John M Mathis 1
Vertebroplasty is a term that describes a surgical therapy that has been performed as an open operative procedure for decades, using bone graft, cement, or metal implants to modify or reconstruct damaged or destroyed vertebra.1-12 In these procedures, polymethylmethacrylate PMMA has been the cement most often used for reconstruction and augmentation of bone damaged by trauma or tumor invasion.1,3,11,12 Shortly after Galibert and Deramond13 performed the first percutaneous vertebroplasty PV in...
Usa
Library of Congress Cataloging-in-Publication Data Mathis, John M. Image-guided spine interventions John M. Mathis. 1. Spine imaging. 2. Spine Surgery. 3. Surgery Data processing. I. Title. RD768.M388 2003 ISBN 0-387-40320-5 Printed on acid-free paper. 2004 Springer-Verlag New York, Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA ,...
Surgical Implantation Technique
The implantation procedure may be accomplished under general or local anesthesia with anesthesia monitoring. The latter technique is of- ten preferred in an outpatient setting because it lends itself to rapid recovery following the procedure. Prior to implantation, some time should be spent with the patient to optimize the side and location of the pump. About the only area amenable to the implantation of these generally large devices is the right or left lower quadrant of the abdomen. Some time...
Neurodestructive Techniques
We rarely deliberately destroy primary motor or mixed motor sensory nerves. We often use radiofrequency lesioning techniques of the spine, however, to treat known facet disease. Patients who are found to have facet arthropathy on imaging and or physical exam patients with exacerbation of pain on extension and facet arthropathy on imaging studies are frequently treated with facet rhizolysis. This technique has an extremely high success rate and very low complications. We generally delay use of...
Reherniation at the Level of Previous Surgery
With experience, it is now clear that in a number of clinical situations percutaneous discectomy is particularly useful. Perhaps APLD could have the greatest impact in a patient who has had a reherniation at the site and level of previous disc surgery. Patients who reherniate after open back surgery constitute approximately 5 of that patient population. Of great importance is that success rates are lower for patients who are reoperated on with an additional open discectomy at the same level as...
Minimally Invasive Intradiscal Therapy
From a therapeutic point of view, the treatment of discogenic pain appears to be rather limited. On the one hand, appropriate conservative care e.g., active physical therapy, pharmacological management should be expected to yield success in the vast majority of cases. However, failing this, the only other available treatment has been arthrodesis. Clearly, this is a very limited treatment continuum. From a philosophical point of view, a minimally invasive intradiscal treatment technique is quite...
Mario Muto Cosma Andreula and Marco Leonardi
Low back pain and nerve root pain are among the most common conditions affecting the lumbar spine. Approximately 80 of the population in western countries will experience one or more episodes of low back pain in their lifetime, and 55 will suffer from low back pain associated with a radicular component.1 Back pain is commonly caused by disc disease however, other factors may be responsible for nerve root syndromes, and these should be considered when clinical symptoms fail to match computed...
Conclusion Mrt
Discography has become an indispensable assessment tool to evaluate pain of spinal origin no longer is it reserved for those who are fusion candidates. With the continuous evolution of spinal interventions and the growing recognition of discogenic pain as a major clinical problem, the demand for this procedure is certain to increase. Our experience has been that when discography is performed with appropriate clinical indication s by skilled, knowledgeable, and experienced procedu-ralists, it...
Therapeutic Indications and Contraindications
The indications and contraindications for diagnostic epidurography with possible epidurolysis consist of one or more of the following 1. Back or neck pain, with or without radicular pain of chronic duration 2. Unresponsiveness to conservative therapy 3. Lack of obvious source of pain pathology 4. Absence of focal neurological deficit A good rule of thumb is to consider that the presence of a focal neurological deficit requires surgical decompression until another diagnosis is reached, while...
Far Lateral Herniation
Another special patient population for which APLD should be the first procedure chosen consists of patients whose herniations occur in the far lateral location beyond the intervertebral foramen. Such patients are difficult to treat with a traditional interlaminar approach of mi-crodiscetomy, which sometimes requires the removal of all or a large portion of the facet Figure 8.4 . Our excellent results with APLD in this patient population are understandable, since the percutaneous disc-ectomy...
