Interventional

Spine
Procedures
A Case-based Approach
 Interventional
Spine
Procedures
A Case-based Approach
Editors
Jeremy Simon MD
Clinical Instructor, Rothman Institute
1118 West Baltimore Pike
Media, Pennsylvania, USA

Mitchell Freedman DO
Medical Director
Physical Medicine and Rehabilitation
Rothman Institute
Associate Professor, Physical Medicine and Rehabilitation
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, USA

Michael J Mehnert MD
Clinical Instructor of Rehabilitation Medicine
Thomas Jefferson Medical College
Department of Physical Medicine and Rehabilitation
Philadelphia, Pennsylvania, USA

Alexander R Vaccaro MD PhD

Vice Chairman and Professor
Department of Orthopedics and Neurosurgery
Thomas Jefferson University
Philadelphia, Pennsylvania, USA

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Interventional Spine ProceduresA Case-based Approach

First Edition: 2014
ISBN978-93-5152-169-3
Printed at:
 Dedicated to
My wonderful wife, Karen Simon, who is the smartest person I know
and a dedicated wife, mother and OB/Gyn. She is an unending supply of
encouragement, support and inspiration. I also dedicate this book to my
beautiful children, Zachary and Rosanna Simon, who had to sacrifice some
time with Daddy to let him work on this book. Lastly, to my wonderful
parents Alan and Jill Simon, who encouraged me to be the best I could be.
Jeremy Simon

This book is a reflection of the hard work and dedication of Jeremy Simon,
Michael Mehnert and the Physical Medicine and Rehabilitation team of the
Rothman Institute.
Mitchell Freedman

For the many great teachers, I have had along the way....
Michael J Mehnert

Effective spinal care without the support of pain management physicians

specializing in diagnoses, medicinal treatment, physical therapy, diagnostic
and interventional injections and behavioral therapy would be nonexistent.
Alexander R Vaccaro
 Contributors

Arjang Abbasi DO Ari Greis DO

Interventional Pain Management and Rothman Institute
Spine Rehabilitation 925 Chestnut Street
Long Island Spine Specialists Philadelphia, Pennsylvania, USA
Larkfield Road, New York, USA
Melissa Guanche MD
Zachary Broyer MD Program Development
Rothman Institute Chief Resident
925 Chestnut Street Department of Rehabilitation
Philadelphia, Pennsylvania, USA
Medicine
Gary P Chimes MD PhD
Thomas Jefferson University Hospital
Physician, Lake Washington Sports Philadelphia, Pennsylvania, USA
and Spine, Chief Medical Advisor Gautam Kothari DO
ActivAided Orthotics
Rothman Institute
Washington DC, USA
3300 Tillman Drive
Theodore Conliffe MD Bensalem, Pennsylvania, USA
Rothman Institute
Gautam Malhotra MD
925 Chestnut Street
Philadelphia, Pennsylvania, USA Attending Physician
Department of Veterans Affairs
Madhuri Dholakia MD Physical Medicine and
Rothman Institute Rehabilitation Service
925 Chestnut Street East Orange, New Jersey, USA
Philadelphia, Pennsylvania, USA Clinical Associate Professor
Department of Physical
Natacha Falcon DO Medicine and Rehabilitation
Rothman Institute Rutgers New Jersey Medical School
925 Chestnut Street Newark, New Jersey, USA
Philadelphia, Pennsylvania, USA
Lisa Marino DO
Patrick M Foye MD Rothman Institute
Professor and Interim Chair 925 Chestnut Street
Physical Medicine and Rehabilitation Philadelphia, Pennsylvania, USA
Director, Coccyx Pain Center
Rutgers New Jersey Medical School Matthew McAuliffe MD

Newark, New Jersey, USA PGY-3 Resident

Co-Director, Musculoskeletal/Spine/ Department of Rehabilitation
Pain Fellowship, Co-Director, Spine Medicine
Injection Clinic, University Hospital Thomas Jefferson University Hospital
Newark, New Jersey, USA Philadelphia, Pennsylvania, USA
viii Interventional Spine ProceduresA Case-based Approach

Michael J Mehnert MD Ferheen Shamim MD

Clinical Instructor of Rehabilitation Chief Resident of Program
Medicine, Thomas Jefferson Medical Development
College, Department of Physical Department of Rehabilitation
Medicine and Rehabilitation
Medicine
Philadelphia, Pennsylvania, USA
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, USA
Michael Molter DO
Rothman Institute Jeremy Simon MD
925 Chestnut Street Clinical Instructor, Rothman Institute
Philadelphia, Pennsylvania, USA 1118 West Baltimore Pike
Media, Pennsylvania, USA
Shounuck I Patel DO
Department of Physical Medicine and Anupam Sinha DO
Rehabilitation
Rothman Institute
Rutgers New Jersey Medical School
925 Chestnut Street
Newark, New Jersey, USA
Philadelphia, Pennsylvania, USA
Jesse A Sally MD
Physician, Medical Rehabilitation Kelly Williams DO

Incorporated, Director of Sports Resident

Medicine and Acute Rehabilitation Department of Rehabilitation
Washington Health System Medicine
240, Wellness Way Thomas Jefferson University Hospital
Washington DC, USA Philadelphia, Pennsylvania, USA
 Preface

This book is intended as a teaching tool to reinforce the concepts of

common problems encountered in the spine clinic. It presents real case
scenarios and emphasizes the importance of a thorough history and physical
examination, as well as confirmation via appropriate imaging. The judicious
and appropriate use of procedures in spine care cannot be stressed enough.
Proper patient selection and realistic goals, as well as the use of a multi-
disciplinary approach are paramount to patient success. This text may be used
in the clinic and as a spring-board for discussion as well, as other treatments
may often be considered in select patient presentations.
We hope that you find this text educational and thought-provoking.

