Spinal Pain: Diagnosis and Interventional Procedures

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1 Spinal Pain: Diagnosis and Interventional Procedures Dr Ilias Drivas MBBS FRANZCR Diagnostic and Interventional Radiologist Alfred Imaging Group Staff Specialist Royal Prince Alfred Hospital

2 Overview Go over some relevant anatomy Common patterns of disc pathology as well as radiological terminology which can be confusing/inconsistent Talk about spinal canal stenosis and facet joint arthritis Focus on which type of intervention may be most appropriate for different clinical scenarios and imaging appearances

3 Types of Imaging Xrays CT MRI Good initial test Cannot see disc pathology or assess canal stenosis Very good test for pretty much everything Much less radiation now with new CT scanners and dose reducing techniques Best test No radiation Bone scan Multilevel facet disease

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17 I Drivas IWSML 2014

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20 Degenerative Disc Disease Loss of fluid in the disc (disc dessication) Loss of disc height Vaccuum phenomenon Anular fissure Endplate degenerative changes Osteophyte formation Disc bulge or disc protrusion

21 Degenerative Disc Disease Symptoms Commonly asymptomatic Low back pain +/- radiculopathy Restricted ROM, extension may exacerbate Treatment Non operative Bed rest, exercise, medication, epidural injection Operative Spinal fusion

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24 Anular Fissure

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28 Disc Terminology Disc bulge Broad based Disc herniation Disc protrusion Disc extrusion Disc sequestration

29 Disc Bulge Generalised extension of disc beyond margin of vertebral endplates >50% of disc circumference, 3mm Commonly lower cervical or lower lumbar Clinical 40% of asymptomatic adults have disc bulges Neck/back pain +/- radiculopathy Pain worse with flexion, relieved by lying flat with flexed hips and knees Disc bulge less important, but often associated with degenerative discs which cause pain Treatment NSAIDS, physio, epidural injection, discectomy

30 Broad Based Disc Bulge

31 Disc Herniation Localised displacement of disc material beyond the limits of the intervertebral disc space in any direction <50% disc circumference Focal vs broad based Types Protrusion Extrusion Sequestration Location Central Paracentral Foraminal Extraforaminal (far lateral)

32 Disc Herniation Clinical Neck pain or lower back pain Radiculopathy (lateral disc herniation) Cord compression/cauda equina syndrome (central disc herniation) Treatment NSAIDS, physio, perineural or epidural injections Indications for surgery Development of a neurological deficit Intractable pain unrelieved by conservative measures

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35 Foraminal

36 Far Lateral

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49 Facet Joint Disease Very common as you age Often multilevel Can be hard to tell which is the most symptomatic level Symptoms Neck pain Paravertebral lower back pain/stiffness Associated abnormalities Neural foraminal stenosis, spinal canal stenosis Synovial cyst Degenerative spondylolisthesis Poor correlation between severity of pain and extent of degeneration

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55 Lumbar Spinal Canal Stenosis Causes Congenital short pedicles Disc bulge/disc herniation Facet joint disease Ligamentum flavum thickening/hypertrophy Clinical Lower back pain Lower leg pain, paraesthesia and weakness (neurogenic claudication) Bladder bowel dysfunction Radiculopathy Degree of spinal canal stenosis on imaging may not correlate with symptoms

56 Lumbar Spinal Canal Stenosis Treatment NSAIDS Exercise Epidural injection Surgery (decompression and laminectomy)

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59 Cervical Spondylosis Spinal canal and neural foraminal narrowing due to multifactorial degenerative changes Disc osteophyte complex compressing cord Uncovertebral and facet joint hypertrophy Narrowing of neural foramina Cord T2 hyperintensity (myelomalacia) Clinical Radiculopathy (if compress nerve roots) Neck pain radiating to arms/occiput Upper limb numbness/weakness, sensory loss Myelopathy (if compress spinal cord) Lower motor neuron signs and symptoms at the level of lesion Upper motor neuron signs below the level of lesion, eg difficulty walking, increased tone, extensor Babinski

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62 Spondylolisthesis Displacement of one vertebral body relative to the inferior vertebral body Anterolisthesis Retrolisthesis Causes Degenerative (usually facets) Spondylolysis (pars defects) Trauma Post surgical Pathologic (tumour, infection)

63 Spondylolisthesis Clinical Back pain Radiculopathy (neural foraminal narrowing) Degenerative listhesis presents as spinal canal stenosis

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67 CT Guided Injections Increasingly utilised and very effective Low risk and can provide temporary or permanent relief of neck/back pain or radicular pain

68 Indications for Spinal Injections Diagnostic Conflict between symptoms and location of imaging findings No imaging findings correlating with clinical symptoms Presurgical testing Adjacent segment deterioration after spinal fusion Therapeutic Adjunct to conservative therapy Poor surgical candidate Post operative pain delaying recovery

69 Which Injection? Radicular symptoms Perineural injection Spinal canal stenosis symptoms Epidural injection Facet joint OA and pain Facet joint injection Sacroiliac joint Sacroiliac joint injection

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71 Which Joint to Inject? Based on clinical findings Identify point of maximal tenderness to palpation Imaging can be unreliable in predicting level of facet joint pain

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73 Nerve Root Injection Treatment of radicular pain Indicated in: Radicular symptoms with a known cause (eg disc, osteophyte) Radicular symptoms not localised clinically with multilevel degenerative changes on imaging (will help define levels for surgery) Post operative patients with unexplained recurrent pain Equivocal neurological examination Minimal or no definite imaging findings

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75 Epidural Injections Treatment of local back pain or radiculopathy Indications Disc degenerative disease or herniation Spinal nerve root compression Spinal canal or neural foraminal stenosis Absence of imaging findings Often difficult to determine which level to inject with multilevel disease

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77 Contraindications Local skin infection Unable to lie prone (lumbar), on their side (cervical) Anticoagulations (relative contraindication) Facets: all OK Perineural: aspirin OK, warfarin variable Epidural: cease all Need to weigh up risks vs benefit when ceasing anticoagulants

78 Medications Steroid provides an anti-inflammatory effect Local anaesthetic (short or long acting) Can take up to a week or two to work

79 Complications Infection Haemorrhage Can have small glucose rise in diabetics; should be monitored

80 Post Intervention Care Rest for a couple of days Keep the skin clean Unusual for symptoms to worsen after the injection Monitor if this occurs May need to reimage

81 How Many/How Frequent? No good evidence Current standard is you can have 3 injections per area per year No real limit on how many you can have

82 How to Manage the Complex Patient with Multilevel Disease Can be very difficult Back pain can be multifactorial/multilevel Determine if it is facet pain, radicular symptoms or spinal canal stenosis Correlate clinical with radiological findings Pick injection type and level Often can be trial and error Injection can be diagnostic as well as therapeutic If injection doesn t work, it may have been the wrong level or wrong type of injection

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85 Thank You!

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