Ed Guidelines

Educational Guidelines for Interventional Spinal Procedures

Author - 2001: Kevin J. Pauza, MD

Critical Review June 2001, pgs. 4-31: Charles Aprill, MD; Nikolai Bogduk, MD; Roger Catlin, MD; Richard Derby, MD; Paul Dreyfuss, MD; Stephen Endres, MD; Michael Furman, MD; Michael Geraci, Jr., MD; Michael Karasek, MD; Garrett Kine, MD; Roy Lerman, MD; Gregory Lutz, MD; Gerard A. Malanga, MD; Michael McCann, MD; John Prunskis, MD; Lawrence Rosenfield, MD; Steven Sabers, MD; Terry Sawchuk, MD; Barry Smith, MD; Jeffrey Young, MD; and Stuart Weinstein, MD Accepted by the PASSOR Board of Governors and AAPM&R Board of Governors - June 2001, update April 2004 Critical Review January 2004, pgs. 32-44: David L. Bagnall, MD; Bruce E. Becker, MD; Stuart M. Weinstein, MD Accepted by the PASSOR Board of Governors and AAPM&R Board of Governors - March 2004 Editorial Update June 2007: Larry H. Chou, MD; Kirk M. Puttlitz, MD; Santhosh A. Thomas, DO; and Joseph P. Zuhosky, MD Editorial Update May 2008: Brian A. Casazza, MD; Larry H. Chou, MD; Shelton A. Davis, MD; David K. deDianous, MD; Paul H. Lento, MD; Scott T. Roberts, MD; Michael Saffir, MD; and Joseph P. Zuhosky, MD Accepted by the PASSOR Board of Governors and AAPM&R Board of Governors June 2008 and October 2008, respectively. Disclaimer: Physician discretion is recognized with medication dosage. These guidelines mention commonly used doses. This document, based on consensus opinion, is an educational tool and not to be considered a practice guideline.

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Table of Contents Recommended Pre-procedure Anticoagulant Holding Schedule .......................................................... 3 Lumbar Zygapophysial Intra-articular Injection ....................................................................................... 4 Lumbar Medial Branch and L5 Dorsal Ramus Blocks ............................................................................. 7 Sacroiliac Joint Injection .......................................................................................................................... 10 Lumbar Interlaminar Epidural Injection .................................................................................................. 14 Lumbar Transforaminal Epidural Injection ............................................................................................. 17 Lumbar Diagnostic Spinal Nerve Block .................................................................................................. 21 S1 Diagnostic Spinal Nerve Block ........................................................................................................... 25 S1 Transforaminal Epidural Injection...................................................................................................... 28 Lumbar Intervertebral Disc Stimulation (Provocation Discography) .................................................. 32 Cervical Zygapophysial Intra-articular Injection .................................................................................... 37 Cervical Transforaminal Injection ........................................................................................................... 41 Cervical Medial Branch Block and Third Occipital Nerve Block .......................................................... 45

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PASSOR Educational Guidelines for Interventional Spinal Procedures The universal protocol applies to persons receiving the interventions listed below. These individuals should be properly identified through use of at least 2 patient identifiers. Prior to the start of any of these procedures, the providers and staff involved in the procedure should conduct a final verification, mark the site if necessary, and take a time-out so as to confirm the correct patient, procedure, and site using active communication techniques. Procuring active patient involvement in their own care provides an added benefit for patient safety. Recommended Pre-procedure Anticoagulant Holding Schedule Medications and compounds affecting clotting mechanisms pose a potential risk for iatrogenic hematoma during the performance of spinal procedures. Therefore, these medications are relative contraindications when performing spinal procedures outside the neural axis and considered to be absolute contraindications when performing procedures within the neural axis. Although they are considered absolute contraindications when performing procedures within the lumbar and sacral neural axis, specifically in these regions, the risk of cord compression or myelopathy is minimal or nil, and therefore the risks/benefit ratio for stopping anticoagulants when performing lumbar neural axis procedures must be considered. There may be situations where the risk of hemetoma may be outweighed by the risk associated with discontinuing anticoagulants or avoiding the procedure. The following medication holding schedule is suggested; optimally after authorization is obtained from the physician initiating or prescribing the anti-coagulant.

Medication or Compound

Days to hold before procedure

Aspirin or aspirin containing medications: (i.e., Excedrin, Equagesic, synalogos-DC, BC Powder) 7 days

Non-steroidal anti-inflammatory drugs: (i.e., ibuprofen, Naproxen, Mobic, Arthrotec, Relafen, Daypro and Celebrex) 3 days

Coumadin (warfarin) 6 days

Ticlid (ticlopidine) 14 days

Plavix (clopidogrel) 10 days

Pletal (cilostazol) and Trental (pentoxifylline) 2 days

Persantine (dipyridamole) Aggrenox (dipyridamole/aspirin) 7 days

Herbals containing ginger, ginko biloba, or feverfew 7 days

Orgaran (damaparoid) 5 days

Heparin, Lovenox (enoxaparin), Innohep (tinzaparin), Fragmin (dalteparin), Normiflo (ardaparin) 12 hours

Vitamin E (greater than 400 IU) 7 days

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PASSOR Educational Guidelines for Interventional Spinal Procedures Lumbar Zygapophysial Intra-articular Injection I. Rationale

Controlled studies demonstrate that the prevalence of lumbar zygapophysial (z) joint pain ranges from 15% - 45%1,2,8,9,10 in those with chronic low back pain. Lumbar z-joint pain cannot be diagnosed by history, clinical examination1,2,3,7, CT4, or SPECT scanning5. Diagnostic blocks of these joints or their nerve supply are the only means available to confirm or deny these structures as pain generators.

II. Indications

Lumbar z-joint (intra-articular) injections are both diagnostic and therapeutic and may facilitate other treatment options such as manual or physical therapy. Injection should be limited to those with low back or somatic referred pain, who failed to respond to conservative treatments including NSAIDS, corticosteroids, or therapies. With severe limitation of function, one could consider performing the injection prior to the initiation more conservative options to facilitate those options. There is no role for a series of z-joint injections given without regard to response of initial corticosteroid injection6. The injection should not be repeated on a patient who experienced no significant relief during the anesthetic phase of a prior z-joint injection, which rules out the diagnosis of intra-articular z-joint pain. A patient may receive 2 procedures at intervals of 2-3 weeks. Procedures can be repeated in 2-3 months provided that >50% relief is obtained for 6 weeks. Although short term effects of repeated steroid injections appear to be safe in some synovial joints, long-term effects on the zygapophysial joint are unclear at this time. Therefore, repeat zygapophysial steroid injections should be limited to 3-4 injections in a year11.

III. Contraindications

Absolute Bacterial infection: systemic or localized at injection site Bleeding diathesis: due to anticoagulants or hematological disease

Relative Allergy to injectants; steroid psychosis Pregnancy NSAIDs, aspirin, or other antiplatelet agents (e.g.,Ticlid, Plavix, Coumadin, Trental, Pletal, Heparin, Lovenox, Innohep, Fragmin, Normiflo, Persantine, Aggrenox, Ginko Biloba, Orgaran, and Damaparoid) Hyperglycemia, adrenal suppression, immune compromise, or congestive heart failure

IV. Complications Potential complications include, but are not limited to:

Infection (cellulitis and osteomyelitis with potential spread to include epidural abscess, discitis, meningitis, arachnoiditis, sepsis)

Bleeding (epidural and subdural hematoma) Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia,

vasovagal reaction) Respiratory (oversedation, central nervous system trauma) Urologic (urinary retention, incontinence) Neurologic injury (direct neural trauma, compression from hematoma or abscess, radicular

or vertebral artery trauma, arterial particulate injection, spinal cord injury, seizure) Dural puncture (spinal headache, uncal herniation, arachnoiditis, spinal block) Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness,

anxiety, incoherent speech, light-headedness, perioral parethesias, blurred vision, tremors, drowsiness, seizures, cardiac arrest, excessive intrathecal or epidural local anesthetic injection resulting in spinal block or leg weakness)

Adverse steroid reaction (facial flushing, injection site hypopigmentation, subcutaneous fat atrophy, increased appetite, fluid retention, gastritis, malaise, euphoria, insomnia, headache, immunosupression, aseptic meningitis, arachnoiditis, congestive heart failure,

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increased intraocular pressures, adrenal insufficiency, steroid myopathy, mania, hyperglycemia, hypertension, epidural lipomatosis, menstrual irregularity)

Allergic reaction (to non-ionic contrast agent allergy, local anesthetic, corticosteroid, or latex causing urticaria, laryngeal edema, bronchospasm, anaphylaxis)

Potential post-procedural complaints include, but are not limited to:

Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope) Pain (injection site, radicular, corticosteroid flare) Headache (corticosteroids, dural puncture)

V. Objective

To deliver up to 1.0 ml of injectant, including contrast, anesthetic, and possibly corticosteroid, into the z-joint space, to both test the hypothesis that the joint is the source of pain and decrease intra-articular inflammation.