Jeremy Simon
Mitchell Freedman
Michael J Mehnert
Alexander R Vaccaro
 Acknowledgments

I would like to give special thanks to my right hand and medical assistant
Esther Coward, my caring and dedicated nurses Stephanie Graham RN BSN
and Merrie Fitzgerald RN, and my awesome X-ray Technician Patricia Chase.
All of you played an important role in obtaining pictures and treating my
patients with dignity and respect.
I would also like to thank my mentor, friend and former fellowship director
Michael Furman MD MS who taught me to be a clinician first and inter
ventionalist second. He also taught me how to thoughtfully approach
interventional spine procedures.
Many thanks to M/s Jaypee Brothers Medical Publishers (P) Ltd.
New Delhi, India, for their invaluable guidance and support in this endeavor.

Jeremy Simon
 Contents Contributors xiii

Introduction xxiii
1. Basic Principles of Fluoroscopically-guided
Procedures 1
Jeremy Simon
Sterile Preparation1
Needle-Driving2
Fluoroscopy2
Contrast4
Anticoagulants4

2. Lumbar Disc Herniation with Radiculopathy:

Selective Spinal Nerve Injection 8
Lisa Marino, Jeremy Simon
Chief Complaint8
History of Presenting Illness8
Past Medical/Surgical History9
Review of Systems9
Family History9
Social History9
Current Medications9
Allergies9
Physical Examination9
Imaging Studies10
Electrodiagnostic Studies10
Diagnosis10
Treatment10

3. Lumbar Disc Herniation with Radiculopathy:

Lumbar Transforaminal Epidural
Steroid Injection 17
Natacha Falcon, Jeremy Simon
Chief Complaint17
History of Present Illness17
Review of Systems17
xiv Interventional Spine ProceduresA Case-based Approach

Past Medical History18

Surgical History18
Medications18
Allergies18
Family History18
Social History18
Physical Examination18
Imaging19
Diagnosis19
Noninterventional Treatment Options20
Interventional Options20
Patient Discussion21
Plan21

4. Lumbar Spinal Stenosis with Radiculopathy 25

Michael Molter, Jeremy Simon
Chief Complaint25
History of Present Illness25
Past Medical History26
Past Surgical History26
Review of Systems26
Family History26
Social History27
Medications27
Allergies27
Physical Examination27
Diagnosis28
Treatment Options29
Complications/Pitfalls32

5. Coccygodynia 37
Michael J Mehnert, Ferheen Shamim, Patrick M Foye
Chief Complaint37
History of Present Illness37
Past Medical/Surgical History38
Review of Systems38
Family History38
Social History38
Current Medications38
 Contents xv
Allergies38
Physical Examination38
Imaging39
Diagnosis39
Differential Diagnosis40
Coccygodynia40
Treatment Options41
Interventional Options41
Plan42
Procedure42
Concerns, Pitfalls and Tips44

6. Lumbar Facet Syndrome 50

Jeremy Simon, Kelly Williams
Chief Complaint50
History of Present Illness50
Past Medical History51
Past Surgical History51
Review of Systems51
Family History51
Social History51
Current Medications51
Allergies51
Physical Examination51
Imaging52
Diagnosis53
Treatment Options53
Interventional Options54
Sample Procedure Notes57

7. Sacroiliac Joint Pain 61

Ari Greis, Melissa Guanche
Chief Complaint61
History of Present Illness61
Past Medical History61
Past Surgical History62
Review of Systems62
Family History62
Social History62
xvi Interventional Spine ProceduresA Case-based Approach

Current Medications62
Allergies62
Physical Examination62
Imaging63
Diagnosis64
Treatment Options66
Interventional Options66

8. Cervical Disc Herniation with Radiculopathy 71

Theodore Conliffe, Jeremy Simon, Zachary Broyer
Chief Complaint71
History of Present Illness71
Past Medical History72
Past Surgical History72
Family History72
Medications72
Allergies73
Social History73
Review of Systems73
Physical Examination73
Imaging Studies74
Diagnosis74
Treatment Options74
Indications75
Discussion76
Clinical Outcome77

9. Cervical Disc Herniation without Radiculopathy 79

Gautam Kothari, Jeremy Simon
Chief Complaint79
History of Present Illness79
Past Medical/Surgical History80
Family History80
Social History80
Medications81
Allergies81
Review of Systems81
Physical Examination81
Imaging82
Diagnosis84
 Contents xvii
Treatment Options84
Interventional Options84

10. Cervical Facet Syndrome 88

Matthew McAuliffe, Jeremy Simon
Chief Complaint88
History of Present Illness88
Past Medical History/Past Surgical History89
Review of Systems89
Family History90
Social History90
Current Medications90
Allergies90
Physical Examination90
Imaging91
Diagnosis91

11. Hip Pain 100

Anupam Sinha, Madhuri Dholakia
Chief Complaint100
History of Present Illness100
Past Medical History/Past Surgical History100
Review of Systems100
Family History101
Social History101
Current Medications101
Allergies101
Physical Examination101
Imaging102
Diagnosis102

12. Complex Regional Pain Syndrome

Lower Extremity 105
Jeremy Simon, Matthew McAuliffe
Chief Complaint105
History of Present Illness106
Treatments to Date106
Past Medical History106
Past Surgical History106
Review of Systems106
xviii Interventional Spine ProceduresA Case-based Approach

