SPINAL INFILTRATIONS UNDER RADIOLOGIC GUIDANCE

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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
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Purpose

• How to do spinal infiltrations safely?
• To review the neurological complications
  described by some authors.

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INTRODUCTION

• Procedures are now well codified and secure
• Only very few randomized-controlled studies
• Strong professional consensus

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INTRODUCTION

• Clinical signs and radiologic appearance in
  accordance

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TECHNICAL ASPECTS

• Fluoroscopy, CT

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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

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CERVICAL FORAMINAL INFILTRATIONS

• Foraminal infiltration
• C1-C2 latéral joint infiltration

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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

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CERVICAL FORAMINAL INFILTRATIONS
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MORVAN
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CERVICAL FORAMINAL INFILTRATIONS
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CERVICAL FORAMINAL INFILTRATIONS
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CERVICAL FORAMINAL INFILTRATIONS

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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)

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CERVICAL FORAMINAL INFILTRATION

• Complications
• Vaso-vagal reaction
• Isolated cases
• Medullar injury
• Vertebral artery injury
• Cerebellar/medullar/brain stem infarcts
  (micro-aggregate of corticosteroids)

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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.

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INFILTRATION OF C1-C2 LATERAL JOINTS

• Invalidant inflammatory and degenerative
  C1-C2 arthritis

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INFILTRATION OF C1-C2 LATERAL JOINTS
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MORVAN
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INFILTRATION OF C1-C2 LATERAL JOINTS
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INFILTRATION OF C1-C2 LATERAL JOINTS

• Efficiency
• GLEMAREC (2000) 26 patients
• Efficiency 63
• Rheumatoid artritisgtOsteo arthritis

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CERVICAL ZYGAPOPHYSEAL JOINT
INFILTRATION

• Indications
• Degenerative arthritis
• - osteo-radicular conflict
• - segmental instability
• Best performed under CT.

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LUMBAR INFILTRATIONS TECHNICAL ASPECTS

• Direct posterior approach

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LUMBAR INFILTRATIONS TECHNICAL ASPECTS

• Postero-lateral approach

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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

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EPIDURAL INFILTRATION UNDER FLUOROSCOPIC GUIDANCE
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EPIDURAL INFILTRATION UNDER FLUOROSCOPIC GUIDANCE
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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.

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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

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FORAMINAL INFILTRATION
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FORAMINALINFILTRATION
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11 intravenous injections
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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

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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

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ZYGAPOPHYSEAL JOINT INFILTRATION
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ZYGAPOPHYSEAL JOINT INFILTRATION
A.Chevrot
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ZYGAPOPHYSEAL JOINT INFILTRATION
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ZYGAPOPHYSEAL JOINT INFILTRATION
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• 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).

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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

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• 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).

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• 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).

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• 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).

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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.

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• 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.

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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.

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• THANKS