Cervical Transforaminal Epidural injections Pro-view. Richard Kendall, D.O. Associate Professor, PM&R
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1 Cervical Transforaminal Epidural injections Pro-view Richard Kendall, D.O. Associate Professor, PM&R
2 Disclosures No financial disclosures
3 Overview of procedure Anatomical reasoning Physiological reasoning Risks/complications Benefits Techniques Flouro, CT, US Why not interlaminar?
4 Cervical Epidemiology Radharkrishnan et al. Average annual age-adjusted incidence of 83.2 per (0.08% of population) Men 107.3/ , Women 63.5/ Peak incidence between years of age History of trauma/ physical exertion prior to onset in just under 15% Order of decreasing frequency: C7 (31-81%), C6 (19-25%), C8 (4-12%), C5 (2-14%)
5 Anatomical reasoning Cervical Radiculopathy Disc herniation Spondylosis
6 Indications Should have extensive trial or medications, PT, activity modification given the potential risks of ALL cervical epidural injections. Scanlon GC, et al. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine. 2007;32(11): Abbassi A, et al. Complications of interlaminar Cervical Epidural Steroid Injections. Spine 2007;32(19):
7 Anatomic approach Transforaminal Oblique view Posterior foramen Midpoint to inferior SAP Fluoroscopy, CT, US guided Inter-laminar catheter C7-T1 or C6-C7 level Inter-laminar approach Feed catheter to level desired Spineuniverse.org ISIS practice guidelines for Spinal Diagnostic & Treatment procedures
8 Physiological reasoning Steroids Placement of steroids near site of inflammation Increased inflammatory markers TNF-α, IL-6, IL-8, Decreased nerve thesholds Direct c-fiber inhibition
9 CTF ESI Outcome studies Good Bush 1996 N=68, 76% cured, 24% minimal pain, 39m f/u Berger 1999 CT-guided, 59% improved Slipman % excellent at 21m, 2.2 injections, 30% surgery Riew, % cancel surgery, no difference steroid, bupivicaine Poor Slipman Whiplash, nml imaging 14% good outcome Slipman Whiplash, foraminal stenosis 20% good outcome
10 Outcome studies No direct comparisons CIL to CTF Lumbar studies show benefit for radiculopathy with TF approach. Schaufele MK, et al. Pain Physician. 2006;9(4):
11 Risks
12 Bleeding Epidural Hematoma ASA closed claims database % of all chronic pain mgmt claims were epidurals Most common complication was nerve injury- 25% Pre-fluoroscopy, pre-ultrasound nerve blocks Spinal cord injury is leading cause of type of nerve injury in 1990 s. Epidurals 50% of these. ~1% of interlaminar epidurals hematoma. Cheney FW. Nerve injury associated with anesthesia: A closed claims analysis. Anesthesiology 1999,90:
13 Bleeding Risk Factors Coagulopathy Thrombolytics NSAIDs Herbal Medications Garlic, Ginko, Ginseng, Supplements fish oils, including omega 3 s!!
14 Bleeding NSAIDs No significant risk or hematoma Minor Hemorrhagic complications Horlocker TT. Anest Analg 2002; 95: Horlocker TT. Anest Analg 1995; 80: Antiplatelet Meds (clopidrogrel, ticlopidine, asa/dipyridamole, dabigatran, rivaroxaban) Increases risk of bleeding complications, stop 7 days prior Supplements/Herbals (MSM, garlic, ginseng, ginger, Fish oil*) Concurrent use with other meds affecting clotting mechanisms increase the risk of bleeding *- recommend stop 7 days in advance.
15 Bleeding Need to be aware of WHY patient is anticoagulated. ISIS ASM Furman: Pt cancelled day of appt, died unexpectedly stopping ASA 7 days prior. Stents: recommendations are for 1 yr anticoagulation plavix/asa- drug eluting, then ASA for life. Bare metal: 6 mo. ALWAYS consult with prescribing MD before stopping anticoagulants.