Family History107
Social History107
Current Medications107
Allergies107
Physical Examination107
Imaging108
Diagnosis108
Treatment Options110
Plan112
Sample Dictation112

13. Complex Regional Pain Syndrome

Upper Limb 115
Michael J Mehnert, Jeremy Simon, Matthew McAuliffe
Chief Complaint115
History of Present Illness115
Treatments to Date116
Past Medical History117
Past Surgical History117
Review of Systems117
Family History117
Social History117
Current Medications117
Allergies117
Physical Examination117
Imaging118
Diagnosis118
Treatment Options119
Plan121
Procedure Note121
Indications121
Preoperative Diagnosis121
Postoperative Diagnosis121
Procedure Performed121

14. Dural Puncture Headache 125

Jeremy Simon
Chief Complaint125
History of Present Illness125
 Contents xix
Past Medical History125
Past Surgical History126
Review of Systems126
Family History126
Social History126
Current Medications126
Allergies126
Physical Examination126
Imaging127
Diagnosis127
Discussion127
Treatment127

15. Adverse Reactions to Medications 132

Jeremy Simon
Chief Complaint132
History of Present Illness132
Past Medical History132
Past Surgical History132
Review of Systems133
Family History133
Social History133
Current Medications133
Allergies133
Physical Examination133
Imaging134
Diagnosis134
Additional Diagnosis135
Discussion136

16. Discogenic Low Back Pain/Lumbar Disc

Herniation without Radiculopathy 139
Jeremy Simon, Zachary Broyer, Theodore Conliffe
Chief Complaint139
History of Present Illness139
Past Medical History140
Past Surgical History140
Review of Systems140
Family History140
xx Interventional Spine ProceduresA Case-based Approach

Social History140
Current Medications141
Allergies141
Physical Examination141
Imaging141
Diagnosis142
Discussion144
Treatment Options147

17. Thoracic Facet Pain 152

Michael J Mehnert, Jesse A Sally, Gary P Chimes
Chief Complaint152
History of Present Illness152
Past Medical History153
Past Surgical History153
Review of Systems153
Family History153
Social History154
Current Medications154
Allergies154
Physical Examination154
Imaging155
Diagnosis155
Differential Diagnosis155
Treatment Options156

18. Thoracic Disc Herniation 172

Arjang Abbasi, Shounuck I Patel, Gautam Malhotra
Chief Complaint172
History of Present Illness173
Past Medical History174
Allergies174
Family History174
Social History175
Medication History175
Review of Systems175
Physical Examination176
Assessment with Differential Diagnosis177
Background178
 Contents xxi
Indications for Injection179
Treatment Alternatives179
Contraindications179
Thoracic Transforaminal Epidural Steroid Injection179
Equipment and Medications180
Technique: Oblique Subpedicular Transforaminal Approach180
Other Techniques183
Complications184
Evidence to Support the Procedure186

Index 189
 Introduction

As clinician-instructors, we often teach during office hours or in the procedure

room. Having a case-based, concise text for reference and to drive home the
important teaching points and patient presentations for clinical vignettes
serves as an efficient tool. This book is intended to introduce common
problems and presentations faced in the practice of interventional spine care.
This text is not intended to be a purely a how-to book on interventional
procedures. A formal fellowship with experienced and competent instructors
is recommended for learning safe and proper technique. This text is also not
meant to suggest that all patients with these presentations should have a
procedure as a treatment. Appropriate non-invasive conservative care and
careful patient selection is paramount to ethical care. In addition, procedures
performed for pain should be used judiciously and presented as therapeutic
options, not as the only method of treatment.
As a clinician and a teacher, having texts for medical students, residents
and fellows to refer is very helpful to direct their learning. There are several
excellent and comprehensive books for reinforcing interventional techniques
in spine care. There are excellent texts that give detailed background
information and in-depth discussions regarding pathophysiology and
pharmacology.
The purpose of this text is to allow the clinician-instructor to present a
typical pain pattern, patient history and physical examination findings with
appropriate imaging and their interpretation. We emphasize the importance
of the history and physical examination, as well as alternative treatment
options.
All of the contributors in this book practice musculoskeletal medicine
and these vignettes represent real patients in our practices. The bolded type
in the physical examination section is intended to emphasize clues to making
the diagnosis.
We hope that you find this text to be educational and informative.
 Basic Principles of
Fluoroscopically-guided 1
Procedures
Jeremy Simon

INTRODUCTION
Interventional procedures in the treatment of pain have become a common
practice. While the use of fluoroscopy can significantly reduce the risk of
complications, some basic principles must be utilized to reduce the potential
for harm. The practitioner should be well-educated and competent in
anatomy, fluoroscopic anatomy and in needle-driving to safely deliver the
treatment. It is recommended that a formal fellowship with an experienced
clinician(s) be performed before using these procedures in clinical practice.
Ultimately these are elective procedures. The principle of Primum non
nocere, first do no harm must be considered in patient selection. This
applies to the patients ability to stop anticoagulants, poor experiences with
prior injections, glycemic control, and degree of neurologic impairment. The
author will not perform cervical interlaminar epidural injections in patients
with signs and symptoms of myelopathy, cord edema, or significant cord
compression as demonstrated by the lack of cerebrospinal fluid around the
cervical spinal cord on axial X-rays. This is for fear of placing pressure on a
tenuous spinal cord and potential reversible or irreversible cord damage.1
While other practitioners may differ in their opinion on this matter, the con-
cept of do no harm should always be considered when planning any inter-
ventional procedure.

