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Category: Spinal Injection

Spinal pain, especially low back pain (5% incidence and 60% to 80% lifetime prevalence in the United States), is very common (1). Low back pain is the leading cause of disability in people younger than 45 years. Although spinal pain often improves and resolves, a significant proportion of patients have ongoing symptoms and pain recurrence. Low back pain is a costly disorder with an annual cost approaching $50 billion (1). Therefore, a comprehensive rehabilitation approach that improves outcomes for patients with spinal pain can have a significant positive medical and economic impact. Adequate pain control can minimize disability, maximize function, improve quality of life, and potentially improve long-term outcomes by preventing the development of chronic pain syndromes. Spinal injection procedures have become an integral part of comprehensive rehabilitative management for individuals with spinal pain. Judicious use of these interventional procedures on carefully selected patients can provide optimal pain control, reduce disability, and improve functional outcome. This chapter is intended to discuss common spinal interventional procedures in an evidence-based manner and provide some instruction on performance of these procedures.

Coccyx Injections

Coccyx Injections

Coccyx pain (coccydynia) apparently occurs far less commonly than lumbosacral pain. Coccydynia can be a severe and persistent pain, causing significant suffering, frustration, and functional limitations (199). These patients often have a history of coccyx trauma (e.g., from a fall or childbirth) resulting in contusions, fractures, dislocations, or other injuries. However, other cases are idiopathic. Typical symptoms include focal tailbone pain, particularly worse with sitting and sometimes immediately worse upon going from sit-to-stand (199). Careful screening should seek to exclude…

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Discography (Diagnostic Disc Injection)

Discography (Diagnostic Disc Injection)

Although still controversial, discography (diagnostic intervertebral disc injection) is both an imaging study and a provocative physiologic study for determining whether an intervertebral disc is in fact a pain generator in a given patient (Table 68-7). Inserting a spinal needle into the center of the intervertebral disc and injecting contrast dye provides both physiologic information on whether a degenerative disc is painful and on anatomic features of the intervertebral disc. There is currently no other method to establish reliably whether…

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Sacroiliac Joint Injection

Sacroiliac Joint Injection

The sacroiliac (SI) joint can be a significant source of low back pain (141–143). Etiologies of SI pain include spondylo arthropathy, crystal arthropathy, septic arthritis, trauma, and pregnancy diasthesis (144). In addition, SI joint dysfunction (pain from a biomechanical disorder without a demonstrable lesion) has been proposed as a possible etiology of SI pain (145). Among patients with chronic low back pain, a study using a single block technique of the SI joint with a local anesthetic, estimated the prevalence…

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Radiofrequency Neurotomy for Z-joint Pain

Radiofrequency Neurotomy for Z-joint Pain

Radiofrequency neurotomy interrupts the nociceptive afferent from the Z-joint by thermally coagulating the two medial branches that innervate a given Z-joint. The exposed terminal portion of radiofrequency probe delivers heat at 80°C. For each Z-joint (except the C2-3 joint, which is innervated by the third occipital nerve), two medial branches need to be ablated. Indications Radiofrequency neurotomy can provide relative long-term benefit symptoms from persistent or recurrent Z-joint pain despite conservative care (that have had transient benefit from Z-joint injections),…

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Zygapophyseal Joint Injection

Zygapophyseal Joint Injection

Introduction The prevalence of lumbar zygapophyseal joint (Z-joint) pain has been reported to be approximately 6% in a primary care setting (94). However, in a tertiary spine center, lumbar Z-joint pain has been reported to range from 15% in younger individuals (96) to 40% in older populations (98) with chronic low back pain. In individuals with chronic neck pain after a whiplash injury, Z-joint pain occurred in approximately 50% of patients (99,100). More recent literature examining 500 patients has reported…

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Selective Nerve Root Block

Selective Nerve Root Block

Diagnostic Nerve Root Block Because of the overlap pattern of dermatomal innervation and the anatomic variants of spinal nerves, clinical history and physical examination alone are often not sufficient to accurately diagnose the segmental level of a spinal nerve lesion. In addition, current imaging studies and electrodiagnostic tests have limited sensitivity and specificity in reaching a conclusive diagnosis of radicular pain at a specific spinal level. Therefore, a diagnostic SNRB can be an important test with respect to providing a…

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Fluoroscopic Guidance and Contrast

Fluoroscopic Guidance and Contrast

Fluoroscopic guidance and contrast enhancement are essential for accuracy when performing epidural injections (43). Published data show that even in experienced hands, epidural injections without fluoroscopic and contrast-enhanced guidance (i.e., “blind injections”) often result in inaccurate placement (Table 68-3) (43). These misplacements include the needle being inadvertently positioned into the subarachnoid, intravascular (Table 68-4), or subcutaneous regions (caudal approach) or fascial plane superficial to the ligamentum flavum for interlaminar ESI. Misplacement into the subarachnoid or intravascular regions has major potential…

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Caudal Lumbar Epidural Injections

Caudal Lumbar Epidural Injections

Caudal lumbar epidural injections are performed by inserting a needle through the sacral hiatus into the epidural space at the sacral canal (Figs. 68-9 and 68-10). The patient is placed in a prone position. The legs are slightly abducted and feet turned inward to separate the gluteal fold to facilitate palpation of the sacral cornu. The sacral skin is prepped and draped in a sterile manner. AP imaging can be used to visualize the location of the sacral hiatus. Alternatively,…

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Transforaminal Epidural Injection

Transforaminal Epidural Injection

Comment In one systematic review comparing transforaminal, interlaminar, and caudal ESIs, the authors concluded that there was moderate evidence for long-term (>6 weeks) relief of lumbar radicular pain using the transforaminal and caudal approaches, but limited evidence using the interlaminar approach (30). The authors also concluded that there was moderate evidence for relief of cervical nerve root pain using both the transforaminal and interlaminar approaches (30). Another study concluded that the transforaminal approach was more effective than the interlaminar or…

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Interlaminar Epidural Injection

Interlaminar Epidural Injection

Technique The patient is placed in a prone position, ideally with a pillow or abdominal roll under the abdomen to help open up the lumbar interlaminar space by reversing the lumbar lordosis. The skin is then prepped and draped in a sterile manner. The targeted interlaminar space is identified using an anteroposterior (AP) fluoroscopic view, the vertebral body endplates at the targeted level are “squared off ” by adjusting the relative cephalad-caudad orientation of the fluoroscope, and the fluoroscope position…

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