Basic spine injections

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Basic spine injections

  1. 1. DEVIN PECK, M.D. DIVISION OF PAIN MEDICINE DEPARTMENT OF ANESTHESIA WEILL CORNELL MEDICAL CENTER BASIC SPINE INJECTIONS
  2. 2. ROLE OF INTERVENTIONS <ul><li>Most effective as part of a multi-modal approach </li></ul><ul><li>Pharmacotherapy, physical therapy, behavioral therapy </li></ul><ul><li>Outcomes are best in those with localized pain, recent onset, without secondary gain </li></ul>
  3. 3. WHAT WILL WE DISCUSS <ul><li>Trigger point injections </li></ul><ul><li>Lumbar ESI </li></ul><ul><li>Transforaminal ESI </li></ul><ul><li>Cervical ESI </li></ul><ul><li>Median Branch Blocks and RFA </li></ul><ul><li>Sacroiliac Joint Injections </li></ul>
  4. 4. BASIC INJECTION PEARLS <ul><li>Anchor yourself against the patient </li></ul><ul><li>Skin wheal is the most important part of local </li></ul><ul><li>Gun barrel </li></ul><ul><li>When redirecting needle, mark your depth and pull back to soft tissue/skin </li></ul><ul><li>A slow injection is less painful </li></ul><ul><li>Careful sterile technique </li></ul><ul><li>Positioning is key </li></ul><ul><ul><li>Patient </li></ul></ul><ul><ul><li>Practitioner </li></ul></ul>
  5. 5. RISKS <ul><li>Infection </li></ul><ul><li>Bleeding </li></ul><ul><li>Dural puncture  headache </li></ul><ul><li>Nerve injury (exceedingly rare) </li></ul><ul><li>Intravascular injection/injury </li></ul><ul><li>Allergic reactions </li></ul><ul><li>Steroid effects </li></ul><ul><ul><li>Mood changes </li></ul></ul><ul><ul><li>Hyperglycemia </li></ul></ul><ul><ul><li>HTN </li></ul></ul><ul><ul><li>Menstrual changes </li></ul></ul>
  6. 6. TRIGGER POINT INJECTIONS <ul><li>Indications: </li></ul><ul><ul><li>Muscle spasm </li></ul></ul><ul><ul><li>Myofascial pain </li></ul></ul><ul><ul><li>Fibromyalgia </li></ul></ul><ul><ul><li>Tender points </li></ul></ul>
  7. 7. TRIGGER POINT INJECTIONS <ul><li>Technique : </li></ul><ul><ul><li>Trigger points palpated as “taught bands”, TTP </li></ul></ul><ul><ul><li>Muscle pinched up away from pt. </li></ul></ul><ul><ul><li>25-30g needle inserted, directed in 4 directions </li></ul></ul><ul><ul><li>Inject 1-1.5 cc lidocaine 1%, bupivacaine 0.5%, 10 mg depo-medrol or equivalent </li></ul></ul><ul><ul><li>Dry needling or saline may be effective </li></ul></ul><ul><ul><li>Can use botox </li></ul></ul>
  8. 8. ESI-MECHANISM (?) <ul><ul><li>Anti-inflammatory effect of steroid </li></ul></ul><ul><ul><li>Washout of chemical mediators of pain/inflammation </li></ul></ul><ul><ul><ul><li>PLA-2 (releases AA from cell membranes) </li></ul></ul></ul><ul><ul><ul><li>Interleukins </li></ul></ul></ul><ul><ul><ul><li>Proteoglycans </li></ul></ul></ul><ul><ul><li>Anti-nociceptive effect of LA’s (“break the pain cycle”) </li></ul></ul><ul><ul><li>Decreased edema, wallerian degeneration, and fibrotic changes to neural tissues </li></ul></ul><ul><ul><li>Steroid may: </li></ul></ul><ul><ul><ul><li>Block some C fiber transmission </li></ul></ul></ul><ul><ul><ul><li>Stabilize membranes </li></ul></ul></ul><ul><ul><ul><li>Decrease CNS sensitization (preventing chronic pain) </li></ul></ul></ul>
  9. 9. INTERLAMINAR ESI-TECHNIQUE <ul><li>Positioning: prone with pillow under mid-lower abdomen (reduces lumbar lordosis, opens interspinous spaces) </li></ul><ul><li>AP view-spinous processes equidistant between pedicle shadows </li></ul><ul><li>C-arm with caudal tilt, about parallel with spinous processes </li></ul><ul><li>“ Square off” the superior endplate of caudad body and inferior endplate of superior body </li></ul>