STERILE PREPARATION
Thorough handwashing or scrubbing should be performed prior to gloving.
Sterile gloves should be utilized and put on the hands without touching the
outer portion with the ungloved fingers.
2 Interventional Spine ProceduresA Case-based Approach

A sterile field consists of a preparation of the skin with a povidone solu-

tion or chlorhexidine. Some studies showed superiority of chlorhexidine2-6
while others have shown no difference.7-11 The preparation should be made
after locating the area with a spot film and making concentric circles from
the target area outward. This reduces the chance of inoculating the target
region with bacteria present on other areas of the skin. The area should be
allowed to dry prior to skin puncture. A fenestrated sterile drape or sterile
towels should be placed around the target area.
The use of sterile medications from an FDA-regulated (Food and Drug
Administration regulated) pharmaceutical company is a must. Reports of
fungal meningitis from presumed sterile medications have made it imperative
to obtain medications from well-vetted companies.12-14 Medications should
be drawn in a sterile fashion at the time of the procedure and placed in the
sterile tray.

NEEDLE-DRIVING
The spinal needle has a notch at the top and a beveled tip. The inner portion,
or cannula, is removable and gives added stiffness to the needle as well as
helps to prevent tissue from entering the needle during placement. The
tendency of the needle is to move in the direction of the slope of the bevel.
Tissue will deflect against the bevel. This is the opposite direction as the
notch. For example, if the notch is up, the tendency of the needle is to go
down. If it is facing left, it will tend to go right.
The further the needle is into tissue, particularly stiffer tissues such as
muscle, it will be more difficult to direct. Many practitioners will accentuate
the bevel by placing a bend on the needle of about 10 degrees. This allows for
larger movements to be made in deeper tissues.
Tuohy needles utilized in interlaminar approaches are of typically larger
bore, often 18- or 20-gauge. They are thus more difficult to steer in tissue. The
bevel and notch are in the same orientation, i.e. the needle will tend to move
in the same direction as the notch.

Fluoroscopy
The use of fluoroscopy adds a significant advantage in procedural safety.
The use of an anterior-posterior (AP) and lateral views allow the practitioner
to determine the precise location of the needle before administering the
treatment. The AP view lets the practitioner how close to the midline, or how
medial the needle tip is placed. The lateral view shows the depth of the
needle. This allows for subtle adjustments so that the needle can be placed
accurately and without violation of the spinal canal.
 Basic Principles of Fluoroscopically-guided Procedures 3
Care should be exercised by the inter ventionalist to minimize their
exposure to radiation in the procedure suite. Radiation badges and rings
should be worn and monitored to keep record of year-to-date and lifetime
exposure. Lead aprons should be used to keep the soft-tissues, particularly the
gonads and thyroid, covered. X-ray reducing goggles should also be worn to
minimize eye exposure. X-ray reducing gloves may also be worn underneath
the sterile gloves when possible.
Planning the procedure ahead of time by noting on plain films and
magnetic resonance imaging (MRI)/computed tomography (CT) scan if there
is transition anatomy (lumbarization of S1, sacralization of L5), hardware,
osteophytes or obesity may also allow for reduced fluoroscopy times. A study
in obese individuals showed a significantly longer fluoroscopy times in obese
individuals.15
The use of pulsed, intermittent and half-dose fluoroscopy can reduce
exposures, particularly at noncritical portions of the placement of the needle.
Reducing the fluoroscopy time is also useful in so far as patient and procedure
safety are not compromised.
The top of the C-arm is known as the image intensifier and the bottom is
the source of the X-ray. Keeping farther away from the source when possible
will reduce the interventionalists exposure, as well as the scatter of the X-ray
from the patient. The X-ray exposure will decrease as an inverse square of
the distance from the source.16 Placing lead over the patient in areas outside
of the field, when practical, may reduce scatter.17
Potential risks of radiation exposure include cataracts, radiation burns
and various types of cancers.18 These risks are cumulative and monthly
readings are essential for helping to alert the practitioner of their exposure.

Parallax
Maximizing safety, minimizing risk and improving accuracy are all part of
advantages in the use of fluoroscopy in interventional spine procedures.
Knowing how to position the patient and how to obtain ideal images in set-up
helps also to expedite the procedure and reduce patient discomfort through
reducing needle manipulation.
The top of the fluoroscopy unit, the image intensifier, can be thought of
as the physicians eyes. The picture on the screen represents the X-ray image
of the segment at that angle. If the needle is placed in line with the beam, it
will appear as a dot with the hub of the needle visible (Fig. 1.1). Following
the beam, or following this target trajectory, allows for minimal needle
manipulation. The concept of aligning the needle with the X-ray beams is also
known as parallax.
4 Interventional Spine ProceduresA Case-based Approach

Fig. 1.1: Sacroiliac denervation. Note the needle over the right L5 dorsal
ramus is seen in parallax, while the needles placed below are not

CONTRAST
Nonionic iodinated contrast allows the interventionalist to confirm that the
medication is placed in the desired location. The use of extension tubing
allows for the live injection of contrast while keeping the hands out of the
field and reducing X-ray exposure. While aspiration of blood is a specific
indicator of vascular placement, it is not sensitive.19,20
Patients with known allergy to iodine need to have proper medication
prophylaxis and monitored during and after the procedure (see Chapter 15:
Adverse Reactions to Medications). Attempts to minimize the amount of
contrast injected should be made within reason.

