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Basic spine injections

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  • 1. DEVIN PECK, M.D. DIVISION OF PAIN MEDICINE DEPARTMENT OF ANESTHESIA WEILL CORNELL MEDICAL CENTER BASIC SPINE INJECTIONS
  • 2. ROLE OF INTERVENTIONS
    • Most effective as part of a multi-modal approach
    • Pharmacotherapy, physical therapy, behavioral therapy
    • Outcomes are best in those with localized pain, recent onset, without secondary gain
  • 3. WHAT WILL WE DISCUSS
    • Trigger point injections
    • Lumbar ESI
    • Transforaminal ESI
    • Cervical ESI
    • Median Branch Blocks and RFA
    • Sacroiliac Joint Injections
  • 4. BASIC INJECTION PEARLS
    • Anchor yourself against the patient
    • Skin wheal is the most important part of local
    • Gun barrel
    • When redirecting needle, mark your depth and pull back to soft tissue/skin
    • A slow injection is less painful
    • Careful sterile technique
    • Positioning is key
      • Patient
      • Practitioner
  • 5. RISKS
    • Infection
    • Bleeding
    • Dural puncture  headache
    • Nerve injury (exceedingly rare)
    • Intravascular injection/injury
    • Allergic reactions
    • Steroid effects
      • Mood changes
      • Hyperglycemia
      • HTN
      • Menstrual changes
  • 6. TRIGGER POINT INJECTIONS
    • Indications:
      • Muscle spasm
      • Myofascial pain
      • Fibromyalgia
      • Tender points
  • 7. TRIGGER POINT INJECTIONS
    • Technique :
      • Trigger points palpated as “taught bands”, TTP
      • Muscle pinched up away from pt.
      • 25-30g needle inserted, directed in 4 directions
      • Inject 1-1.5 cc lidocaine 1%, bupivacaine 0.5%, 10 mg depo-medrol or equivalent
      • Dry needling or saline may be effective
      • Can use botox
  • 8. ESI-MECHANISM (?)
      • Anti-inflammatory effect of steroid
      • Washout of chemical mediators of pain/inflammation
        • PLA-2 (releases AA from cell membranes)
        • Interleukins
        • Proteoglycans
      • Anti-nociceptive effect of LA’s (“break the pain cycle”)
      • Decreased edema, wallerian degeneration, and fibrotic changes to neural tissues
      • Steroid may:
        • Block some C fiber transmission
        • Stabilize membranes
        • Decrease CNS sensitization (preventing chronic pain)
  • 9. INTERLAMINAR ESI-TECHNIQUE
    • Positioning: prone with pillow under mid-lower abdomen (reduces lumbar lordosis, opens interspinous spaces)
    • AP view-spinous processes equidistant between pedicle shadows
    • C-arm with caudal tilt, about parallel with spinous processes
    • “ Square off” the superior endplate of caudad body and inferior endplate of superior body
  • 10. INTERLAMINAR ESI-TECHNIQUE
    • Identify target (midline vs. R-L sided)
    • Mark with opaque marker (i.e. 18g needle)
    • Local in approximate gun barrel
    • Needle in gun barrel and advance in AP until engaged in ligament
  • 11. INTERLAMINAR ESI-TECHNIQUE
    • Obtain lateral view
      • Can’t be sure of true lateral to confirm needle depth
    • Loss of resistance
      • Saline vs. Air
      • Continuous pressure vs. intermittent
    • Still necessary even when fluoroscopy used
      • Precise location of epidural space can’t be identified
    • Inject contrast under live fluoro
    • Wait a few seconds, take an image
    • AP epidurogram to confirm spread
  • 12. TRANSFORAMINAL ESI
    • Approach to epidural space and spinal nerve via intervertebral foramen
    • Posterolateral approach
    • Borders of the foramen:
      • Superior/Inferior-pedicles
      • Anterior-Vertebral body and disc
      • Posterior-SAP/IAP/facet joint
  • 13. TRANSFORAMINAL ESI
    • Spinal nerve exits from superoanterior portion of foramen and runs inferiorly and anteriorly
    • Superior aspect of foramen thought of as “safe triangle”
    • This may be re-thought, as the variable vasculature is most often present here (See article by Glaser and Shah in Pain Physician, 2010)
  • 14. TRANSFORAMINAL ESI
    • Fluoroscopy setup
      • AP view
      • Cephalocaudal tilt to “square off” vertebral bodies
      • Oblique angulation towards operative side until the SAP is at the mid-pedicular line
  • 15. TRANSFORAMINAL ESI
    • Insert local-approximately coaxial with fluoro beam
    • Insert needle (i.e. 22g 3.5 in spinal needle)
    • Target:
      • Inferior margin of transverse process
      • Superior to tip of SAP
      • Lateral to lateral margin of IAP or pars
  • 16. TRANSFORAMINAL ESI
    • Obtain AP image and advance needle until tip is about midway under pedicle shadow
    • Obtain lateral view and advance needle until tip is short of midway into the foramen
    • Aspirate, inject contrast under live lateral fluoroscopy
    • Obtain live AP fluoroscopy with contrast injection
  • 17. CERVICAL ESI
    • Anatomy differs from lumbar spine significantly
    • Ligamentum flavum is much thinner and may have midline gaps
      • Paper by Lirk and Kolbitsch in Anesthesiology 2003:
        • C3–C4: 66% C4–C5: 58%
        • C5–C6: 74% C6–C7: 64%
        • C7–T1: 51% Th1–Th2: 21%
        • Mean width of mid-line gaps: 1.0 +/- 0.3 mm
    • Some advocate performing no higher than C7-T1
      • Epidural space wider here (1.5-2 mm)
      • May be minimal in higher spaces as shown in cadavers
  • 18. CERVICAL ESI
    • Can be performed midline or paramedian