  10. 10. INTERLAMINAR ESI-TECHNIQUE <ul><li>Identify target (midline vs. R-L sided) </li></ul><ul><li>Mark with opaque marker (i.e. 18g needle) </li></ul><ul><li>Local in approximate gun barrel </li></ul><ul><li>Needle in gun barrel and advance in AP until engaged in ligament </li></ul>
  11. 11. INTERLAMINAR ESI-TECHNIQUE <ul><li>Obtain lateral view </li></ul><ul><ul><li>Can’t be sure of true lateral to confirm needle depth </li></ul></ul><ul><li>Loss of resistance </li></ul><ul><ul><li>Saline vs. Air </li></ul></ul><ul><ul><li>Continuous pressure vs. intermittent </li></ul></ul><ul><li>Still necessary even when fluoroscopy used </li></ul><ul><ul><li>Precise location of epidural space can’t be identified </li></ul></ul><ul><li>Inject contrast under live fluoro </li></ul><ul><li>Wait a few seconds, take an image </li></ul><ul><li>AP epidurogram to confirm spread </li></ul>
  12. 12. TRANSFORAMINAL ESI <ul><li>Approach to epidural space and spinal nerve via intervertebral foramen </li></ul><ul><li>Posterolateral approach </li></ul><ul><li>Borders of the foramen: </li></ul><ul><ul><li>Superior/Inferior-pedicles </li></ul></ul><ul><ul><li>Anterior-Vertebral body and disc </li></ul></ul><ul><ul><li>Posterior-SAP/IAP/facet joint </li></ul></ul>
  13. 13. TRANSFORAMINAL ESI <ul><li>Spinal nerve exits from superoanterior portion of foramen and runs inferiorly and anteriorly </li></ul><ul><li>Superior aspect of foramen thought of as “safe triangle” </li></ul><ul><li>This may be re-thought, as the variable vasculature is most often present here (See article by Glaser and Shah in Pain Physician, 2010) </li></ul>
  14. 14. TRANSFORAMINAL ESI <ul><li>Fluoroscopy setup </li></ul><ul><ul><li>AP view </li></ul></ul><ul><ul><li>Cephalocaudal tilt to “square off” vertebral bodies </li></ul></ul><ul><ul><li>Oblique angulation towards operative side until the SAP is at the mid-pedicular line </li></ul></ul>
  15. 15. TRANSFORAMINAL ESI <ul><li>Insert local-approximately coaxial with fluoro beam </li></ul><ul><li>Insert needle (i.e. 22g 3.5 in spinal needle) </li></ul><ul><li>Target: </li></ul><ul><ul><li>Inferior margin of transverse process </li></ul></ul><ul><ul><li>Superior to tip of SAP </li></ul></ul><ul><ul><li>Lateral to lateral margin of IAP or pars </li></ul></ul>
  16. 16. TRANSFORAMINAL ESI <ul><li>Obtain AP image and advance needle until tip is about midway under pedicle shadow </li></ul><ul><li>Obtain lateral view and advance needle until tip is short of midway into the foramen </li></ul><ul><li>Aspirate, inject contrast under live lateral fluoroscopy </li></ul><ul><li>Obtain live AP fluoroscopy with contrast injection </li></ul>
  17. 17. CERVICAL ESI <ul><li>Anatomy differs from lumbar spine significantly </li></ul><ul><li>Ligamentum flavum is much thinner and may have midline gaps </li></ul><ul><ul><li>Paper by Lirk and Kolbitsch in Anesthesiology 2003: </li></ul></ul><ul><ul><ul><li>C3–C4: 66% C4–C5: 58% </li></ul></ul></ul><ul><ul><ul><li>C5–C6: 74% C6–C7: 64% </li></ul></ul></ul><ul><ul><ul><li>C7–T1: 51% Th1–Th2: 21% </li></ul></ul></ul><ul><ul><ul><li>Mean width of mid-line gaps: 1.0 +/- 0.3 mm </li></ul></ul></ul><ul><li>Some advocate performing no higher than C7-T1 </li></ul><ul><ul><li>Epidural space wider here (1.5-2 mm) </li></ul></ul><ul><ul><li>May be minimal in higher spaces as shown in cadavers </li></ul></ul>
