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Image guided interven.ons of lumbar spine
Interven.onal CT guided pain management
Yvonne K. Maratos, Grégory Lenczner, DHW Grönemeyer, Nicolas Amore?
Paris PrevenAon, 155 Blvd Haussman Paris
Dr. Maratos reports have no conflict of interest
Aim of the talk
§ Radiologist role in backpain management
§ Explain different treatments and their hierarchy in treatment of lombalgia
ü Z-‐joint
ü Periradicular
ü Intradiscal procedures
§ Show “how to do” interven.ons
§ Present new techniques
Aim of the talk
§ Radiologist role in backpain management
§ Explain different treatments and their hierarchy in treatment of lombalgia
ü Z-‐joint
ü Periradicular
ü Intradiscal procedures
§ Show “how to do” interven.ons
§ Present new techniques
Ministry of health Statistics, Germany, 2008
§ 26 Billions € are spend every year in Germany for treatment of lumbalgia1
§ 71,5 millions disability /year
§ Most frequent cause of disability (20% due to degenera.ve spine disease)
§ 80% of the popula.on between 30 and 60 years old will experience at least one episode of lumbago
Back pain’s social cost
Advantage of being a radiologist
§ Diagnose and treat ü In favor of CT Image guidance
-‐ Precise targeAng -‐ Control during the intervenAon -‐ Reproducibility -‐ Par.cularly suited in obese pa.ents, osteoporosis and important degenera.ve disease -‐ Contrast media allergy
Mul.-‐disciplinary therapy concept
General therapy plan in back pain
Progressive
increase in
therapeu.c
invasivity
Short period of rest An.-‐inflammatory drugs Physical therapy/ Balneotherapy (Mesotherapy or injec.on by a rheumatologist) Image guided injec.on therapy (a]er 6 weeks of complaints) Surgery
Contra-‐indica.ons
§ Neurologic deficits imposing surgery:
ü Motor deficit >3/5
ü Cauda-equina-syndrome
§ Infection
§ Coagulation disorders
ü Z-joint injections: Aspirin, Anti-vitamin K are no
contra-indication
ü Nerve root injections: stop anti-platelet therapy 8 days
before; stop AVK and replace with LMWH
Importance of combining complementary techniques for pa.ent wellbeing
Work-‐up’s central element Step 1: Pre-‐interven.on Consulta.on
Patient’s complaint Physical exam Imaging Findings
+ - complementary exams (e.g. neurological or vascular work-up)
Pain origin
RADICULAR Disc herniaAon e.g. sciaAca
PSEUDO RADICULAR Z joint Lumbalgia
DISCOGENIC disc
OTHER
informed consent is signed
Step 2: Treatment
§ Treatments in local anesthesia on an out-patient basis
§ Low dose protocol CT Scanner ü Sequential acquisition ü mAs 30, 100-120 KV ü DLP 15-40 DLP
§ Trained team, precise workflow
Complete sterility during the procedure
Pain into the limb with no radicular
compression
Pseudo-‐radicular pain
Workup for pseudo-‐radicular pain
Progressive
increase
in
therapeu.c
invasiveness
Local Pain Morning s.ffness Pain while turning in bed/posi.on
Workup for pseudo-‐radicular pain
Progressive
increase
in
therapeu.c
invasiveness
Local Pain Morning s.ffness Pain while turning in bed/posi.on
Treatment at corresponding z-‐joint -‐ Facet joint blocks
Workup for pseudo-‐radicular pain
Progressive
increase
in
therapeu.c
invasiveness
Local Pain Morning s.ffness Pain while turning in bed/posi.on
Treatment at corresponding z-‐joint -‐ Facet joint blocks -‐ Neurolysis
Workup for pseudo-‐radicular pain
Progressive
increase
in
therapeu.c
invasiveness
Physiotherapy once pain <30 %
Local Pain Morning s.ffness Pain while turning in bed/posi.on
Treatment at corresponding z-‐joint -‐ Facet joint blocks -‐ Neurolysis
Workup for pseudo-‐radicular pain
Progressive
increase
in
therapeu.c
invasiveness
Physiotherapy once pain <30 %
Local Pain Morning s.ffness Pain while turning in bed/posi.on
No Pain at palpa.on Pain at the end of the day Pain while standing a long .me/a]er physical ac.vity
Treatment at corresponding z-‐joint -‐ Facet joint blocks -‐ Neurolysis
Workup for pseudo-‐radicular pain
Progressive
increase
in
therapeu.c
invasiveness Treatment at disc level
Physiotherapy once pain <30 %
Local Pain Morning s.ffness Pain while turning in bed/posi.on
No Pain at palpa.on Pain at the end of the day Pain while standing a long .me/a]er physical ac.vity
Treatment at corresponding z-‐joint -‐ Facet joint blocks -‐ Neurolysis
Pain resistance
How to?
