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Lumbar and cervical pain management procedures: When - Agility

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Lumbar and cervical pain
management procedures:
When and how to do them
Yair Safriel, MD
ain of spinal origin is a significant
public health concern in the
United States and is among the most
common reasons people seek medical
care.1-4 It is the also the second-leading,
medically related reason for missed
work, resulting in 40% of lost workdays
annually.2 Between 1997 and 2006, the
use of interventional pain management
procedures increased by 235% in the
Medicare population.2 The cost-perinjection also doubled, from $115 to
$227, between 1994 and 2001.1 While
clinical trials are difficult to perform due
to the multiple factors that can influence
a patient’s perception of pain, evidence is
building that early imaging and intervention result in better outcomes.1-9
Conservative approaches to pain
management utilize medication, rehabilitative therapies and behavioral
approaches. Interventional pain management approaches employ diagnostic and therapeutic techniques to assist
in identifying and relieving pain. Compared to traditional pain management
methods, which have shown mixed
outcomes, 10-12 interventional therapies
that rely on injection procedures have
demonstrated promising results.5-22
Degenerative back and neck pain is
most easily classified into 3 broad categories according to its anatomical origin:
disc degeneration, disc protrusions/
Dr. Safriel is the lead neuroradiologist in
the Dunedin Neuro-Spine Institute, University of South Florida, Radiology Associates of Clearwater, Clearwater, FL.
herniations and facet degeneration. The
primary role of imaging is to exclude
causes of non-degenerative pain (e.g.,
compression fractures, tumors, neural
disorders and traumatic injuries) and indicate which of the above three categories
may be the primary pain generator.
This article describes procedural techniques developed through extensive
experience, a thorough literature review,
and feedback from spine- and neurosurgeons. It is important to recognize that
the techniques outlined here are among
many possible options.
This paper will first review the
safety profile of injection procedures
as a guide to obtaining informed consent and outline the pertinent differences between lumbar and cervical
injections. Then, epidural, nerve block
and facet injections will each be examined separately, with a particular focus
on outlining the differences between
lumbar and cervical therapy.
The arsenal of interventional pain
management includes many other injection procedures, such as stellate ganglion blocks and trigger point, sacroiliac
joint, synovial cyst rupture, and intradiscal steroid injections. A complete
review of all these procedures is beyond
the scope of this article.
But by initially focusing on epidural
injections/nerve blocks and facet injections—the most common procedures—
the interventional musculoskeletal- or
neuroradiologists can subsequently
expand their practices to include other
Safety profile: What you need to
know for informed consent
The safety of both lumbar and cervical epidural steroid injections (ESI) and
nerve blocks has been confirmed by
multiple large studies ranging from 322
to 5,334 patients, with no permanent
adverse procedure-related outcomes and
a complication rate of <1% requiring
additional treatment.23-27 In all studies,
both lumbar and cervical procedures
were performed in outpatient settings,
though not necessarily in ambulatory
surgery centers. A C-arm (portable or
fixed) or CT was used for guidance.
There is no evidence in the literature
comparing fluoroscopic to CT guidance
in either the lumbar or cervical spine
(although many operators are passionate
on their choice of imaging modality).
Ultimately, operators will choose the
imaging modality that best suits their
One aspect that may favor fluoroscopic over CT guidance is the risk of
intravascular injections in the superiorinferior plane (Figure 1) that may not be
visualized on CT. This risk is higher in
the cervical spine with transforaminal
injection due to: 1) tortuosity of the vertebral artery (Figure 2); 2) direct injection into the cord; and 3) injection into
microvasculature that supplies the spinal
cord. Isolated reports, documenting
lower cord infarction and cauda equinalike symptoms,28,29 emphasize the
importance of avoiding intravascular
injection. As these techniques utilize
contrast for guidance, complications
December 2010
FIGURE 1. Fluoroscopic image of a right
C6-7 nerve root block showing accidental
intravascular injection (arrowheads). This
may be missed with CT guidance.