      • Paramedian offers advantages of bony landmark and avoidance of midline gaps in flavum
    • Position prone with neck slightly flexed
    • Obtain AP view with caudal tilt (15-20°)
  • 19. CERVICAL ESI
    • Identify level by counting up from T1
      • When in doubt, check a lateral
    • Use radio-opaque marker to identify lamina of inferior vertebra-just lateral to spinous process
    • Walk cephalad and medial until off of os
    • Check lateral, advance with LOR and frequent lateral shots
  • 20. FACET JOINTS
    • One of the most common sources of LBP
    • True synovial joints
    • Formed by SAP of level below, and IAP of level above
    • Volume capacity of 1-1.5cc
    • Motion-restricting joint-adds stability
    • Upper lumbar joints oriented sagittally-able to resist rotation
    • Progressively coronal in orientation as you move caudally-resist forward displacement
  • 21. FACET JOINT INNERVATION
    • Innervated by medial branch of dorsal ramus of spinal nerve
    • Each has an ascending and descending branch
    • Each MB supplies joint at its own level, and 1 below (i.e.  L3 MB innervates the L3-L4 and L4-L5 joints)
    • Each joint is supplied by MB at that level, and 1 level above (i.e.  L4-L5 joint is innervated by L3 and L4)
  • 22. FACET JOINT PAIN
    • Arthropathy can lead to low back pain (i.e. axial pain)
    • Hypertrophy or cysts can lead to spinal nerve impingement and radicular pain
    • Referral patterns vary between studies
    • Pain pattern can be:
      • Low back
      • Radiating pain to hip/ buttock/proximal leg
      • Radicular
  • 23. MEDIAL BRANCH BLOCKS
    • May be diagnostic of facetogenic pain
      • MB nerves do innervate surrounding structures as well
      • LA can spread to lateral and intermediate branches
    • More closely correlated than H and P or radiology
    • Perform 1-2 prior to RFA of median branch
    • May also perform facet joint injections
      • No evidence of benefit over MBB
      • Technically more difficult
      • Volume 1-1.5cc-can rupture capsule  leakage of LA to surrounding structures (including MB)
  • 24. MEDIAL BRANCH BLOCKS
    • AP view (remember to square off endplates)
    • Can perform in AP or oblique
    • Target: junction between SAP and transverse process
    • Remember:
      • MB is located at the junction BELOW the level of the nerve root (i.e. L1 MB at SAP/TP of L2 vertebra)
      • Facet joint innervated by MB of that level and level above
      • So, to block L4-5 facet, inject at SAP/TP junction of L4 (L3 MB) and L5 (L4 MB)
      • L5 (dorsal ramus, NOT MB) located at junction of SAP of S1 and sacral ala
  • 25. MEDIAL BRANCH BLOCKS
  • 26. MEDIAL BRANCH RFA
    • Probes placed along medial branches
    • Heated (usually to 80 degrees) to lesion nerves
    • Nerves regrow at about 1mm/day
    • Can give long-term (6-12 mo) pain relief
    • Coming from somewhat caudad allows needle tip to lie closer to parallel to nerve (large lesion)
  • 27. MEDIAL BRANCH RFA
    • Lesion is spheroidal and may extend several mm beyond active tip
    • Majority of lesion surrounds the axis of the electrode
    • Cross section is 5-6 cm
    • Because lesioned end of nerve is coagulated, must repair itself before regeneration
    • Time for repair is proportional to length of nerve coagulated
  • 28. MEDIAL BRANCH RFA
    • Fluoro view similar to MBB (can use more caudal tilt)
    • When injecting LA, don’t go too deep as will need to do sensorimotor test
    • Needle placement similar to MBB (10cm RF cannula with 5mm active tip)
    • Sensory testing: 50Hz should lead to concordant pain (1V max)
    • Motor testing: 2Hz up to 3V should cause no myotomal stimulation
    • Inject .5-1cc LA
    • Lesion at 80º C for 60-90s
  • 29. SI JOINT ANATOMY
    • Mainly a support structure, multiple wide ligaments
    • Biomechanical studies indicate some motion
    • Superior 2/3 fibrocartilaginous, caudal 1/3 true joint
    • Innvervation is from dorsal
    • primary rami of L5-S3
      • Some authors suggest L4
      • (or even L3) and S4 contribute
  • 30. SACROILIITIS
    • SI dysfunction
      • Mechanical dysfunction
      • Inflammation
      • Infection
      • Trauma
      • Degeneration
    • Symptoms
      • Low back pain
      • May radiate into buttocks or legs (rarely past knee)
      • Often exacerbated by prolonged standing/sitting
  • 31. SACROILIITIS
    • Diagnosis
      • Primarily by history and physical
      • Can incorporate imaging (X-Ray/CT/MRI) although there are many false positives and negatives
      • Diagnostic/therapeutic blocks
    • Physical findings
      • SI tenderness
      • Patrick’s/FABER signs
      • Gaenslen's test
  • 32. SI JOINT INJECTION
    • Patient prone
    • Caudal C-arm angulation (i.e. 20º)
    • Identify posterior (medial) and anterior (lateral) joint lines
    • Oblique angulation away from affected side
      • Angle varies, but can do live fluoro to align anterior and posterior joint lines
    • 22g g, 3.5 in spinal needle
    • Insert in inferior 1/3 of joint
    • If contact os, walk off into joint
    • Older patients may be unable to enter joint, can inject periarticular
  • 33. SACROILIAC JOINT INJECTIONS
  • 34. RFA OF SI JOINT
    • Proceed by diagnostic injection
    • Can be done with a single, multi-electrode probe
    • Must cover L5-S3 dorsal primary rami
  • 35.