TERMINOLOGY Definitions Sacrum is large triangular bone formed from 5 fused vertebrae at base of vertebral column GROSS ANATOMY You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here
KEY FACTS Terminology Fine-needle aspiration of intervertebral disc material ± core biopsy Preprocedure Coagulopathy/anticoagulation studies Prothrombin time, activated partial thromboplastin time, international normalized ratio Hemoglobin, hematocrit, and platelet count Suspected osteomyelitis/discitis To confirm infectious organism Procedure For thoracic and lumbar levels use “Scotty dog” anatomy Superimpose superior endplate of vertebra below disc to be intervened upon Place “ear” of “Scotty dog” (superior articular process) at center…
KEY FACTS You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here
You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here
KEY FACTS Terminology Percutaneous disc removal to reduce intradiscal pressure → protruded disc retracts back in place, reduced irritation on annulus nociceptive nerve receptors Also decompresses nerve root from disc Another proposed mechanism: Removing disc material may prevent release of chemical mediators that directly injure nerve root Preprocedure Radicular pain usually greater than back pain/neck pain Positive CT or MR scan for disc herniation Contained herniated…
KEY FACTS Terminology Image-guided percutaneous vertebral biopsy Cerebrospinal fluid Preprocedure Indications Suspected tumor (biopsy ± vertebroplasty/kyphoplasty) Osteomyelitis/discitis (identify responsible organism, determine antimicrobial sensitivity) Procedure Biopsy ± fine-needle aspiration (FNA) ± vertebroplasty, kyphoplasty, vertebral augmentation Selection of biopsy system to use depends on Lesion size, location Operator experience/preference Post Procedure Ensure proper specimen handling, communication of results to clinician Follow-up on biopsy results Operator quality assurance Accountability…
KEY FACTS Terminology Percutaneous stabilization of sacral fracture via bone cement injection Preprocedure Indications Insufficiency fracture Pathologic fracture Posttraumatic fracture Laboratory data Coagulation parameters Infection/inflammation markers Imaging Consistent with acute/subacute fracture Look for retropulsion of bone fragments into sacral canal or neural foramina Look for cortical breakthrough and epidural extension associated with tumors Procedure Prone AP fluoroscopy angled slightly to optimize visualization of entire sacrum Direct…
KEY FACTS Terminology Vertebral fracture reduction via bipedicular balloon inflation followed by polymethylmethacrylate (PMMA) cement augmentation Preprocedure Carefully determine correct level STIR MR is most sensitive for vertebral edema Ensure level of pain is consistent with acutely fractured vertebra on imaging Procedure Angle C-arm toward side of pedicle to be accessed Must have clear view of pedicle cortex Lateral fluoroscopy is essential in determining needle depth…
KEY FACTS Terminology Percutaneous cement augmentation of vertebral body Preprocedure STIR MR provides excellent depiction of bone marrow edema in acute fracture Clinical examination Consistent with imaging findings Point tenderness should be assessed prior to sedation Procedure Can be performed with unipedicular or bipedicular access Ensure that medial pedicle cortex is not violated Use of mallet may be advantageous with nonthreaded access needles Once needle is…
KEY FACTS Terminology Corticosteroid/anesthetic injection into lumbar epidural space via interlaminar, transforaminal, or caudal approach Preprocedure Indications Lumbar radiculopathy Residual pain following vertebroplasty/kyphoplasty Things to check Prior imaging: Adequate epidural space (especially important in postoperative back!) Avoid interlaminar approach in patient with severe canal stenosis without identifiable epidural space on preprocedure imaging Literature supports use of nonparticulate steroid (dexamethasone) to minimize possibility of small vessel vascular…
KEY FACTS Terminology Selective corticosteroid and long-acting anesthetic injection of lumbar nerve root at level of neural foramen Preprocedure Imaging Single or multilevel involvement Procedure Carefully determine correct level(s) for injection Nerve root exits below pedicle of same numbered vertebral body 2 approaches for lumbar selective nerve root block Angle C-arm toward side to be injected and target beneath pedicle/“eye” of “Scotty dog” Using AP projection,…