relating to contrast administration must
also be considered. In patients who are
not candidates for non-ionic contrast,
gadolinium may be substituted.30,31
The most common complications in
neck and back procedures are pain23,25
and needle misplacement, primarily in
the subarachnoid space (Figure 3). Transforaminal cervical injections are more
controversial. While some studies have
shown their safety, 32,33 many physicians
have reconsidered performing these34,35
due to an unfavorable safety profile
shown by other studies. 36-42 Cervical
nerve blocks that target the nerve along
its extraspinal course using fluoroscopy
may be a safer alternative.26,27
Epidural steroid injections
Rationale and patient selection
The literature is replete with articles
describing the benefits of ESIs.5-22
These injections are of value to patients
with both spinal stenoses and acute herniations.17, 22 In cases of chronic stenosis, especially among the elderly,
patients can remain functional despite a
relatively high degree of pain, but they
are often incapacitated by acute exacerbations. Pain management injections are
very useful in combating these episodes
and returning the patient to baseline
function. The alternatives to injection
may be surgery or, in those for whom
surgery is not an option, a life of pain.
The patient should understand that one
injection is not a permanent cure. Back
pain that returns with activity, requiring
reinjection at the same location, does not
December 2010
FIGURE 2. CT angiogram 3D reformat
showing a markedly tortuous vertebral
artery (arrows) in the right foramen that
would be at risk in a foraminal injection.
mean the original injection was a failure.
Many patients settle into a routine of bior tri-annual injections to control pain.
In instances of multilevel disease,
selective nerve blocks may help in planning the extent of fusion surgery, or a
series of successful facet blocks may
shift attention to the posterior column.
Surgeons may also use these procedures
as a gatekeeper in selecting patients for
surgery.7,43 As a tool for predicting 1year surgical outcome, spinal injections
have a reported sensitivity between 65%
and 100%, a specificity between 71%
and 95%, and a positive predictive value
as high as 95%.7
ESIs can result in significant pain
relief,18,19 decreased operative rates43 and
cost savings,44 particularly in those over
65 years of age. Acute lesions and radicular pain respond better to ESI;6,8,45 disc
herniations respond better than spinal stenoses (61% vs. 38%).8 In spinal stenoses,
however, patient response is independent
of the degree of stenosis.46 Injections may
be the only effective pain-relief mechanism for patients with multilevel disease
(especially in the cervical spine, where
there are no FDA-approved devices for
fusions of greater than three levels), or
those who cannot undergo surgery.
Fluoroscopic needle guidance is
needed for optimum efficacy.47-49 The
epidural space can be reached via caudal, interlaminar or transforaminal
approaches. Of the three, the transforaminal and interlaminar approaches
FIGURE 3. CT scan showing different
appearance of needle placement and subsequent contrast test injection: (A) epidural
injection of contrast and (B) intrathecal
injection of contrast.
are employed most often (Figures 47).4,16 The caudal approach is the least
used24 but easiest to perform and
aimed at the sacral notch (Figure 4).
For the lumbar interlaminar approach, the patient is positioned prone
on the table. Tilting the C-arm at an
approximately 5-degree angle ipsilateral
to the side of entry and a 2-degree to
5-degree caudal/Ferguson tilt may better
expose the apex of the interlaminar
space (Figure 5). Optimal needle position is at the midline (Figure 5). Needle
placement too far from the midline may
result in the injectate remaining ipsilateral and not crossing the midline.50 In
the cervical spine, due to the smaller size
of the epidural space more superiorly,
the injection is almost always performed
at C7-T1 or C6-C7.42 A lateral projection usually is of little value, due to
the shoulders’obscuring the lower cervical spine. Therefore, an alternative
approach entails obtaining an obliquity
of approximately 45 degrees contralateral to the side of injection. Correct position is achieved when the needle tip is in
в– 15
FIGURE 4. Fluoroscopic AP (A) and lateral (B) images of caudal placement of needle and
injectate through the sacral notch.
FIGURE 5. (A) 3D CT reformation demonstrating the optimal approach (+) for an interlaminar
epidural injection at L4-5. The image is at approximately 5 degrees of cephalad and 5 degrees of
left angulation. (B) Fluoroscopic AP lumbar image of interlaminar placement of needle and injectate. (C) Fluoroscopic lateral lumbar image of interlaminar placement of needle and injectate.
the spinolaminar line (Figure 6). The
injectate is then directed upward by
turning the needle (with a curved tip or
side hole) cephalad.
