Supporting Evidence
In 1990, Antti-Poika et al. conducted a prospective study of 279 injected discs in 100 patients. Exact reproduction of pain on injection was more common in fissured or ruptured discs. The results indicated that discography had a sensitivity of 81 and specificity of 64 for pain. Additional information yielded by follow-up CT scan was minimal 44 . Also in 1990, Bernard prospectively studied 250 patients with low back pain who underwent lumbar dis cography followed by CT scan. In 93 of the...
Technical Considerations Bone Biopsy Needles
FNA Needles FNA needles represent a class of thin-walled fine-caliber beveled needles with a removable inner stylet 43,44 Figs. 1 and 2 . They are typically used on soft-tissue lesions to obtain material for cytology and microbiology. The beveled tips provide a cutting surface and negative pressure is applied to the needle to aspirate tissue 45,46 . Typically, 20- to 22-gauge needles are used with variable bevel angles spinal 30 Chiba 25 Meditech, Boston Scienti-fic, Natick, MA Turner 45 ,...
Functional Vascular Anatomy Important To The Interventionist
Arterial supply to the spine arises at segmental levels based on embryologic development of the somites. In the adult, arterial origins are variable based on the level of the spine. From the T3-5 to the L4 vertebral levels, segmental arteries arise from the thoracic or abdominal aorta. In the cervical region, supply to the segments is predominantly from the vertebral arteries as well as the ascending and deep cervical branches of the thyrocervical and costocervical trunks of the subclavian...
Facet Joint Injections
In 1911, Goldthwait first stated that the facet joints were responsible for cases of low back pain and instability 36 . Like many clinicians of that time, he was struck by the asymmetry of the facet joints seen on radiography. He believed that the joint asymmetry could cause pain from nerve root pressure 36 . An Italian surgeon, Putti, published an article in 1927 that supported Goldthwait's findings and focused specifically on articular facet degeneration as a cause of back pain 37 . In 1933,...
Anatomy Orv
The sacroiliac articulation is complex and multiplanar, providing a stable attachment between the pelvis and the axial skeleton. The sacroiliac joints primarily serve to absorb and transmit forces between the more cephalad spinal column and the lower extremities. Previously classified as an amphiarthrodial joint two hyaline cartilage surfaces joined by fibrocartilage , and a synarthrosis in which the articular surfaces are joined by fibrous tissue , there is now general agreement that the...
Distinguishing Pars Injuries From Facet Arthritis Using Spect
Abnormal uptake in the pars interarticularis is usually due to a stress injury or spondylolysis. Facet lesions are usually arthritic although fractures and osteoid osteomas may be present. Lesions in the vertebral arch must be accurately localized to differentiate between these disorders. SPECT is particularly useful in lesion location because multiple projections can be reconstructed 1 . It is difficult to distinguish a pars injury from facet arthritis in the coronal and transverse...
Local Anesthetics
Local anesthesia can be produced with the direct administration of any of the following agents 1.0 lidocaine Xylocaine, AstraZeneca Pharmaceuticals , 0.25 bupi-vacaine Marcaine, AstraZeneca Pharmaceuticals, and Sen-sorcaine, AstraZeneca Pharmaceuticals , 0.5 ropivacaine Naropin, AstraZeneca Pharmaceuticals , and 1.0 mepi-vacaine Carbocaine, Sanofi-Winthrop Pharmaceuticals . The administration of these agents into the epidural space or perineural space is capable of producing adequate sensory...
Vertebral Fractures And Vertebroplasty
Vertebral body fractures show an intense increase in acti-vity that occurs within 72 h in most patients 30 . Osteopenic compression fractures do not extend posteriorly into the vertebral arch and do not obscure the disc space. Matin et al. showed that 59 of fractures are normal by the end of the first year, 91 by the second year, and 95 by the third year 30 . Planar bone scintigraphy is useful in predicting pain relief from percutaneous vertebroplasty in patients with osteoporotic vertebral...
References Fsv
1. Schwartzer AC, Aprill C, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995 20 1878-1883. 2. Mixter WJ, Barr JS. Rupture of the intervertebral disk with involvement of the spinal canal. N Engl J Med 1934 211 210-215. 3. Smith L. Enzyme dissolution of nucleus pulposus in humans. JAMA 1964 187 137-140. 4. Onik GM, Helms CA, Ginsburg L, et al. Percutaneous lumbar diskectomy using a new aspiration probe. Am J...