§ Lumbar spine needle (21-‐23 Gauge)
ü The local anesthe.c: Short (Lidocaïne 1% (Xylocaïne®) and long lasAng (naropeine)
ü Contrast medium CompaAble with intra-‐thecal injecAon : ioméprol
(Ioméron®) 300mg/ml (0.5 cc)
§ Cor.coid § Drugs are injected carefully and slowly; no pain § No injec.on of crystalloid cor.coid if bleeding occurs (in that case hydro soluble cor.coid)
Drugs and material
§ A]er placement of the pa.ent on a prone posi.on a scout view is performed § Axial images are obtained at the level of interest § Planning of the procedure § Mark introduc.on point on the skin
§ Step to step inser.on of the canula; drugs are injected a]er sa.sfactory contrast media spread
§ Disinfec.on
Procedure workflow
Targe.ng
Progression of the probe in a axial plane
Amedo Smart Tacking Solu.ons, Germany
Laser naviga.on
Amedo Smart Tacking Solu.ons, Germany
Laser naviga.on
Faster More secure Less irradiaAon
Amedo Smart Tacking Solu.ons, Germany
Laser naviga.on
Faster More secure Less irradiaAon
§ First line treatment: injec.on therapies
ü Z-‐joint:
-‐ block tests, chemical or thermal rhizolyse
ü Periradicular: -‐ epidurals, foraminal and double access injec.ons
Lumbar spine procedures
Local pain or pseudo radicular
pain into the limb with no
radicular compression
Z-‐joint syndrome: the chameleon
Peri-articular positionning on medial branch
§ Bloc test: Therapeu.c and diagnos.c tool also using long las.ng anesthe.c on the ar.cula.on
Z-‐joint: Injec.on procedures
MB: medial branch of ramus dorsalis
Is intra-‐ar.cular injec.on required?
§ Not mandatory because the joint inerva.on is peri-‐ar.cular
Intra-‐ar.cular Injec.on
§ Intra-‐ar.cular injec.on may cause diffusion of the drug in the epidural space
68 years old female paAent acAve recreaAonal dancer
Sacroiliac joint
Z joint injec.on
Posi.ve bloc test but temporary relieve
What can we do?
Rhizolysis: nerve abla.on of ramus dorsalis
§ Either chemical (Alcohol) or thermal (radiofrequency or cryotherapy)
§ Abla.on of the medial or lateral branch of ramus dorsalis
§ Monosegmental, step to step neurolysis
Ethanol Rhizolysis
§ On an outpa.ent basis in local anesthesia
§ Posi.oning on the z-‐joint
§ Injec.on of 2 ml contrast
§ Verifica.on scanner excluding contrast in the spinal canal or in proximity of nerve roots
§ Slow Injec.on of 0,2-‐0,5ml ethanol (96%)
§ A]er procedure posi.oning on procubitus for 30min
Intensive physiotherapy is mandatory for long term results
Mono-‐segmental approach
Unilateral muscle athrophie
§ Axial T2 Image of the lumbar spine at L5-‐S1-‐
Sacrum
CI to apply alcohol if CM is at the contact of nerve root
Ethanol Rhizolysis: cau.on
Local tissue-coagulation
How does radio-‐frequency work?
Alternating high-frequency-currents cause an important electric field near the RF-active tip. Thereby the adjacent tissue is heated locally.
Radiofrequency Neurolysis
the “groove“ where the lateral branch is located
A side view of the dermatomes (after Foerster). From Haymaker, W and Woodhall, B.: Peripheral Nerve Injuries. Philadelphia, W.B. Saunders Company, 1945:20. (With permission of the publisher)
Radicular Syndrome
§ Radicular pain: pain projec.ng into the limb due to a nerve irrita.on
§ Pseudoradicular pain: pain into the limb with no nerve irrita.on
Postero lateral conflict: where to treat?
Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effec7veness of transforaminal epidural steroid injec7on by using a preganglionic approach: a prospec7ve randomized controlled study. Radiology. 2007 Nov;245(2):584-‐90.
Epidural injec.on
Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injecAons for the treatment of symptomaAc lumbar intervertebral disc herniaAons. Pain Physician. 2006 Oct;9(4):361-‐6.
Other Therapy options!!!
You have to live with your pain!?
Still in Pain? Second line treatment
§ Second line treatment: Intra-‐discal procedures
ü Discography
ü Intra-‐discal Laser decompression
ü Percutaneous mechanical herniated disc decompression
Lumbar spine procedures
Discography: important diagnos.c & therapeu.c tool
Intradiscal cor.coid applica.on in erosive discopathies
CT guided laser disc decompression
Tissular steam
• Decrese of intradiscal pressure • Fast rehabilitation
CT guided laser disc decompression
Using a motorised device, Stryker ®
CT guided Percutaneous decompression of a disc hernia.on
Local
anesthesia
Other image guided
invasive technique
sagital and axial T2 weighted images of a 24 year old paAent with moderate lumbalgia
Isthmic Spondylolisthesis
First line: injec.on procedure
Second line: Percutaneous arthrodesis under CT guidance Isthmic lysis screw fixaAon
§ No large incision § No muscle dissec.on § Fast rehabilita.on
Dorsal percutaneous arthrodesis CT guided transfaceoar athrodesis in CT guidance
Ø Efficient therapy option for resistant pain syndrome
Ø Pre-intervention consultation in difficult cases
Ø Start with the less invasive treatment
Ø Z-joint, sacroiliac-joint
Ø Be systematic
Ø Intensive physiotherapy
CT guided procedure of lumbar spine: Take home messages
CT Guided procedure an open road for progress!
Thanks for your aoen.on!
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