The lumbar transforaminal approach
may require a steeper angulation of
approximately 30 degrees ipsilateral to
the entry site. A cephalad/reverse Ferguson tilt should be obtained until the endplates of the target level overlap (the
angle will be most severe at L5-S1 and
least at L2-L3). Optimal needle position
is in a �safe triangle’ bounded by the exiting nerve at its base with the sides made
up by the undersurface of the transverse
process and the lateral margin of the vertebral body (Figure 7). The target point is
underneath (i.e., 6 o’clock) the pedicle
(Figure 7). There is a posterolateral variation to the lumbar transforaminal
approach that places the needle more
medially and advances the needle until it
arrives at the posterior portion of the foramen on the lateral view.51 An S1 injection
involves only minimal ipsilateral obliquity and a 20-degrees-of-cephalad tilt of
the C-arm until the posterior and anterior
S1 foramina overlap. A lateral projection
is used to ensure that the needle is not
advanced too deeply beyond the sacrum.
Approach selection depends on the
location of disc pathology and the
nerves involved. A patient with subarticular or posterolateral impingement on a
nerve root (Figure 8) would benefit from
a transforaminal injection at that level or
the level below (as flow in the epidural
space is often preferentially cephalad,
along the nerve roots as they track back
to the thecal sac). A patient with a broadbased disc bulge may benefit more from
an interlaminar injection, although the
location of the injection must consider
that the epidural space may be located
either above or below the disc (Figure
9). In the postoperative spine where
laminectomy has removed the posterior
epidural space, transforaminal injections
or an approach above or below the surgical level may be necessary (Figure 10).
Foraminal herniations present a particular challenge. While they may be easily
accessed by the transforaminal route, the
narrowing of the foramen may make
such injections very painful (Figure 11).
Systematic reviews of foraminal injections as well as our own experience have
found marginal benefit over interlaminar injections in pain relief.4, 16
Needles for ESI
The type and size of needles available
for epidural injections vary considerably; there is little evidence to support
choosing one needle over another (Figure 12). There are curved and straight
needles. Among the straight variety, a
22-gauge spinal Quincke (end hole/
spinal) needle may be used in the lumbar
spine, while a 25-gauge needle may be
used in the cervical spine. Many operators prefer a 22-gauge Whitacre or
Pajunk (side-hole) needle in the cervical
spine; some use this needle in the lumbar spine, as well. A blunt-tip Whitacre
or Pajunk needle will require an introducer to penetrate the skin. A 1.5-inch,
18-gauge standard injection needle is
adequate for this purpose, although
some manufacturers make special introducer sheath/needle combinations. The
curved (Tuohy) needle is an alternative
to the straight needle. The use of a
curved needle requires a minimum of
22-gauge. Ultimately, the choice of needles depends on operator comfort.
Medication for ESI
The choice of injectate is operator
dependent, with many combinations
reported. The injectate consists of a contrast agent followed by local anesthesia
and a steroid. Some operators inject the
local anesthesia separately, followed by
the steroid, while others mix the two.
Contrast is used to verify epidural
location and to indicate the distribution of
injectate. Some physicians use contrast as
December 2010
FIGURE 6. Fluoroscopic 30-degree contralateral cervical oblique images of interlaminar placement of needle and injectate.
a volume expander while others prefer
saline for this use. The contrast is typically
non-ionic and low-osmolar. In patients
with contrast allergies gadolinium can be
safely used in most lumbar procedures.30,31,52,53 If using gadolinium, the
amount should be just enough to
document epidural injection. Gadolinium
should not be used as a substitute for volume expander. The typical amount of contrast or contrast-saline mixture used for
either cervical or lumbar interlaminar
epidurography is 4 cc to 5 cc (less in nerve
blocks; see below). A smaller amount will
not provide sufficient contrast for an
epidurogram to evaluate for adhesions or
distribution of injectate. For coding purposes, an epidurogram is considered to
have been performed when approximately 4 cc to 5 cc of contrast is injected
regardless of the route (transforaminal or
interlaminar). The report, CPT code, and
amount billed must be adjusted if an
epidurogram is not performed. The
amount of contrast injected may be
reduced in spinal stenosis. Many patients
will feel pressure or leg cramping from
almost any volume, no matter how small.
