y maratos image guided interventions of lumbar spine jfim hanoi 2015

Image guided interven.ons of lumbar spine

Interven.onal CT guided pain management

Yvonne K. Maratos, Grégory Lenczner, DHW Grönemeyer, Nicolas Amore?

Paris PrevenAon, 155 Blvd Haussman Paris

Dr. Maratos reports have no conflict of interest

Aim of the talk

§  Radiologist role in backpain management

§  Explain different treatments and their hierarchy in treatment of lombalgia

ü Z-‐joint

ü Periradicular

ü Intradiscal procedures

§  Show “how to do” interven.ons

§  Present new techniques

Ministry of health Statistics, Germany, 2008

§  26 Billions € are spend every year in Germany for treatment of lumbalgia1

§  71,5 millions disability /year

§  Most frequent cause of disability (20% due to degenera.ve spine disease)

§  80% of the popula.on between 30 and 60 years old will experience at least one episode of lumbago

Back pain’s social cost

Advantage of being a radiologist

§  Diagnose and treat ü  In favor of CT Image guidance

-‐  Precise targeAng -‐  Control during the intervenAon -‐  Reproducibility -‐ Par.cularly suited in obese pa.ents, osteoporosis and important degenera.ve disease -‐ Contrast media allergy

Mul.-‐disciplinary therapy concept

General therapy plan in back pain

Progressive

increase in

therapeu.c

invasivity

Short period of rest An.-‐inflammatory drugs Physical therapy/ Balneotherapy (Mesotherapy or injec.on by a rheumatologist) Image guided injec.on therapy (a]er 6 weeks of complaints) Surgery

Contra-‐indica.ons

§  Neurologic deficits imposing surgery:

ü  Motor deficit >3/5

ü  Cauda-equina-syndrome

§  Infection

§  Coagulation disorders

ü  Z-joint injections: Aspirin, Anti-vitamin K are no

contra-indication

ü  Nerve root injections: stop anti-platelet therapy 8 days

before; stop AVK and replace with LMWH

Importance of combining complementary techniques for pa.ent wellbeing

Work-‐up’s central element Step 1: Pre-‐interven.on Consulta.on

Patient’s complaint Physical exam Imaging Findings

+ - complementary exams (e.g. neurological or vascular work-up)

Pain origin

RADICULAR Disc herniaAon e.g. sciaAca

PSEUDO RADICULAR Z joint Lumbalgia

DISCOGENIC disc

OTHER

informed consent is signed

Step 2: Treatment

§  Treatments in local anesthesia on an out-patient basis

§  Low dose protocol CT Scanner ü  Sequential acquisition ü  mAs 30, 100-120 KV ü  DLP 15-40 DLP

§  Trained team, precise workflow

Complete sterility during the procedure

Pain into the limb with no radicular

compression

Pseudo-‐radicular pain

Workup for pseudo-‐radicular pain

Progressive

increase

in

therapeu.c

invasiveness

Local Pain Morning s.ffness Pain while turning in bed/posi.on


Progressive

increase

in

therapeu.c

invasiveness


Treatment at corresponding z-‐joint -‐ Facet joint blocks


Progressive

increase

in

therapeu.c

invasiveness


Treatment at corresponding z-‐joint -‐ Facet joint blocks -‐ Neurolysis


Progressive

increase

in

therapeu.c

invasiveness

Physiotherapy once pain <30 %




Progressive

increase

in

therapeu.c

invasiveness



No Pain at palpa.on Pain at the end of the day Pain while standing a long .me/a]er physical ac.vity



Progressive

increase

in

therapeu.c

invasiveness Treatment at disc level



No Pain at palpa.on Pain at the end of the day Pain while standing a long .me/a]er physical ac.vity


Pain resistance

How to?

§  Lumbar spine needle (21-‐23 Gauge)

ü  The local anesthe.c: Short (Lidocaïne 1% (Xylocaïne®) and long lasAng (naropeine)

ü  Contrast medium CompaAble with intra-‐thecal injecAon : ioméprol

(Ioméron®) 300mg/ml (0.5 cc)

§  Cor.coid §  Drugs are injected carefully and slowly; no pain §  No injec.on of crystalloid cor.coid if bleeding occurs (in that case hydro soluble cor.coid)

Drugs and material

§  A]er placement of the pa.ent on a prone posi.on a scout view is performed §  Axial images are obtained at the level of interest §  Planning of the procedure §  Mark introduc.on point on the skin

§  Step to step inser.on of the canula; drugs are injected a]er sa.sfactory contrast media spread

