INJECTION TECHNIQUES Jwalant S. Mehta MS (Orth) MCh (Orth) FRCS (Orth)
TYPES OF INJECTIONS Nerve root block Epidural Discogram SI joint injection Facet block Pars block IDET Coccyx injection
OUTLINE Purpose Technique What are the likely outcomes
SURGERY DOES NOTHING FOR BACK PAIN most of the time
ENKER S FORMULA Surgical success = I x T PS 4 x BU I = indication T = technique PS = Psychological factors BU = Biological unknowns
BIOLOGICAL UNKNOWNS
Invasiveness CLINICAL PATHWAY: PHASE I CONSERVATIVE MEASURES Physiotherapy Medications Alternative therapies Time
Invasiveness CLINICAL PATHWAY: PHASE II INJECTIONS Physiotherapy Medications Alternative therapies Injections: Facet blocks Root blocks Epidural steroids Time
DISC PATHOLOGY
ROOT PATHOLOGY
ROOT BLOCKS
ROOT BLOCK Diagnostic Reduces the root inflammation Clarity on level / side Clinical / MRI concordance
ANATOMY OF THE NERVE ROOT
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
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
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
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
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
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
SUMMARY OF TECHNIQUE Scottie (red dot) Align Inject: Marcaine + steroids Rootagram Leg pain reproduction
ROOT BLOCK: POSSIBLE RESPONSES No relief Transient relief (hours) Longer period of relief (weeks / months)
EPIDURAL STEROID INJECTIONS
EPIDURAL STEROIDS Low back pain ± radicular Inflammation caused by chemicals from disc Lumbar Caudal
EPIDURAL INJECTION Lack of clarity on side; level Central + foraminal compression Multi-level pathology Larger volume of injectate: Marcaine + steroids
EPIDURAL STEROIDS: TECHNIQUE Lumbar Caudal
CARPET BOMBS OR CRUISE MISSILES Epidural steroids: Bilateral symptoms Mixed dermatomes Multiple levels Selective root blocks: Unilateral symptoms Single level MRI Clinical correlated
LUMBAR CANAL STENOSIS
FACET BLOCKS
FACET SYNDROME MOONEY ET AL CLIN ORTHOP 1976 Pain: Mid-posterior pain non-dermatomal, ± symmetrical with hyper-extension Referred to hips; legs Normal neurology
FACET BLOCK Facets as pain generators Diagnostic only Medial branch of posterior primary ramus
Facet joint injections Medial branch technique Intra-articular technique
FACET RHIZOLYSIS Success with facet blocks Longer term effect Buzz the facet joint innervation
PARS BLOCKS
PARS BLOCKS Diagnostic for pain source Immediate relief of activity related pain Repair or fusion
DISCOGRAMS
BACK PAIN
MECHANICAL CAUSES OF BACK PAIN
ANNULAR TEARS
DISC INNERVATION
Invasiveness CLINICAL PATHWAY: PHASE II INJECTIONS Fusion Spine arthroplasty & Non fusion alternatives Discogram IDET Decompressions Fusion Time
DISCOGRAPHY
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
INJECTION TECHNIQUES L4/5 discogram L5 root block Facet joints 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
CORRECT NEEDLE PLACEMENT
WITH POST DISCOGRAPHY CT
NORMAL DISCOGRAMS
NORMAL NUCLEOGRAMS
ABNORMAL DISCOGRAMS
SACRO-ILIAC JOINT INJECTIONS
SACRO-ILIAC JOINT INJECTION
IDET
Intradiscal Electrothermal Therapy Thermal annuloplasty
IDET Annular collagen shrinkage Thermocoagulation of nerve endings in the annulus 75 C 60 C 90 C 42 C 38 C
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
MUA, INJECTION OF COCCYX
COCCYDYNIA: MUA, INJECTION