Patients undergoing first-time injections
may confuse this with pain. Careful questioning and reassurance that pressure is
normal will be adequate in most cases.
The injectate volume should be reduced if
significant pain is experienced.
The choice and amount of epidural
anesthetic agent is subjective. Lidocaine
1% and 2%; and Marcaine 0.25%, 0.5%
FIGURE 7. (A) 3D CT reformation demonstrating the optimal approach for a transforaminal
epidural injection/nerve block at L3-4. The image is at approximately 5 degrees of caudate and
35 degrees of left angulation. P=Pedicle; N=Nerve. The safe triangle where needle position is
desired (+) is created by the exiting nerve at the base (yellow line) with the sides (green lines)
made up by the undersurface of the transverse process and the lateral margin of the vertebral
body. Ideal position is underneath (i.e., 6 oКјclock) the pedicle within this triangle. (B) Fluoroscopic oblique image of lumbar transforaminal placement of needle and injectate. (C) Fluoroscopic AP image of lumbar transforaminal placement of needle and injectate.
and 1% have all been used. The epidural
anesthetic agent should not contain epinephrine. Marcaine will have a stronger
effect than lidocaine. While lidocaine is
FDA-approved for use in the epidural
and intrathecal space, Marcaine is used
off label for this purpose. Generally, the
stronger the local anesthesia, the greater
the chance the patient will have difficulty
ambulating and may fall after a procedure. The use of Marcaine is generally
less prevalent in the literature 6,23-25,30,
and there have been no studies on the
use of Marcaine in ESIs. Regardless of
the type of epidural anesthetic agent, all
patients receiving such an agent can not
drive themselves immediately after the
procedure to avoid the potential of foot
drop while driving. Patients who do not
have an accompanying driver should
be kept in the office for 60 minutes to
120 minutes.
In the author’s practice 3 cc to 4 cc of
lidocaine 1% is used. In cases where
injectate volume must be reduced (due to
spinal stenosis) but a full anesthetic effect
is still desired, 2 cc of lidocaine 2% may
be an alternative (injectate amounts for
nerve block are reduced). Evaluating the
patient’s response to the anesthetic agent
while the patient is still monitored in the
suite may indicate whether the injection
correctly targeted the pain generator.
Many operators do not use epidural anesthetic agents in the cervical spine due to
the risk of anesthesia in the C3, C4 and
C5 regions of the cord responsible for
diaphragmatic function. These areas, if
anesthetized, may cause diaphragmatic
paralysis and respiratory arrest.
Of the several steroid preparations
available, Dexamethasone sodium phosphate (DecadronВ®, Sicor Pharmaceuticals
Inc, Irvine, CA) is the only steroid FDAapproved for intravenous use. In theory, it
would be the safest in case of accidental
intravenous administration. However,
due to the short-acting nature of dexamethasone, it has not gained widespread
use in pain management as evidenced by
the fact that there have been very few
reports on its effects as compared with
other preparations.54 Of the longer-acting
preparations, the most soluble and least
particulate is Betamethasone sodium
phosphate (Celestone SoluspanВ®, Schering, Kenilworth, NJ). 6 mg of Betamethasone is equivalent to 0.75 of Dexamethasone. It will not elicit the arachnoiditis
that may occur with other steroids in the
event of accidental intrathecal injection.55,56 The greater solubility of Celestone compared to other preparations
results in a lower chance of embolism in
the event of accidental intravascular
administration.57 Typically, 12 mg of
Celestone is used (less in nerve blocks;
see below). In vitro data also show that
more soluble steroids (such as Decadron
and Celestone) are safer than particulate
December 2010
FIGURE 8. (A) T2 axial image showing a right posterolateral disc herniation impinging on the
S1 nerve root (arrow). (B) Fluoroscopic PA image of a S1 transforaminal epidural injection
with delivery of injectate to the S1 nerve root sleeve.
FIGURE 10. T1 sagittal image showing a
disrupted epidural space subsequent to
surgery (arrows).
FIGURE 9. T1 sagittal image showing different configurations of the L5-S1 epidural space.
