1. Image Guided Epidural for Back Pain
Dr. Amr Abdelfatah M.D.
Dep. of Anesthesia, Intensive Care medicine & Pain Management
Ain Shams University, EGYPT

2. Image Guided Epidural Intervention
Interventional Injections
Interventional Implants

3. Interventional Epidural Injections
Interlaminar Epidural
Transforaminal Epidural
Caudal (sacral ) Epidural

4. Imaging Guidance: Is efficacy improved?

5. Imaging Guidance: Is efficacy improved?
LOR to identify lumbar epidural space, was too superficial in 17% of cases.
Inconsistent LOR in Adhesions & fibrosis
(Mehta M, Salmon N. Anaesthesia. 40:1009–1012, ).
Fluoro.: Reduces technical failures & difficulties with ESI up to 60%.
(Manchikanti L, et al Anesth Analg 89:1330–1331, 1999).

6. Imaging Guidance: Is efficacy improved?
Blind caudal for ESI :
48% incorrect by trainee
15 % experienced hands
9.2% i.v. injection.
(Renfrew DL, et al. Am J Neuroradiol 12:1003–1007, 1991.)
Fluoro.: 91% - 97% success on first attempt on caudal ESI
(Stitz M, et al. Spine, 24:1371–1376, 1999).

8. Needle and pathology location
Blind Cervical ESIs:
53% false LOR on 1st trail
unilateral spread in 51%
ventral spread in 28%
(Stojanovic MP, et al. Spine 27:509–514, 2002)
Better viewing for contrast spread.
Needle and pathology location

9. Imaging Guidance: Is efficacy improved?
Success rate increased in BMI > 30 vs. BMI <30
(Price CM, et al: Ann Rheum Dis 2000;59:879–882)
Previous back surgery and fixation

10. Indications Tissue irritation and inflammation HNP
Nerve root irritation (Lumbosacral radiculopathy)
Previous back surgery
Post spinal fixation
Spinal canal stenosis.
Spondylolisthesis & degerative disc disease !!

11. Interventional Injection
Steroids
Betamethasone, methylprednisolone, triamsinolone
Particle size counts
Local anesthetics
Adjunctive:
Hypertonic saline
Clonidine
Opioids
Ziconotoid

12. Lumbar Epidural Steroids
Interlaminar vs Transforaminal Injections ?!

13. Interlaminar vs Transforaminal Injections
Rhee and colleagues:
 TFESI:
46% reduction in pain score
10% required surgery.
Interlaminar injections:
19% reduction in pain score
25% required surgery.
(Rhee Jm, et al.  J Bone Joint Surg Am.  2006)

14. Improvement was 70% of pt. in TFESI compared to 45% in interlaminar group.
(Schaufele MK; et al: Pain physician , 2006)
5 yrs follow up post-TFESI : (81%) studied population didn’t approach for surgery
(Riew KD et al. . J Bone Joint Surg Am.  2006).

15. Interlaminar vs Transforaminal Injections
Depositing steroids in the anterior epidural space as only 28% ventral epidural spread of dye with interlaminar route (Stojanovic MP, et al. Spine, 2002).
Systematic review on TFESI confirmed its efficacy over interlaminar approach.
(Buenaventura RM, et al. Pain Physician. Jan-Feb 2009)

16. Conclusions. In the current study, neither transforaminal
Clark C. Smith, MD,* Thomas Booker, MD,§
Michael K. Schaufele, MD,*† and P. Weiss, MS‡
Departments of *Rehabilitation Medicine,
†Orthopedics and ‡Biostatistics, Emory University, Atlanta, Georgia;
§Crystal Run Healthcare LLP, Middletown, New York, USA
Conclusions. In the current study, neither transforaminal
nor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions when compared with each other.

17. Fluoroscopy guided TFESI

18. Artery of Adamkiewicz (supplies lumbosacral enlargement )
Radicular artery close to sup.& middle portion of the foramen.
Risk of paraplegia esp. with particulate steroids
Dexamethasone and betamethasone are better choices, particles <50 µm
(Christopher WA review: Current Rev. Musculoskelet Med 2009).