VI. Materials

A. Equipment and Supplies 1. Fluoroscopy is mandatory 2. 22-26 gauge spinal or Chiba needle is recommended 3. Medication and contrast syringes 4. Connection tubing (recommended so that contrast can be injected during fluoroscopic

visualization to confirm proper anatomical and extra-vascular needle placement) 5. Physiologic monitor 6. Skin marker (optional)

B. Medications

1. Intravenous solutions, sedation, or antibiotics are not mandatory C. Agents

1. Contrast medium Radiographic contrast medium is essential to confirm extra-vascular and intra-articular needle placement. A nominal amount (0.1-0.3ml) is sufficient. It is used to obtain an arthrogram prior to any subsequent injection. Examples include Omnipaque 240 and Isovue 300/370.

2. Local anesthetics Agents commonly used include lidocaine 1%-2% and bupivacaine 0.25%-0.50% 3. Corticosteroids Isolated role is controversial. Should be used to facilitate more aggressive

conservative care and not as a treatment isolation6. VII. Technique

A. Preparation Physiologic monitoring is recommended and intravenous access is not mandatory. Skin is sterilely prepared. Sedation should be avoided or short acting to prevent analgesic effect.

B. Target Identification

Patient prone, image AP. Rotate image intensifier ipsilateral obliquely until the joint silhouette first appears. Target is within the silhouette of the joint cavity. Alternatively, one may begin with the image intensifier positioned ipsilateral oblique, visualizing the joint silhouette, and then rotate the image intensifier back towards AP until the joint silhouette begins to fade away. Target is within the silhouette of the joint cavity at that point where it begins to fade away. At that angle, the image intensifier best visualizes the most posterior aspect of the joint space, the point of entry. Note that the joint silhouette appears more distinct as the image intensifier rotates more obliquely, however the middle and anterior aspect of the joint is visualized as the image intensifier rotates more obliquely, not the posterior entry point of the joint space.

C. Needle Placement

The needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam. Capsule penetration is perceived with a subtle change of

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resistance. Injecting a trace amount of contrast during fluoroscopic visualization makes confirmation of intra-articular needle placement. It is not necessary to obtain a complete arthrogram. After confirmation, no more than 1.0 ml of injectant should be introduced.

D. L5-S1 Z-joint Posterior Approach

If the iliac crest obscures needle trajectory, simply rotate C-arm cephalocaudad so that the iliac crest is not superimposed over the L5-S1 z-joint. If the iliac crest still obscures the trajectory use this posterior approach. Patient prone. Image laterally, marking inferior aspect of joint silhouette. Rotate image intensifier to AP, following mark horizontally with skin pointer. At AP, the needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam. Joint silhouette will likely not be visible AP. After contacting bone, rotate image intensifier back to lateral to confirm contrast flows into joint space.

E. Assessment Following completion of injection, the patient is asked to rate his pain while attempting to provoke his usual symptoms. Significant pain relief (75-100%) lasting equal to or greater than the expected duration of the anesthetic suggests a positive response.

References 1. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from

the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994;19:1132-7.

2. Schwarzer AC, Wang S, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain, Ann Rheum Dis 1995;54:100-6.

3. Schwarzer AC, Derby R, Aprill CN, et al. Pain from the lumbar zygapophysial joints: a test of two models. J Spinal Disord 1994;7:331-6.

4. Schwarzer AC, Wang S, ODriscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine 1995;20:907-12.

5. Schwarzer AC, Scott AM, Wang S, et al. The role of bone scintigraphy in chronic low back pain: comparison of SPECT and planar images and zygapophysial joint injection [abstract]. Aust NZ J Med 1992;22:185.

6. Dreyfuss PH, Dreyer SJ, Herring SA. Contemporary concepts in spine care: lumbar zygapophysial (facet) joint injections. Spine 1995;20:2040-47.

7. Manchikanti L, Pampati V, Fellows B, Baha AG. The inability of the clinical picture to characterize pain from facet joints. Pain Physician 2000; 3:158-166.

8. Manchikanti L, Pampati V, Rivera J, Fellows B, Beyer C, Damron K. Role of facet joints in chronic low back pain in the elderly: A controlled comparative prevalence study. Pain Practice 2001; 1:332-337.

9. Manchikanti L, Hirsch JA, Pampati V. Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions? Pain Physician 2003; 6:399-405.

10. Manchikanti L, Singh V, Pampati S, Damron K, Beyer C, Barnhill R. Is there correlation of facet joint pain in lumbar and cervical spine? Pain Physician 2002; 5:365-371.

11. Raynauld J, Buckland-Wright C, Ward R, Choquette D, haraoui B, Martel-Pelletier J, Uthman I, Khy, V, Tremblay J, Bertrand C. Safety and efficacy of long-term intra-articular steroid injections in osteoarthritis of the knee. Arth and Rheum 2003:48(2);370-377.

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PASSOR Educational Guidelines for Interventional Spinal Procedures Lumbar Medial Branch and L5 Dorsal Ramus Blocks I. Rationale

Lumbar medial branch and L5 dorsal ramus blocks effectively diagnose lumbar zygapophysial (z) joint pain1. Controlled studies demonstrate that the prevalence of lumbar z-joint pain ranges from 15%2 to 40%3 in those with chronic low back pain. History, clinical examination 2,3,4 , CT5, or SPECT scanning6 in isolation or combination may suggest but cannot diagnose lumbar z-joint pain. Each z-joint is innervated by two medial branch nerves; one from its segmental level and one from the suprasegmental level. Blocks of their nerve supply or the z-joint proper are the only means available to confirm or deny these structures as pain generators. At L5, the dorsal ramus, rather than its medial branch, is more amenable to blockade7.

II. Indications

Lumbar medial branch (mb) blocks and L5 dorsal ramus (dr) blocks are diagnostic1 and specific8. The procedure should be limited to those with low back and referred pain who have failed to respond to conservative treatment.


Absolute Bacterial infection: systemic or localized at injection site Bleeding diathesis: due to anticoagulants or hematologic disease

Relative Allergy to injectants NSAIDs, aspirin, or other antiplatelet agents (e.g., Ticlid, Plavix, Coumadin, Trental, Pletal, Heparin, Lovenox, Innohep, Fragmin, Normiflo, Persantine, Aggrenox, Ginko Biloba, Orgaran, and Damaparoid) Hyperglycemia, adrenal suppression, immune compromise, or congestive heart failure Pregnancy


Infection (cellulitis, osteomyelitis with potential spread to include epidural abscess, discitis, meningitis, arachnoiditis, sepsis)

Bleeding Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia,

vasovagal reaction) Respiratory (oversedation, central nervous system trauma) Urologic (urinary retention, incontinence) Neurologic injury (direct neural trauma, compression from hematoma or abscess, radicular

or vertebral artery trauma, arterial particulate injection, seizure) Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness,


Adverse steroid reaction (facial flushing, injection site hypopigmentation, subcutaneous fat atrophy, increased appetite, fluid retention, gastritis, malaise, euphoria, insomnia, headache, immunosupression, aseptic meningitis, arachnoiditis, congestive heart failure, increased intraocular pressures, adrenal insufficiency, steroid myopathy, mania, hyperglycemia, hypertension, epidural lipomatosis, menstrual irregularity)



Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope) Pain (injection site, radicular, corticosteroid flare)

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Headache (corticosteroids) V. Objective

To deliver anesthetic to the medial branch nerve or L5 dorsal ramus to test the hypothesis that the joint is the pain source.

VI. Materials

A. Equipment and Supplies 1. Fluoroscopy is mandatory 2. 26 to 22-guage spinal needle 3. Medication and contrast syringes 4. Connection tubing (recommended so that contrast can be injected during

fluoroscopic visualization to confirm proper anatomical and extra-vascular needle placement)

B. Medications 1. Intravenous solutions, sedation, or antibiotics are not mandatory C. Agents (total volume of anesthetic is 0.5ml per level)

1. Contrast medium Radiographic contrast medium is essential to confirm proper anatomical and extra-vascular needle placement, thus avoiding false negative results1. A nominal amount (0.1-0.3ml) is sufficient. It is used to obtain a small puddle of contrast along the target nerve prior to anesthetic injection. Examples include Omnipaque 240 and Isovue 300/370.

