Image guided interventions of lumbar Spine Interventional CT guided pain management 1

1. Image
guided
interven.ons
of
lumbar
spine
Interven.onal
CT
guided
pain
management
Yvonne
K.
Maratos,
Grégory
Lenczner,
DHW
Grönemeyer,
Nicolas
Amore?
Paris
PrevenAon,
155
Blvd
Haussman
Paris
Dr.
Maratos
reports
have
no
conflict
of
interest

2. Aim
of
the
talk
§
Radiologist
role
in
backpain
management
§
Explain
different
treatments
and
their
hierarchy
in
treatment
of
lombalgia
ü Z-­‐joint
ü Periradicular
ü Intradiscal
procedures
§
Show
“how
to
do”
interven.ons
§
Present
new
techniques

3. Aim
of
the
talk
§
Radiologist
role
in
backpain
management
§
Explain
different
treatments
and
their
hierarchy
in
treatment
of
lombalgia
ü Z-­‐joint
ü Periradicular
ü Intradiscal
procedures
§
Show
“how
to
do”
interven.ons
§
Present
new
techniques

4. Ministry of health Statistics, Germany, 2008
§
26
Billions
€
are
spend
every
year
in
Germany
for
treatment
of
lumbalgia1
§
71,5
millions
disability
/year
§
Most
frequent
cause
of
disability
(20%
due
to
degenera.ve
spine
disease)
§
80%
of
the
popula.on
between
30
and
60
years
old
will
experience
at
least
one
episode
of
lumbago
Back
pain’s
social
cost

5. Advantage
of
being
a
radiologist
§
Diagnose
and
treat
ü
In
favor
of
CT
Image
guidance
-­‐
Precise
targeAng
-­‐
Control
during
the
intervenAon
-­‐
Reproducibility
-­‐ Par.cularly
suited
in
obese
pa.ents,
osteoporosis
and
important
degenera.ve
disease
-­‐ Contrast
media
allergy

6. Mul.-­‐disciplinary
therapy
concept
General
therapy
plan
in
back
pain
Progressive
increase
in
therapeu.c
invasivity
Short
period
of
rest
An.-­‐inflammatory
drugs
Physical
therapy/
Balneotherapy
(Mesotherapy
or
injec.on
by
a
rheumatologist)
Image
guided
injec.on
therapy
(a]er
6
weeks
of
complaints)
Surgery

7. Contra-­‐indica.ons
§ Neurologic deficits imposing surgery:
ü Motor deficit >3/5
ü Cauda-equina-syndrome
§ Infection
§ Coagulation disorders
ü Z-joint injections: Aspirin, Anti-vitamin K are no
contra-indication
ü Nerve root injections: stop anti-platelet therapy 8 days
before; stop AVK and replace with LMWH

8. Importance
of
combining
complementary
techniques
for
pa.ent
wellbeing

9. Work-­‐up’s
central
element
Step
1:
Pre-­‐interven.on
Consulta.on
Patient’s complaint Physical exam Imaging Findings
+ - complementary exams (e.g. neurological or vascular work-up)
Pain origin
RADICULAR
Disc
herniaAon
e.g.
sciaAca
PSEUDO
RADICULAR
Z
joint
Lumbalgia
DISCOGENIC
disc
OTHER
informed consent is signed

10. Step
2:
Treatment
§ Treatments in local anesthesia on an out-
patient basis
§ Low dose protocol CT Scanner
ü Sequential acquisition
ü mAs 30, 100-120 KV
ü DLP 15-40 DLP
§ Trained team, precise workflow

11. Complete
sterility
during
the
procedure

12. Pain into the limb with no radicular
compression
Pseudo-­‐radicular
pain

13. Workup
for
pseudo-­‐radicular
pain
Progressive
increase
in
therapeu.c
invasiveness
Local
Pain
Morning
s.ffness
Pain
while
turning
in
bed/posi.on

14. Workup
for
pseudo-­‐radicular
pain
Progressive
increase
in
therapeu.c
invasiveness
Local
Pain
Morning
s.ffness
Pain
while
turning
in
bed/posi.on
Treatment
at
corresponding
z-­‐joint
-­‐
Facet
joint
blocks

15. Workup
for
pseudo-­‐radicular
pain
Progressive
increase
in
therapeu.c
invasiveness
Local
Pain
Morning
s.ffness
Pain
while
turning
in
bed/posi.on
Treatment
at
corresponding
z-­‐joint
-­‐
Facet
joint
blocks
-­‐
Neurolysis