Viscosupplementation
Degenerative disease of the sacroiliac joint includes pregressive erosion of the articular cartilage and synovial inflammation. Further, there is loss of the viscoelastic properties of the synovial fluid, making the cartilage more susceptible to further mechanical damage 5,23,24 . The loss of the viscoelasticity is felt to be the direct result of the loss of the protective effect of hyaluronan, a naturally occurring lubricating glycasaminoglycan found in synovial fluid 5,25-28 ....
Discitis And Osteomyelitis
MRI plays a pivotal role in the evaluation of infectious spondylitis particularly because the diagnosis is often a difficult one to make clinically. Patients with spinal infections present with nonspecific symptoms such as malaise, focal tenderness, radiculopathy, and back pain 38-40 . These symptoms may be attributable to other etiologies such as degenerative disorders, spinal stenosis, and neoplasms. In fact, back pain the most common symptom in patients with infectious spondylitis 40,41 is...
The Technique
The basic technique for accessing the epidural space is the same for access to the cervical, thoracic, or lumbar areas. Atthe same time, there are specific anatomic con- Fig. 3. The needle is directed across the medial aspect of the lamina into the epidural space. Fig. 5. Contrast syringe with small air bubbles, which allow the recognition of a change in pressure when entering the epidural space. These bubbles will allow the recognition of the pressure change by a sudden limited movement toward...
The Discovery Of Xrays
The specialty of interventional radiology would not exist had it not been for the work of Wilhelm Conrad Roentgen. On November 8, 1895, Roentgen observed a bright fluorescence of barium platinocyanide crystals while experimenting with the Hittorf-Crookes tube. He assumed that the fluorescence might be caused by cathode P rays. Using a fluorescent screen he filtered out cathode rays but the phenomenon persisted he became aware that the effect was produced by a new kind of ray that he called...
Technique Uej
Injection therapies are interventional techniques used to treat pain conditions that have failed to respond to other, more conservative therapies. It is important, among other items, to inquire as to the allergy history of the patient prior to proceeding with any invasive injection of the sacroiliac joint. Specifically, providone iodine based skin preparation agents, iodine-based arthrography contrast agents, local anesthetic agents, steroids, and agents used for preserving various...
Anatomy Dnr
Zygapophyseal apophyseal or facet joints are found paired throughout the spine between the third cervical level and the first sacral level. Facet joints are diarthrodial synovial joints between the posterior elements of the spine with articular surfaces lined by hyaline cartilage, with marked variability in the size, shape, and position of the joint capsule 19,20 . The facet joint is comprised of the superior articular facet originating from the caudad vertebral body and inferior articular...
Osteoid Osteoma
Osteoid osteoma is a benign bone tumor often associated with severe skeletal pain. The tumor is usually lt 2 cm in size and consists of a nidus of osteoid and bone in highly vascular tissue. The lesion causes an intense reaction in the surrounding periosteum. Seventy percent of osteoid osteoma patients are younger than 20 yr of age. Osteoid osteoma occurs 2.3 times more frequently in males 27 . Kaweblum et al. collected 52 cases of osteoid osteoma in children from the English literature and...
Indications
ESI is commonly used for relief of upper and lower back pain secondary to spinal stenosis, disc herniation with or without radicular pain, and refractory back pain of unknown etiology. ESI may help delay or prevent surgical treatment because many patients receive pain relief that allows them to endure an acute exacerbation of pain. ESI when combined with physical therapy and antiin-flammatory medications can provide satisfactory pain relief in patients who are not surgical candidates. Fig. 2....
Spinal Stenosis 1
The spinal cord is surrounded by ligaments and bones that provide support and protection. The central canal containing the cord is constructed from bones of the spine, ligaments, and fat. Depending on the patient's body habi Fig. 4. A Ankle reflex S1. B Knee reflex L2, 3, Fig. 4. A Ankle reflex S1. B Knee reflex L2, 3, tus, a central canal anteroposterior AP diameter of lt 14 mm in the cervical region and lt 15 mm in the lumbar region could be diagnostic 14 . Neural compression may be...
Info Ilv
venous, intramuscular, subcutaneous, intrasynovial, perineural, and intralesional routes , and topically dermal ointments, creams, and lotions ophthalmic ointments and solutions respiratory aerosols and enemas . With all forms of topical administration, there is some systemic absorption of steroid. There are a wide variety of commercially available corticosteroids however, a limited number of injectable formulations exist for spinal injection procedures. Cortisol is available in several...
Idet Gja
There have been several studies reporting the clinical outcomes of IDET in the literature since 1998. The most publicized study was reported by Saal et al., a group of physiatrists from Stanford 29 . These investigators reported on a consecutive series of 1116 patients presenting with chronic low back pain of 3 mo duration or longer. Of the study group, 1025 92 improved significantly with conservative treatment measures and were discharged to self-care. Surgical fusion was offered to the 91...