2. Local anesthetics Agents commonly used include lidocaine 2%-4% and bupivacaine 0.25%-0.75%

3. Corticosteroids Not indicated

VII. Technique A. Preparation

Physiologic monitoring is recommended and intravenous access is not mandatory. Skin is sterilely prepared. Sedation should be avoided, or short acting, to prevent analgesic effect.


1. L1-4 medial branch blocks: Patient prone, image ipsilateral oblique to view the scotty dog. Target is the top of the eye of the scotty dog. More specifically, the target is midway along the linear junction of the superior articular process and the transverse process. This point is midway between the mamillo-accessory ligament and the superior junction of the superior articular process (SAP) and the transverse process. Nomenclature dictates that the identity of the joint is numerically identical to the transverse process onto which the needle is placed, but the names of the nerves are one segment less.

2. L5 dorsal ramus blocks:

Patient prone, image posteroanterior, occasionally with 15-20 degrees of ipsilateral obliquity to visualize behind the S1 SAP. Target is approximately 5mm below the superior junction of the sacral ala with the superior articular process of the sacrum. The L5 DR lies in a notch between these two bones.

C. Needle Placement

The needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam to bone. At bone, in the groove, the needles bevel is oriented medial and inferior to direct injectant along the target nerve and away from the neural foramen. Appropriate anatomical and extra-vascular needle placement is confirmed by injecting a trace amount of contrast while visualizing fluoroscopically before injecting 0.5 ml anesthetic. AP imaging should be used to assure the needle and subsequent dye is placed medial enough.

D. Assessment

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Following completion of injection the patient is asked to rate his pain while attempting to provoke his usual symptoms. A positive response is suggested by significant pain relief (75-100%) lasting equal to or greater than the expected duration of the anesthetic. Ideally, patients will respond favorably as defined above to two separate blockades of the medial branches with local anesthetics of different durations of action (double block paradigm) prior to proceeding with a radiofrequency ablation procedure. A favorable response to intraarticular injection of the z-joint may also serve as one of the trials to justify radiofrequency ablation of the medial branch innervation of the z-joint. In the absence of new trauma/injury, or significant change in the patients clinical presentation, diagnostic medial branch block injections should be limited to two injections blocking the medial branches of a specific z-joint level. Patients who do not desire radiofrequency ablation but do realize sustained relief with medial branch blockade (several months duration) may benefit from repeated injections at the discretion of the treating physician and patient.

References

1. Kaplan M, Dreyfuss, PH, Bogduk N, et al. The ability of the lumbar medial branch blocks to anesthetize the zygapophysial joint: a physiologic challenge. Spine 1998;23:1847-52.

2. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994;19:1132-7.

3. Schwarzer AC, Wang S, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain, Ann Rheum Dis 1995;54:100-6.

4. Schwarzer AC, Derby R, Aprill CN, et al. Pain from the lumbar zygapophysial joints: a test of two models. J Spinal Disord 1994;7:331-6.

5. Schwarzer AC, Wang S, ODriscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine 1995;20:907-12.

6. Schwarzer AC, Scott AM, Wang S, et al. The role of bone scintigraphy in chronic low back pain: comparison of SPECT and planar images images and zygapophysial joint injection [abstract]. Aust NZ J Med 1992;22:185.

7. Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. J Anat 1982;134:383-97. 8. Dreyfuss P, Schwarzer AC, Lau P, et al. Specificity of lumbar medial branch and L5 dorsal

ramus blocks. A computed tomography study. Spine 1997;22(8):895-902. Additional References

Bogduk N. Diagnostic nerve locks in chronic pain. Best Pract Res Clin Anaesthesiol 2002;16:565-78.

Bogduk N. Diagnostic blocks. A truth serum for malingering. Clin J Pain 2004;20:409-14. Fairbank JC, Park WM, McCall IW, OBrien JP. Apophyseal injection of local anesthetic as a

diagnostic aid in primary low back pain syndromes. Spine 1981;6:598-605. International Spine Intervention Society. Lumbar medial branch blocks. In: Bogduk N, editor.

Practice Guidelines for spinal diagnostic and treatment procedures. San Francisco, CA: International Spinal Intervention Society, 2004:47-65.

Manchikanti L, Pampati V, Fellows B, Bakhit CE. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain 2000; 4:337-44.

McCall IW, Park WM, OBrien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine 1979;4:441-6.

Mooney V, Robertson J. The facet syndrome. Clin Orthop 1976;115:149-56. Revel M, Poiraudeau S, Auleley GR, et al. Capacity of the clinica picture to characterize low back

pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 1998;23:1972-7.

Schwarzer AC, Aprill CN, Derby R, Fortin J, Kline G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58:195-200.

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PASSOR Educational Guidelines for Interventional Spinal Procedures Sacroiliac Joint Injection I. Rationale

Controlled studies demonstrate that the prevalence of intra-articular sacroiliac joint (SIJ) pain ranges from 13-30%1,3. Though SIJ pain cannot solely be diagnosed by history or clinical examination alone2,3,4, composite examination techniques may improve clinical diagnostic accuracy 5,6. Unfortunately imaging techniques such as plain film radiographs7, SPECT scanning8 or MRI are not reliable in diagnosing sacroiliac joint dysfunction.MRI may aid in early diagnosis and disease progression in cases of inflammatory sacroilitis due to spondyloarthropathy9, however these changes may not be associated with clinical symptoms10. Diagnostic block of the SIJ is the only means available to confirm or deny the SIJ as a pain generator, although a single sacroiliac joint diagnostic block may have a false positive response of 7.7-20.5%11,12.

II. Indications

SIJ Injections are primarily diagnostic and may facilitate other treatment options such as manual or physical therapy. Indications for therapeutic sacroiliac joint injections also included those patients with sacroillitis as well as sacroiliac joint dysfunction. Long-term efficacy has been reported in those with SIJ pain due to inflammatory spondyloarthropathies13. Studies revealing the efficacy of fluoroscopically guided joint injections due to sacroiliac dysfunction have been limited14. One retrospective study involving patients with sacroiliac joint dysfunction based on a single diagnostic injection showed improvement in pain and functional scores15. The sacroiliac joint has also been considered a pain generator in approximately 30-35% of patients following lumbar fusion surgery16,17 but to date no outcomes have been reported following therapeutic SI joint injections. Consideration for an SI joint injection should be limited to those with pain below L52 who failed to respond to conservative treatment, and have had pain for the duration of at least four weeks. With severe limitation of function, one could perform the injection prior to the initiation of therapy to facilitate the therapy. There is no role for a series of sacroiliac joint injections given without regard to response of initial diagnostic or therapeutic injection. Although short term effects of repeated steroid injections appear to be safe in some synovial joints, long-term effects on the sacroiliac joint are unclear at this time. Therefore, repeat sacroiliac steroid injections should be limited to 3-4 injections in a year18.

III. Contraindications Absolute Bacterial infection: systemic or localized at injection site Bleeding diathesis: due to anticoagulants or hematological disease

Relative Allergy to injectants; steroid psychosis Pregnancy NSAIDs, aspirin, or other antiplatelet agents (e.g. Ticlid, Plavix, Coumadin, Trental, Pletal, Heparin, Lovenox, Innohep, Fragmin, Normiflo, Persantine, Aggrenox, Ginko Biloba, Orgaran, and Damaparoid) Hyperglycemia, adrenal suppression, immune compromise, or congestive heart failure

IV. Complications

Potential complications include, but are not limited to: Worsening pain Infection (abcess, discitis, meningitis, osteomyelitis, sepsis) Bleeding (local or intrapelvic) Cardiovascular (dysrhythmias, congestive heart failure, vasovagal reaction) Respiratory (oversedation) Pelvic organ injury due to improper needle placement and/or visualization Neurologic injury (direct neural trauma, compression from hematoma or abscess, vascular

particulate injection, spinal cord injury, stroke, seizure) Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness,

anxiety, incoherent speech, light-headedness, perioral parethesias, blurred vision, tremors, drowsiness, seizures, cardiac arrest)

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Adverse steroid reaction (facial flushing, hyperglycemia, injection site hypopigmentation, subcutaneous fat atrophy, increased appetite, fluid retention, gastritis, malaise, euphoria, insomnia, headache, immunosupression, aseptic meningitis, arachnoiditis, congestive heart failure, increased intraocular pressures, adrenal insufficiency, steroid myopathy, mania, menstrual irregularity)




V. Objective

To deliver injectant, including contrast, anesthetic, and corticosteroid, into the SIJ, to both test the hypothesis that the sacroiliac joint is the source of pain and to decrease intra-articular inflammation.

