SPINAL INJECTIONS - Elsevier · 2013-12-20 · ACCURACY Performing spinal injections under imaging can ensure correct placement but requires specialized training and is expensive

Comp. by: Kkala Stage: Revises2 Chapter No.: 5 Title Name: SaundersPage Number: 0 Date:18/7/11 Time:13:53:30

SECTION 5

SPINAL INJECTIONS

SPINAL INJECTION GUIDELINES 219

Overview 219Safety 219Accuracy 220Efficacy 220Indications for spinal injection 221Summary 222

EXAMINATION OF THE SPINE 223

CAUDAL EPIDURAL 224

Acute or chronic low back pain or sciatica 224

LUMBAR FACET JOINT 226

Chronic capsulitis 226

LUMBAR NERVE ROOT 228

Nerve root inflammation 228

SACROCOCCYGEAL JOINT 230

Coccydynia – strain of coccygeal ligaments, subluxation 230

SACROILIAC JOINT 232

Acute or chronic sprain or capsulitis 232

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CERVICAL FACET JOINT 234

Acute or chronic capsulitis 234

SUMMARY OF SUGGESTED SPINAL DOSAGES 236

REFERENCES 236

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SPINAL INJECTION GUIDELINES

We strongly recommend that clinicians wishing to give spinal injections attendrecognized training courses and undergo a period of supervised practice with anexperienced colleague before attempting them on their own.

OVERVIEW Low back pain without disc herniation is the most common problemamong chronic pain disorders, but a patho-anatomical cause can beestablished in only 15 % of all cases.1 Treatments to relieve this affliction havebeenmany, among them spinal injections – engenderingmuch controversy inthe literature; opinions about efficacy, safety and relevance have differedgreatly since their inception in the 1920s, with many studies considered poorquality.2–17

Although epidural injections are one of the most commonly used invasiveinterventions in the treatment of low back pain, with or without radicularpain, there is currently little consensus about this technique and wide varia-tion in practice.21 There is also no agreement on the most effective approachfor lumbar epidural injection, whether to use steroid, local anaesthetic,saline or a combination, or the exact volume required. Depot steroids arenot licensed for spinal use18,19 but orthopaedic and pain specialists,rheumatologists and others use these injections extensively.20 The caudalroute of administration may require a larger volume but is least likely to causedural puncture.22,23

A paucity of well designed, randomized controlled studies, and a lack ofstatistically significant results in the existing literature mean that a solid foun-dation for the effectiveness of spinal injection therapy is lacking.9 NICE, the UKNational Institute for Health and Clinical Excellence, recommended thatpatients with persistent non-specific low back pain should not be offeredinjections of therapeutic substances,24 but what impact this has had on clinicalpractice is uncertain.

A Cochrane Review found minor side-effects such as headache, dizziness,transient local pain, tingling, numbness and nausea reported in a small numberof patients in only half the trials reviewed. The review concluded that there is nostrong evidence for or against the use of any type of injection therapy forindividuals with subacute or chronic low-back pain.10

SAFETY All the contraindications listed in Section 2 apply, but particularly:

l anticoagulant therapy with warfarin is an absolute contraindication.

The incidence of intravascular uptake during lumbar spinal injection proceduresis approximately 8.5%; it is greater in patients over 50, and if the caudal route isused rises to 11%. Absence of flashback of blood on pre-injection aspiration doesnot predict extravascular needle placement.31 Epidural steroid injection is safe inpatients receiving aspirin-like antiplatelet medications, with no excess risk of

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serious haemorrhagic complications, i.e. spinal haematoma. Increased age, largeneedle gauge, needle approach, insertion at multiple interspaces, number ofneedle passes, large volume of injectant and accidental dural puncture are allrelative risk factors for minor haemorrhagic complications.32

Safety precautions and strict aseptic techniques are the same as for allinjections. An additional hazard is the rare possibility of an intrathecal injectionof local anaesthetic which may be avoided by using corticosteroid alone. Therationale is that the benefit of the brief relief of pain and the diagnostic infor-mation obtained from using an anaesthetic does not outweigh the potentialrisks. Normal saline can be added or Adcortyl used instead of Kenalog if addi-tional volume is required.