19. A detailed photograph shows the anterior spinal canal branches lying anterior to the emerging lumbar nerve root at the intervertebral foramen, together with the ascending anterior and posterior nerve root branches (neural branches) of the lumbar artery. Reprinted with permission from Crock et al. The blood supply of the vertebral column and spinal cord Fig. 3. Course of artery of Adamkiewicz (red) and its feeding in man. RR Donnelly & Sons, Chicago, 1977 (32).t

20. Needle Tip Position ? Safe Triangle Kambin’s Triangle Post. Inferior
anterior-superior
Kambin’s Triangle
Post. Inferior

21. So Image & contrast prior to injection
Paraplegia Following Image-Guided Transforaminal Lumbar Spine Epidural Steroid Injection: Two Case University of Florida College of Medicine
(David J, et al. Pain Medicine, 10: 1389–1394)
So Image & contrast prior to injection

22. 0.2 LAO
0.00 CRA
AP projection

23. 20-30 degree lateral projection
Scotty Dog
20-30 degree lateral projection

24. L4
Spinal 22G L5

26. L4 L5
Lat. projection

29. Omnipaq contrast in Ant. Epidural Space

30. Anteroposterior fluoroscopic view showing the
Omnipaq outlining the nerve root and diffusing through the intervertebral
foramina into the epidural space

31. Anteroposterior fluoroscopic view showing the
Omnipaq outlining the nerve root and diffusing into the intervertebral
foramina into the epidural space

32. Anteroposterior fluoroscopic view showing the
Omnipaq outlining the nerve root and diffusing into the intervertebral
foramina into the epidural space

34. L5 S1

35. L5

36. L5

38. Caudal(Sacral) Epidural Adhesolysis

39. Fluoroscopic guided Caudal
previous laminectomy
Post-Spine fixation
Dural Adhesion & fibrosis (LOR)
Epidural in high BMI
Normal epidurogram

40. Faulty Subcut. Injection
Correct Needle placement

41. RACZ Catheter Dr. Gabor Racz scar tissue entrapping nerves
Flex tip & Steering end
L.A + Steroids hyaluronidases
3%, 7%, 10 % NaCl
RACZ Catheter

42. Caudal Adhesolysis RACZ cath. Through Tuohy needle
Touhy needle through Sacral hiatus

43. OMNIPAQ WITH
FILLING DEFECT

44. Hazards of Caudal Adhesolysis
Hypertonic saline injected into the SCF
cardiac arrhythmias
Myelopathy
Paralysis & loss of sphincter control
So Image & contrast prior to injection
Cord compression, hematoma, bleeding, infection, dural puncture.
A Retained Racz® Catheter Fragment After Epidural adhesolysis : Implications During Magnetic Resonance Imaging.
(William J. Perkins, et al. Anesth Analg 2003;96:1717–9)

45. Interventional Implants
Spinal Cord Stimulator
Drug delivery system

46. Spinal Cord Stimulator

47. SCS Melzack and Wall gate control theory in 1965
Pulsed electrical stimulation for the dorsal column
(large fibers stim. can signal hyperalgesia ?!)
Neurochemical alteration
Non-pharmacological method
Failed back surgery
Neuropathic pain , CRPS
Ischemic limb
Intractable anginal pain
In the epidural space since 1967.

48. Image guided for cord level determination.
Dermatomal level representation in the dorsal columns is higher than the corresponding vertebral level (e.g. sciatic pain around T9-11).
Kunnumpurath S, et al. Journal of Clinical Monitoring and Computing, (2009) 23,

49. Coverage pattern of SCS

50. SCS implantation Lead seated at desired spinal level
Image guided Epidural
Lead seated at desired spinal level

51. SCS implantation
AP projection
Prone position

52. SCS
Neurostimulator leads: (left to right) percutaneous type to paddle type

53. SCS T9
T10
T11
T12

54. SCS success rate Depends on proper pt. selection
Fluoroscopic guidance is a must for proper visualization of exact spinal level
Reported “success” rates (generally defined as a minimum of 50% pain relief ) vary from 12 to 88% at follow- ups of 0.5–8 years.

55. Radiological Contrast Media

57. Message to take
Image-guided spine procedures provide physiological information not available from diagnostic imaging studies.
Real-time observation during contrast injection
Assess for vascular opacification reduce jeopardizing radicular vessels .
CT and MRI are additional modalities.

58. Message to take Image-guided spine injection procedures are
minimally invasive
performed on an outpatient basis
Perfection =
extensive training
imaging equipment safety
familiarity with image-based anatomy.

59. Dr. Amr Abdelfatah M.D. dramrafatah@yahoo.com
Thanks
Dr. Amr Abdelfatah M.D.