VI. Materials

A. Equipment and Supplies 1. Fluoroscopy is mandatory 2. 22-26 gauge spinal or Chiba needle is recommended 3. Medication and contrast syringes 4. Connection tubing (recommended so that contrast can be injected during


5. Physiologic monitor (optional) 6. Skin marker (optional)

B. Medications 1. Intravenous solutions, sedation, or antibiotics are not mandatory C. Agents (total volume up to 2.5 ml per joint.)

1. Contrast medium Radiographic contrast medium is essential to confirm extra-vascular and intra-articular needle placement. A nominal amount (0.1-0.3 ml) is sufficient. It is used to obtain an arthrogram prior to any subsequent injection. Examples include Omnipaque 240 and Isovue 300/370

2. Local anesthetics (combined with the corticosteroid in a 2:1 or 1:1 ratio) Agents commonly used include lidocaine 1%-2% and bupivacaine 0.25%-0.50%

3. Corticosteroids Employed to decrease intra-articular inflammation and facilitate more aggressive conservative care; not as a treatment isolation8

VI. Technique

A. Preparation Physiologic monitoring is recommended and intravenous access is not mandatory. Skin is sterilely prepared. Sedation should be avoided or short acting to prevent analgesic effect.


Patient prone. Image two divergent joint planes (silhouettes) on AP or ipsilateral oblique view. The medial joint silhouette represents the posterior joint plane and the lateral joint silhouette the anterior joint plane. Purposefully attempt to radiographically separate the anterior and posterior joint planes. Next, optimally visualize the medial silhouette (this occurs when the inferior aspect of the medial cortical line is maximally defined). The target is within the inferior 2.0 cm aspect of the medial joint silhouette.

If the above technique fails, an alternative target is the hyperlucent zone formed where the caudal aspects of the medial and lateral joint silhouettes cross with rotation of the C-arm19.

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An additional alternate target is the upper one-third of the joint silhouette. This target is reached by imaging contralateral oblique, superimposing the medial and lateral joint silhouettes. Continue rotating contralateral oblique until the ipsilateral iliac crest no longer obscures the joint lines. The iliac crest will appear to shift laterally as the image intensifier is rotated contralateral oblique. The target is within the joint silhouette.

C. Needle Placement The needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam. Capsule penetration is perceived with a subtle change of resistance. Confirm intra-articular needle placement by injecting a trace amount of contrast during fluoroscopic visualization. It is not necessary to obtain a complete arthrogram. After confirmation, up to 2.5 cc of injectant is introduced.

D. Assessment Following completion of injection the patient is asked to rate his pain while attempting to provoke his usual symptoms. Significant pain relief (75-100%) lasting equal to or greater than the expected duration of the anesthetic suggests a positive response. Long-term relief attributed to the corticosteroid should also be noted.

References

1. Schwarzer AC, Aprill CN, Bogduk N: The sacroiliac joint in chronic low back pain. Spine 1994;20:31-37.

2. Dreyfuss P, Michaelson M, Pauza K, McCarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996:21(22);2594-2602.

3. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;2:889-92.

4. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-37.

5. Laslett, M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac joint provocation tests. Aust J Physiother 2003;49:89-97.

6. van der Wurff, P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys med Rehabil 2006;87:10-4.

7. Cohen AS, McNeill JM, Calkins E, et al. The normal sacroiliac joint: analysis of 88 sacroiliac roentgenograms. Am J Roentgenol Radium Ther 1967;100:559-63.

8. Slipman C, Sterenfeld EB, Chou LH, et al. The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine 1996;21:2251-54.

9. Puhakka KB, Jurik AG, Schittz-Christensen B, Hansen GV, Egund N, Christiansen JV, Stengaard-Pedersen. MRI abnormalities of sacroiliac joints in early spondylarthropathy: a 1-year follow-up study. Scand J Rheum 2004:33;332-338.

10. Puhakka KB, Jurik AG, Schiottz-Christensen B, Hansen GV, Egund N, Christiansen JV, Stengaard-Pedersen K. Magnetic resonance imaging of sacroiliitis in early seronegative spondylarthropathy. Abnormalities correlated to clinical and laboratory findings. Rheum 2004:43(2);234-7.

11. Schwarzer, AC, Aprill, C, Bogduk, N. The sacroiliac joint in chronic low back pain. Spine 1995:20(1);31-7.

12. Maigne JY, Aivaliklis A, Pfefer F.Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996:21(16);1889-92.

13. Maugars Y, Mathis C, Berthelot JN, et al. Assessment of efficacy of sacroiliac corticosteroid injections in spondyloarthropathies: A double blind study. Br J Rheum 1996; 35:767-70.

14. Hansen HC. McKenzie-Brown AM. Cohen SP. Swicegood JR. Colson JD. Manchikanti L. Sacroiliac joint interventions: a systematic review. [Review] [132 refs] [Journal Article. Review] Pain Physician. 10(1):165-84, 2007 Jan.

15. Slipman CW. Lipetz JS. Plastaras CT. Jackson HB. Vresilovic EJ. Lenrow DA. Braverman DL. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. [Journal Article] American Journal of Physical Medicine & Rehabilitation. 80(6):425-32, 2001 Jun.

16. Katz V, Schofferman J, Reynolds J. The sacroiliac joint: A potential cause of pain after lumbar fusion to the sacrum. Jrl of Spinal Dis and Tech 2003:16(1);96-99.

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17. Maigne JY, Planchon CA. Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks. Eur Spine Jrl 2005:14;654-58.

18. Raynauld J, Buckland-Wright C, Ward R, Choquette D, haraoui B, Martel-Pelletier J, Uthman I, Khy, V, Tremblay J, Bertrand C. Safety and efficacy of long-term intra-articular steroid injections in osteoarthritis of the knee. Arth and Rheum 2003:48(2);370-377.

19. Dreyfuss P, Cole AJ, Pauza K, et al. Sacroiliac joint injection techniques. In: Weinstein SM, editor. Injection Techniques: Principles and Practice. Philadelphia: W.B.

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PASSOR Educational Guidelines for Interventional Spinal Procedures Lumbar Interlaminar Epidural Injection I. Rationale

Lumbar interlaminar epidural steroid injections can be helpful in the management of lumbar radicular symptoms. Lumbar interlaminar epidural injections instill medication into the posterior epidural space with variable spread into the anterior epidural space1,2. Lumbar spinal stenosis (central or foraminal) and herniated nucleus pulposus can induce nerve root inflammation3. Inflammation of the nerve root induces neurophysiologic and histologic changes4 that can result in radicular symptoms5. Corticosteroid reduces morphologic and functional nerve root changes6, and lidocaine decreases nerve root inflammation7, while increasing intraradicular blood flow8. While there is some conflicting literature, several randomized placebo-controlled trials have shown short-term9-12 and long-term13 radicular pain relief and functional improvement with lumbar interlaminar epidural steroid injections. Evidence for lumbar interlaminar epidural steroid injections for axial back pain is limited.

II. Indications

Lumbar interlaminar epidural steroid injections can be performed for lower extremity radicular symptoms recalcitrant to conservative interventions including medications and physical therapy. With severe limitation of function, one could perform the injection prior to the initiation of more conservative options to facilitate those options. No role exists for a series of lumbar interlaminar epidural injections given without regard to the response of the initial or previous injection. A subsequent injection may be considered in a patient with partial or temporary pain relief from a previous injection. While there is limited evidence in the area of repeat injections, consensus indicates that, with rare exception, injections should be limited to 3 in a 6-month period or 4 in a year. These should ideally be spaced by at least 14 days to assess full response and minimize adrenal suppression.