  18. 18. CERVICAL ESI <ul><li>Can be performed midline or paramedian </li></ul><ul><ul><li>Paramedian offers advantages of bony landmark and avoidance of midline gaps in flavum </li></ul></ul><ul><li>Position prone with neck slightly flexed </li></ul><ul><li>Obtain AP view with caudal tilt (15-20°) </li></ul>
  19. 19. CERVICAL ESI <ul><li>Identify level by counting up from T1 </li></ul><ul><ul><li>When in doubt, check a lateral </li></ul></ul><ul><li>Use radio-opaque marker to identify lamina of inferior vertebra-just lateral to spinous process </li></ul><ul><li>Walk cephalad and medial until off of os </li></ul><ul><li>Check lateral, advance with LOR and frequent lateral shots </li></ul>
  20. 20. FACET JOINTS <ul><li>One of the most common sources of LBP </li></ul><ul><li>True synovial joints </li></ul><ul><li>Formed by SAP of level below, and IAP of level above </li></ul><ul><li>Volume capacity of 1-1.5cc </li></ul><ul><li>Motion-restricting joint-adds stability </li></ul><ul><li>Upper lumbar joints oriented sagittally-able to resist rotation </li></ul><ul><li>Progressively coronal in orientation as you move caudally-resist forward displacement </li></ul>
  21. 21. FACET JOINT INNERVATION <ul><li>Innervated by medial branch of dorsal ramus of spinal nerve </li></ul><ul><li>Each has an ascending and descending branch </li></ul><ul><li>Each MB supplies joint at its own level, and 1 below (i.e.  L3 MB innervates the L3-L4 and L4-L5 joints) </li></ul><ul><li>Each joint is supplied by MB at that level, and 1 level above (i.e.  L4-L5 joint is innervated by L3 and L4) </li></ul>
  22. 22. FACET JOINT PAIN <ul><li>Arthropathy can lead to low back pain (i.e. axial pain) </li></ul><ul><li>Hypertrophy or cysts can lead to spinal nerve impingement and radicular pain </li></ul><ul><li>Referral patterns vary between studies </li></ul><ul><li>Pain pattern can be: </li></ul><ul><ul><li>Low back </li></ul></ul><ul><ul><li>Radiating pain to hip/ buttock/proximal leg </li></ul></ul><ul><ul><li>Radicular </li></ul></ul>
  23. 23. MEDIAL BRANCH BLOCKS <ul><li>May be diagnostic of facetogenic pain </li></ul><ul><ul><li>MB nerves do innervate surrounding structures as well </li></ul></ul><ul><ul><li>LA can spread to lateral and intermediate branches </li></ul></ul><ul><li>More closely correlated than H and P or radiology </li></ul><ul><li>Perform 1-2 prior to RFA of median branch </li></ul><ul><li>May also perform facet joint injections </li></ul><ul><ul><li>No evidence of benefit over MBB </li></ul></ul><ul><ul><li>Technically more difficult </li></ul></ul><ul><ul><li>Volume 1-1.5cc-can rupture capsule  leakage of LA to surrounding structures (including MB) </li></ul></ul>
  24. 24. MEDIAL BRANCH BLOCKS <ul><li>AP view (remember to square off endplates) </li></ul><ul><li>Can perform in AP or oblique </li></ul><ul><li>Target: junction between SAP and transverse process </li></ul><ul><li>Remember: </li></ul><ul><ul><li>MB is located at the junction BELOW the level of the nerve root (i.e. L1 MB at SAP/TP of L2 vertebra) </li></ul></ul><ul><ul><li>Facet joint innervated by MB of that level and level above </li></ul></ul><ul><ul><li>So, to block L4-5 facet, inject at SAP/TP junction of L4 (L3 MB) and L5 (L4 MB) </li></ul></ul><ul><ul><li>L5 (dorsal ramus, NOT MB) located at junction of SAP of S1 and sacral ala </li></ul></ul>
  25. 25. MEDIAL BRANCH BLOCKS
