INJECTION TECHNIQUES. Jwalant S. Mehta MS (Orth) MCh (Orth) FRCS (Orth)

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1 INJECTION TECHNIQUES Jwalant S. Mehta MS (Orth) MCh (Orth) FRCS (Orth)

2 TYPES OF INJECTIONS Nerve root block Epidural Discogram SI joint injection Facet block Pars block IDET Coccyx injection

3 OUTLINE Purpose Technique What are the likely outcomes

4 SURGERY DOES NOTHING FOR BACK PAIN most of the time

5 ENKER S FORMULA Surgical success = I x T PS 4 x BU I = indication T = technique PS = Psychological factors BU = Biological unknowns

6 BIOLOGICAL UNKNOWNS

7 Invasiveness CLINICAL PATHWAY: PHASE I CONSERVATIVE MEASURES Physiotherapy Medications Alternative therapies Time

8 Invasiveness CLINICAL PATHWAY: PHASE II INJECTIONS Physiotherapy Medications Alternative therapies Injections: Facet blocks Root blocks Epidural steroids Time

9 DISC PATHOLOGY

10 ROOT PATHOLOGY

11 ROOT BLOCKS

12 ROOT BLOCK Diagnostic Reduces the root inflammation Clarity on level / side Clinical / MRI concordance

13 ANATOMY OF THE NERVE ROOT

14 Nerve root block: technique Identify level Safe triangle: Superior: pedicle Lateral: lat border of body Outer margin of nerve root Fluoroscopy Reproduction of leg pain Rootagram

15 INJECTION TECHNIQUES L5/S1 disc endplates at angle Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x- ray beam Target area depends on investigation. Contrast for discograms and root/foraminal blocks

16 INJECTION TECHNIQUES L5/S1 disc endplates parallel Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x- ray beam Target area depends on investigation. Contrast for discograms and root/foraminal blocks

17 INJECTION TECHNIQUES Facet joints L4/5 discogram L5 root block S1 foramen- S1 block Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x- ray beam Target area depends on investigation. Contrast for discograms and root/foraminal blocks

18 INJECTION TECHNIQUES L5 and S1 root blocks Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x- ray beam Target area depends on investigation. Contrast for discograms and root/foraminal blocks

19 INJECTION TECHNIQUES S1 root block Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x- ray beam Target area depends on investigation. Contrast for discograms and root/foraminal blocks

20 SUMMARY OF TECHNIQUE Scottie (red dot) Align Inject: Marcaine + steroids Rootagram Leg pain reproduction

21 ROOT BLOCK: POSSIBLE RESPONSES No relief Transient relief (hours) Longer period of relief (weeks / months)

22 EPIDURAL STEROID INJECTIONS

23 EPIDURAL STEROIDS Low back pain ± radicular Inflammation caused by chemicals from disc Lumbar Caudal

24 EPIDURAL INJECTION Lack of clarity on side; level Central + foraminal compression Multi-level pathology Larger volume of injectate: Marcaine + steroids

25 EPIDURAL STEROIDS: TECHNIQUE Lumbar Caudal

26 CARPET BOMBS OR CRUISE MISSILES Epidural steroids: Bilateral symptoms Mixed dermatomes Multiple levels Selective root blocks: Unilateral symptoms Single level MRI Clinical correlated

27 LUMBAR CANAL STENOSIS

28 FACET BLOCKS

29 FACET SYNDROME MOONEY ET AL CLIN ORTHOP 1976 Pain: Mid-posterior pain non-dermatomal, ± symmetrical with hyper-extension Referred to hips; legs Normal neurology

30 FACET BLOCK Facets as pain generators Diagnostic only Medial branch of posterior primary ramus

31 Facet joint injections Medial branch technique Intra-articular technique

32 FACET RHIZOLYSIS Success with facet blocks Longer term effect Buzz the facet joint innervation

33 PARS BLOCKS

34 PARS BLOCKS Diagnostic for pain source Immediate relief of activity related pain Repair or fusion

35 DISCOGRAMS

36 BACK PAIN

37 MECHANICAL CAUSES OF BACK PAIN

38 ANNULAR TEARS

39 DISC INNERVATION

40 Invasiveness CLINICAL PATHWAY: PHASE II INJECTIONS Fusion Spine arthroplasty & Non fusion alternatives Discogram IDET Decompressions Fusion Time

41 DISCOGRAPHY

42 INJECTION TECHNIQUES Discograms Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x- ray beam Target area depends on investigation. Contrast for discograms and root/foraminal blocks

43 INJECTION TECHNIQUES L4/5 discogram L5 root block Facet joints S1 foramen- S1 block

44 Patient prone II and radiolucent table AP spine and lordosis Oblique picture for Scotty Dog Needle perpendicular to x-ray beam

45 CORRECT NEEDLE PLACEMENT

46 WITH POST DISCOGRAPHY CT

47 NORMAL DISCOGRAMS

48 NORMAL NUCLEOGRAMS

49 ABNORMAL DISCOGRAMS

50 SACRO-ILIAC JOINT INJECTIONS

51 SACRO-ILIAC JOINT INJECTION

52 IDET

53 Intradiscal Electrothermal Therapy Thermal annuloplasty

54 IDET Annular collagen shrinkage Thermocoagulation of nerve endings in the annulus 75 C 60 C 90 C 42 C 38 C

55 IDET: indications Back pain > 6 mo Failed non-op programme Neuro N; SLR free MRI: N disc height; no compression Discogram: concordant pain; low pressure; painless control level Realistic outcomes

56 MUA, INJECTION OF COCCYX

57 COCCYDYNIA: MUA, INJECTION

58

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