SPINAL INFILTRATIONSUNDER

RADIOLOGIC GUIDANCE

M. Ben Hamouda, N.Zamali, C. Drissi, K.Walha,

N. Hammami, R.Sebai, S. Nagi (Tunisia)

DEPARTMENT OF NEURO-RADIOLOGYNATIONAL 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 factorR. 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 (micro-

aggregate 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

Efficiency• GLEMAREC (2000) : 26 patients

– Efficiency 63%

– Rheumatoid artritis>Osteo arthritis

INFILTRATION OF C1-C2 LATERAL JOINTS

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) : literature review:

- short-term relief : 42 to 92 %.

- long-term relief : 18% to 62%.

FORAMINALOR 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

FORAMINALINFILTRATION

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 juxta-zygoapophyseal 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 macro-aggregates, 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