  26. 26. MEDIAL BRANCH RFA <ul><li>Probes placed along medial branches </li></ul><ul><li>Heated (usually to 80 degrees) to lesion nerves </li></ul><ul><li>Nerves regrow at about 1mm/day </li></ul><ul><li>Can give long-term (6-12 mo) pain relief </li></ul><ul><li>Coming from somewhat caudad allows needle tip to lie closer to parallel to nerve (large lesion) </li></ul>
  27. 27. MEDIAL BRANCH RFA <ul><li>Lesion is spheroidal and may extend several mm beyond active tip </li></ul><ul><li>Majority of lesion surrounds the axis of the electrode </li></ul><ul><li>Cross section is 5-6 cm </li></ul><ul><li>Because lesioned end of nerve is coagulated, must repair itself before regeneration </li></ul><ul><li>Time for repair is proportional to length of nerve coagulated </li></ul>
  28. 28. MEDIAL BRANCH RFA <ul><li>Fluoro view similar to MBB (can use more caudal tilt) </li></ul><ul><li>When injecting LA, don’t go too deep as will need to do sensorimotor test </li></ul><ul><li>Needle placement similar to MBB (10cm RF cannula with 5mm active tip) </li></ul><ul><li>Sensory testing: 50Hz should lead to concordant pain (1V max) </li></ul><ul><li>Motor testing: 2Hz up to 3V should cause no myotomal stimulation </li></ul><ul><li>Inject .5-1cc LA </li></ul><ul><li>Lesion at 80º C for 60-90s </li></ul>
  29. 29. SI JOINT ANATOMY <ul><li>Mainly a support structure, multiple wide ligaments </li></ul><ul><li>Biomechanical studies indicate some motion </li></ul><ul><li>Superior 2/3 fibrocartilaginous, caudal 1/3 true joint </li></ul><ul><li>Innvervation is from dorsal </li></ul><ul><li>primary rami of L5-S3 </li></ul><ul><ul><li>Some authors suggest L4 </li></ul></ul><ul><ul><li>(or even L3) and S4 contribute </li></ul></ul>
  30. 30. SACROILIITIS <ul><li>SI dysfunction </li></ul><ul><ul><li>Mechanical dysfunction </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Degeneration </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>Low back pain </li></ul></ul><ul><ul><li>May radiate into buttocks or legs (rarely past knee) </li></ul></ul><ul><ul><li>Often exacerbated by prolonged standing/sitting </li></ul></ul>
  31. 31. SACROILIITIS <ul><li>Diagnosis </li></ul><ul><ul><li>Primarily by history and physical </li></ul></ul><ul><ul><li>Can incorporate imaging (X-Ray/CT/MRI) although there are many false positives and negatives </li></ul></ul><ul><ul><li>Diagnostic/therapeutic blocks </li></ul></ul><ul><li>Physical findings </li></ul><ul><ul><li>SI tenderness </li></ul></ul><ul><ul><li>Patrick’s/FABER signs </li></ul></ul><ul><ul><li>Gaenslen's test </li></ul></ul>
  32. 32. SI JOINT INJECTION <ul><li>Patient prone </li></ul><ul><li>Caudal C-arm angulation (i.e. 20º) </li></ul><ul><li>Identify posterior (medial) and anterior (lateral) joint lines </li></ul><ul><li>Oblique angulation away from affected side </li></ul><ul><ul><li>Angle varies, but can do live fluoro to align anterior and posterior joint lines </li></ul></ul><ul><li>22g g, 3.5 in spinal needle </li></ul><ul><li>Insert in inferior 1/3 of joint </li></ul><ul><li>If contact os, walk off into joint </li></ul><ul><li>Older patients may be unable to enter joint, can inject periarticular </li></ul>
  33. 33. SACROILIAC JOINT INJECTIONS
  34. 34. RFA OF SI JOINT <ul><li>Proceed by diagnostic injection </li></ul><ul><li>Can be done with a single, multi-electrode probe </li></ul><ul><li>Must cover L5-S3 dorsal primary rami </li></ul>

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