spinal injections and a rational approach to treating low ... · spinal injections and a rational...

1

Spinal Injections and A

Rational Approach to Treating

Low Back Pain

Pietro A. Memmo, MD

Interventional Physiatrist

Orthopedic Associates of

Hartford

Conflicts of Interest

⚫ Dr. Memmo does not have any financial or

non-financial conflicts of interest or

relationships to disclose, and I will not be

discussing products in my presentation.

Dr. Memmo’s CV

⚫ Philosophy (St. Charles Seminary)

⚫ Pre-Med (Columbia University)

⚫ Medical School (Albert Einstein College)

⚫ Internship/Medicine (Columbia

Presbyterian Medical Center)

⚫ Physical Medicine (UMDMJ/Kessler)

⚫ Fellowship: Spine/Pain (Beth Israel)

1

2

3

CCSU Sports Medicine Symposium - Tuesday March 3, 2020

2

Our Goal

- “Diagnosis”

- “Prognosis”

- “Treatment Plan”

Physiatrist Philosophy

⚫ Getting Patients Functional and Back to

Work or Sporting Activity…..

⚫ …Safely

⚫ ….Reasonably

⚫ ….Incrementally

Two Categories of Spine Pain

⚫ Mechanical Pain

⚫ Neuropathic Pain

4

5

6


3

Mechanical Low Back Pain

⚫ Discogenic

– DDD

– Annular Tear

⚫ Facet Mediated

⚫ SIJ

Neuropathic Pain

⚫ Radiculopathy: Radiating arm or leg pain

– Disc Herniation

– Spinal Stenosis

⚫ What can present like a Radiculopathy

– Sacroiliac Joint

– Annular Tear

Anatomy

7

8

9


4

Anatomy

Anatomy

Anatomy-Disc Herniation

10

11

12


5

The Jelly Donut

So how do you decide on

source of the pain?⚫ Physical exam

– Inspection- Atrophy/ Scoliosis

– Lumbar spine ROM/pain

– Palpation

– Sensory exam

– Motor exam

– Reflexes

– Provocative maneuvers

So how do you decide on

source of the pain?

⚫ Radiologic studies

– X-ray- good for arthritis and bony lesions (if

evidence of instability, check flex/ext)

– CT scan- good for bony lesions/ not so good for

soft tissue

– MRI- good for soft tissue

– Bone scan- good to determine if fractures are

acute as well as bony lesions

13

14

15


6

Pain Treatments

⚫ Do Nothing

⚫ Physical Therapy

⚫ Medications

⚫ Injections

⚫ Surgery

Pain Treatments

⚫ Physical Therapy

– Goals include:

⚫ Lumbar stabilization

⚫ Lower extremity stretching & strengthening

⚫ Pain relief / modalities

⚫ Assistive devices

Pain Treatments

⚫ Medications

– NSAID’s

– Muscle Relaxers

– Pure Pain Medicines

– Oral Steroids

– Anti-epileptics / Anti-depressants

16

17

18


7

Injections – Epidural Steroids

⚫ Benefits of epidural steroids

– Due to presence of arachnoid villi in epidural

space => steroids directly bathe the nerve roots

– May block “C-fiber” conduction

Saal, Spine 1990/ Odonnel, Spine

1988/ Takahashi, Spine, 1996


⚫ Benefits of epidural steroids

– Studies have shown that radicular pain may be

caused by inflammatory mediators (not just

mechanical compression)

– Steroids inhibit the synthesis/ release of pro-

inflammatory cascade and therefore decrease

inflammation


⚫ Controversy

– No evidence to support that steroids alter the

rate of disc regression.

19

20

21


8


⚫ Small but not significant difference in favor

of Discectomy versus Conservative care

(Jama 2006)

⚫ No statistical difference between surgery

and non-operative treatment of disc

herniation (Clin Orthop Relat Res, 2015)


⚫ Decreasing patient’s pain

⚫ Allows body to heal

⚫ Allows patient to do physical therapy better

=> helps prevent recurrences

⚫ Maximum of 3 epidural injections in a 12

month period of time.

Fluoroscopy

⚫ Fluoroscope vs. no fluoroscope

- Blind interlaminar injections are in the wrong

place 13-30% of the time without fluoroscopy and

contrast (Andrade, ISIS newsletter,1993, Mehta,

Anesthesia 1985).

- Transforaminal injections not possible without

fluoroscopy.

22

23

24


9

Fluoroscopy

⚫ Advantages of fluoroscope

– Increase safety of procedure

– Ensures accuracy of procedure

– Documents procedure for future reference

– Decreases patient’s pain (more comfortable

positioning)

Fluoroscopy

⚫ Disadvantage of fluoroscope

– Slight exposure to radiation

– Equipment cost

Three ESI Techniques

- Interlaminar (Traditional)

– Transforaminal (“Selective nerve root block”).

Transforaminal ESIs are better for paramedian

and foraminal disc herniations (Turk

NeuroSurg, 2019)

– Caudal

25

26

27


10

Injections - Interlaminar

– A Tuohey needle is advanced under direct

fluoroscopic guidance until the ligamentum

flavum is encountered.

