SPINAL INFILTRATIONS
UNDER
RADIOLOGIC GUIDANCE
M. Ben Hamouda, N.Zamali, C. Drissi, K.Walha,
N. Hammami, R.Sebai, S. Nagi (Tunisia)
DEPARTMENT OF NEURO-RADIOLOGY
NATIONAL INSTITUTE OF NEUROLOGY
TUNIS
SESSION : PAIRS – Spine Interventional- 25-26th
April 2012 TUNISIA
Purpose
• How to do spinal infiltrations safely?
• To review the neurological complications
described by some authors.
INTRODUCTION
• Procedures are now well codified and
secure
• Only very few randomized-controlled
studies
• Strong professional consensus
INTRODUCTION
Clinical signs and radiologic appearance in
accordance
TECHNICAL ASPECTS
• Fluoroscopy+++, CT
TECHNICAL ASPECTS
• Corticosteroids (CS) :
– Moderated long acting CS: Hydrocortancyl® (prednisolone
acetate), Dectancyl® (Dexaméthasone acétate), Depomedrol®
(Methylprednisolone acetate).
– Long acting CS: Altim®
• Anaesthesics : Xylocaïne 1%®
– Local anaesthesia, Block test.
– With CS in foraminal, zygapohseal lumbar infiltration
– No in cervical
• Spinal needles: 20-22 G
CERVICAL FORAMINAL
INFILTRATIONS
• Foraminal infiltration
• C1-C2 latéral joint infiltration
CERVICAL FORAMINAL
INFILTRATIONS
* Indications :
Persistant cervical radicular pain
- disk herniation
- Foraminal degenerative stenosis
( disk bulging, hypertrophic osteoarthritis of
the zygapophyseal joint, or an osteophytic ridge of the posterior vertebral body)
*Iatrogenic risk
(proximity of spinal cord and vertebral and vertebral
arteries )
Importance of the anatomy
CERVICAL FORAMINAL
INFILTRATIONS
MORVAN
CERVICAL FORAMINAL
INFILTRATIONS
CERVICAL FORAMINAL
INFILTRATIONS
CERVICAL FORAMINAL
INFILTRATIONS
CERVICAL FORAMINAL
INFILTRATIONS
Efficiency
MATHIEU (GETROA,2000) (18 patients)
neck cast (VAS-4) >>> without neck cast (VAS-1,4)
uncarthrosis (VAS-4,6) / DH (VAS-3,2)
D. KRAUSE (JNR,2002) (75 patients)
Efficiency 75% (56/75) 1 year
CYTEVAL (AJNR,2004) (30 patients)
Effectiveness 60%
No predective factor
R. KRAUSE, Loffroy (JFR 2008) (300 patients)
Efficiency 63.7 % (1-14 days)
CERVICAL FORAMINAL
INFILTRATION
Complications
• Vaso-vagal reaction
• Isolated cases :
– Medullar injury
– Vertebral artery injury
– Cerebellar/medullar/brain stem infarcts (microaggregate of corticosteroids)
Steroid injection of the cervical
spine Complications
• In the literature, 3 cases of tetraplegia following a foraminal epidural
steroid injections reported: related to arterial injection of corticosteroid
into a radiculomedullary artery with subsequent occlusion.
• Tiso et al. [spinee.2003 ] reported a case of cerebellar infarction after a
C6 foraminal Cervical epidural steroid injections: intra-vascular
injection of particulate steroid resulting in embolic occlusion through
the vertebral artery with subsequent infarction was postulated as the
cause.
• 2 cases of Epidural hematoma after fluoroscopically guided
interlaminar Cervical epidural steroid injections has been reported:
Puncturing of the epidural venous plexus is the probable etiology.
INFILTRATION OF C1-C2
LATERAL JOINTS
Invalidant inflammatory and
degenerative C1-C2 arthritis
INFILTRATION OF C1-C2
LATERAL JOINTS
MORVAN
INFILTRATION OF C1-C2
LATERAL JOINTS
INFILTRATION OF C1-C2
LATERAL JOINTS
Efficiency
• GLEMAREC (2000) : 26 patients
– Efficiency 63%
– Rheumatoid artritis>Osteo arthritis
CERVICAL ZYGAPOPHYSEAL
JOINT INFILTRATION
Indications:
Degenerative arthritis:
- osteo-radicular conflict
- segmental instability
Best performed under CT.
LUMBAR INFILTRATIONS
TECHNICAL ASPECTS
• Direct posterior approach +++
LUMBAR INFILTRATIONS
TECHNICAL ASPECTS
• Postero-lateral approach
EPIDURAL
INFILTRATION
• Can be well done by physicians
( inaccurate needle placement in 25-30 % )
• Fluoroscopic guidance
• Indications : persistant radicular lumbar pain in disk
herniation & spinal canal stenosis
– Technical difficulties (scoliosis)
– Failure of blinded epidural infiltration
EPIDURAL INFILTRATION
UNDER FLUOROSCOPIC GUIDANCE
EPIDURAL INFILTRATION
UNDER FLUOROSCOPIC GUIDANCE
EPIDURAL INFILTRATION
UNDER FLUOROSCOPIC GUIDANCE
EFFICIENCY
• Wilfred Peh (Biomed Imaging Interv J. 2011)
- short-term relief : 42 to 92 %.