ANTICOAGULANTS
Differing opinions exist regarding the cessation of anticoagulants during
interventional spine procedures. Spinal injections in fully anticoagulated-
patients are generally contraindicated.21,22 Clearance from the prescribing
physician is essential, and the risks and benefits need to be weighed by both
physicians prior to scheduling the procedure.
Nonsteroidal anti-inflammatory agents are generally accepted to be
safe for most nonsurgical interventional spine procedures.23 A survey of
interventional pain physicians showed that most held antithrombotics
prior to procedures and fewer held nonsteroidal anti-inflammatory drugs
(NSAIDs).24 While not a standard, below is the authors practices antico
agulation protocol.
 Basic Principles of Fluoroscopically-guided Procedures 5

Protocol for Holding Anticoagulants25-27

The following anticoagulant holding schedule is recommended prior to
spinal procedures (clearance must be obtained from the prescribing physi-
cian first):
Ticlopidine (Ticlid): Hold for 14 days
Aspirin: Hold for 7 days
including: Alka-Seltzer, Anacin, Fiorinal, Ascriptin, Bayer, Bufferin,
Lortab ASA, Dar von, Ecotrin, Excedrin, Percodan, Midol, Pepto-
Bismol, Talwin
Clopidogrel (Plavix): Hold for 7 days
Dipyridamole (Aggrenox or Persantine): Hold for 7 days
Cilostazol (Pletal): Hold for 7 days
Pentoxifylline (Trental): Hold for 7 days
Agrylin (Anagrelide): Hold for 7 days
Prasugrel (Effient): Hold for 7 days
Ticagrelor (Brilinta): Hold for 7 days
Warfarin (Coumadin): Hold for 5 days
INR (drawn day before or day of procedure) should be below 1.3 to
proceed with injection
Dabigratan (Pradaxa): Hold for 5 days
Rivaroxaban (Xarelto): Hold for 5 days
Apixaban (Eliquis): Hold for 5 days
NSAIDs: Hold for 5 days for cervical and thoracic procedures. Does not
need to be held for lumbar and hip procedures
including: Diclofenac, Etodolac, Fenoprofen, Flurbiprofen, Ibupro-
fen, Indomethacin, Ketoprofen, Ketorolac, Meloxicam, Nabumetone,
Naproxen, Oxaprozin, Piroxicam, Sulindac, Celebrex
Fondaparinux (Arixtra): Hold for 2448 hours
Enoxaparin (Lovenox): Hold for 12 hours (prophylactic dose) or 24 hours
(therapeutic dose)
Heparin: Hold for 4 hours.
Herbal drugs (specifically garlic, ginseng and gingko) seem to represent
no added significant risk for the development of spinal hematoma in patients
having epidural or spinal anesthesia.

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surgery: comparison of chlorhexidine-ethanol and povidone-iodine. Chemo-
therapy. 2010;56:261-7.
11. Kasuda H, Fukuda H, Togashi H, et al. Skin disinfection before epidural
catheterization: comparative study of povidone-iodine versus chlorhexidine
ethanol. Dermatology. 2002;204 (Suppl 1): 42-6.
12. Bell BP, Khabbaz RF. Responding to the outbreak of invasive fungal infections:
the value of public health to Americans. JAMA. 2013;309:883-4.
13. Smith RM, Schaefer MK, Kainer MA, et al. Fungal infections associated with
contaminated methylprednisolone injectionsPreliminary Report. The New
England Journal of Medicine; 2012.
14. Kainer MA, Reagan DR, Nguyen DB, et al. Fungal infections associated with
contaminated methylprednisolone in Tennessee. The New England Journal of
Medicine. 2012;367:2194-203.
15. Smuck M, Zheng P, Chong T, et al. Duration of fluoroscopic-guided spine inter-
ventions and radiation exposure is increased in overweight patients. PM & R:
The Journal of Injury, Function, and Rehabilitation. 2013;5:291-6.
16. Shafiei SA, Hassanzadeh H. A simple calculation method for determination
of equivalent square field. Journal of Medical Physics/Association of Medical
Physicists of India. 2012;37:107-11.
17. Manchikanti L, Cash KA, Moss TL, et al. Effectiveness of protective measures
in reducing risk of radiation exposure in interventional pain management: a
prospective evaluation. Pain Physician. 2003;6:301-5.
 Basic Principles of Fluoroscopically-guided Procedures 7
18. Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of
ionizing radiation: assessing what we really know. Proceedings of the National
Academy of Sciences of the United States of America. 2003;100:13761-6.
19. Furman MB, OBrien EM, Zgleszewski TM. Incidence of intravascular
penetration in transforaminal lumbosacral epidural steroid injections. Spine.
2000; 25:2628-32.
20. Furman MB, Giovanniello MT, OBrien EM. Incidence of intravascular penetra-
tion in transforaminal cervical epidural steroid injections. Spine. 2003;28:21-5.
21. Gogarten W, Vandermeulen E, Van Aken H, et al. Regional anaesthesia
and antithrombotic agents: recommendations of the European Society of
Anaesthesiology. European Journal of Anaesthesiology. 2010;27:999-1015.
22. Millar FA, Mackenzie A, Hutchison G, et al. Hemostasis-altering drugs and cen-
tral neural block. A survey of anesthetic practice in Scotland and the United
Kingdom. Regional Anesthesia. 1996;21:529-33.
23. Horlocker TT, Bajwa ZH, Ashraf Z, et al. Risk assessment of hemorrhagic
complications associated with nonsteroidal antiinflammatory medications
in ambulatory pain clinic patients undergoing epidural steroid injection.
Anesthesia and Analgesia. 2002;95:1691-7, table of contents.
24. Manchikanti L, Benyamin RM, Swicegood JR, et al. Assessment of practice
patterns of perioperative management of antiplatelet and anticoagulant therapy
in interventional pain management. Pain Physician. 2012;15:E955-68.
25. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient
receiving antithrombotic or thrombolytic therapy: American Society of Regional
Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).
Regional Anesthesia and Pain Medicine. 2010;35:64-101.
26. Horlocker TT, Wedel DJ, Rowlingson JC, et al. American College of Chest P.
Executive summary: regional anesthesia in the patient receiving antithrombotic
or thrombolytic therapy: American Society of Regional Anesthesia and Pain
Medicine Evidence-Based Guidelines (Third Edition). Regional Anesthesia and
Pain Medicine. 2010;35:102-5.
27. Ortel TL. Perioperative management of patients on chronic antithrombotic
therapy. Hematology/American Society of Hematology Education Program.
2012;2012:529-35.
 Lumbar Disc Herniation
with Radiculopathy:
Selective Spinal Nerve 2
Injection
Lisa Marino, Jeremy Simon