New neurological symptoms or worsening of pre-existing complaints thatpersist for more than 24 hours (median duration of symptoms 3 days, range1–20 days)might occur after epidural injection,32 but in the authors’ experiencethis is rare.

The British Society for Rheumatology and the Royal College of Anaesthetistsproduce guidelines for the use of epidural injections. We commend them to allpractitioners who give these injections. They can be found at:

l www.rheumatology.org.ukl www.rcoa.ac.uk

ACCURACY Performing spinal injections under imaging can ensure correct placement butrequires specialized training and is expensive to perform, especially if done intheatre; many doctors perform these techniques ‘blind’ and obtain satisfactoryresults.

Accuracy of blind caudal epidural injections compared with targeted place-ment has been assessed in a few studies. In one, successful placement on thefirst attempt occurred in three out of four subjects. Results were improved whenanatomical landmarks were identified easily (88%) and no air was palpablesubcutaneously over the sacrum when injected through the needle (83%).The combination of these two signs predicted a successful injection in 91%of attempts. In another study blind injections were correctly placed in onlytwo out of three attempts, even when the operator was confident of accurateplacement. When the operator was less certain, the success rate was less thanhalf and if the patient was obese the success rate reduced even further. In a thirdprospective randomized, double-blind trial, the results showed no advantage ofspinal endoscopic placement compared with the more traditional caudalapproach.26–29,34,39

EFFICACY Lumber epidurals: a systematic review of epidural corticosteroids for backpain found at least 75% pain relief in the short term (1–60 days) with thenumber needed to treat (NNT) of 7 (7–16) and at least 50% pain relief inthe long term (3–12 months) with NNT of 13 (7–314).3 A randomized,double-blind, controlled trial concluded that lumbar interlaminar epidural

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of local anaesthetic with steroid was effective in 86% of patients, and withoutsteroid in 74%.31

A systematic review indicated positive evidence (Level II-2) for short-termrelief of pain from disc herniation or radiculitis utilizing blind interlaminarepidural steroid injections; there was less strong evidence for long-termpain relief for these conditions and for the short- and long-term relief of painfrom spinal stenosis and from discogenic pain without radiculitis or discherniation.25 Another review of both caudal and lumbar epidurals alsoconcluded that the best studies showed inconsistent results and benefitswere of short duration only.6 Yet another showed strong evidence forepidurals in the management of nerve root pain due to disc prolapse, but lim-ited evidence in spinal stenosis.22 A multicentre randomized controlled trialof epidurals for sciatica reported significant relief at 3 weeks but no long-termbenefit.14

In the past, large volumes have been injected into the epidural space;33 how-ever, a total injection volume of 8 ml is sufficient for a caudal epidural injectionto reach the L4/5 level.34

Selective guided nerve-root injections of corticosteroids are significantlymore effective than those of bupivacaine alone in obviating the need for opera-tive decompression for 13–28 months following the injections in operativecandidates. This finding suggests that patients who have lumbar radicular painat one or two levels should be considered for treatment with selective nerve-rootinjections of corticosteroids prior to operative intervention. A significantlygreater proportion of patients treated with transforaminal injection of steroidachieve relief of pain compared with those treated by transforaminal injectionof local anesthetic or saline or intramuscular steroids.30 When symptoms havebeen present for more than 12 months, local anaesthetic alone may be just aseffective as steroid and local anaesthetic together.

When conservative measures fail, nerve-root injections are effective inreducing radicular pain in patients with osteoporotic vertebral fracturesand no evidence of nerve root palsy. These patients may be considered forthis treatment before percutaneous vertebroplasty or operative interventionis attempted.35,36,38

Injection of the sacroiliac joints for painful sacroiliitis appears to be safeand effective. It can be considered in patients with contraindications orcomplications with NSAIDs, or if other medical treatment is ineffective,37

though often manipulative techniques can obviate the need for an injection.However, accurate placement of the drug without the use of fluoroscopy isestimated to be successful in only 12 % of patients.40

INDICATIONSFOR SPINALINJECTION

The techniques described here include caudal epidural, nerve root, facet joint,sacroiliac joint and sacrococcygeal joint injections and the far less commontechnique for cervical nerve root pain. The choice between giving a caudalor nerve root injection can be aided by the site of pain; if this is clearlyunilateral in the lumbar area, or radiating down one leg, a nerve rootinjection may be effective. If the pain is bilateral or central in the lumbarspine, a caudal epidural may be a better choice; however, this guide is notan absolute.