- long-term relief : 18% to 62%.
: literature review:
FORAMINAL
OR PERIRADICULAR
INFILTRATION
• Always radio guided
• Indications:
– Foraminal lumbar disk herniation
– Foraminal stenosis (disk bulging, hypertrophic
osteoarthritis of the zygapophyseal joint, facet subluxation, ligamentum
flavum hypertrophy )
– Postero lateral lumbar disk herniation
– Radicular pain post diskectomy
– Isthmic spondylolisthesis
FORAMINAL INFILTRATION
FORAMINAL
INFILTRATION
11% intravenous injections
FORAMINAL INFILTRATION
Efficiency
•
•
•
•
•
DEBIE (1995) 52 Patients = 77%
WEINER (1997) 30 Patients = 80%
VITON (1998) 4 0 Patients = 50%
VAD (2002) 48 Patients (randomized study) = 84
CYTEVAL (AJNR,2006) 229 Patients : 41%
Duration of symptoms : only predective factor (18 months)
The age of the patients, cause of pain, conflict location,
and pain intensity graded byVAS were not predictive factors
• LEE (AJNR,2007) 108 patients : 70%
Better efficiency: foraminal lumbar stenosis
foraminal lumbar herniation
ZYGAPOPHYSEAL JOINT
INFILTRATION
Radio guidance Indications
• Diagnostic test
• Degenerative arthritis: (osteo-radicular conflict,
articular synovitis on arthrosic arthropathy, Segmental
instability)
• Synovial cyst:
Possibility of calcifications with Altim®
ZYGAPOPHYSEAL JOINT
INFILTRATION
ZYGAPOPHYSEAL JOINT
INFILTRATION
A.Chevrot
ZYGAPOPHYSEAL JOINT
INFILTRATION
ZYGAPOPHYSEAL JOINT
INFILTRATION
• GOUPILLE (Rev Rhum,1993) 206 patients
76% (Short and midlle term)
54% (long term)
• Berger (J Radiol 1999), Bush (Eur Spine 1996), Mathieu (Sauramps
médical Ed 2000), Vallée (Radiology 2001): 60% good results.
Reproduction of symptomatic pain during the
procedure does not seem to have predictive value
for clinical outcome (Vallee JN, RADIOLOGY).
Steroid injection of the lumbar spine
Complications
• Literature research:
- 5948 study titles were checked
- 12 published cases of paraplegia following
foraminal steroid injection of the lumbar
spine were found (5 french).
• Some complications may remain unreported
• The foraminal route was the only one
involved in nonoperated patients (4/12),
while foraminal, interlaminar, or juxtazygoapophyseal routes are a risk in patients
with a history of lumbar spine surgery
(8/12).
• High rate of operated-on patients
the
presence of epidural scar tissue increases
the risk.
• High rate of French cases when compared
to literature review
might arise from the
almost exclusive use of prednisolone acetate
(molecule with a high tendency to coalesce in macroaggregates, putting the spinal cord at risk of arterial supply
embolization).
• As each lumbar radiculomedullary artery runs along the
corresponding spinal nerve root, usually on the anterior
aspect of its dural sheat, it may be hypothesized that the
needle sometimes penetrates or injures the artery,
especially if both share an almost parallel orientation
within the narrow space of the foramen.
• Compression, vasospasm, dissection and intravascular
thrombosis may result from arterial injury.
• Intra arterial injection of prednisolone acétate
(embolization) or after injection of lidocaine only
(vasoconstriction , IA toxicity).
To avoid risk of paraplegia
• Injection of Altim® foraminal infiltration(
Hydrocortancyl: direct toxicity on vascular
structures).
• Needle: > 22G.
• Anatomy (injection of contrast ): +++
• Avoid the epidural scar tissue.
• Image-guided selective particulate steroid injections of the
lumbar spine carry a minimal, however inestimable, risk of
sudden-onset paraplegia.
• Finally, before undergoing a selective steroid injection of
the lumbar spine, patients should be warned of the risk of
paraplegia if the foraminal approach is still proposed. This
warning should be extended to the interlaminar and the
juxta-zygoapophyseal approaches in operated-on patients.
CONCLUSION
• Spinal infiltrations are the last step in the medical treatment
before surgery.
• Radioguidance is obligatory in cervical and
lumbar peri-radicular infiltrations
• Procedures are now well codified and secure.
•
Few reported complications should not challenge the use of this
technique.
THANKS