CHIEF COMPLAINT
The patient complains about lower back pain and left thigh pain.

HISTORY OF PRESENTING ILLNESS

A 47-year-old right-handed male presents for consultation with complaints
of left-sided low back and buttock pain that radiates into the posterolateral
thigh with associated numbness into all five toes of the left foot on plantar
and dorsal aspects. He describes his pain as a constant burning type rated at
a 9/10 on the numeric pain scale. The pain began 4 months ago after playing
18 holes of golf and became progressively worse. The symptoms are
aggravated with standing, walking and lying down. He gets some relief with
sitting and medications. He denies fevers, chills, and/or night sweats. There
are no associated bowel or bladder symptoms, progressive weakness, saddle
anesthesia or night-time pain.
Treatment has consisted of physical therapy for 6 weeks, two
fluoroscopically-guided transforaminal epidural injections, hydrocodone and
celecoxib. The physical therapy offered no relief of pain. He underwent two L5
transforaminal epidural injections and received 210 days of subsequent pain
relief, after which the symptoms returned to baseline. The pain was interfering
with the patients sleep and ability to work as an elevator repairman. He had
a lumbar microdiscectomy at L5-S1 10 years prior with complete resolution
of his left lower extremity radicular symptoms until the aforementioned
episode. He was referred to a spinal interventionalist by the spine surgeon for
a series of diagnostic selective nerve root injections to determine if surgery
would be indicated.
 Lumbar Disc Herniation with Radiculopathy: Selective Spinal Nerve Injection 9

PAST MEDICAL/Surgical HISTORY

Lumbar microdiscectomy L5-S1 10 years prior

REVIEW OF SYSTEMS
Otherwise negative

FAMILY HISTORY
Mother alive and healthy, father deceased from head and neck cancer.

SOCIAL HISTORY
No alcohol, tobacco or illicit drug history. He is married, with two children.
Employed fulltime in elevator repair and construction, no workmens
compensation claims.

CURRENT MEDICATIONS
Celecoxib 200 mg daily, Hydrocodone/apap 10/325 one to two tablets daily
to bid prn pain.

ALLERGIES
None

PHYSICAL EXAMINATION
Height: 67, Weight: 275 lbs, Pulse: 84/min, Blood Pressure (BP):
132/88 mm Hg. The patient was pleasant, conversant, well developed,
oriented and in no acute distress. Affect and mood were normal. Rapid
alternating movement was unremarkable. The patient demonstrated no overt
pain behavior and was fully cooperative with the examination. Inspection and
palpation did not identify significant misalignment, atrophy or asymmetry in
the head, neck, thoracolumbar spine and lower limbs. There was no evidence
of dislocation or fracture in the neck, back, and either lower limb. The
pelvis was level without evidence of significant scoliosis. The patient had an
antalgic gait favoring left lower extremity weight bearing. Toe and heel walk
were intact. Lumbar flexion, extension, rotation and side bending range of
motion were diminished in all planes by 50% secondary to pain. Bilateral
hip and knee range of motion was grossly functional and symmetric.
Strength testing was 5/5 in the hip flexors, extensors, knee flexors, extensors,
dorsiflexors, everters, inverters and extensor hallucis longus (EHL) as well
10 Interventional Spine ProceduresA Case-based Approach

as grossly in the neck, spine and pelvis. Sensation to light touch and distal
pulses were within normal limits in the lower limbs. The trunk and lower
limbs were without evidence of lymphadenopathy, edema or rash. Muscle
stretch reflexes were 2+ and symmetric in the knees and ankles without
upper motor neuron signs. Straight leg raise test was negative, but reproduced
left thigh pain.

IMAGING STUDIES
Radiographs of the lumbar spine were reviewed. There were posterior-
anterior, lateral, flexion and extension views. Five normal appearing
lumbar vertebrae were present without evidence of fracture, spondylolysis
or spondylolisthesis. There was evidence of decreased disc height at the
L3-4, L4-5 and L5-S1 levels and evidence of a left hemilaminotomy.
Magnetic resonance imaging (MRI) of the lumbar spine showed moderate
degenerative changes at the L3-4 and L4-5. L5-S1 disc was significantly
degenerated. A disc bulge was present at all three lower lumbar levels with
lateral recess stenosis at L3-4 and L4-5. L5-S1 had severe bilateral foraminal
stenosis with evidence of a hemilaminotomy.