Injection Details
Preparation of the cement has been previously described 3,17 . Individual operators have their own preferred recipes but minimal variations do not appear to alter significantly the use or strength of the material 40 . Fig. 5. A-E This elderly female patient with a severely compressed L1 vertebral body presented for treatment. The 25-gauge anesthetic needle arrows is used to determine the initial needle trajectory on the AP A and lateral B views. Owing to the degree of compression, the needle is...
Idet
The process of patient selection involves identification and exclusion of patients who would be unlikely to ben- Fig. 4. Sagittal T2-weighted MRI of the lumbar spine showing disc desiccation dark signal on T2-weighted image and a bulge at L5-S1. Also note a high-intensity zone HIZ posteriorly. A HIZ has a strong correlation with an annular tear. Fig. 4. Sagittal T2-weighted MRI of the lumbar spine showing disc desiccation dark signal on T2-weighted image and a bulge at L5-S1. Also note a...
The Pathophysiology Of Lumbar Disc Disruption
Understanding the pathophysiology of discogenic pain is critical for understanding the treatment options. Discogenic pain represents a complex interaction of multiple pathologies. The intervertebral disc is an innervated structure capable of producing severe pain 7 . In addition, pain fibers nociceptors are present in the outer posterolateral portion of the disc. Nociceptor afferent pain transmissions are relayed through the dorsal root ganglion 8 . Ingrowth of granulation tissue and small...
History And Physical Examination
History and physical examination are key components in the evaluation of patients being considered for percutaneous vertebroplasty. A focused history and examination concentrating on the patient's back pain, mobility level, and medication use including analgesics, steroids, and osteoporosis antagonists is recommended. Presenting symptoms, pertinent medical, surgical and allergy histories, a list of current medications, and evidence of failed medical therapy are documented. Use of visual analog...
Hjq Ijs
Fig. 2. The sodium channel. The channel may exist in three distinct states. The closed or resting state is impermeable to sodium ions but does remain voltage responsive. The open state represents a transmembrane channel that is permeable to an inward sodium ion flux. The inactivated state is in an open channel configuration but has been rendered impermeable to sodium ions because a local anesthetic molecule is bound to the gating receptor site. Because local anesthetic renders the membrane...
Anatomy 1
The epidural space lies circumferentially around the dural sac and extends from the foramen magnum to the sacrococcygeal membrane at the sacral hiatus Fig. 1 . Its anterior boundary is the posterior longitudinal ligament. Posteriorly, it is limited by the ligamentum flavum, the laminae, and pedicles. It is connected to the paravertebral space through the intervertebral foraminae, which contains the exiting nerve roots. This communication is utilized in the transforaminal epidural approach. The...
Imaging Modalities For Needle Guidance
Fluoroscopy, CT scan, nuclear medicine, ultrasound, and MRI have been used for imaging guidance in vertebral biopsies. The lesion morphology, size, and location as well as the interventional radiologist's experience and the availability of equipment often determine the type of imaging used during a biopsy. Ultrasound has a limited role in vertebral biopsy but has proven to be effective with superficial lesions and aggressive lesions with extra-osseous extension 10,26,70,71 . MRI Advances in...
Spinecath Catheter
Once the needle is in the disc, position is checked in the frontal and lateral projection. The optimal needle position is within the center of the disc Fig. 11 . The stylet is then removed and the Spine Cath, a steerable and flexible probe with a distal thermal resistive coil portion, is advanced using frontal and lateral fluoroscopy for guidance Fig. 12 . The catheter will pass through the nucleus and curl along the interface of the nucleus and annulus with little resistance. If resistance is...
Info Car
Fig. 15. CT-guided transpedicular approach to biopsy a localized lesion in the right hemivertebrae. to document the precise placement of the needle into the lesion. The Transpedicular Approach. The patient is placed in the prone or lateral position. When using fluoroscopy, the needle system coaxial trephine or combination should be positioned directly down the pedicle in a manner approximating a bulls eye appearance 12 . The needle system is advanced to the superior lateral aspect of the...
Sacroiliitis
There is conflicting information regarding the role of planar bone scintigraphy in the evaluation of sacroiliitis. Some studies show planar bone scintigraphy to be efficatious in the diagnosis of sacroiliitis 32,33 while other studies show poor diagnostic accuracy 34,35 . Hanley et al. showed SPECT bone scintigraphy to be superior to quantitative planar bone scintigraphy in diagnosing sacroiliitis 36 . Hanley et al. also compared MRI and SPECT bone scintigraphy in early sacroiliitis and found...