Cement Injection
Cement is prepared only after all needles are placed, as described earlier Cement Selection and Preparation . Cement with an appropriate opacification is prepared and injected using small syringes typically 1 mL or devices made specifically for injection Figure 14.11 . This allows easy control of the cement introduction. Either the cement Figure 14.11. Cement injection with a 1 mL syringe. Note bipedicular needle placement prior to beginning cement injection. injection should be monitored in...
General Considerations
The original Racz procedure technique is well documented.6,8,15,20,24 As expected, modifications of this original procedure have emerged over the years.10,20,25 Changes in procedural technique, medications, and equipment may provide improved outcomes, safety, and cost effec- We suggest that practitioners proposing to add this therapy to their practice initially adopt a standard method well reported in the literature without modification. This establishes a dependable method during acquisition...
Spinal Vascular Malformations
The following entities have been listed as spinal vascular malformations hemangioblastomas, cavernous malformations angiomas, spinal aneurysms, arteriovenous fistulas, and arteriovenous malformations. With regard to vascular lesions of the vertebral bodies, aneurysmal bone cysts and vertebral hemangiomas can also be mentioned. Many different classification schemes have been suggested over the past three decades. The newest proposed classification for spinal vascular lesions is by Spetzler et...
OslerWeberRendu Syndrome Hereditary Hemorrhagic Telangiectasia
The autosomal dominant syndrome named after Osler, Weber, and Rendu consists of two genotypes types 1 and 2 . Type 1 is associated with mucocutaneous telangiectasias, pulmonary arteriovenous fistulas, and arteriovenous shunts of the central nervous system. The associated spinal arteriovenous shunts are most often seen in the pediatric population and are always intradural pial arteriovenous fistulas, subtype C ventral intradural AVF or type IV, subtype C . The endothelial cells in this syndrome...
Equipment Requirements
Image guidance can be accomplished with several different modalities. These include fluoroscopy, computed tomography, computed tomography combined with a multidirectional fluoroscope, computed tomographic fluoroscopy, and magnetic resonance imaging.8 The choice of equipment is determined by its availability, operator preference, and by the location and size of the suspected lesion. A CT-guided spine biopsy can be performed without or with the use of a stereotactic apparatus to guide the...
Pain Digest 2000 10 16-23
Intraspinal drug delivery systems have made the chronic delivery of intrathecal medication a manageable and safe tool in the management of chronic pain due to cancer, as well as other causes. Careful attention to patient selection, screening, drug selection, implantation technique, and refill technique will assure that this modality will be an important adjunct to any pain management clinic. Additional acceptance and understanding by the lay community is necessary to bring reasonable...
Procedural Steps
1. Choosing the entry point for the instruments. The entry point for the instruments is usually chosen by measuring the distance from the mid-line on a CT scan that shows the whole abdomen through the disc space of interest. The path is calculated to the center of the disc passing just anterior to the facet joint. Using a CT scan in this manner excludes the possibility that the bowel will be in the path of the instruments and also eliminates the possibility of choosing an entry point too far...
Patient Selection 1
The selection criteria for balloon kyphoplasty are similar but not equivalent to those for PV see Chapter 14 . As with PV, the patient selection process includes obtaining a detailed history and physical examination. The patient's symptoms need to be linked to the VCF. Evaluation of the patient's films radiographs, computed tomography CT , magnetic resonance imaging MRI , and bone scans should correlate symptoms with the fracture location and image characteristics. Balloon kyphoplasty has been...
Image Guidance
Since the first PV procedure,13 fluoroscopy has been the preferred method of image guidance for performing PV, although CT has infrequently been used as a primary or adjunctive tool.44,45 Because this procedure was initiated and popularized by interventional neuroradiolo-gists, biplane fluoroscopic equipment was commonly available and often used. This equipment allows multiplanar, real-time visualization for cannula introduction and cement injection and permits rapid alternation between imaging...
Surgical Complications
In the perioperative period, bleeding with the subsequent development of a pocket hematoma is perhaps the most troublesome and preventable problem. Meticulous attention to hemostasis during pump pocket formation will avoid this problem. An additional aid in prevention is the placement of an abdominal binder, such as a 6 in. Ace wrap, around the abdomen and lightly compressing the fresh pump pocket for 24 to 48 hours. This compression dressing helps to avoid the accumulation of blood or fluid in...