– A lateral view is checked and then the needle is

advanced into the epidural space using the ‘loss

of resistance’ technique.

28

29

30


11

31

32

33


12

Injections - Transforaminal

⚫ Pros

– Very Specific- gets

medicine anteriorly

– Very Effective for

radicular pain

– Smaller needle size /

Less pain

⚫ Cons

– Technical

– Need Fluoroscopy

– ? Not as effective for

back pain

– Risk of nerve damage

due to vascular injury

34

35

36


13

37

38

39


14

Injections - Caudal

⚫ A 22 gauge needle is guided through the

sacral hiatus which lies between the sacral

cornu and advanced until it reaches the S2

level.

⚫ Usually requires higher volumes (10-20 cc)

40

41

42


15

Caudal

Caudal

Injections- ? Which Approach

⚫ For leg pain > back pain = transforaminal

⚫ For back pain > leg pain = interlaminar

⚫ For post surgical = transforaminal vs.

caudal

43

44

45


16

Joint Injections

– Facet Joints aka Zygapophyseal joints (Medial

Branch Block & Radiofrequency Lesioning)

– Sacroiliac Joints

Facet Joints

⚫ Z-joints are responsible for prevention ofanterior/posterior translation of the spine aswell as lateral.

⚫ They are a true joint with articular cartilageand a fibrous capsule.

⚫ Can be affected by RA ,OA , AS

⚫ May be related to prior spinal fusion/degenerative changes

Anatomy

46

47

48


17

Facet (Zygapophysial) Joints

⚫ Cause pain in 10-20% LBP patients

⚫ Symptoms are low back pain/ buttock pain

⚫ Should not radiate past the knee

⚫ Worse with extension

⚫ Better with flexion

49

50

51


18

Injections- Facet Joints

⚫ The joint is innervated by the medial branch

of the dorsal rami at the level of the joint

and the one above.

Injections- Facet joints

⚫ Intrarticular joint injection with steroid/

anesthetic.

– Simple

– Low risk

– May give long term relief

– Can be diagnostic

Injections- Facet Joints

⚫ Medial branch blocks

– Diagnostic only (just anesthetic)

– Block the nerves innervating the joint you are

suspecting. (2 levels for each joint)

– If patient gets relief then can send for

radiofrequency ablation of suspected nerves.

52

53

54


19

Medial Branch Blocks

MBB-Contrast

MBB-Lateral Image

55

56

57


20

Radio-Frequency Ablation of

the Medial Branch Nerves

– Use a nerve stimulator attached to a probe to

find the median braches.

– The probe also has a small heating element to

cauterize the nerve via an electrical current.

– As long as you know where you need to be

with the probe low risk.

– Need RF machine and probes.

RF-AP View

RF-Oblique View

58

59

60


21

RF-Lateral View

Sacroiliac Joint Dysfunction

⚫ True joint

⚫ Should be minimal movement

⚫ Covered by extensive ligamentous structure

Sacroiliac Joint Dysfunction

⚫ Unilateral LBP

⚫ 10-15% of chronic low back pain

⚫ Can radiate to hamstring area, lateral thigh or

groin

⚫ Worse with activity/standing

⚫ Better with rest

⚫ Can related to trauma

⚫ L5-S1 disc may mimic symptoms

61

62

63


22

SIJ

SIJ Injection

SIJ-Contrast Flow

64

65

66


23

Treatments- Surgery

⚫ Bowel or bladder changes (cauda equina)

⚫ Progressive weakness

⚫ Progressive/ unremitting pain

References

⚫ Study Protocol-Lumbar Epidural Steroid Corticosteroid Injection: A

double blind, randomized controlled study of epidural steroid

injections for Lumbar stenosis among older adults. Friedly et al.,

BMC Mucsculskel Disorder (2012 Mar 29. 13:48.

⚫ What are the long term predictors of outcomes for lumbar disc

herniation? A randomized and observational study. Keur et al. Clin

Orthop Relat Res. 2015 Jun. 473 (6):1920-30.

⚫ Transforaminal Epidural Steroid injections in the treatment of pain in

foraminal and paramedian lumbar disc herniations. Guch B, et al.

Turk Neurosurgery, 2019 Sept 17.

References

⚫ Which variables are associated with patient reported outcomes after

discectomy? A review of SPORT disc herniatons. Koerner JD. Clin

Orthop Relat Res. 2015 June. 473(6): 1200-6.

⚫ Systemic review of outcomes following 10 year mark of Spine Patient

Outcome Research Trial (SPORT) for intervertebral disc herniations.

Oster BA, et al., Spine (Phila, PA, 1976) 2020 Jan 30.

⚫ Surgical versus non-operative treatment for lumbar disc herniations:

The SPORT observation cohort. Weinstein JN et al, Jama 2006, Nov

22. 296 (20).

67

68

69


24

References

⚫ The effectiveness of Radiofrequency ablation of medial branch nerves

for chronic lumbar facet joint syndrome in patients selected by

guidelines-concordant dual comparative medial branch blocks. Conger

A, et al. Pain Med. 2019 Oct 14.

Thank You

70

71