Range Of Motion
Limitation of the range of motion can suggest the muscle systems involved 11 . Determine if decreased range of motion affects any activities, including walking, standing, bending over, sitting, climbing stairs, or raising arms over the head. Range of motion can be evaluated with the following graded scale Mild Slight motion loss, lt 15 , with minimal clinical Moderate Loss of up to 50 , and is clinically significant Marked Loss of 50 or greater in a major joint Fig. 1. A, B Anterior and...
Deep Tendon Reflexes
The deep tendon reflex is an involuntary muscle contraction created from a brisk tap on a tendon. The tap generates a sensory impulse that travels to a neuromuscular junction and returns as a muscle contraction. This reflex arc depends on an intact sensory nerve fiber, functional synapse in the spinal cord, intact motor nerve fibers, and functional muscle fibers Fig. 4 . The reflexes are tested in an ascending segmental order Fig. 2. E Test of shoulder abduction C5. F Test of elbow flexion C6....
Needle Placement
The disc to be treated is localized under fluoroscopy. The image intensifier II is angled either cranially or cau-dally to open the disc space. The II is then rotated into an oblique position until the superior articular process SAP bisects the disc space. A metal marker can be used to determine the skin entry site. The skin is infiltrated with Fig. 8. Sagittal T2-weighted MRI of the lumbar spine showing multilevel degenerative disc disease with severe disc space narrowing at L5-S1. Fig. 8....
Patient Preparation
Preprocedure instructions are similar to those for other spinal injections or vertebral biopsy-type procedures. These are related to the patient on an instruction sheet as follows. No solid food should be eaten 6 h prior to the procedure sips of water for medications are allowed . No aspirin-containing products should be used for at least 1 wk prior to the procedure. Nonsteriodal antiinflammatory medications e.g., acetaminophen or ibuprofen or other pain control medication is accep-table as...
Indications 1
The indications for performing a facet joint injection are twofold, diagnostic and therapeutic. Intraarticular injection of a local anesthetic can provide diagnostic infor- Fig. 4. A Axial T2-weighted MR image demonstrating normal appearing facet joints. Notice the high signal intensity from the synovial fluid in the joint. Note the disc herniation arrowhead . B Axial T1-weighted MR image demonstrating degenerative hypertrophic facet joint changes at the L4 level in a symptomatic patient. Fig....
History Of Discography
Lumbar discography developed as a complementary modality for studying the lumbar intervertebral discs at a time when oil-based myelography was associated with high false-negative rates, particularly at the lumbosacral junction. Radiographic contrast was first injected into a normal disc in 1941 by Lindgren in Scandinavia. In 1948, Knut Lindblom, a radiologist in Stockholm, Sweden, was the first to publish in vitro studies on discography by using a posterior transdural approach and coined the...
Technique 1
It is important, among other items, to inquire as to the allergy history of the patient, prior to proceeding with any invasive injection of the facet joint. Specifically, providone iodine based skin preparation agents, iodine-based arthrography contrast agents, local anesthetic agents, steroids, and agents used for preserving various pharmaceuticals may all be present for utilization during portions of this procedure. Specific investigation as to whether there is a history of latex allergy...
Idet 1
Contraindications to the IDET procedure include large disc herniations Fig. 7 , nerve root irritation secondary to mass effect, central stenosis, instability, and disc height loss beyond 50 Fig. 8 . Fig. 5. A Frontal image of discography needles in position before contrast injection. B Lateral image of a three-level discogram. Fig. 6. Sagittal T2-weighted MRI of the lumbar spine showing disc bulges and desiccation dark signal on T2-weighted image at L4-5 and L5-S1. Fig. 5. A Frontal image of...
Clinical Features
As degenerative changes of facet joints are commonly found on plain radiographs, computed tomography CT examination, magnetic resonance imaging MRI examination, and even nuclear medicine skeletal examinations in otherwise asymptomatic patients, careful and insightful patient selection is necessary when considering facet joint injection therapy. Facet joint asymmetry, joint space narrowing, subchondral sclerosis, erosions, and facet hypertrophy have all been found in patients with facet...
Anatomy
The neural foramen provides a passageway for the spinal nerve as it exits from its intradural position to its extraspinal course. The intervertebral disc and the vertebral body form the anterior boundary. The posterior boundary is the zygapophyseal joint formed by the inferior and superior facets Fig. 1 . The superior and inferior boundaries are the pedicles Fig. 2 . The foramen commu nicates medially with the epidural space. The dura mater has extensions that follow the exiting spinal nerves...
