Spinal Pain: Diagnosis and Interventional Procedures

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Spinal Pain: Diagnosis and Interventional Procedures
Spinal Pain:
Diagnosis and Interventional
Procedures
Dr Ilias Drivas MBBS FRANZCR
Diagnostic and Interventional Radiologist
Alfred Imaging Group
Staff Specialist Royal Prince Alfred Hospital
I Drivas IWSML September 2014
Overview
• Go over some relevant anatomy
• Common patterns of disc pathology as well as
radiological terminology which can be
confusing/inconsistent
• Talk about spinal canal stenosis and facet joint
arthritis
• Focus on which type of intervention may be
most appropriate for different clinical scenarios
and imaging appearances
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Types of Imaging
• Xrays
– Good initial test
– Cannot see disc pathology or assess canal stenosis
• CT
– Very good test for pretty much everything
– Much less radiation now with new CT scanners and dose
reducing techniques
• MRI
– Best test
– No radiation
• Bone scan
– Multilevel facet disease
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Degenerative Disc Disease
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Loss of fluid in the disc (disc dessication)
Loss of disc height
Vaccuum phenomenon
Anular fissure
Endplate degenerative changes
Osteophyte formation
Disc bulge or disc protrusion
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Degenerative Disc Disease
• Symptoms
• Commonly asymptomatic
• Low back pain +/- radiculopathy
• Restricted ROM, extension may exacerbate
• Treatment
• Non operative
• Bed rest, exercise, medication, epidural injection
• Operative
• Spinal fusion
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Anular Fissure
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Disc Terminology
• Disc bulge
– Broad based
• Disc herniation
– Disc protrusion
– Disc extrusion
– Disc sequestration
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Disc Bulge
• Generalised extension of disc beyond margin of vertebral
endplates
• >50% of disc circumference, ≤3mm
• Commonly lower cervical or lower lumbar
• Clinical
– 40% of asymptomatic adults have disc bulges
– Neck/back pain +/- radiculopathy
• Pain worse with flexion, relieved by lying flat with flexed hips and knees
– Disc bulge less important, but often associated with
degenerative discs which cause pain
• Treatment
– NSAIDS, physio, epidural injection, discectomy
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Broad Based Disc Bulge
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Disc Herniation
• Localised displacement of disc material beyond the limits of the
intervertebral disc space in any direction
• <50% disc circumference
• Focal vs broad based
• Types
– Protrusion
– Extrusion
– Sequestration
• Location
– Central
– Paracentral
– Foraminal
– Extraforaminal (far lateral)
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Disc Herniation
• Clinical
– Neck pain or lower back pain
– Radiculopathy (lateral disc herniation)
– Cord compression/cauda equina syndrome (central disc
herniation)
• Treatment
– NSAIDS, physio, perineural or epidural injections
• Indications for surgery
– Development of a neurological deficit
– Intractable pain unrelieved by conservative measures
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Central
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Paracentral
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Foraminal
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Far Lateral
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Facet Joint Disease
• Very common as you age
• Often multilevel
• Can be hard to tell which is the most symptomatic level
• Symptoms
– Neck pain
– Paravertebral lower back pain/stiffness
• Associated abnormalities
– Neural foraminal stenosis, spinal canal stenosis
– Synovial cyst
– Degenerative spondylolisthesis
• Poor correlation between severity of pain and extent of
degeneration
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Lumbar Spinal Canal Stenosis
• Causes
– Congenital short pedicles
– Disc bulge/disc herniation
– Facet joint disease
– Ligamentum flavum thickening/hypertrophy
• Clinical
– Lower back pain
– Lower leg pain, paraesthesia and weakness (neurogenic
claudication)
– Bladder bowel dysfunction
– Radiculopathy
• Degree of spinal canal stenosis on imaging may not
correlate with symptoms
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Lumbar Spinal Canal Stenosis
• Treatment
– NSAIDS
– Exercise
– Epidural injection
– Surgery (decompression and laminectomy)
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Cervical Spondylosis
• Spinal canal and neural foraminal narrowing due to
multifactorial degenerative changes