Relative Allergy to injectants; steroid psychosis Pregnancy NSAIDs, aspirin, or other antiplatelet agents (e.g. Ticlid, Plavix, Coumadin, Trental, Pletal, Heparin, Lovenox, Innohep, Fragmin, Normiflo, Persantine, Aggrenox, Ginko Biloba, Orgaran, and Damaparoid) Hyperglycemia, adrenal suppression, immune compromise, or congestive heart failure Altered anatomy (post surgical) Severe central vertebral canal stenosis


Infection (epidural abscess, discitis, meningitis, arachnoiditis, osteomyelitis, sepsis) Bleeding (epidural and subdural hematoma) Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia,

vasovagal reaction) Respiratory (oversedation, central nervous system trauma, excessive intrathecal or epidural

local anesthetic injection) Urologic (urinary retention, incontinence) Neurologic injury (direct neural trauma, compression from hematoma or abscess, radicular


anxiety, incoherent speech, light-headedness, perioral parethesias, blurred vision, tremors,

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drowsiness, seizures, cardiac arrest, excessive intrathecal or epidural local anesthetic injection resulting in spinal block or leg weakness)





V. Objective

To deliver anesthetic and corticosteroid to the epidural space at the inflamed disc and nerve root interface

VI. Materials A. Equipment and Supplies

1. Fluoroscopy required (Controlled studies demonstrate misplacement of medication in 13% -34 % of non-fluoroscopic interlaminar epidurals.)14,15

2. 17-22 gauge Tuohy needle (3.5 7.0 inches) 3. Loss of resistance (LOR) syringe 4. Medication syringe 5. Physiologic monitor 6. Connection tubing (recommended so that contrast can be injected during


7. Skin marker (optional)

B. Medications 1. Sedation optional 2. Antiobiotics not routinely required C. Agents

1. Radiographic contrast medium (e.g. Isovue 300/370 or Omnipaque) 2. Local anesthetics or other agents (optional)

Volumes range from 3.0ml to 5.0ml. Common agents include: lidocaine 1% - 2% and bupivacaine 0.125% - 0.50%

3. Corticosteroids Agents commonly used include but are not limited to dose equivalent of: betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan) (6 - 18mg); dexamethasone (Decadron Phosphate); and triamcinolone hexacetonide (Aristospan)

VII. Technique

A. Preparation Physiologic monitoring, intravenous access is recommended and not mandatory. Skin is sterilely prepared. Sedation optional. Fluoroscopy is necessary14,15.


Patient is positioned prone or in the lateral decubitus position. Image AP with or without cephalad tilt. Target is the superior interlaminar space on the symptomatic side at the level of pathology or one segmental level caudad16. (Owing to maximum epidural region potential space and typical contrast flow patterns respectively.) Alternatively, radiographic anatomy may dictate optimum placement site.

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C. Needle Placement The needle punctures the skin slightly caudal to the target and is directed cephalad towards the paramedian interlaminar space. Entering the site with an oblique rather than a perpendicular trajectory will decrease risk of dural puncture17. Lateral imaging confirms depth. Ligamentum flavum penetration is perceived with a subtle change of resistance and epidural location is noted by loss of resistance to injection of air or saline. Injecting contrast (approx. 1.0 -2.0 ml) during lateral and AP fluoroscopic visualization makes confirmation of epidural needle placement. After interpreting appropriate epiduragram, and appropriate target tissue spread, injectant is introduced. The alternative technique of contacting bone and walking off bone into interlaminar space should only be used with caution, owing to the fact that initially missing bone may cause misjudgment of needle depth.

References

1. Botwin KP, Natalicchio J, Hanna A. Fluorscopic guided lumbar interlaminar epidural injections: A prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician 2004;7:77-80.

2. Weil L, Frauwirth NH, Amirdelfan K, Grant D, Rosenberg JA. Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection. Arch Phys Med Rehabil 2008;89:413-416.

3. McCarron RF, Wimpee MW, Hudkins PG, et al. The inflammatory effects of nucleus pulposus. A possible element in the pathogenesis of low back pain. Spine 1987;12:760-64.

4. Olmarker K, Rydevik B, Nordborg C. Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. Spine 1993;18:1425-32.

5. Murphy RW. Nerve roots and spinal nerves in degenerative disk disease. Clin Orthop Rel Research 1977;46-60.

6. Olmarker K, Byord G, Cornfjord M, et al. Effects of methylprednisolone on nucleus pulposus-induced nerve root injury. Spine 1994;19:1803-8.

7. Yabuki S, Kawaguchi Y, Nordborg C, et al. Effects of lidicaine on nucleus pulposus-induced nerve root injury. Spine 1998;23:2383-89.

8. Yabuki S, Kikuchi S. Nerve root infiltration and sympathetic block. Spine 1995;20:901-6. 9. Wilson-MacDonald J, Burt G, Griffin D, Glynn C. Epidural steroid injection for nerve root

compression: a randomized, controlled trial. J Bone Joint Surg Br 2005; 87-B:352-355. 10. Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper

C, WEST Study Group. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology(Oxford) 2005; 44:1399-1406.

11. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R, Parent F, Levesque J, Bergeron V, Montminy P, Blanchette C. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336:1634-1640.

12. Ridley MG, Kingsley GH, Gibson T, Grahame R. Outpatient lumbar epidural corticosteroid injection in the management of sciatica. Br J Rheumatol 1988; 27:295-299.

13. Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in the management of lumbar nerve root compression. Br Med J 1973; 2:635-637.

14. Mehta M, Salmon N. Extradural block. Confirmation of the injection site by x-ray monitoring. Anesth 1985;40:1009-12.

15. Renfrew DL. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR 1991;12:1003-7.

16. Burn JM. The spread of solutions directed into the epidural space. A study using epidurograms in patients with the lumbo-sciatic syndrome. Br J Anesthesia 1973; 45:338.

17. Cousins M, Bromage P. Epidural neural blockade. Neural Blockade in Clinical Anesthesia and Management of Pain 1988;8:253-360.

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PASSOR Educational Guidelines for Interventional Spinal Procedures Lumbar Transforaminal Epidural Injection I. Rationale

Transforaminal epidural steroid injections (TFESIs) can be very helpful in the management of lumbar radicular symptoms. Transforaminal epidural injections instill medication along the affected nerve root and into the anterior epidural space at the site of inflammation. Lumbar spinal stenosis (central or foraminal) and herniated nucleus pulposus can induce nerve root inflammation1. Inflammation of the nerve root induces neurophysiologic and histologic changes2 that can result in radicular symptoms3. Corticosteroid reduces morphologic and functional nerve root changes4, and lidocaine decreases nerve root inflammation5, while increasing intraradicular blood flow6. There is increasing literature to support the use of transforaminal epidural injections to treat radicular symptoms from lumbar spinal stenosis and herniated nucleus pulposus. There have been a myriad of case series and cohort studies demonstrating significant improvement in both pain and function with follow up ranging from 2 weeks to 3.4 years7-19. In a placebo controlled trial, Vad et. al. demonstrated successful outcome (both pain reduction and improved function) in 84% of patients receiving a TFESI compared to 48% in the control group, with an average follow-up of 1.4 years20. Other controlled trials have been performed comparing TFESI to other therapeutic injections, including interlaminar epidural steroids21-23, transforaminal bupivicaine24,25 and transforaminal saline26. Patients receiving TFESI in all studies improved, and in 3 of the 7 studies21,23,24 demonstrated superior outcome to the alternative intervention, with follow-up ranging from 1 to 23 months. Evidence for transforaminal epidural steroid injections for axial back pain is limited.

II. Indications Lumbar transforaminal epidural steroid injections can be performed for lower extremity radicular symptoms recalcitrant to conservative interventions including medications and physical therapy. With severe limitation of function, one could perform the injection prior to the initiation of more conservative options to facilitate those options. No role exists for a series of lumbar transforaminal epidural injections given without regard to the response of the initial or previous injection. A subsequent injection may be considered in a patient with partial or temporary pain relief from a previous injection. While there is limited evidence in the area of repeat injections, consensus indicates that, with rare exception, injections should be limited to 3 in a 6-month period or 4 in a year. These should ideally be spaced by at least 14 days to assess full response and minimize adrenal suppression.




IV. Complications Potential complications include, but are not limited to: Infection (epidural abscess, discitis, meningitis, arachnoiditis, osteomyelitis, sepsis) Bleeding (epidural and subdural hematoma) Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia, vasovagal

reaction) Respiratory (oversedation, central nervous system trauma, excessive intrathecal or epidural

local anesthetic injection) Urologic (urinary retention, incontinence)

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Neurologic injury (direct neural trauma, compression from hematoma or abscess, radicular or vertebral artery trauma, arterial particulate injection, spinal cord injury, seizure)

Dural puncture (spinal headache, uncal herniation, arachnoiditis, spinal block) Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness, anxiety,

incoherent speech, light-headedness, perioral parethesias, blurred vision, tremors, drowsiness, seizures, cardiac arrest, excessive intrathecal or epidural local anesthetic injection resulting in spinal block or leg weakness)



Potential post-procedural complaints include, but are not limited to: Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope) Pain (injection site, radicular, corticosteroid flare) Headache (corticosteroids, dural puncture)

V. Objective To instill anesthetic and corticosteroid along the affected nerve root and into the anterior epidural space.