§  Disinfec.on

Procedure workflow

Targe.ng

Progression of the probe in a axial plane

Amedo Smart Tacking Solu.ons, Germany

Laser naviga.on

Amedo Smart Tacking Solu.ons, Germany

Laser naviga.on

Faster More secure Less irradiaAon

§  First line treatment: injec.on therapies

ü Z-‐joint:

-‐ block tests, chemical or thermal rhizolyse

ü Periradicular: -‐ epidurals, foraminal and double access injec.ons

Lumbar spine procedures

Local pain or pseudo radicular

pain into the limb with no

radicular compression

Z-‐joint syndrome: the chameleon

Peri-articular positionning on medial branch

§  Bloc test: Therapeu.c and diagnos.c tool also using long las.ng anesthe.c on the ar.cula.on

Z-‐joint: Injec.on procedures

MB: medial branch of ramus dorsalis

Is intra-‐ar.cular injec.on required?

§  Not mandatory because the joint inerva.on is peri-‐ar.cular

Intra-‐ar.cular Injec.on

§  Intra-‐ar.cular injec.on may cause diffusion of the drug in the epidural space

68 years old female paAent acAve recreaAonal dancer

Sacroiliac joint

Z joint injec.on

Posi.ve bloc test but temporary relieve

What can we do?

Rhizolysis: nerve abla.on of ramus dorsalis

§  Either chemical (Alcohol) or thermal (radiofrequency or cryotherapy)

§  Abla.on of the medial or lateral branch of ramus dorsalis

§  Monosegmental, step to step neurolysis

Ethanol Rhizolysis

§  On an outpa.ent basis in local anesthesia

§  Posi.oning on the z-‐joint

§  Injec.on of 2 ml contrast

§  Verifica.on scanner excluding contrast in the spinal canal or in proximity of nerve roots

§  Slow Injec.on of 0,2-‐0,5ml ethanol (96%)

§  A]er procedure posi.oning on procubitus for 30min

Intensive physiotherapy is mandatory for long term results

Mono-‐segmental approach

Unilateral muscle athrophie

§  Axial T2 Image of the lumbar spine at L5-‐S1-‐

Sacrum

CI to apply alcohol if CM is at the contact of nerve root

Ethanol Rhizolysis: cau.on

Local tissue-coagulation

How does radio-‐frequency work?

Alternating high-frequency-currents cause an important electric field near the RF-active tip. Thereby the adjacent tissue is heated locally.

Radiofrequency Neurolysis

the “groove“ where the lateral branch is located

A side view of the dermatomes (after Foerster). From Haymaker, W and Woodhall, B.: Peripheral Nerve Injuries. Philadelphia, W.B. Saunders Company, 1945:20. (With permission of the publisher)

Radicular Syndrome

§ Radicular pain: pain projec.ng into the limb due to a nerve irrita.on

§  Pseudoradicular pain: pain into the limb with no nerve irrita.on

Postero lateral conflict: where to treat?

Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effec7veness of transforaminal epidural steroid injec7on by using a preganglionic approach: a prospec7ve randomized controlled study. Radiology. 2007 Nov;245(2):584-‐90.

Epidural injec.on

Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injecAons for the treatment of symptomaAc lumbar intervertebral disc herniaAons. Pain Physician. 2006 Oct;9(4):361-‐6.

Other Therapy options!!!

You have to live with your pain!?

Still in Pain? Second line treatment

§  Second line treatment: Intra-‐discal procedures

ü  Discography

ü  Intra-‐discal Laser decompression

ü  Percutaneous mechanical herniated disc decompression

Lumbar spine procedures

Discography: important diagnos.c & therapeu.c tool

Intradiscal cor.coid applica.on in erosive discopathies

CT guided laser disc decompression

Tissular steam

•  Decrese of intradiscal pressure • Fast rehabilitation

CT guided laser disc decompression

Using a motorised device, Stryker ®

CT guided Percutaneous decompression of a disc hernia.on

Local

anesthesia

Other image guided

invasive technique

sagital and axial T2 weighted images of a 24 year old paAent with moderate lumbalgia

Isthmic Spondylolisthesis

First line: injec.on procedure

Second line: Percutaneous arthrodesis under CT guidance Isthmic lysis screw fixaAon

§  No large incision §  No muscle dissec.on §  Fast rehabilita.on

Dorsal percutaneous arthrodesis CT guided transfaceoar athrodesis in CT guidance

Ø  Efficient therapy option for resistant pain syndrome

Ø  Pre-intervention consultation in difficult cases

Ø  Start with the less invasive treatment

Ø  Z-joint, sacroiliac-joint

Ø  Be systematic

Ø  Intensive physiotherapy

CT guided procedure of lumbar spine: Take home messages

CT Guided procedure an open road for progress!

Thanks for your aoen.on!

y maratos image guided interventions of lumbar spine jfim hanoi 2015

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