dr. amr abdelfatah m.d. dep. of anesthesia, intensive care medicine & pain management ain shams...
TRANSCRIPT
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Dr. Amr Abdelfatah M.D.Dep. of Anesthesia, Intensive Care medicine & Pain Management
Ain Shams University, [email protected]
IMAGE GUIDED EPIDURAL FOR BACK PAIN
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Interventional InjectionsInterventional Implants
Image Guided Epidural Intervention
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Interventional Epidural Injections
Interlaminar Epidural
Transforaminal Epidural
Caudal (sacral ) Epidural
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Imaging Guidance:Is efficacy improved?
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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, 1985. 1985).
Fluoro.: Reduces technical failures & difficulties with ESI up to 60%.
(Manchikanti L, et al Anesth Analg 89:1330–1331, 1999).
Imaging Guidance:Is efficacy improved?
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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).
Imaging Guidance:Is efficacy improved?
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Blind Cervical ESIs: ◦ 53% false LOR on 1st 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
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Imaging Guidance:Is efficacy improved?
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)
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Tissue irritation and inflammation
HNP
Nerve root irritation (Lumbosacral radiculopathy)
Previous back surgery
Post spinal fixation
Spinal canal stenosis.
Spondylolisthesis & degerative disc disease !!
Indications
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Lumbar Epidural Steroids
Interlaminar vs Transforaminal Injections ?!
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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)
Interlaminar vs Transforaminal Injections
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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).
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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)
Interlaminar vs Transforaminal Injections
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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 transforaminalnor 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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Fluoroscopy guided TFESI
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Artery of Adamkiewicz (supplies
lumbosacral enlargement )
Radicular artery close to DRG @ 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).
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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
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Needle Tip Position ?
Safe Triangle anterior-superior
Kambin’s TrianglePost. Inferior
P A
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Paraplegia Following Image-Guided
Transforaminal Lumbar Spine Epidural Steroid
Injection: Two Case Reports @ University of
Florida College of Medicine(David J, et al. Pain Medicine, 10: 1389–1394)
So Image & contrast prior to injection
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AP projection
0.2 LAO0.00 CRA
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Scotty Dog 20-30 degree lateral projection
L5
L4
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Spinal 22G
L4
L5
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Lat. projection
L5
L4
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Omnipaq contrast in Ant. Epidural Space
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Anteroposterior fluoroscopic view showing theOmnipaq outlining the nerve root and diffusing through the intervertebralforamina into the epidural space
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Anteroposterior fluoroscopic view showing the
Omnipaq outlining the nerve root and diffusing into the intervertebral
foramina into the epidural space
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Anteroposterior fluoroscopic view showing the
Omnipaq outlining the nerve root and diffusing into the intervertebral
foramina into the epidural space
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Caudal(Sacral) Epidural Adhesolysis
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Fluoroscopic guided Caudal previous laminectomy
Post-Spine fixation
Dural Adhesion &
fibrosis (LOR)
Epidural in high BMI
Normal epidurogram
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Faulty Subcut. Injection
Correct Needle placement
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RACZ Catheter
Dr. Gabor Racz
scar tissue entrapping
nerves
Flex tip & Steering end
L.A + Steroids
hyaluronidases
3%, 7%, 10 % NaCl
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Caudal Adhesolysis
RACZ cath. Through Tuohy needle
Touhy needle through Sacral hiatus
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OMNIPAQ WITH FILLING DEFECT
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Hazards of Caudal Adhesolysis
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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SPINAL CORD
STIMULATOR
DRUG DELIVERY SYSTEM
Interventional Implants
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Spinal Cord Stimulator
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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.
SCS
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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, 333-339.
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Coverage pattern of SCS
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SCS implantation
Image guided Epidural Lead seated at desired spinal level
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SCS implantation
AP projection Prone position
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SCS
Neurostimulator leads: (left to right) percutaneous type to paddle type
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SCS
T12
T11
T10
T9
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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.
SCS success rate
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Radiological Contrast Media
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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.
Message to take
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Image-guided spine injection procedures are
◦ minimally invasive
◦ performed on an outpatient basis
Perfection =
◦ extensive training
◦ imaging equipment safety
◦ familiarity with image-based anatomy.
Message to take