ELECTRODIAGNOSTIC STUDIES
Electromyography (EMG)/Nerve conduction studies (NCS) of the bilateral
lower extremities were normal.

DIAGNOSIS
Lumbar radiculopathy

TREATMENT
The patient presented to the clinic with several conservative treatments
producing unsuccessful outcomes including medication management,
physical therapy and therapeutic spinal inter ventions. Certainly, in the
absence of neurological dysfunction, conservative measures should be tried
before surgical intervention. Nonetheless, the patient was significantly limited
by pain and was interested in pursuing definitive treatment. Subsequent to
surgical consultation, it was determined that if further testing confirmed an
L5 radiculopathy surgery would be indicated.
The patient presented with severe left-sided buttock and thigh pain
associated with foot numbness. There were several diagnoses that could
be the cause of his symptoms including lumbar radiculopathy, sacroiliac
joint dysfunction, hamstring tendonitis, lumbar internal disc disruption
 Lumbar Disc Herniation with Radiculopathy: Selective Spinal Nerve Injection 11
syndrome with somatic referral and piriformis syndrome, among others.
Although symptoms associated with standing and walking are expected with
radiculopathy from spinal stenosis, the patients pain radiated only into a
portion of the L5 dermatome, not the classic area below the knee, making the
diagnosis of L5 radiculopathy indeterminate.
The physical examination offered little evidence of lumbar radiculopathy.
The patient had no dural root tension signs, myotomal weakness or
dermatomal patterns of sensory disturbance that is often seen with lumbar
radiculopathy.
The normal NCS/EMG was not supportive for ruling in the presence of
acute radiculopathy. Electrodiagnostic evidence of radiculopathy can often
be absent, with test sensitivity ranging from 49% to 92%.1 Therefore, the
patients normal study did not exclude a lumbar radiculopathy as a source
of his pain. Even if the NCS/EMG showed evidence of a chronic lumbar
radiculopathy, it would not be useful given his previous history of lumbar
surgery for left-sided lumbar radiculopathy.
The imaging studies showed three lower lumbar discs with abnormalities
and varying degrees of lateral recess and foraminal stenosis; any of which
could contribute to the patients symptoms.
The short-term pain relief from the L5 transforaminal injection did not
definitively indicate that the L5 nerve root was the pain generator. The L5
transforaminal injection was performed with both steroid and lidocaine and
subsequent pain relief could have been a systemic steroid response.
Lumbar internal disc disruption syndrome was a consideration as a
source of the patients pain; therefore lumbar discography could have been
an alternate diagnostic procedure. However, the use of discography for
accurately pinpointing a pain generator is a controversial topic. In a study
by Berg et al. discography was shown to influence surgical decision making
in up to 72% of cases, thus supporting its use.2 Opposing arguments report a
best-case positive predicted value for provocative discography to be 5060%,
meaning that a positive discogram does not necessarily correlate with effective
pain relief after fusion of the proposed painful disc.3 Additionally, modern
discography methods have been shown to accelerate the degenerative
changes of the disc on imaging studies.4
In this case, lumbar radiculopathy was the leading differential diagnosis
for the patient, however further diagnostic information was desired by the
surgeon. Lumbar disc herniation with radiculopathy. Selective nerve root
injections in conjunction with a pain diary would help to clarify the presence
of an L5 radiculopathy since the other studies and physical examination was
equivocal.
Diagnostic selective nerve injections have been used since the 1970s to
determine sources of pain and have been shown to provide a sensitivity of
9095%.5,6 False positives can occur but can be minimized with appropriate
injection technique.6,7 A diagnostic selective nerve root injection was
12 Interventional Spine ProceduresA Case-based Approach

recommended in this case because less invasive testing was unable to

accurately pinpoint the pain generator of the abnormal radicular pattern. The
surgeon requested an L3, L4 and L5 diagnostic selective nerve root injection
for confirmation of the suspected diagnosis of L5 radiculopathy. A positive
diagnostic injection would change treatment, since the patient would be a
surgical candidate if pain was relieved with the test injection.
Given the patients pain distribution into the posterior thigh, an S1
selective nerve block could also be considered. In this case, the selective nerve
root injections were requested to determine if surgical intervention would be
of benefit. The L3, L4 and L5 nerve roots had the most compressive pathology
on MRI making them a potential for decompressive surgical intervention and
therefore were the only nerves selected for targeted diagnostic injections.
Diagnostic injections should be performed one nerve level per visit. The
patient should complete a pre- and post-injection standard pain drawing
and a numeric pain rating scale. The injection should be performed with
fluoroscopic guidance and contrast dye confirmation of nerve outline. The
spinal nerve and the dorsal root ganglion are the desired target.
In this case, informed consent was obtained and risks of the procedure
were reviewed with the patient which include, but were not limited to
infection, allergic reaction, nerve damage, paralysis, epidural hematoma,
syncope, headache, respiratory or cardiac arrest, worsening pain and scar
formation.
Vital signs were monitored prior to, during, and after the procedure.
The patient was placed in the prone position on the fluoroscopy table.
The C-arm was rotated to a slightly oblique and ipsilateral position. The
lumbar area was prepped and draped in the usual sterile fashion. Next, the
L5 neuroforamen was identified under fluoroscopic guidance. A small skin
wheel was raised over the insertion site with local anesthetic. Using a sterile
technique, a 22-gauge, 3.5-inch spinal needle was inserted into the skin.
Under intermittent fluoroscopic guidance, the needle was advanced towards
the foramen in the oblique position aiming for the uppermost aspect of the
superior articular process and just inferior to the pedicle. Once the needle
entered the muscle adjacent to the spine, the C-arm was rotated to the anterior-
posterior view. The needle was then advanced into the safe triangle,8 inferior
to the 6 oclock position of the pedicle and superolateral to the exiting spinal
nerve. The borders of the safe triangle are the horizontal base of the pedicle,
the traversing nerve as the hypotenuse, and the posterolateral border of the
vertebral body. The needle position was checked in the anterior-posterior
and lateral positions.
Extension tubing was then attached to the spinal needle and under live
fluoroscopy 12 milliliters of contrast dye was injected to verify spinal nerve
and dorsal root ganglion outline. The injection of contrast medium should
be slow, about 1 mL per 20 seconds; this was done to determine the volume
 Lumbar Disc Herniation with Radiculopathy: Selective Spinal Nerve Injection 13

