Dr. Amr Abdelfatah M.D.Dep. of Anesthesia, Intensive Care medicine & Pain Management

Ain Shams University, EGYPTdramrafatah@yahoo.com

IMAGE GUIDED EPIDURAL FOR BACK PAIN

Interventional InjectionsInterventional Implants

Image Guided Epidural Intervention

Interventional Epidural Injections

Interlaminar Epidural

Transforaminal Epidural

Caudal (sacral ) Epidural

Imaging Guidance:Is efficacy improved?

LOR to identify lumbar epidural space, was too superficial in 17% of cases.

Inconsistent LOR in Adhesions & fibrosis(Mehta M, Salmon N. Anaesthesia. 40:1009–1012, 1985. 1985).

Fluoro.: Reduces technical failures & difficulties with ESI up to 60%.

(Manchikanti L, et al Anesth Analg 89:1330–1331, 1999).

Imaging Guidance:Is efficacy improved?

Blind caudal for ESI : ◦ 48% incorrect by trainee◦ 15 % experienced hands◦ 9.2% i.v. injection.

(Renfrew DL, et al. Am J Neuroradiol 12:1003–1007, 1991.)

Fluoro.: 91% - 97% success on first attempt on caudal ESI

(Stitz M, et al. Spine, 24:1371–1376, 1999).

Imaging Guidance:Is efficacy improved?

Blind Cervical ESIs: ◦ 53% false LOR on 1st trail◦ unilateral spread in 51%◦ ventral spread in 28%

(Stojanovic MP, et al. Spine 27:509–514, 2002)

Better viewing for contrast spread.

Needle and pathology location

Imaging Guidance:Is efficacy improved?

Previous back surgery and fixation

Success rate increased in BMI > 30 vs. BMI <30

(Price CM, et al: Ann Rheum Dis 2000;59:879–882)

Tissue irritation and inflammation

HNP

Nerve root irritation (Lumbosacral radiculopathy)

Previous back surgery

Post spinal fixation

Spinal canal stenosis.

Spondylolisthesis & degerative disc disease !!

Indications

Lumbar Epidural Steroids

Interlaminar vs Transforaminal Injections ?!

Rhee and colleagues:

◦  TFESI:

46% reduction in pain score

10% required surgery.

◦ Interlaminar injections:

19% reduction in pain score

25% required surgery. (Rhee Jm, et al.  J Bone Joint Surg Am.  2006)

Interlaminar vs Transforaminal Injections

Improvement was 70% of pt. in TFESI

compared to 45% in interlaminar group. (Schaufele MK; et al: Pain physician , 2006)

5 yrs follow up post-TFESI : (81%) studied population didn’t approach for surgery

(Riew KD et al. . J Bone Joint Surg Am.  2006).

Depositing steroids in the anterior epidural space as only 28% ventral epidural spread of dye with interlaminar route (Stojanovic MP, et al. Spine,

2002).

Systematic review on TFESI confirmed its efficacy over interlaminar approach.

(Buenaventura RM, et al. Pain Physician. Jan-Feb 2009)

Interlaminar vs Transforaminal Injections

Clark C. Smith, MD,* Thomas Booker, MD,§Michael K. Schaufele, MD,*† and P. Weiss, MS‡Departments of *Rehabilitation Medicine,†Orthopedics and ‡Biostatistics, Emory University, Atlanta, Georgia;§Crystal Run Healthcare LLP, Middletown, New York, USA

Conclusions. In the current study, neither transforaminalnor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions when compared with each other.

Fluoroscopy guided TFESI

Artery of Adamkiewicz (supplies

lumbosacral enlargement )

Radicular artery close to DRG @ sup.&

middle portion of the foramen.

Risk of paraplegia esp. with particulate

steroids Dexamethasone and betamethasone are better

choices, particles <50 µm(Christopher WA review: Current Rev. Musculoskelet Med 2009).

A detailed photograph shows the anterior spinal canal branches lying anterior to the emerging lumbar nerve root at the intervertebral foramen, together with the ascending anterior and posterior nerve root branches (neural branches) of the lumbar artery. Reprinted with permission from Crock et al. The blood supply of the vertebral column and spinal cord Fig. 3. Course of artery of Adamkiewicz (red) and its feeding in man. RR Donnelly & Sons, Chicago, 1977 (32).t

Needle Tip Position ?

