Dr. Amr Abdelfatah M.D. Dep. of Anesthesia, Intensive Care medicine & Pain Management Ain Shams University, EGYPT

1. Image Guided Epidural for Back Pain Dr. AmrAbdelfatah M.D. Dep. of Anesthesia, Intensive Care medicine & Pain Management Ain Shams University, EGYPT dramrafatah@yahoo.com

2. Image Guided Epidural Intervention

3. Interventional Epidural Injections

4. Imaging Guidance:Is efficacy improved?

5. Imaging Guidance:Is efficacy improved? • 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 alAnesthAnalg 89:1330–1331, 1999).

6. Imaging Guidance:Is efficacy improved? • 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).

8. Blind Cervical ESIs: • 53% false LOR on 1st trail • unilateral spread in 51% • ventral spread in 28% (StojanovicMP, et al. Spine 27:509–514, 2002) • Better viewing for contrast spread. Needle and pathology location

9. Imaging Guidance:Is efficacy improved? • Success rate increased in BMI > 30 vs. BMI <30 (Price CM, et al: Ann Rheum Dis 2000;59:879–882) Previous back surgery and fixation

10. Indications • Tissue irritation and inflammation • HNP • Nerve root irritation (Lumbosacral radiculopathy) • Previous back surgery • Post spinal fixation • Spinal canal stenosis. • Spondylolisthesis & degerative disc disease !!

11. Lumbar Epidural Steroids Interlaminar vs Transforaminal Injections ?!

12. Interlaminar vsTransforaminal Injections • 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)

13. 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).

14. Interlaminar vsTransforaminal Injections • 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)

15. 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 transforaminal nor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions when compared with each other.

16. Fluoroscopy guided TFESI

17. 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).

18. 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

19. Needle Tip Position ? P A Safe Triangle anterior-superior Kambin’s Triangle Post. Inferior

20. 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

21. 0.2 LAO 0.00 CRA AP projection

22. L4 L5 Scotty Dog 20-30 degree lateral projection

23. L4 Spinal 22G L5

25. L4 L5 Lat. projection

28. Omnipaq contrast in Ant. Epidural Space

29. Anteroposterior fluoroscopic view showing the Omnipaq outlining the nerve root and diffusing through the intervertebral foramina into the epidural space

30. Anteroposterior fluoroscopic view showing the Omnipaq outlining the nerve root and diffusing into the intervertebral foramina into the epidural space

31. Anteroposterior fluoroscopic view showing the Omnipaqoutlining the nerve root and diffusing into the intervertebral foramina into the epidural space

33. Caudal(Sacral) Epidural Adhesolysis

34. Fluoroscopic guided Caudal • previous laminectomy • Post-Spine fixation • Dural Adhesion & fibrosis (LOR) • Epidural in high BMI Normal epidurogram

35. Faulty Subcut. Injection Correct Needle placement

36. Dr. Gabor Racz • scar tissue entrapping nerves • Flex tip & Steering end • L.A + Steroids hyaluronidases • 3%, 7%, 10 % NaCl RACZ Catheter

37. Caudal Adhesolysis RACZ cath. Through Tuohyneedle Touhy needle through Sacral hiatus

38. OMNIPAQ WITH FILLING DEFECT

39. 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, duralpuncture. • A Retained Racz® Catheter Fragment After Epidural adhesolysis : Implications During Magnetic Resonance Imaging. (William J. Perkins, et al. AnesthAnalg2003;96:1717–9)

40. Interventional Implants Spinal Cord Stimulator Drug delivery system

41. Spinal Cord Stimulator

42. SCS • 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.

43. 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.

44. Coverage pattern of SCS

45. SCS implantation Image guided Epidural Lead seated at desired spinal level

46. SCS implantation AP projection Prone position

47. SCS Neurostimulator leads: (left to right) percutaneous type to paddle type

48. SCS T9 T10 T11 T12

49. SCS success rate • 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.

50. Radiological Contrast Media