Info Udj
47. Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain a caution. Neurosurgery 36 732-739, 1995. 48. Slipman C, Jackson H, Lipetz J, Chan K, Lenrow D, Vresilovic E. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil 81 334-338, 2000. 49. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint a roentgen stereophotogrammatic analysis. Spine 23 10 1124-1129,...
L2
Figure 12.4. Continued. E Lateral radiograph after injection of 3 mL of radiographic contrast medium arrowheads . The contrast material spreads along the margin of the vertebra, and there is no sign of vascular filling. It is now safe to inject the local anesthetic for the sympathetic block. lent is used to confirm needle tip position and to ensure the absence of any vascular communication Figure 12.4C-E . Injection of 10 to 20 mL of bupivacaine 0.25 will provide temporary relief. This...
Conclusion Qah
Treatment and diagnosis of chronic back pain is a challenge that faces nearly all medical practitioners at some time. While back pain syndromes are far from completely understood, pathology and inflammation involving the facet joints do play a role in pain generation in some patients with both chronic and acute back pain. Familiarity with the facet joints as pain generators and with injection techniques and blocks is critically important to the practicing spine interventionist. Imaging studies...
Autonomic Nerve Blockade
Sensory nerves from deep visceral and somatic organs travel with sympathetic nerves of the autonomic nervous system also see Chapter 1 for more detail about autonomic nerve anatomy . The ability to block sympathetic nerves at key points can help to reduce pain of deep somatic and visceral origin. In addition, some of these sensory inputs along the sympathetic pathways may establish reflex arcs capable of sending impulses back to deep visceral and somatic organs. These reflex arcs can exacerbate...
Info Wdy
as opposed to joint blocks.19-21 In the lumbar spine, patient positioning is identical to that used for facet joint injections. The approach is from posterolateral, but the target is the superior and medial-most aspect of the transverse process at the junction with the superior articular facet Figure 11.12 . The fluoroscopy tube is obliqued minimally laterally to visualize and profile the junction of the superior articular process and the transverse process of the level to be injected. Recall...
Info Urp
Figure 5.4. Axial CT image shows a localizing needle adjacent to the right pedicle long arrow of a lumbar vertebra. A transpedicular approach was chosen to access the most proximal small arrow of three sclerotic lesions in a patient with a history of breast cancer. Figure 5.4. Axial CT image shows a localizing needle adjacent to the right pedicle long arrow of a lumbar vertebra. A transpedicular approach was chosen to access the most proximal small arrow of three sclerotic lesions in a patient...
Intraspinal Drug Delivery Clinic
The effective utilization of drug administration systems within the pain management community requires a minimum level of resources. A designated implant coordinator does coordination of patient education and follows a patient through the implant routine. This person should be a healthcare professional skilled in monitoring all aspects of the technique, including preoperative screening trials, surgical implantation and support, pump programming, pump refilling, long-term management of the...
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Calcified disc herniation, 355 intradiscal oxygen-ozone treatment, results with, 355 Cancer, screening for, 44 Cancer-related pain, implanted drug delivery systems, 284-285 Capsaicin, mechanism of action, 50 Carbamazepine for depression, 34 mechanism of action, 49 abnormalities, patients with, 48 C-arm fluoroscopic imaging equipment, mobile, 29 Catheter tip obstruction, as implanted drug delivery complication, 288 Caudal epidural steroid injection, 157-160, 158-159 initial description of, 149...
J
Figure 5.8. Axial CT image shows a left parapedicular approach arrow used to sample this destructive vertebral body lesion. Figure 5.9. Axial CT image shows a right transcostovertebral approach arrow used to sample this destructive vertebral body lesion fungal osteomyelitis . Figure 5.9. Axial CT image shows a right transcostovertebral approach arrow used to sample this destructive vertebral body lesion fungal osteomyelitis . Figure 5.10. Steps in a CT-guided biopsy. A To use a right...
Selective Nerve Root Blockade
Selective nerve root blockade has received attention as a diagnostic and therapeutic tool in the management of referred pain, presumably of radicular origin. From the surgical point of view, the potential utility of this test lies in diagnostic specificity not in its ability to identify a radicular etiology as the source of referred pain, but to localize a symptomatic level. In certain instances with clinical evidence of radiculopathy and no underlying structural cause, nerve root blockade has...