16. Workup
for
pseudo-­‐radicular
pain
Progressive
increase
in
therapeu.c
invasiveness
Physiotherapy
once
pain
<30
%
Local
Pain
Morning
s.ffness
Pain
while
turning
in
bed/posi.on
Treatment
at
corresponding
z-­‐joint
-­‐
Facet
joint
blocks
-­‐
Neurolysis

17. Workup
for
pseudo-­‐radicular
pain
Progressive
increase
in
therapeu.c
invasiveness
Physiotherapy
once
pain
<30
%
Local
Pain
Morning
s.ffness
Pain
while
turning
in
bed/posi.on
No
Pain
at
palpa.on
Pain
at
the
end
of
the
day
Pain
while
standing
a
long
.me/
a]er
physical
ac.vity
Treatment
at
corresponding
z-­‐joint
-­‐
Facet
joint
blocks
-­‐
Neurolysis

18. Workup
for
pseudo-­‐radicular
pain
Progressive
increase
in
therapeu.c
invasiveness
Treatment
at
disc
level
Physiotherapy
once
pain
<30
%
Local
Pain
Morning
s.ffness
Pain
while
turning
in
bed/posi.on
No
Pain
at
palpa.on
Pain
at
the
end
of
the
day
Pain
while
standing
a
long
.me/
a]er
physical
ac.vity
Treatment
at
corresponding
z-­‐joint
-­‐
Facet
joint
blocks
-­‐
Neurolysis
Pain
resistance

19. How
to?

20. §
Lumbar
spine
needle
(21-­‐23
Gauge)
ü
The
local
anesthe.c:
Short
(Lidocaïne
1%
(Xylocaïne®)
and
long
lasAng
(naropeine)
ü
Contrast
medium
CompaAble
with
intra-­‐thecal
injecAon
:
ioméprol
(Ioméron®)
300mg/ml
(0.5
cc)
§
Cor.coid
§
Drugs
are
injected
carefully
and
slowly;
no
pain
§
No
injec.on
of
crystalloid
cor.coid
if
bleeding
occurs
(in
that
case
hydro
soluble
cor.coid)
Drugs
and
material

21. §
A]er
placement
of
the
pa.ent
on
a
prone
posi.on
a
scout
view
is
performed
§
Axial
images
are
obtained
at
the
level
of
interest
§
Planning
of
the
procedure
§
Mark
introduc.on
point
on
the
skin
§
Step
to
step
inser.on
of
the
canula;
drugs
are
injected
a]er
sa.sfactory
contrast
media
spread
§
Disinfec.on
Procedure
workflow

22. Targe.ng

23. Progression
of
the
probe
in
a
axial
plane

24. Amedo
Smart
Tacking
Solu.ons,
Germany
Laser
naviga.on

25. Amedo
Smart
Tacking
Solu.ons,
Germany
Laser
naviga.on
Faster
More
secure
Less
irradiaAon

26. Amedo
Smart
Tacking
Solu.ons,
Germany
Laser
naviga.on
Faster
More
secure
Less
irradiaAon

27. §
First
line
treatment:
injec.on
therapies
ü Z-­‐joint:
-­‐
block
tests,
chemical
or
thermal
rhizolyse
ü Periradicular:
-­‐ epidurals,
foraminal
and
double
access
injec.ons
Lumbar
spine
procedures

28. Local pain or pseudo radicular
pain into the limb with no
radicular compression
Z-­‐joint
syndrome:
the
chameleon

29. Peri-articular positionning on medial branch
§
Bloc
test:
Therapeu.c
and
diagnos.c
tool
also
using
long
las.ng
anesthe.c
on
the
ar.cula.on
Z-­‐joint:
Injec.on
procedures
MB: medial branch
of ramus dorsalis

30. Is
intra-­‐ar.cular
injec.on
required?
§
Not
mandatory
because
the
joint
inerva.on
is
peri-­‐ar.cular

31. Intra-­‐ar.cular
Injec.on
§
Intra-­‐ar.cular
injec.on
may
cause
diffusion
of
the
drug
in
the
epidural
space

32. 68
years
old
female
paAent
acAve
recreaAonal
Sacroiliac
joint

33. Z
joint
injec.on
Posi.ve
bloc
test
but
temporary
relieve
What
can
we
do?

34. Rhizolysis:
nerve
abla.on
of
ramus
dorsalis
§ Either
chemical
(Alcohol)
or
thermal
(radiofrequency
or
cryotherapy)
§ Abla.on
of
the
medial
or
lateral
branch
of
ramus
dorsalis
§ Monosegmental,
step
to
step
neurolysis