Cervical Spine
The cervical spine is more biomechanically challenged than the rest of the spine. The ligaments and supporting soft tissues are important for mobility. Recent anatomical reevaluation of this area has determined that the AF is a crescentic anterior interosseous ligament rather than a completely circumferential O-ring that surrounds the NP, as in the lumbar spine 16 . It tapers laterally where the uncinate processes exist and is deficient in the posterolateral aspects. Posteriorly, there is a...
Anatomic Considerations
Cervical Spine Biopsy Anterolateral and postero-lateral approaches are used in cervical vertebral biopsy. Fluoroscopic, CT, and MRI guidance has been used with cervical biopsy 29,32,33,77 . Fluoroscopic guidance requires adequate knowledge of cervical anatomy to be performed safety. CT and MRI allow visualization of the soft tissue structures of the neck during needle placement Fig. 11. Biopsy techniques. CT-guided direct posterolateral approach. Fig. 11. Biopsy techniques. CT-guided direct...
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clinical examination, and surgical options, and should be discussed with the referring physician before the procedure is performed. Injection generally includes L3-4, L4-5, and L5-S1. The patient is positioned in a prone or prone-oblique position with the less painful side up. Each level is set up fluoroscopically so the disc is parallel to the beam and obliqued so that the superior articular process of the overlying facet joint is slightly posterior to the center of the endplate 30-50 zone ....
The Pathophysiology Of Pain Production
The sensation of pain represents a complex series of events designed to protect the central nervous system CNS . The integration of multiple components of the neuroaxis begins with activation of specific nociceptors, signaling potential injury to sensory fibers and potential damage to the CNS. This type of neuropathic pain is considered maladaptive, yielding harmful sequelae. Nocice-ptive pain is, however, more of a warning to the rest of the body, indicating some form of injury, signifying...
Primary And Metastatic Spinal Tumors
Approximately 10 of spinal tumors are intramedullary. Ependymoma is the most common type of intramedullary tumor in adults 21 . The remainder are other types of gliomas. Intramedullary lesions disrupt cord function by invasion and infiltration. Extramedullary tumors may be extradural or intradural in location. Among the primary extramedullary tumors, neurofibromas and meningiomas are relatively common, often benign, and either intradural or extradural. Carcinomatous metastases, lymphomatous or...
Radicular Pain
Radicular pain can be created by compression or irritation of the nerve root in the lateral recess or from zygapophysial joint hypertrophy. Extruded disc material within the neural foramen compresses the ipsilateral exiting nerve root and is most often seen at the C4-5 and C5-6 levels in the cervical region and at the L3-4 and L4-5 levels in the lumbar region. The disc can bulge initially, and later the disc can herniate through the fibers of the annulus centrally or laterally. Radicular...
References Eaw
1. Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 1987 33 166-168. in French 2. Kaemmerlen P, Thiesse P, Bouvard H, Biron P, Mornex F, Jonas P. Percutaneous vertebroplasty in the treatment of metastases. Technique and results. J Radiol 1989 70 557-562. in French 3. Jensen ME, Evans AJ, Mathis JM, et al. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteo-porotic...
22 Gauge Needle
Fig. 5. Coaxial trephine system. Geremia, Cook, Bloomington, IN. A Coaxial introduction cannula. B 22-Gauge guiding needle with removable hub. C Trephine needle. Fig. 5. Coaxial trephine system. Geremia, Cook, Bloomington, IN. A Coaxial introduction cannula. B 22-Gauge guiding needle with removable hub. C Trephine needle. Fig. 6. Diagram of coaxial trephine needle system. After local anesthesia, the 22-gauge needle is advanced to the desired site on the bony surface A . The stylet is removed...
Mri Appearance Of The Normal Spine
T1- and T2-weighted images are routinely performed in the evaluation of the spine. With Tl-weighting, the intervertebral disc demonstrates fairly homogeneous signal intensity that is slightly less than that of the vertebral body red marrow. Epidural fat can be distinguished by its relatively bright appearance or high signal intensity 1 . Nerve tissue, on the other hand, is of low intensity dark appearance but may still be differentiated from cerebrospinal fluid CSF , which appears black with an...
Transforaminal Esi
The transforaminal approach to the epidural space is very similar to the approach used for selective nerve root blocks. With the patient in the prone or prone oblique position, fluoro-scopy is used to identify the appropriate neural foramen. Using C-arm equipment, the fluoroscope can be angled to open the neural foramen. This usually requires 30-40 ipsilateral angulation. The needle is then advanced through the neural foramen immediately inferior to the pedicle Fig. 10 . The epidural space can...