VI. Materials

A. Equipment and Supplies 1. Fluoroscopy necessary 2. 20-25 gauge spinal, or Chiba needle (Note that if the double needle technique is

utilized, both a large gauge introducer needle (17G 20G) and a smaller gauge inner injectant needle(22G 26G) will be necessary)

3. Medication and contrast syringes 4. Physiologic monitor (optional) 5. Connection tubing (recommended so that contrast can be injected during



B. Medications 1. Sedation optional 2. Antibiotics not routinely required

C. Agents

1. Radiographic contrast medium (e.g. Isovue 300/370 or Omnipaque) 2. Local anesthetics or other agents (optional)

Volumes range from 3.0ml to 5.0ml. Common agents include: lidocaine 1% - 2% or bupivacaine 0.125% - 0.50%

3. Corticosteroids Agents commonly used include but are not limited to dose equivalent of: betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan) (6 - 18mg); dexamethasone (Decadron Phosphate); and triamcinolone hexacetonide (Aristospan)

VII. Technique

A. Preparation Physiologic monitoring and intravenous access is recommended and not mandatory Skin is sterilely prepared. Sedation is optional.


1. AP approach

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Patient prone. Image AP. Target is superior, lateral, and anterior aspect of the neural foramen of exiting nerve root. This correlates with the six oclock position of pedicle which forms the superior margin of the intervertebral foramen.

2. Oblique approach

Patient positioned oblique or patient prone with image intensifier oriented oblique. Target is superior, lateral, and anterior aspect of neural foramen of exiting nerve root. This correlates with the most inferior aspect of the pedicle which forms the superior margin of the intervertebral foramen. The apex of the superior articular process should be visualized under the pedicle when the obliquity is adequate. A cephalad to caudad tilt can maximize the foramen opening. This also correlates with the six oclock position of the pedicle. Note that the six oclock position of the pedicle is not visualized on the oblique projection because it is a radiographic observation uniquely associated with the PA or AP projections.

C. Needle Placement

1. AP approach (single needle technique) The needle punctures the skin caudal and lateral to the target. This often correlates with the radiographic lateral tip of the transverse process immediately caudal to the target foramen. The needle is directed cephalad, medial, and anterior towards the six oclock position of the pedicle. Image intensifier is rotated lateral to confirm needle location in the superior, lateral, and anterior aspect of the neural foramen. Confirmation of needle placement is made by injecting contrast (approx. 0.25 - 0.5ml) during lateral and AP fluoroscopic visualization. After confirmation, injectant is introduced.

2. Oblique approach (single needle technique)

The needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam towards the superior aspect of the neural foramen. Determine depth by rotating the image intensifier to AP, allowing for visualization of medial distance instead of using bone contact to determine medial distance. Bone contact for depth determination may increase likelihood of thecal penetration. Confirmation of needle placement is made by injecting contrast (approx. 0.25 - 0.5cml) during lateral and AP fluoroscopic visualization. After confirmation, injectant is introduced.

3. AP (Paramedian) approach (double needle technique)

The introducer needle punctures the skin approx. 12 cm lateral to the target. The introducer needle is directed anterior towards the six oclock position of the pedicle. Image intensifier is rotated lateral to confirm that the introducer needle tip is located posterior and lateral to the target. The injectant needle, occasionally with a curved tip, is passed through the introducer needle and directed medially into the anterior superior aspect of the neural foramen. Confirmation of needle placement is made by injecting contrast (approx. 0.25 - 0.5cml) during lateral and AP fluoroscopic visualization. After confirmation, injectant is introduced.

References

1. McCarron RF, Wimpee MW, Hudkins PG, et al. The inflammatory effects of nucleus pulposus. A possible element in the pathogenesis of low back pain. Spine 1987;12:760-64.

2. Olmarker K, Rydevik B, Nordborg C. Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. Spine 1993;18:1425-32.

3. Murphy RW. Nerve roots and spinal nerves in degenerative disk disease. Clin Orthop Rel Research 1977;46-60.

4. Olmarker K, Byord G, Cornfjord M, et al. Effects of methylprednisolone on nucleus pulposus-induced nerve root injury. Spine 1994;19:1803-8.

5. Yabuki S, Kawaguchi Y, Nordborg C, et al. Effects of lidicaine on nucleus pulposus-induced nerve root injury. Spine 1998;23:2383-89.

6. Yabuki S, Kikuchi S. Nerve root infiltration and sympathetic block. Spine 1995;20:901-6. 7. Weiner BK, Fraser RD. Foraminal Injection for Lateral Lumbar Disc Herniation. J Bone Joint

Surg [Br] 1997;79-B:804-7.

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8. Viton JM, Peretti-Viton P, Rubino T, Delarque A, Salamon N. Short-term assessment of periradicular corticosteroid injections in lumbar radiculopathy associated with disc pathology. Neuroradiology 1998;40:59-62.

9. Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic Transforaminal Lumber Epidural Steroids: An Outcome Study. Arch Phys Med Rehabil 1998;79:1362-1366.

10. Pfirrmann CWA, Oberholzer PA, Zanetti M, Boos N, Trudell DJ, Resnick D, Hodler J. Selective Nerve Root Blocks for the Treatment of Sciatica: Evaluation of Injection Site and Effectiveness A Study with Patients and Cadavers. Radiology 2001;221:704-711.

11. Narozny M, Zanetti M, Boos N. Therapeutic efficacy of selective nerve root blocks in the treatment of lumbar radicular leg pain. Swiss Med Wkly 2001;131:75-80.

12. Wang JC, Lin E, Brodke DS, Youssef JA. Epidural Injections for the Treatment of Symptomatic Lumber Herniated Discs. J Spinal Disord & Techniques 2002;15:269-272.

13. Rosenberg SK, Grabinsky A, Kooser C, Boswell MV. Effectiveness of Transforaminal Epidural Steroid Injections in Low Back Pain: A One-Year Experience. Pain Physician 2002;5:266-270.

14. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, Slaten WK, Rao S. Fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil 2002;81:898-905.

15. Delport EG, Cucuzzella AR, Marley JK, Dip, Pruitt CM, Fisher JR. Treatment of lumbar spinal stenosis with epidural steroid injections: A retrospective outcome study. Arch Phys Med Rehabil 2004;85:479-84.

16. Cooper G, Lutz GE, Boachie-Adjei O, Lin J. Effectiveness of Transforaminal Epidural Steroid Injections in Patients with Degenerative Lumbar Scoliotic Stenosis and Radiculopathy. Pain Physician 2004;7:311-317.

17. Ng LCL, Sell P. Outcomes of a prospective cohort study on peri-radicular infiltration for radicular pain in patients with lumbar disc herniation and spinal stenosis. Eur Spine J 2004;13:325-329.

18. Schaufele MK, Hatch L, Jones W. Interlaminar Versus Transforaminal Epidural Injections for the Treatment of Symptomatic Lumbar Intervertebral Disc Herniations. Pain Physician 2006;9:361-366.

19. Lee JW, Kim SH, Lee IS, Choi J, Choi J, Hong SH, Kang HS. Therapeutic Effect and Outcome Predictors of Sciatica Treated Using Transforaminal Epidural Steroid Injection. AJR 2006;187:1427-1431.

20. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine 2002;27:11-15.

21. Thomas E, Cyteval C, Abiad L, Picot MC, Taourel P, Blotman F. Efficacy of transforaminal versus interspinous corticosteroid injection in discal radiculalgia-a prospective, randomized, double-blind study. Clin Rheumatol 2003;22:299-304.

22. Kolsi I, Delecrin J, Berthelot JM, Thomas L, Prost A, Maugars Y. Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study. Joint, Bone, Spine: Revue du Rhumatisme. 67(2):113-8, 2000.

23. Ackerman WE, Ahmad M. The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations. Anesth & Analg 2007;104:1217-1222.

24. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. J Bone Joint Surg Am, 2000;82:1589-93.

25. Ng L, Chaudhary N, Sell P. The Efficacy of Corticosteroids in Periradicular Infiltration for Chronic Radicular Pain: A Randomized, Double-Blind, Controlled Trial. Spine 2005: 30(8): 857-862.

26. Karppinen J, Malmivaara A, Kurunlahti M, Kyllonen E, Pienimaki T, Nieminen P, Ohinmaa A, Tervonen O, Vanharanta H. Periradicular infiltration for sciatica: a randomized controlled trial. Spine 2001:26:1059-67.

