5Imaging 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).
6Imaging Guidance: Is efficacy improved? Blind caudal for ESI :48% incorrect by trainee15 % experienced hands9.2% 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).
8Needle and pathology location Blind Cervical ESIs:53% false LOR on 1st trailunilateral 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
9Imaging 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
12Lumbar Epidural Steroids Interlaminar vs Transforaminal Injections ?!
13Interlaminar vs Transforaminal Injections Rhee and colleagues: TFESI:46% reduction in pain score10% required surgery.Interlaminar injections:19% reduction in pain score25% required surgery.(Rhee Jm, et al. J Bone Joint Surg Am. 2006)
14Improvement 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).
15Interlaminar 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)
16Conclusions. 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, USAConclusions. In the current study, neither transforaminalnor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions when compared with each other.
18Artery of Adamkiewicz (supplies lumbosacral enlargement ) Radicular artery close to sup.& middle portion of the foramen.Risk of paraplegia esp. with particulate steroidsDexamethasone and betamethasone are better choices, particles <50 µm(Christopher WA review: Current Rev. Musculoskelet Med 2009).
19A 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
20Needle Tip Position ? Safe Triangle Kambin’s Triangle Post. Inferior anterior-superiorKambin’s TrianglePost. Inferior
21So 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
44Hazards of Caudal Adhesolysis Hypertonic saline injected into the SCFcardiac arrhythmiasMyelopathyParalysis & loss of sphincter controlSo Image & contrast prior to injectionCord 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)
45Interventional Implants Spinal Cord StimulatorDrug delivery system
47SCS Melzack and Wall gate control theory in 1965 Pulsed electrical stimulation for the dorsal column(large fibers stim. can signal hyperalgesia ?!)Neurochemical alterationNon-pharmacological methodFailed back surgeryNeuropathic pain , CRPSIschemic limbIntractable anginal painIn the epidural space since 1967.
48Image 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,
54SCS success rate Depends on proper pt. selection Fluoroscopic guidance is a must for proper visualization of exact spinal levelReported “success” rates (generally defined as a minimum of 50% pain relief ) vary from 12 to 88% at follow- ups of 0.5–8 years.
57Message to takeImage-guided spine procedures provide physiological information not available from diagnostic imaging studies.Real-time observation during contrast injectionAssess for vascular opacification reduce jeopardizing radicular vessels .CT and MRI are additional modalities.
58Message to take Image-guided spine injection procedures are minimally invasiveperformed on an outpatient basisPerfection =extensive trainingimaging equipment safetyfamiliarity with image-based anatomy.
59Dr. Amr Abdelfatah M.D. email@example.com ThanksDr. Amr Abdelfatah M.D.