16 Infections Meningitis Rarely Reported Morris 1994 Daugherty. J Neurosurg : case reports Nelson 1973 Civen 2006 Clin Infect dz: Serratia from compound betamethasone Dural Puncture Arachnoiditis (infectious and medication etiology) Ryan 1981 Abscess- most common organism Staph. Epi. Major risk factor: Indwelling catheter Second most common complication in ASA claims- 21% (nerve inj 25%) Epidural abscess Hooten WM. Mayo Clin Proc 2004; 79: Huang RC. Spine 2004; 29 E7-9. Extra dural abscess Gouke, British Journal of Anesthesia 1990; 65: Facet joint infections. Local infection
17 Procedure Specific Complications Interlaminar Possible Intrathecal Injection Venous Injection Inadvertant Discogram- hopefully not, though been done. Epimembranous Injection Wiltse LL. Spine. 1993; 18: Chiba K. Spine. 2001; 26: Gundry CR. Radiology. 1993; 187: Intra-articular facet joint injection Lack of flow past an area of stenosis Peculiar flow pattern along the circumneural sheaths Renfrew DL. Atlas of Spinal Injection 2004 Table 2-4 p. 23. Fungal Infection Torula Meningitis Shealy CN JAMA 1966; 197:
18 Procedure Specific Complications Transforaminal Botwin KP. Arch Phys Med Rehab. 2000; 81: Audit of 322 injections Overall incidence of minor complications 9% Transient headaches 3% Increased back pain 2% Facial Flushing 1% Increased Leg Pain 0.6% Vaso-vagal reaction 0.3%
19 Neuraxis Injury Direct Mechanical Injury Spinal Cord Spinal Nerve Vascular Injury Anterior Spinal Artery Syndrome Sudden painless onset of LE weakness Variable sensory deficits, with relative preservation of proprioception Supplies Cauda Equina and anterior 2/3 of spinal cord
20 Procedure Specific Complications Transforaminal Intrathecal/Subarachnoid injection (dural sleeve) Intravascular injection Furman MB. Spine 2003; 28: Audit of 504 cervical injections-19% incidence of intravascular injection Baker R. Pain 2002; 103: Presence of reinforcing arteries are more common in lower cervical spine Brain or cord infarcts, vertebrobasilar infarcts, death. 78 cases reported by Scanlon et al. Spine 2007;32(11):
21 Figure 2 Axial 3-dimensional T2 sequence through the C3-C4 neural foramina Vertebral artery loops within the C3-C4 neural foramina (arrows). Fink J R et al. Neurology 2010;75: by Lippincott Williams & Wilkins
22 Anatomical hazards Cervical Vasculature Vertebral artery May have medullary branch Deep cervical May have medullary branch Ascending cervical may have medullary branch Usually lie just lateral to foramen in posterior midinferior position C5-6, C6-7 most common entry Malhotra, G. etal. Complications of transforaminal cervical epidural steroid injections. Spine 2009;34(7):731-9
23 Procedure Specific Complications Transforminal Cervical Decreasing Risk of Complications Advance needle from Anterior Oblique approach Ensure needle remains over SAP along the posterior aspect of the intervertebral foramen Use AP view to adjust final needle depth into foramen Do not advance needle >50% across medial-lateral dimension of the foramen Use contrast under live fluoro. Leave tubing connected. Test dose, then steroid. Use of a non-particulate steroid? Riew intravertebral a. injection
24 Needle choice Blunt tip needles Less likely to penetrate vascular? Trucath Still 10% vascular uptake with catheter. 3% unable to get to foramen Kloth D, et al.pain Physician 2011;14:
25 Summary Try ALL non-interventional therapies first!! Use for radiculopathy ONLY. Not axial. Have extensive training, excellent radiology. Low threshold to abort. Especially if flashback seen in needle. Digital subtraction imaging, if available. Non-particulate steroid.
26 Safest Approach? Unclear, both have rare catastrophic complications But then again.
27 MEDICATION COMPLICATIONS Google images.
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