Epidurography
Epidurography is the diagnostic portion of the procedure without which epidurolysis or adhesiolysis cannot be accomplished. At this point a few pearls must be understood. First, an area of abnormal contrast filling must be identified this area must correlate with the patient's clinical presentation. For example, a patient who presents with symptoms of neurological dysfunction in a right L5 distribution should demonstrate a SOL involving the right L5 nerve root. A SOL involving an unaffected...
Suspected Discitis
The last group of paticnts for whom APLD must be considered the procedure of choice are those suspected of having infectious discitis. Although percutaneous fine-needle aspiration biopsy sampling of a suspected disc space has strong advocates owing to its inherent safety, the samples obtained are so small that the accuracy of negative bacteriological results is in doubt. The small sample also, although perhaps adequate for culture and Gram's stain, prevents any meaningful histo-logical...
Complications
Generally, complications following fluoroscopically guided injections are minor and resolve without morbidity.35,36 Obviously, the complication rate associated with spinal injections is higher in inexperienced hands. Minor complications and failures occurred early in the author's experience and were seen in fewer than 1 of patients.37 Burn and Langdon reported a 5.8 incidence of complications none of which were serious in their first year of experience.14 The use of imaging and Figure 9.9....
Results Njt
There are numerous protocols to objectively analyze the clinical results in patients with low back pain and herniated nucleus pulposus HNP .2-26 We evaluated our results with a modified MacNab method Table 19.1 . In patients with degenerative disease complicated by herniation, results were Excellent in 40 Good or fair in 40 Mediocre or bad in 20 In patients with L4-L5 or L5-S1 herniated discs results were Excellent in 64 Good or fair in 13 Mediocre or bad in 23 Figure 19.2. This patient with...
Info Ryc
a3 gt 1 in most patients, three veins would be present some would have only one 1 gt 3 in most patients, one vein would be present some would have three. a3 gt 1 in most patients, three veins would be present some would have only one 1 gt 3 in most patients, one vein would be present some would have three. ventral epidural veins receive venous drainage from the vertebral bodies through anterior and posterior venules , the spinal cord via radicu-lomedullary veins , the dura, and are also...
Technical Considerations 1
Epidurography and epidurolysis can be performed at any level of the spine from the sacral hiatus to the foramen magnum. The details provided here are generalized to all areas sacral, lumbar, thoracic, and cervical unless identified as specific to a particular area of the spine. Once it has been determined that a patient meets the accepted criteria for diagnostic epidurography, a detailed discussion of the potential Figure 10.3. A Loculated contrast filling with no epidural runoff of contrast. B...
John M Mathis
Most image-guided spine interventions are accomplished well with fluoroscopic guidance. It goes without saying that good visualization of the anatomical area being treated is necessary. Most modern fluoro-scopic equipment will provide this capability. It is important to view the target anatomy from multiple projections, and therefore a C-arm configuration is need. Fixed-plane fluoroscopic equipment commonly used for gastrointestinal work is not sufficient. The most sophisticated equipment in...
Metastatic Lesions Affecting the Spine
Neoplastic and metastatic lesions can involve the vertebral bodies as well as intra- and extramedullary structures. The goal of endovascular treatment remains devascularization prior to a planned surgery or biopsy Figure 16.7 . Embolization significantly reduces the blood loss and improves the surgical resection.34-37 Because the embolization is performed with Gelfoam, PVA, or on some occasions with dehydrated ethanol, attention has to be paid to the potential supply of radiculomedullary...
Cervical and Thoracic Epidurography and Epidurolysis
Similar symptoms in the cervical and thoracic spine can be safely treated by means of epidurography and epidurolysis. Cervical disc disruption, degenerative disc disease, spondylosis, and postherpetic neuralgia are all capable of producing epidural fibrosis and chronic pain. The pain pathologies that accompany these syndromes can be identified by epidurography and effectively treated by epidurolysis. It is generally held that cervical and thoracic procedures respond exceptionally well to this...
Biopsy Techniques
An important decision that is made before and during spine biopsy is the choice of approach. The determinants for the approach are lesion location and lesion size Table 5.4 .14 A posterior approach is used for thoracic, lumbosacral, and posterior cervical lesions. An anterior approach is used for most cervical spine biopsies. The location of critical normal anatomical structures will also modify the approach. Unless the lesion is clearly localized to the left side of the spine, for example, a...