Safe Triangle anterior-superior

Kambin’s TrianglePost. Inferior

P A

Paraplegia Following Image-Guided

Transforaminal Lumbar Spine Epidural Steroid

Injection: Two Case Reports @ University of

Florida College of Medicine(David J, et al. Pain Medicine, 10: 1389–1394)

So Image & contrast prior to injection

AP projection

0.2 LAO0.00 CRA

Scotty Dog 20-30 degree lateral projection

L5

L4

Spinal 22G

L4

L5

Lat. projection

L5

L4

Omnipaq contrast in Ant. Epidural Space

Anteroposterior fluoroscopic view showing theOmnipaq outlining the nerve root and diffusing through the intervertebralforamina into the epidural space

Anteroposterior fluoroscopic view showing the

Omnipaq outlining the nerve root and diffusing into the intervertebral

foramina into the epidural space

Anteroposterior fluoroscopic view showing the

Omnipaq outlining the nerve root and diffusing into the intervertebral

foramina into the epidural space

Caudal(Sacral) Epidural Adhesolysis

Fluoroscopic guided Caudal previous laminectomy

Post-Spine fixation

Dural Adhesion &

fibrosis (LOR)

Epidural in high BMI

Normal epidurogram

Faulty Subcut. Injection

Correct Needle placement

RACZ Catheter

Dr. Gabor Racz

scar tissue entrapping

nerves

Flex tip & Steering end

L.A + Steroids

hyaluronidases

3%, 7%, 10 % NaCl

Caudal Adhesolysis

RACZ cath. Through Tuohy needle

Touhy needle through Sacral hiatus

OMNIPAQ WITH FILLING DEFECT

Hazards of Caudal Adhesolysis

Hypertonic saline injected into the SCF◦ cardiac arrhythmias◦ Myelopathy◦ Paralysis & loss of sphincter control

So Image & contrast prior to injection

Cord compression, hematoma, bleeding, infection, dural puncture.

A Retained Racz® Catheter Fragment After Epidural adhesolysis : Implications During Magnetic Resonance Imaging.

(William J. Perkins, et al. Anesth Analg 2003;96:1717–9)

SPINAL CORD

STIMULATOR

DRUG DELIVERY SYSTEM

Interventional Implants

Spinal Cord Stimulator

Melzack and Wall gate control theory in 1965

Pulsed electrical stimulation for the dorsal column

(large fibers stim. can signal hyperalgesia ?!)

Neurochemical alteration

Non-pharmacological method

◦ Failed back surgery

◦ Neuropathic pain , CRPS

◦ Ischemic limb

◦ Intractable anginal pain

In the epidural space since 1967.

SCS

Image guided for cord

level determination.

Dermatomal level

representation in the

dorsal columns is higher

than the corresponding

vertebral level (e.g.

sciatic pain around T9-

11).

Kunnumpurath S, et al. Journal of Clinical Monitoring and Computing, (2009) 23, 333-339.

Coverage pattern of SCS

SCS implantation

Image guided Epidural Lead seated at desired spinal level

SCS implantation

AP projection Prone position

SCS

Neurostimulator leads: (left to right) percutaneous type to paddle type

SCS

T12

T11

T10

T9

Depends on proper pt. selection

Fluoroscopic guidance is a must for proper

visualization of exact spinal level

Reported “success” rates (generally defined

as a minimum of 50% pain relief ) vary from

12 to 88% at follow- ups of 0.5–8 years.

SCS success rate

Radiological Contrast Media

Image-guided spine procedures provide

physiological information not available from

diagnostic imaging studies.

Real-time observation during contrast injection

Assess for vascular opacification reduce

jeopardizing radicular vessels .

CT and MRI are additional modalities.

Message to take

Image-guided spine injection procedures are

◦ minimally invasive

◦ performed on an outpatient basis

Perfection =

◦ extensive training

◦ imaging equipment safety

◦ familiarity with image-based anatomy.

Message to take

Dr. Amr Abdelfatah M.D.dramrafatah@yahoo.com

THANKS