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PASSOR Educational Guidelines for Interventional Spinal Procedures Lumbar Diagnostic Spinal Nerve Block I. Rationale

Spinal nerve segmental level of involvement may not be discernible owing to variability of pain referral patterns. Additionally, imaging studies or electrodiagnostic studies may not elucidate the segmental level of involvement. (Diagnostic selective spinal nerve blocks (SSNB), are often called spinal nerve root blocks (SNRB), however, because anesthetic is placed directly on the spinal nerve and not directly on the nerve root, correct anatomical nomenclature dictates that the procedure be called a selective spinal nerve block.) SSNBs corroborate well with surgically confirmed pathology (87-100%)1,2,3,4,5,6 and prove favorable when compared with EMG2, CT5 or myelography2 in predicting level of lesion. Positive SSNBs provide important prognostic information about surgical outcome3,4,5,6,7,8. Even when appropriately limited volumes of anesthetic were not used, negative responses to blocks possessed predictive value9.

II. Indications

A diagnostic test performed to identify a segmental level when negative or equivocal imaging studies are associated with clinical findings of nerve root irritation10. The radicular symptoms prove recalcitrant to conservative interventions.





Infection (epidural abscess, discitis, meningitis, arachnoiditis, osteomyelitis, sepsis) Bleeding (epidural and subdural hematoma) Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia,







Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope) Pain (injection site, radicular) Headache (dural puncture)

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V. Objective To test the hypothesis that the spinal nerve transmits or is the pain source. This is done by instilling anesthetic along a spinal nerve and not onto adjacent structures or the epidural space to maintain diagnostic specificity.

VI. Materials

A. Equipment and Supplies 1. Fluoroscopy necessary 2. 20-25 gauge spinal, or Chiba needle (Note that if the double needle technique is

utilized, both large gauge introducer needle (17G 20G) and a smaller gauge inner injectant needle(22G 26G) will be necessary)

3. Medication and contrast syringes 4. Physiologic monitor 5. Connection tubing (recommended so that contrast can be injected during



B. Medications 1. Sedation (optional) 2. Antibiotics not routinely required

C. Agents

1. Radiographic contrast medium (e.g. Isovue 300/370 or Omnipaque) 2. Local anesthetics (0.5-1.0ml) Agents commonly used include lidocaine 2%-4% and

bupivacaine 0.75% VII. Technique

Overview The technique utilized is similar to that which is employed for performing transforaminal epidural injections with two distinctions: 1) The injectant medication is local anesthetic, and 2) the volume is limited to 0.5 1.0 ml. to maintain diagnostic specificity. If contrast is observed proximal to the foramen within the epidural space than the infrasegmantel nerves may also be anesthetized, potentially decreasing the procedures diagnostic specificity.

A. Preparation

Physiologic monitoring, intravenous access is recommended but is not mandatory. Sedation should be avoided or short acting, to prevent analgesic effect. Skin is sterilely prepared.


1. AP approach Patient prone. Image AP. Target is the inferior, lateral, and anterior aspect of the neural foramen of exiting spinal nerve. (This is slightly lateral and inferior to the six oclock position of pedicle on AP imaging, which is targeted when performing transforaminal selective epidural injections. Instead, this target is more distal along the course of the spinal nerve, not at the root level, thus avoiding epidural flow which may limit diagnostic specificity.) If the six oclock position of the pedicle is targeted, than one must be certain that no anesthetic flows proximal into the epidural space.

2. Oblique approach

Patient positioned oblique or patient prone with image intensifier oriented oblique. Target is inferior, lateral, and anterior aspect of neural foramen of exiting spinal nerve. The apex of the superior articular process should be visualized under the pedicle when the obliquity is adequate. A cephalad to caudad tilt can maximize foramina opening, especially at the L5 spinal nerve. If the superior interforaminal space is targeted, as it is in transforaminal selective epidural injections, than one must be certain that no anesthetic flows proximal into the epidural space, potentially limiting diagnostic specificity.

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C. Needle Placement 1. AP approach (single needle technique)

The needle punctures the skin caudal and lateral to the target. This often correlates with the radiographic lateral tip of the transverse process immediately caudal to the target foramen. The needle is directed cephalad, medial, and anterior towards the target until patient begins feeling vague paresthesias (not sharp radicular pain). The needle must never contact the spinal nerve. Image intensifier is rotated lateral to confirm needle location at the inferior, lateral, and anterior aspect of the neural foramen. Confirmation of needle placement is made by injecting contrast (approx. 0.25-1.0 ml) during lateral and AP fluoroscopic visualization. Contrast should flow distally along spinal nerve and not proximal into the epidural space. After confirmation, inject 0.5 to 1.0 ml of local anesthetic.

2. Oblique approach (single needle technique)

The needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam towards the inferior anterior aspect of the neural foramen. The needle is directed towards the target until patient begins feeling vague paresthesias (not sharp radicular pain). Do not try to elicit these symptoms, but instead try to reach the nerves location without provoking the sensation. The needle must never contact the spinal nerve. Determine depth by rotating the image intensifier to AP, allowing for visualization of medial distance. Confirmation of needle placement is made by injecting contrast (approx. 0.25 - 0.5 ml) during lateral and AP fluoroscopic visualization. Contrast should flow distally along spinal nerve and not proximal into the epidural space. After confirmation, inject 0.5 to 1.0 ml of local anesthetic.

3. AP (Paramedian) approach (double needle technique)

The introducer needle punctures the skin approx. 12 cm lateral to the target. The introducer needle is directed anterior towards the six oclock position of the pedicle. Image intensifier is rotated lateral to confirm that the introducer needle tip is located posterior and lateral to the target. The injectant needle, occasionally with a curved tip, is passed through the introducer needle and directed medially towards the anterior superior aspect of the neural foramen, or more distally along the course or the nerve which is the anterior, inferior aspect of the neural foramen. The needle is directed towards the target until the patient begins feeling vague paresthesias (not sharp radicular pain). Do not try to elicit these symptoms, but instead try to reach the nerves location without provoking the sensation. The needle must never contact the spinal nerve. Confirmation of needle placement is made by injecting contrast (approx. 0.25 - 0.5 ml) during lateral and AP fluoroscopic visualization. If a target within the foramen is chosen, one must be certain that anesthetic does not flow into the epidural space, potentially limiting diagnostic specificity. After confirmation, injectant is introduced.

D. Assessment Following completion of injection the patient is asked to rate his pain while attempting to provoke his usual symptoms. Significant pain relief (75-100%) lasting equal to or greater than the expected duration of the anesthetic suggests a positive response.

References

1. Schutz H, Lougheed WM, Wortzman G, et al. Intervertebral nerve-root in the investigation of chronic lumbar disc disease. Can J Surg 1973;16:217-21.

2. Haueisen DC, Smith BS, Myers, et al.The diagnostic accuracy of spinal nerve injection studies. Clin Orthop Rel Res 1985;198:179-83.

3. Krempem JF, Smith BS. Nerve root injection: a method for evaluating the etiology of sciatica. J Bone Joint Surg (Am) 1974;56A:1435-44.

4. Dooley JF, McBroom RJ, Taguchi T, et al. Nerve root infiltration in the diagnosis of radicular pain. Spine 1988;13:79-8.

5. Stanley D, McLaren MI, Euinton HA, et al. A prospective study of nerve root infiltration in the diagnosis of sciatica: A comparison with radiculography, computed tomography, and operative findings. Spine 1990;6:540-43.

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6. van Akkerveeken PF. The diagnostic value of nerve root sheath infiltration. Acta Orthop Scand 1993;64:61-63.

7. Nachemson A. Newest knowledge of low back pain: A critical look. Clin Orthop Rel Res 1992;279:8-20.

8. Derby R, Kine G, Saal JA, et al. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine 1992;6:S176-S183.

9. North RB, Kidd DH, Zahurak M, at al. Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease. Pain 1996 65:77-85.

10. Macnab I. Negative disc exploration: An analysis of the causes of nerve root involvement in sixty-eight patients. J Bone Joint Surg (Am) 1971;53A:5891-5903.

11. Hodges SD, Castleberg RL, Miller t, et al. Cervical epidural steroid injection with intrinsic spinal cord damage. Spine 1998;23:2137-42.

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PASSOR Educational Guidelines for Interventional Spinal Procedures S1 Diagnostic Spinal Nerve Block I. Rationale

Spinal nerve segmental level of involvement may not be discernible owing to variability of pain referral patterns. Additionally, imaging studies or electrodiagnostic studies may not elucidate the segmental level of involvement. (Diagnostic selective spinal nerve blocks (SSNB), are often called spinal nerve root blocks (SNRB), however, because anesthetic is placed directly on the spinal nerve and not directly on the nerve root, correct anatomical nomenclature dictates that the procedure be called a selective spinal nerve block.) SSNBs corroborate well with surgically confirmed pathology (87-100%)1,2,3,4,5,6 and prove favorable when compared with EMG2, CT5 or myelography2 in predicting level of lesion. Positive SSNBs provide important prognostic information about surgical outcome3,4,5,6,7,8. Even when appropriately limited volumes of anesthetic were not used, negative responses to blocks possessed predictive value9.

