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Dr. Amr Abdelfatah M.D. Dep. of Anesthesia, Intensive Care medicine & Pain Management Ain Shams University, EGYPT

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Presentation on theme: "Dr. Amr Abdelfatah M.D. Dep. of Anesthesia, Intensive Care medicine & Pain Management Ain Shams University, EGYPT"— Presentation transcript:

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

2 Interventional InjectionsInterventional Implants

3 Interlaminar EpiduralTransforaminal EpiduralCaudal (sacral ) Epidural

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5  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  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).

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8  Blind Cervical ESIs: ◦ 53% false LOR on 1 st 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 Previous back surgery and fixation  Success rate increased in BMI > 30 vs. BMI <30 (Price CM, et al: Ann Rheum Dis 2000;59:879–882)

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

11  Steroids ◦ Betamethasone, methylprednisolone, triamsinolone ◦ Particle size counts  Local anesthetics  Adjunctive: ◦ Hypertonic saline ◦ Clonidine ◦ Opioids ◦ Ziconotoid

12 Interlaminar vs Transforaminal Injections ?!

13  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  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 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.

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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 Safe Triangle anterior-superior Kambin’s Triangle Post. Inferior PA

21  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

23 20-30 degree lateral projection L5 L4

24 Spinal 22G L4 L5

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26 L4

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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

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34 L5 S1

35 L5

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39  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

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

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44  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)

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46 Spinal Cord Stimulator

47  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,

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50 Image guided Epidural Lead seated at desired spinal level

51 AP projectionProne position

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

53 T12 T11 T10 T9

54  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.

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57  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  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.


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