Depending on the location of pathology, the level of injection may need to be adjusted. (A) at
the level of the disc (arrow). (B) below the level of the disc (arrow). (C) no epidural space seen.
steroids (Depo-MedrolВ® and KenalogВ®)
in the cervical spine.58
Other steroid preparations are methylprednisolone acetate (Depo-Medrol,
Pfizer, New York, NY) and triamcinolone
acetonide (Kenalog, Bristol-Myers
Squibb, Princeton, NJ). A typical dose is
80 mg for both (less in nerve blocks; see
below) which is equivalent to 12 mg of
betamethasone. Depo-Medrol and Kenalog are semi-particulate solutions that are
less soluble than Celestone and, therefore, theoretically may have poorer
spread in the epidural space. DepoMedrol is available as an 80-mg preparation that may be helpful if the injectate
volume must be reduced due to spinal
stenosis. There have been reports of
arachnoiditis due to the neurotoxic polyethylene glycol component of methylprednisolone acetate.56,58-60 There has
been a report of Kenalog crystals found in
the epidural space at surgery in patients
with recent ESIs.61
December 2010
The literature is conflicting as to
whether Kenalog or Celestone is better
for pain relief,62,63 with some suggesting that the crystallization of Kenalog
provides better long-term benefit62 and
others noting that the soluble properties
of Celestone provide quicker onset of
action.63 It is important for both the
operator and patient to understand that
the steroid may take up to 3 days to
begin providing symptomatic relief.
Nerve block injections
Rationale and patient selection
Nerve blocks may be performed as
part of the work-up for potential
surgery as both diagnostic and therapeutic procedures. There is no agreement in the literature on what defines a
positive nerve block result or “good”
pain relief. Smaller volumes are used
in nerve blocks to limit the effect to
only one nerve. Patients may have a
single- or multiple-level nerve block.
FIGURE 11. T1 sagittal image showing a
foraminal herniation at L3-4 (arrow) and displacing/compressing the nerve root. Attempted
transforaminal injection at this level may cause
severe pain. The operator may reduce the
injection volume and inject very slowly.
Multiple blocks may be performed at
the same session or sequentially (but
still on the same day) until the pain
generator is found. When these are performed sequentially, the patient is
brought into the procedure suite for the
first block. Thereafter they are monitored in an observation area for
approximately 30 minutes where their
response to the anesthetic agent is
assessed. If the patient experiences less
than approximately 80% relief, then
the next nerve level is treated (on the
same day), and so on. Once approximately 80% relief is obtained, no further injections are needed as the patient
will not be able to distinguish further
в– 19
FIGURE 12. Representations of the three most commonly used needles showing the side
hole Whitacre needle with a semi-blunt tip, the Quincke needle (referred to by many as a
spinal needle) and the curved Tuohy (images courtesy of BD needles
– reprinted with permission).
FIGURE 15. Axial prone CT image of a
guided facet injection showing a needle
(arrows) in the left facet joint with contrast
(asterisk) opacifying the joint and a synovial
cyst (arrowhead).
FIGURE 13. Fluoroscopic oblique (A) and AP (B) images of cervical placement of needle for
nerve block.
FIGURE 16. Fluoroscopic image of a medial
branch block showing needle at the location
of the medial branch at L5-S1.
FIGURE 14. Photograph of a spine replica showing the different anatomical orientation of a
needle inserted intra-articularly at the L5-S1 (A) and L2-3 (B) facets.
relief. If a total of approximately 80%
pain relief is not attained, another source
of pain should be considered. Bilateral
blocks can be performed, but care
should be taken as the patient may have
difficulty ambulating after these injections. For this reason some operators do
not perform bilateral nerve blocks on the
same day.
Nerve block technique,
medication, and needles
Injectate consists of 1 cc of a contrast
agent, a half-dose of steroid compared
to the ESIs above and 1 cc of lidocaine
2%. Broadly speaking, the technique for
lumbar nerve root injection is similar to
the transforaminal injection. Some variation exists in the lumbar approach;
some operators may attempt to position
the needle tip more laterally compared
with a transforaminal ESIs to prevent
reflux into the epidural space. Cervical
extraforaminal nerve root blocks may
be performed safely with correct technique:26,27 The C-arm is tilted approximately 20 degrees to 30 degrees
ipsilateral to the side of choice, with the
target point at the junction of the middle
and lateral third of the articular pillar
just below the foramen of the nerve root
to be treated (Figure 13).