35. Ethanol
Rhizolysis
§ On
an
outpa.ent
basis
in
local
anesthesia
§ Posi.oning
on
the
z-­‐joint
§ Injec.on
of
2
ml
contrast
§ Verifica.on
scanner
excluding
contrast
in
the
spinal
canal
or
in
proximity
of
nerve
roots
§ Slow
Injec.on
of
0,2-­‐0,5ml
ethanol
(96%)
§ A]er
procedure
posi.oning
on
procubitus
for
30min
Intensive
physiotherapy
is
mandatory
for
long
term
results
Mono-­‐segmental
approach

36. Unilateral
muscle
athrophie
§
Axial
T2
Image
of
the
lumbar
spine
at
L5-­‐S1-­‐
Sacrum

37. CI
to
apply
alcohol
if
CM
is
at
the
contact
of
nerve
root
Ethanol
Rhizolysis:
cau.on

38. Local tissue-coagulation
How
does
radio-­‐frequency
work?
Alternating high-frequency-currents cause an important electric field near the RF-
active tip. Thereby the adjacent tissue is heated locally.

39. Radiofrequency
Neurolysis
the
“groove“
where
the
lateral
branch
is
located

40. A side view of the dermatomes (after Foerster). From Haymaker, W and Woodhall, B.: Peripheral Nerve Injuries.
Philadelphia, W.B. Saunders Company, 1945:20. (With permission of the publisher)
Radicular
Syndrome
§ Radicular
pain:
pain
projec.ng
into
the
limb
due
to
a
nerve
irrita.on
§
Pseudoradicular
pain:
pain
into
the
limb
with
no
nerve
irrita.on

41. Postero
lateral
conflict:
where
to
treat?
Jeong
HS,
Lee
JW,
Kim
SH,
Myung
JS,
Kim
JH,
Kang
HS.
Effec7veness
of
transforaminal
epidural
steroid
injec7on
by
using
a
preganglionic
approach:
a
prospec7ve
randomized
controlled
study.
Radiology.
2007
Nov;245(2):584-­‐90.

42. Epidural
injec.on
Schaufele
MK,
Hatch
L,
Jones
W.
Interlaminar
versus
transforaminal
epidural
injecAons
for
the
treatment
of
symptomaAc
lumbar
intervertebral
disc
herniaAons.
Pain
Physician.
2006
Oct;9(4):361-­‐6.

43. Other Therapy
options!!!
You have to live with your
pain!?
Still in Pain?
Second line treatment

44. §
Second
line
treatment:
Intra-­‐discal
procedures
ü
Discography
ü
Intra-­‐discal
Laser
decompression
ü
Percutaneous
mechanical
herniated
disc
decompression
Lumbar
spine
procedures

49. Discography:
important
diagnos.c
&
therapeu.c
tool
Intradiscal
cor.coid
applica.on
in
erosive
discopathies

50. CT
guided
laser
disc
decompression

51. Tissular steam
•
Decrese of
intradiscal
pressure
• Fast rehabilitation
CT
guided
laser
disc
decompression

52. Using
a
motorised
device,
Stryker
®
CT
guided
Percutaneous
decompression
of
a
disc
hernia.on
Local
anesthesia

53. Other
image
guided
invasive
technique

54. sagital
and
axial
T2
weighted
images
of
a
24
year
old
paAent
with
moderate
lumbalgia
Isthmic
Spondylolisthesis

55. First
line:
injec.on
procedure

56. Second
line:
Percutaneous
arthrodesis
under
CT
guidance
Isthmic
lysis
screw
fixaAon

57. §
No
large
incision
§
No
muscle
dissec.on
§
Fast
rehabilita.on
Dorsal
percutaneous
arthrodesis
CT
guided
transfaceoar
athrodesis
in
CT
guidance

58. Ø Efficient therapy option for resistant pain syndrome
Ø Pre-intervention consultation in difficult cases
Ø Start with the less invasive treatment
Ø Z-joint, sacroiliac-joint
Ø Be systematic
Ø Intensive physiotherapy
CT
guided
procedure
of
lumbar
spine:
Take
home
messages

59. CT
Guided
procedure
an
open
road
for
progress!

60. Thanks
for
your
aoen.on!