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The following are the main indications for caudal and nerve root injections:

l Acute back and/or leg pain where pain makes manipulation impossible toperform

l Chronic back and/or leg pain where conservative treatment has failedl Prior to considering surgery.

Older patients with chronic back pain and stiffness increased on active extensionmay benefit from facet joint injections. A retrospective study of patients with spi-nal stenosis found that 35 % of patients had at least 50 % improvement; thosewith spondylolisthesis, single level stenosis and older than 73 had betteroutcomes.28 Less commonly, injections for coccydinia or sacroiliac joint paincan be attempted in cases of acute traumatic or post-natal pain.

SUMMARY There is a wide variation of opinion about the efficacy of spinal injections forback pain; adverse effects are generally minor and it cannot be ruled out thatspecific subgroups of patients may respond to a specific type of injectiontherapy. A cost-effective intervention which may be performed safely as anoutpatient procedure and rapidly relieve pain, even in the short term, is worthconsidering for carefully selected patients with both acute and chronic lowback pain provided that, as with all injection techniques, resuscitationfacilities are available and the guidelines on aseptic technique are strictlyfollowed.


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EXAMINATION OF THE SPINE

The capsular pattern is a set pattern of loss of motion for each joint. It indicatesthat there is some degree of joint capsulitis caused by degeneration, inflamma-tion or trauma. There may be a hard end feel in advanced capsulitis.

Cervical spine tests

Active: flexionrotationsside flexionsextension

Resisted: shoulder abduction C5shoulder lateral rotation C5shoulder medial rotation C6elbow flexion C6

Passive: rotationsside flexionsextension

elbow extension C7shoulder adduction C7wrist extension C6wrist flexion C7thumb extension C8finger adduction T1

Reflexes: brachioradialis C5, biceps C6, triceps C7Cervical capsular pattern: equal loss of rotations and side flexions, more loss ofextension than flexion

Lumbar spine tests

Active: extensionside flexionsflexion

Resisted: foot plantarflexion S1hip flexion L2foot dorsiflexion L4big toe extension L4/5

Passive: hip flexionhip rotations

Resisted: foot eversion L5/S1knee extension L3knee flexion S1glutei S1

straight leg raiseReflexes: knee L3, ankle L5, S1/2Lumbar capsular pattern: equal loss of side flexions, more loss of extension thanflexion

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CAUDAL EPIDURAL

Acute or chronic low back pain or sciatica

Causes and findings l Disc lesion, acute nerve entrapmentl Central or bilateral pain in low back with or without sciatica or root signsl Painful: flexion and usually side flexion away from pain with nerve root

tension signs

Equipment Syringe Needle Adcortyl Lidocaine Total volume

5 ml Green 21G1.5” (40 mm)

40 mg Nil 4 ml

Anatomy The spinal cord ends at the level of L1 and the thecal sac ends at S2 in mostindividuals. The aim of this injection is to pass a disinflaming solution throughthe sacral hiatus and up the canal so that it bathes the posterior aspect of theintervertebral disc, anterior aspect of the dura mater and any affected nerveroots centrally. The sacral cornua are two prominences that can be palpatedat the apex of an equilateral triangle drawn from the posterior superior spineson the ileum to the coccyx. There is a thick ligament at the entrance to the canal.The angle of the curve of the canal varies widely and the placement of the needlereflects this.

Technique l Patient lies prone over small pillowl Identify sacral cornua at base of imaginary triangle with thumbl Insert needle between cornua and pass horizontally through ligamentl Pass needle a short distance up canal adjusting angle to curve of sacruml Aspirate to ensure needle has not penetrated thecal sac or blood vessell Slowly inject solution into epidural spacel Keep hand on sacrum to palpate for swelling caused by suprasacral injection

Comments Occasionally the canal is difficult to enter. This might be because of a bifid orvery small canal or because the angle of the sacrum is very concave. If this isencountered, a small amount of local anaesthetic can be injected into the liga-ment to make penetration more comfortable and reangulation of the needlemight be necessary. If clear fluid or blood is aspirated at any point the pro-cedure is abandoned and attempted a few days later.