December 2010
FIGURE 17. Flow chart demonstrating the diagnosis and therapeutic intervention of a typical patient with back pain.
Facet injections
Rationale and patient selection
Facet pain often overlaps disc pain and
may co-exist with disc disease. Facets are
synovial joints and, therefore, they can be
affected by arthritis in a fashion similar to
other synovial joints (e.g., the knee, hip,
etc.). Symptoms include pain in the
paraspinal region, buttocks, thigh or
shoulder in cervical spine; pain worsened
on hyperextension following flexion and
pain accompanied by paraspinal tenderness. Age, a prior history of low back
pain, abnormal gait, absence of leg pain,
muscle spasms, and aggravation of pain
on valsalva may indicate pain with its origin in the facet joint.63
Medial branch block injections are
often directed at groups of facets. There is
a known placebo effect with single
blocks64-66 and therefore, prior to surgery
or rhizotomy a patient should have two
successful (80% relief) blocks.64-66 The
decision on whether to perform an intraarticular injection or medial branch facet
nerve block depends on several factors:
December 2010
Medial branch blocks are more useful in
patients who are candidates for rhizotomy, where uncertainty exists over the
origin of back pain and in those where the
facets are so overgrown and deformed by
osteophytes that intra-articular injection
is not possible.67-70 In the cervical spine,
intra-articular injections have shown little
efficacy whereas medial branch blocks
have shown benefits.14
Radiologic guidance (fluoroscopy or
CT) is essential, as facets at different
levels have different orientations (Figures 14, 15). As little as 1 cc of injectate
can rupture a non-diseased facet capsule.71 Studies have postulated that
facet capsule rupture is associated with
increased pain relief possibly due to
injectate bathing the medial ramus
feeding the facet and spreading to the
epidural space.67,68,71 Despite the presumed benefits of extracapsular spread
of injectate, initial needle placement
within the facet joint provides better
pain relief than extracapsular injection.68 There is a dual innervation to
each lumbar facet joint. Each facet is
innervated by the medial branches of
the posterior rami of the spinal nerves
above and below the joint. Thus, the
L4-L5 facet is innervated by the L5
medial branch (coursing over the L5
transverse process) and the L4 medial
branch (coursing over the L4 transverse
process). An exception to this rule is
the C2-C3 facet joint, which is innervated by the third occipital nerve and
the C1 medial branch that courses
superolaterally to the C1 foramen. The
medial branch of levels other than C2C3 and S1 is approached by tilting the
C-arm at approximately 20 degrees
ipsilateral to the nerve in question (Figure 16) and aiming for the junction of
the transverse process and the superior
articulating process (i.e., the ear and
nose of the “Scotty-dog”). Medications
and needles for medial branch blocks are
similar to those described for nerve
blocks. In all cases contrast (В±0.5cc)
в– 21
should be injected to exclude a vascular
injection and, in intra-articular injections, to perform a facet arthrogram (if
this is not performed, the report and CPT
charge should be adjusted). This is then
followed with a 1:1 steroid/local anesthetic mix at half the volume of a nerve
block (i.e., the total steroid/steroid/local
anesthetic volume should be approximately 1 cc). Many operators will use 20
mg Depo-Medrol per facet joint injection as Depo-Medrol is FDA-approved
for joint injections and there is little risk
of intrathecal injection. For similar reasons, either Marcaine or lidocaine may
be used in facet injections. Some operators only use medial branch blocks as a
diagnostic technique, in which case no
steroid is injected.
Basic pain management procedures
benefit patients who are both operative
and non-operative candidates as determined by clinical parameters and
imaging (Figure 17). In those patients
who are not operative candidates,
spinal injections can help identify anterior column (disc herniations and
degeneration) versus posterior column
(facet) disease. Minimally invasive
techniques can produce long-term
relief. In patients who are operative
candidates, pain-relieving injections
can assist in identifying the level of
surgery in multilevel disease and temporizing pain while the patient awaits
surgical scheduling.
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