– Disc osteophyte complex compressing cord
– Uncovertebral and facet joint hypertrophy
– Narrowing of neural foramina
– Cord T2 hyperintensity (myelomalacia)
• Clinical
– Radiculopathy (if compress nerve roots)
• Neck pain radiating to arms/occiput
• Upper limb numbness/weakness, sensory loss
– Myelopathy (if compress spinal cord)
• Lower motor neuron signs and symptoms at the level of lesion
• Upper motor neuron signs below the level of lesion, eg difficulty walking,
increased tone, extensor Babinski
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Spondylolisthesis
• Displacement of one vertebral body
relative to the inferior vertebral body
• Anterolisthesis
• Retrolisthesis
• Causes
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Degenerative (usually facets)
Spondylolysis (pars defects)
Trauma
Post surgical
Pathologic (tumour, infection)
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Spondylolisthesis
• Clinical
• Back pain
• Radiculopathy (neural foraminal narrowing)
• Degenerative listhesis presents as spinal canal
stenosis
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CT Guided Injections
• Increasingly utilised and very effective
• Low risk and can provide temporary or
permanent relief of neck/back pain or
radicular pain
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Indications for Spinal Injections
• Diagnostic
• Conflict between symptoms and location of
imaging findings
• No imaging findings correlating with clinical
symptoms
• Presurgical testing
• Adjacent segment deterioration after spinal fusion
• Therapeutic
• Adjunct to conservative therapy
• Poor surgical candidate
• Post operative pain delaying recovery
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Which Injection?
• Radicular symptoms
– Perineural injection
• Spinal canal stenosis symptoms
– Epidural injection
• Facet joint OA and pain
– Facet joint injection
• Sacroiliac joint
– Sacroiliac joint injection
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Which Joint to Inject?
• Based on clinical findings
• Identify point of maximal tenderness to
palpation
• Imaging can be unreliable in predicting
level of facet joint pain
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Nerve Root Injection
• Treatment of radicular pain
• Indicated in:
– Radicular symptoms with a known cause (eg disc,
osteophyte)
– Radicular symptoms not localised clinically with
multilevel degenerative changes on imaging (will help
define levels for surgery)
– Post operative patients with unexplained recurrent
pain
– Equivocal neurological examination
– Minimal or no definite imaging findings
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Epidural Injections
• Treatment of local back pain or radiculopathy
• Indications
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Disc degenerative disease or herniation
Spinal nerve root compression
Spinal canal or neural foraminal stenosis
Absence of imaging findings
• Often difficult to determine which level to inject with
multilevel disease
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Contraindications
• Local skin infection
• Unable to lie prone (lumbar), on their side
(cervical)
• Anticoagulations (relative contraindication)
• Facets: all OK
• Perineural: aspirin OK, warfarin variable
• Epidural: cease all
• Need to weigh up risks vs benefit when
ceasing anticoagulants
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Medications
• Steroid provides an anti-inflammatory
effect
• Local anaesthetic (short or long acting)
• Can take up to a week or two to work
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Complications
• Infection
• Haemorrhage
• Can have small glucose rise in diabetics;
should be monitored
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Post Intervention Care
• Rest for a couple of days
• Keep the skin clean
• Unusual for symptoms to worsen after the
injection
– Monitor if this occurs
– May need to reimage
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How Many/How Frequent?
• No good evidence
• Current standard is you can have 3
injections per area per year
• No real limit on how many you can have
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How to Manage the Complex
Patient with Multilevel Disease
• Can be very difficult
• Back pain can be multifactorial/multilevel
• Determine if it is facet pain, radicular symptoms or spinal
canal stenosis
• Correlate clinical with radiological findings
• Pick injection type and level
• Often can be trial and error
• Injection can be diagnostic as well as therapeutic
• If injection doesn’t work, it may have been the wrong
level or wrong type of injection
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Thank You!
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