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SPINAL INFILTRATIONS UNDER RADIOLOGIC GUIDANCE

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Title: SPINAL INFILTRATIONS UNDER RADIOLOGIC GUIDANCE


1
SPINAL INFILTRATIONSUNDER RADIOLOGIC GUIDANCE
M. Ben Hamouda, N.Zamali, C. Drissi, K.Walha, N.
Hammami, R.Sebai, S. Nagi (Tunisia) DEPARTMENT OF
NEURO-RADIOLOGYNATIONAL 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
12
CERVICAL FORAMINAL INFILTRATIONS
13
CERVICAL FORAMINAL INFILTRATIONS

14
CERVICAL FORAMINAL INFILTRATIONS
  • Efficiency
  • MATHIEU (GETROA,2000) (18 patients)
  • neck cast (VAS-4) gtgtgt 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
INFILTRATION OF C1-C2 LATERAL JOINTS
  • Efficiency
  • GLEMAREC (2000) 26 patients
  • Efficiency 63
  • Rheumatoid artritisgtOsteo arthritis

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
27
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
FORAMINALOR 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
31
FORAMINALINFILTRATION
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
ZYGAPOPHYSEAL JOINT INFILTRATION
A.Chevrot
37
ZYGAPOPHYSEAL JOINT INFILTRATION
38
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).

40
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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).

44
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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 gt 22G.
  • Anatomy (injection of contrast )
  • Avoid the epidural scar tissue.

47
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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
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