Lisa Watanabe
Cerebrospinal fluid CSF hypovolemia may result from dural puncture, surgery, trauma, or spontaneously. When loss of CSF exceeds CSF production, the resultant low CSF pressure may result in traction on the dura, epidural veins, and cranial nerves. Postural headache and cervicalgia are common presenting symptoms. However, the sagging of the brain could lead to more serious complications owing to potential compression of the diencephalon or ischemic traction on the cranial nerves resulting in...
Transforaminal Epidural Injection
For patients with unilateral and or radicular symptoms, a transforaminal approach is often used. The patient is placed in a prone position on the fluoroscopy table, and the skin is marked with the C-arm oriented posterolaterally. The lateral angle is greater than that used for the interlaminar technique, generally 30 to 45 from the midline. Additionally, caudal angulation allows visualization of the undersurface of the pedicle above the target foramen. Using a slightly caudal angle to project...
Impar Ganglion Blockade
The most caudal ganglion of the sympathetic chain, the impar ganglion is located anterior to the sacrum and posterior to the rectum Figure 12.5 . It marks the end of the sympathetic chain. It receives innervation from the low pelvis and perineum. Indications for impar ganglion blockade include the following Intractable low pelvic pain and perineal pain as a result of rectal cancer, uterine cancer, or prostate cancer Endometriosis causing lower pelvic and perineal pain Figure 12.7. Lateral view...
Intervertebral Discs in Spinal Pain
While incompletely understood, the concept of painful internal disc derangement the discogenic or discopathic pain mechanism has progressively gained acceptance as one source of chronic low back pain.2-4 Discogenic pain is typically characterized by axial mechanical midline low back pain, usually exacerbated by sitting or standing for prolonged periods of time. Hallmarks are reports of sitting intolerance with temporary relief when walking. The pain may be aching or stabbing, and there may be...
Conclusion Yml
Both PV and KP seem to provide the same pain relief from vertebral compression fractures and, in experienced hands, approximately the same risk. However, kyphoplasty may provide an opportunity for restoring vertebral body height before stabilization and reduction of a fracture in the clinical setting. Because the pain relief from both procedures appears to be similar and because variables such as pulmonary function, gastrointestinal issues, and even kyphosis change in the presence of pain...
Intramedullary AVM
The intramedullary arteriovenous malformation is also known as a type II or classic AVM. Spinal cord AVMs are the second most common spinal vascular malformation. The angioarchitecture of these lesions is similar to that of classic brain AVMs, with multiple arterial feeders, a nidus, and draining veins. The nidus can be compact glomus type or diffuse occasionally called juvenile type, not to be confused with the metameric type . The arterial feeders are usually multiple branches of the ventral...
of Herniated Discs
It is approaching 20 years since we published the initial article introducing automated percutaneous lumbar discectomy APLD .1 At that time, there was tremendous resistance to the concept of a minimally invasive treatment for herniated lumbar discs. Chemonucleolysis had rushed onto the scene with great fanfare, only to be destroyed by the occurrence of devastating complications, such as transverse myelitis. At that time there was essentially no field of minimally invasive lumbar spine surgery....
Conclusion 1
Image-guided percutaneous spine biopsy is a procedure that can be performed safely and efficiently by radiologists. The procedure is performed to determine accurately the composition of abnormal tissue. The information obtained from the biopsy procedure can be used to guide patient management. The radiologist is part of a team that includes the patient, the referring clinician, and a pathologist. Optimal communication among the team members will increase the likelihood of a successful...
Thoracic and Splanchnic Sympathetic Blockades
The thoracic sympathetics run vertically along the anterior lateral aspect of the vertebral bodies from T2 to T8 and supply the middle and upper deep mediastinal structures Figure 12.2A . The splanchnic sym- Figure 12.2. A The upper thoracic spine region, showing the sympathetic ganglia along the lateral aspect of the vertebral bodies. B Thoracic sympathetic blockade in a prone patient. Under computed tomography the needle is guided from posterior to anterior obliquely small arrows along the...
Cavernous Malformations Cavernous Angiomas
Cavernous angiomas are slow-flow vascular lesions consisting of sinusoidal vascular channels lined by a single layer of endothelium, separated by collagenous stroma, and without any normal intervening neural tissue. Grossly, they are well-circumscribed reddish-purple lesions, often likened to a mulberry or cluster of mulberries. There is a characteristic gliotic reaction in the surrounding parenchyma, which may form a pseudocapsule. Within the lesion, there is often evidence of hyalinization,...