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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