II. Indications

A diagnostic test performed to identify a segmental level when negative or equivocal imaging studies are associated with clinical findings of nerve root irritation10. The radicular symptoms prove recalcitrant to conservative interventions.

III. Contraindications Absolute Bacterial infection: systemic or localized at injection site Bleeding diathesis: due to anticoagulants or hematological disease


IV. Complications

Potential complications include, but are not limited to: Infection (epidural abscess, discitis, meningitis, arachnoiditis, osteomyelitis, sepsis) Bleeding (epidural and subdural hematoma) Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia,







Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope) Pain (injection site, radicular) Headache (dural puncture)

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V. Objective To test the hypothesis that the S1 spinal nerve transmits or is the pain source. This is done by instilling anesthetic along the spinal nerve and not onto adjacent structures or the epidural space to maintain diagnostic specificity.

VI. Materials

A. Equipment and Supplies 1. Fluoroscopy necessary 2. 20-25 gauge spinal, Tuohy, or Chiba 3. Medication and contrast syringes 4. Physiologic monitor (optional so that contrast can be injected during fluoroscopic

visualization to confirm proper anatomical and extra-vascular needle placement) 5. Connection tubing (recommended) 6. Skin marker (optional)

B. Medications

1. Sedation optional 2. Antibiotics not routinely required

C. Agents

1. Radiographic contrast medium (e.g. Isovue 300/370 or Omnipaque) 2. Local anesthetics (0.5-1.0ml) Agents commonly used include lidocaine 1%-2% or

bupivacaine 0.75% 3. Corticosteroids - agents commonly used include but are not limited to dose

equivalents of: betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan) (6-18 mg); dexamethasone (Decadron Phosphate); and triamcinolone hexacetonide (Aristopan).

VII. Technique

Technique Overview The technique utilized is similar to that which is employed for performing S1 transforaminal epidural injections with two distinctions: The injectant medication is local anesthetic and the volume is limited to 0.5 1.0 ml. to maintain diagnostic specificity. If contrast is observed within the epidural space, realize that other nerves may also be anesthetized, potentially decreasing the procedures diagnostic specificity. A. Preparation

Physiologic monitoring and intravenous access is recommended but not mandatory. Sedation should be avoided or short acting to prevent analgesic effect. Skin is sterilely prepared.


Patient prone. Rotate image intensifier cephalocaudad and occasionally ipsilateral oblique, superimposing anterior and posterior S1 foramen. Target is superior lateral aspect of S1 neural foramen. One may visualize the silhouette of S1 pedicle immediately cephalad to the target10.

C. Needle Placement

The needle punctures the skin directly over the target and the shaft of the needle is directed along the axis of the x-ray beam. With this trajectory the needle passes in an inferior to superior and lateral to medial trajectory, thus minimizing risk of nerve injury or dural puncture. Image intensifier is rotated lateral to confirm maximal needle depth within sacral canal immediately posterior to the vestigial S1-2 intervertebral disc. Avoid nerve root contact. Confirmation of needle placement is made by injecting contrast (approx. 0.25 - 0.5ml) during lateral and AP fluoroscopic visualization. After confirmation, 0.51.0 ml. of anesthetic is introduced. The alternative technique of contacting bone and walking off bone and into the foramen should only be used with caution, owing to the fact that initially missing bone may cause misjudgment of needle depth11.

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D. Assessment Following completion of injection the patient is asked to rate his pain while attempting to provoke his usual symptoms. Significant pain relief (75-100%) lasting equal to or greater than the expected duration of the anesthetic suggests a positive response.

References

1. Schutz H, Lougheed WM, Wortzman G, et al. Intervertebral nerve-root in the investigation of chronic lumbar disc disease. Can J Surg 1973;16:217-21.

2. Haueisen DC, Smith BS, Myers, et al.The diagnostic accuracy of spinal nerve injection studies. Clin Orthop Rel Res 1985;198:179-83.

3. Krempem JF, Smith BS. Nerve root injection: a method for evaluating the etiology of sciatica. J Bone Joint Surg (Am) 1974;56A:1435-44.

4. Dooley JF, McBroom RJ, Taguchi T, et al. Nerve root infiltration in the diagnosis of radicular pain. Spine 1988;13:79-83.

5. Stanley D, McLaren MI, Euinton HA, et al. A prospective study of nerve root infiltration in the diagnosis of sciatica: A comparison with radiculography, computed tomography, and operative findings. Spine 1990;6:540-43.

6. van Akkerveeken PF. The diagnostic value of nerve root sheath infiltration. Acta Orthop Scand 1993;64:61-63.

7. Nachemson A. Newest knowledge of low back pain: A critical look. Clin Orthop Rel Res 1992;279:8-20.

8. Derby R, Kine G, Saal JA, et al. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine 1992;6:S176-S183.

9. North RB, Kidd DH, Zahurak M, at al. Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease. Pain 1996;65:77-85.

10. Macnab I. Negative disc exploration: An analysis of the causes of nerve root involvement in sixty-eight patients. J Bone Joint Surg (Am) 1971;53A:5891-5903.

11. Hodges SD, Castleberg RL, Miller t, et al. Cervical epidural steroid injection with intrinsic spinal cord damage. Spine 1998;23:2137-42.

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PASSOR Educational Guidelines for Interventional Spinal Procedures S1 Transforaminal Epidural Injection I. Rationale

S1 Transforaminal epidural steroid injections (TFESIs) can be very helpful in the management of S1 radicular symptoms. S1 Transforaminal epidural injections instill medication along the affected S1 nerve root and into the anterior epidural space at the site of inflammation. Lumbar spinal stenosis and herniated nucleus pulposus can induce nerve root inflammation1. Inflammation of the nerve root induces neurophysiologic and histologic changes2 that can result in radicular symptoms3. Corticosteroid reduces morphologic and functional nerve root changes4, and lidocaine decreases nerve root inflammation5, while increasing intraradicular blood flow6. There is increasing literature to support the use of transforaminal epidural injections to treat radicular symptoms from lumbar spinal stenosis and herniated nucleus pulposus, and most of these studies include S1 TFESIs. There have been a myriad of case series and cohort studies demonstrating significant improvement in both pain and function with follow up ranging from 2 weeks to 2 years7-17. Several controlled trials have been performed comparing TFESI to other therapeutic injections, including interlaminar epidural steroids18,19, transforaminal bupivicaine20,21 and transforaminal saline22. Patients receiving TFESI in all studies improved, and in 2 of the 6 studies21,23,24 demonstrated superior outcome to the alternative intervention, with follow-up ranging from 1 to 23 months. Evidence for transforaminal epidural steroid injections for axial back pain is limited.

II. Indications S1 Transforaminal epidural steroid injections can be performed for S1 radicular symptoms recalcitrant to conservative interventions including medications and physical therapy. With severe limitation of function, one could perform the injection prior to the initiation of more conservative options to facilitate those options. No role exists for a series of S1 transforaminal epidural injections given without regard to the response of the initial or previous injection. A subsequent injection may be considered in a patient with partial or temporary pain relief from a previous injection. While there is limited evidence in the area of repeat injections, consensus indicates that, with rare exception, injections should be limited to 3 in a 6-month period or 4 in a year. These should ideally be spaced by at least 14 days to assess full response and minimize adrenal suppression.




IV. Complications

Potential complications include, but are not limited to: Infection (epidural abscess, discitis, meningitis, arachnoiditis, osteomyelitis, sepsis) Bleeding (epidural and subdural hematoma) Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia,



or vertebral artery trauma, arterial particulate injection, spinal cord injury, seizure) Dural puncture (spinal headache, uncal herniation, arachnoiditis, spinal block)

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Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness, anxiety, incoherent speech, light-headedness, perioral parethesias, blurred vision, tremors, drowsiness, seizures, cardiac arrest, excessive intrathecal or epidural local anesthetic injection resulting in spinal block or leg weakness)

Adverse steroid reaction (facial flushing, injection site hypopigmentation, subcutaneous fat atrophy, increased appetite, fluid retention, gastritis, malaise, euphoria, insomnia, headache, immunosupression, aseptic meningitis, arachnoiditis, congestive heart failure, increased intraocular pressures, adrenal insufficiency, ster

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