosis Assess target pathology Determine best approach 4 SPINAL INTERVENTION PROCEDURE SUITE Epidural injections Nerve root injections SI joint blocks Trigger injections Facet joint injections Facet nerve blocks / RF 5 High-resolution C-arm Display Procedure table Materials 6 author. 1

2 EPIDURAL S Clinical efficacy Injection techniques Lumbar Cervical Thoracic 7 INTERLAMINAR Paramedian approach: lamina or interlaminar gap Midline trajectory Superior aspect of lamina Advance into dorsal epidural space 8 INTERLAMINAR EPIDURAL 9 10 INTERLAMINAR INTERLAMINAR author. 2

3 TRANSFORAMINAL Unilateral pain Radicular symptoms Post-operative Epidural scarring Severe canal stenosis TRANSFORAMINAL Posterolateral approach Central neuroforamen Advance to bone / response Epidurogram before injection: opacify regional epidural space and nerve sheath TRANSFORAMINAL TRANSFORAMINAL CERVICAL EPIDUROGRAPHY Posterior paramedian approach Whitacre (epidural) needle Advance to T1 lamina Retract 3mm, direct to midline Use AP, oblique fluoroscopy to monitor needle position 17 NEEDLE PLACEMENT 18 author. 3

4 CERVICAL EPIDURAL 19 RADICULAR PAIN Rupture of intervertebral disc with involvement of the spinal canal First to ascribe radicular pain to compression of a spinal nerve root by a herniated lumbar disc Mixter & Barr NEJM RADICULAR PAIN Does mechanical compression explain all pain symptoms? -Present in a minority of cases -Axons produce only brief impulse trains with mechanical compression Wall et al. Exp. Neurol SELECTIVE NERVE BLOCK INDICATIONS Resolve exam / imaging discrepancy Confirm level of pathology Pain relief (anesthetic & steroid) Facilitate treatment decisions Dooley, et al Spine LUMBAR NERVE BLOCK LUMBAR NERVE BLOCK Posterolateral approach Lateral neural foramen Advance to bone / response Radiculogram before injection: opacify nerve sheath minimal epidural reflux author. 4

5 Cervical nerve root Anterolateral approach Lumbar nerve root Posterolateral approach CERVICAL NERVE BLOCK C7 NERVE ROOT BLOCK SI JOINT SYMPTOMS Low back, hip or buttock pain Difficult to dx clinically FABER TEST Flexion, ABduction, and External Rotation Initial groin pain: hip origin pain Pressure on knee and ASIS posterior pain: SIJ origin author. 5

6 SI JOINT Profile inferior 1 cm of joint Use bevel to facilitate access Contrast to assess morphology Concordant symptoms? Evaluate therapeutic response 31 SI JOINT SI JOINT DENERVATION 33 Courtesy Baylis Medical 34 FACET SYNDROME 35 Difficult to correlate mechanical and neurophysiolgic events with clinical expression 36 author. 6

7 FACET JOINT BLOCK INDICATIONS Chronic LBP: clinical suspicion or exclusion (15-40% zygapophyseal pain) Pain pattern variable (not diagnosed by examination) Diagnostic / therapeutic blocks 37 FACET JOINT BLOCK TECHNIQUE Profile joint fluoroscopically Advance to joint or recess Injection may provoke pain Extracapsular extension: Epidural space Neural foramen Pars defect 38 FACET ARTHROGRAPHY CERVICAL FACET JOINT CERVICAL FACET JOINT Percutaneous Radio-Frequency Neurotomy for Chronic Cervical Zygapophyseal-Joint Pain Lord SM, Barnsley L, Wallis BJ, et al Volume 335: author. 7

8 FACET NERVE BLOCK Posterolateral approach SAP / transverse process Inject contrast ( cc) Exclude venous filling Rule out foraminal extension Evaluate for RF rhizotomy RF NEUROTOMY Facet / median branch block Determine response Assess levels Electrode to median branch Motor stimulation testing RF - generated heat lesion CERVICAL RF NEUROTOMY CERVICAL RF NEUROTOMY author. 8

9 SPINAL S Best performed using image guidance Standard of care for many clinical spine specialists and other clinicians Isolation of pain generator / relief Improves outcome Safe and effective outpatient procedures bjohnson@cdirad.com author. 9