1. SPINAL INFILTRATIONS UNDER RADIOLOGIC GUIDANCE M. Ben Hamouda, N.Zamali, C. Drissi, K.Walha, N. Hammami, R.Sebai, S. Nagi (Tunisia) DEPARTMENT OF NEURO-RADIOLOGY NATIONAL INSTITUTE OF NEUROLOGY TUNIS SESSION : PAIRS – Spine Interventional- 25-26th April 2012 TUNISIA

2. Purpose How to do spinal infiltrations safely? To review the neurological complications described by some authors.

3. INTRODUCTION Procedures are now well codified and secure Only very few randomized-controlled studies Strong professional consensus

4. INTRODUCTION Clinical signs and radiologic appearance in accordance

5. TECHNICAL ASPECTS Fluoroscopy+++, CT

6. 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

7. CERVICAL FORAMINAL INFILTRATIONS Foraminal infiltration C1-C2 latéral joint infiltration

8. 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

9. CERVICAL FORAMINAL INFILTRATIONS

10. MORVAN

11. CERVICAL FORAMINAL INFILTRATIONS

14. 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 factor R. KRAUSE, Loffroy (JFR 2008) (300 patients) Efficiency 63.7 % (1-14 days)

15. CERVICAL FORAMINAL INFILTRATION Complications Vaso-vagal reaction Isolated cases : –Medullar injury –Vertebral artery injury –Cerebellar/medullar/brain stem infarcts (micro- aggregate of corticosteroids)

16. 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.

17. INFILTRATION OF C1-C2 LATERAL JOINTS Invalidant inflammatory and degenerative C1-C2 arthritis

18. INFILTRATION OF C1-C2 LATERAL JOINTS

19. MORVAN

20. INFILTRATION OF C1-C2 LATERAL JOINTS

21. Efficiency GLEMAREC (2000) : 26 patients –Efficiency 63% –Rheumatoid artritis>Osteo arthritis INFILTRATION OF C1-C2 LATERAL JOINTS

22. CERVICAL ZYGAPOPHYSEAL JOINT INFILTRATION Indications: Degenerative arthritis: - osteo-radicular conflict - segmental instability Best performed under CT.

23. LUMBAR INFILTRATIONS TECHNICAL ASPECTS Direct posterior approach +++

24. LUMBAR INFILTRATIONS TECHNICAL ASPECTS Postero-lateral approach

25. 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

26. EPIDURAL INFILTRATION UNDER FLUOROSCOPIC GUIDANCE

28. 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%.

29. FORAMINAL OR 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

30. FORAMINAL INFILTRATION

32. 11% intravenous injections

33. 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

34. 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 ®

35. ZYGAPOPHYSEAL JOINT INFILTRATION

36. A.Chevrot

37. ZYGAPOPHYSEAL JOINT INFILTRATION

39. 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).

41. 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

42. 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).

43. 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).

45. 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).

46. 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.

48. 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.

49. 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.

50. THANKS