KEY FACTS Terminology Injection of corticosteroid and anesthetic into lumbar facet joint Preprocedure Facet joint osteoarthritis Synovial cyst causing neurologic symptoms Procedure Prone Angle C-arm or PA fluoroscopy tube slightly toward side of joint to be injected Generally, lower 1/3 of joint is most amenable to needle entry/injection in arthritic joint Ensure proper level Slowly inject only enough contrast to confirm that needle tip is in…
KEY FACTS Terminology Selective anesthesia of lumbar nerve medial branch in diagnostic evaluation of lumbar facet joint pain Preprocedure Facet joint pain Useful in selecting patients for medial branch radiofrequency ablation procedure Procedure Target: Junction of superior articular process and transverse process Medial branch is numbered along with exiting lumbar nerve root L5 medial branch innervates inferior L4/5 and superior L5/S1 facet joint Patient positioning Prone:…
KEY FACTS Terminology Injection of glucocorticoid/long-acting anesthetic into thoracic epidural space via interlaminar or transforaminal approach Procedure Interlaminar epidural steroid injection (ESI) Define margins of lamina and interlaminar space Transforaminal ESI Ensure good visualization of neural foramen on true lateral view Benefit of CT Improved visualization of osseous structures in severely osteopenic patients Improved visualization of pleura/medial chest cavity Post Procedure Expectation Improvement in pain, or…
KEY FACTS Terminology Selective corticosteroid and long-acting anesthetic injection of thoracic nerve root at level of neural foramen Preprocedure Indications Thoracic radiculopathy Persistent pain after vertebroplasty/kyphoplasty Neoplastic compression of thoracic nerve root Procedure Use nonparticulate steroid to minimize vascular risk C-arm angulation must permit visualization of medial pleural surface of lung during procedure CT offers improved soft tissue and lung visualization Sagittal/coronal reformatted CT may facilitate…
KEY FACTS Terminology Injection of long-acting anesthetic ± corticosteroid into thoracic facet joint Preprocedure Preprocedure imaging Correlate level with prior imaging – Evaluate for 12 ribs &/or transitional vertebral anatomy Indications for procedure and future treatment plan Is facet joint injection or medial branch block more appropriate? Procedure Fluoroscopy Align margins of facet joint to maximize visualization of joint space Contrast is useful to evaluate intraarticular…
KEY FACTS Terminology Selective anesthesia of thoracic spinal nerve medial branch in assessment of thoracic facet joint pain Preprocedure Thoracic facet joint pain Confirm clinical suspicion (diagnostic) Evaluate likelihood of successful facet neurolysis Preprocedure imaging Procedure Target Immediately above transverse process/superior articular process junction – Be sure to avoid lung Carefully approach medial branch as close as possible to lateral aspect of superior articular process Record…
KEY FACTS Terminology Percutaneous injection of glucocorticoid into cervical epidural space Interlaminar: Approach epidural space between lamina Transforaminal: Approach epidural space via neural foramen Preprocedure Indication Cervical pain &/or cervical radiculopathy Coagulopathy Preprocedure imaging Assess adequate epidural space to accommodate needle placement/injection Procedure Loss of resistance/free injection of saline reveals tip in epidural space (or intrathecal) Inject contrast to verify needle tip placement Post Procedure Expectation…
KEY FACTS Terminology Selective anesthesia of cervical nerve root at level of neural foramen Preprocedure Radiculopathy corresponding to cervical dermatome Procedure Target Superior articular process of same number vertebra as nerve being injected (nerve comes out 1 level above) At level of superior articular facet, deflect needle anteriorly into neural foramen Verify needle tip placement within neural foramen in frontal and lateral projections Slowly inject iodinated…
KEY FACTS Terminology Anesthetic ± corticosteroid injection into cervical facet joint Diagnostic study for pain referable to cervical facet joint Preprocedure Indications Chronic or acute on chronic cervical facet osteoarthritis Posttraumatic osteoarthritis Preprocedure imaging Correlate imaging abnormality with patient symptoms Assess degree of bone overgrowth and best place to access joint Procedure Supine, decubitus, or prone depending on level to be injected/anatomic relationships Craniocervical junction Occiput/C1:…