Alternativeapproach

If the affected level is higher than the common L5/S1 level or the patient is large,more volume may be required to reach these levels. In this case we recommendthe addition of up to 10 ml of normal saline, depending on the level of thelesion and the size of the patient.39

Aftercare The patient is advised to keep active within pain limits and is reassessed about10 days later. If the injection has only partially helped it can be repeated aslong as improvement continues. The causes of the back pain should then beaddressed – weight, posture, work positions, lifting techniques, exercise,abdominal control, etc.


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LUMBAR FACET JOINT

Chronic capsulitis

Causes and findings l Osteoarthritis, traumatic capsulitis, ankylosing spondylitis, spondylolysisl Uni- or bilateral low back pain, sometimes with dull vague aching down leg/sl Painful: capsular pattern limitation, in spondylolysthesis combined extension

with side flexion to the painful side may be the most painful movement.

Equipment Syringe Needle Kenalog Lidocaine Total volume

1 ml Spinal 22G3–5“ (90 mm)

40 mg Nil 1 ml

Anatomy The lower lumbar facet or zygaphophyseal joints lie lateral to the spinousprocesses – approximately one finger width at L3, one and a half at L4and two fingers’ width at L5. They cannot be palpated but are located by mark-ing a vertical line along the centre of the spinous processes and horizontal linesacross between each process. The posterior capsule of the joint is foundby inserting the needle the correct distance for that level laterally on the hori-zontal line.

Technique l Patient lies prone on small pillow to aid localization of spinous interspacel Identify and mark one or more tender levelsl Insert needle at first selected level verticallyl Angle needle slightly cephalad and medially and pass slowly down to bonel Aspirate to ensure needle point is not intrathecal or in blood vessell Deposit solution into and around capsulel Withdraw needle and repeat at different levels if necessary

Comments Sometimes it is impossible to enter the joint, but controlled studies have shownthat depositing the solution into the capsule can be therapeutically effective11.

Alternativeapproach

These injections are often performed under imaging but this is less costeffective.

Aftercare Patient avoids excessive movement while maintaining activity. Abdominalstrengthening and mobilizing exercises should be performed regularly. Occa-sional mobilization and hamstring stretching will help to maintain flexibility.A lumbar support may be used during activities.


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LUMBAR NERVE ROOT

Nerve root inflammation

Causes and findings l Spinal stenosis, nerve-root entrapmentl Acute or chronic sciatica with or without root signsl Painful: flexion and usually side flexion away from pain plus nerve root

tension signs

Equipment Syringe Needle Kenalog Lidocaine Total volume

1 ml Spinal 22G3.5“ (90 mm)

40 mg Nil 1 ml

Anatomy The lumbar nerve roots emerge obliquely from the vertebral canals between thetransverse processes at the level of the spinous process. Draw a vertical linealong the centre of the spinous processes and horizontal lines at each spinouslevel. A thumb’s width laterally along the horizontal linemarks entry site for theneedle.

Technique l Patient lies prone over small pillow to aid localization of spinous processesl Identify spinous process at painful level andmark spot along horizontal linel Insert needle and pass perpendicularly to depth of about 3“ (7 cm)l Aspirate to ensure needle point is not intrathecall Inject solution as a bolus around nerve root

Comments This injection can be especially effective when the patient is in severe pain andconservative manual therapy techniques are impossible to administer. It canalso be givenwhen caudal epidural has proved unsuccessful – the caudal is tech-nically an easier procedure but the solution might not reach the affected part ofthe nerve root. The needle must be repositioned if it encounters bone at a dis-tance of about 2“ (5 cm) as this means it is touching the lamina or facet joint.Equally, repositioning is necessary if the patient complains of sharp ‘electricshock’ sensation because the needle will be in the nerve root. If clear fluid isaspirated the needle is intrathecal and the procedure must be abandoned,although it can be attempted a few days later. Two levels can be infiltrated ata time. A large patient may require a longer needle.

If the first level injected does not relieve the symptoms, a level above orbelow can be tried. This is well worth trying before considering surgery.

Aftercare Patient keeps mobile within pain limits and is reassessed 10 days later. Repeatas necessary.


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SPINAL INJECTIONS - Elsevier · 2013-12-20 · ACCURACY Performing spinal injections under imaging can ensure correct placement but requires specialized training and is expensive