Fig. 2.1:Pain diagram pre-selective spinal nerve and post-selective spinal nerve
injection performed for the left L5 spinal nerve. Note the patient reports 90% relief of
his typical pain

needed to outline the targeted nerve. The volume needed of contrast dye to
outline the nerve should be the same volume used for the local anesthetic.
The contrast should flow along the surface of the nerve outlining the dorsal
root ganglion and the nerve root sleeve. Medially the dye should curve up
around the pedicle and laterally should outline the nerve. No vascular uptake,
subarachnoid flow, or epidural spread to adjacent levels should be noted on
live fluoroscopic views.
After aspiration was negative for return of blood or cerebrospinal fluid,
0.5 mL of 0.25% Bupivacaine was injected. The needle was then removed
intact. The area was cleansed and a band-aid was applied to the injection site.
Twenty minutes after the injection, the patient completed the post-
injection pain drawing and numeric pain scale.
The same procedure was repeated at the L4 and L3 nerve levels at one-
week intervals. Each time the patient filled out a pre- and post-injection pain
assessment.
The patient had 90% pain relief after the L5 selective nerve root injection
(Fig. 2.1) and no pain relief after the L4 and L3 nerve injections (Fig. 2.2).
14 Interventional Spine ProceduresA Case-based Approach

Any pain relief over 80% would have been considered a positive diagnostic
injection.9 The patient was given a copy of the three pre- and post-injection
pain diagrams for the surgeon. The diagnostic selective nerve injections were
useful in diagnosing an atypical L5 radiculopathy (Fig. 2.3). The surgeon
was confident in the responses of the diagnostic injections and went on to
perform an anterior and posterior L5-S1 interbody fusion. Postoperatively,
the patient had 90% relief of his symptoms and resumed his previous
functional level.
It is important to note that while the diagnostic injections can more
accurately pinpoint the pain generator when conventional methods fail, they
cannot predict surgical outcomes. Additionally, false positives can occur if
the procedure is not carried out correctly. Improper spread of the anesthetic
to other nerve root levels or around the sinuvertebral nerve can anesthetize
nontargeted potential pain generators.10 A proper contrast dye flow pattern
and small volume of anesthetic (less than half a milliliter) can reduce some of
these concerns.11

Fig. 2.2:Pain diagram pre-selective spinal nerve injection and post-selective spinal
nerve injection performed for the left L3 and L4 spinal nerves. Note that the patient
reports 0% relief of his typical pain
 Lumbar Disc Herniation with Radiculopathy: Selective Spinal Nerve Injection 15

Fig. 2.3:Left L5 selective spinal nerve injection. Note the contrast along the spinal
nerve, but not extending past the medial border of the L5 pedicle

SUMMARY
Selective nerve root injections can be a useful tool for diagnosing an atypical
presentation of radicular pain. The indication for such a procedure includes
an atypical radicular pattern with equivocal findings on physical examination
and diagnostic studies. This intervention should be considered only when the
resulting diagnostic information would impact the treatment intervention.

REFERENCES
1. Dillingham TR. Electrodiagnostic approach to patients with suspected
radiculopathy. Physical Medicine and Rehabilitation Clinics of North America.
2002;13:567-88.
2. Berg S, Isberg B, Josephson A, et al. The impact of discography on the surgical
decision in patients with chronic low back pain. The Spine Journal: Official
Journal of the North American Spine Society. 2012;12:283-91.
3. Carragee EJ, Lincoln T, Parmar VS, et al. A gold standard evaluation of the
discogenic pain diagnosis as determined by provocative discography. Spine.
2006;31:2115-23.
4. Carragee EJ, Don AS, Hurwitz EL, et al. 2009 ISSLS Prize Winner: Does
discography cause accelerated progression of degeneration changes in the
lumbar disc: a ten-year matched cohort study. Spine. 2009;34:2338-45.
5. Krempen JF, Smith BS. Nerve-root injection: a method for evaluating the
etiology of sciatica. The Journal of Bone and Joint Surgery American volume.
1974;56:1435-44.
6. Huston CW, Slipman CW. Diagnostic selective nerve root blocks: indications
and usefulness. Physical Medicine and Rehabilitation Clinics of North America.
2002;13:545-65.
16 Interventional Spine ProceduresA Case-based Approach

7. Slipman CW, Issac Z. The role of diagnostic selective nerve root blocks in the
management of spinal pain. Pain Physician. 2001;4:214-26.
8. Bogduk N, Aprill CN, Derby R. Epidural spinal injections. St. Louis: Mosby; 1995.
9. Derby R, Kine G, Saal JA, et al. Response to steroid and duration of radicular
pain as predictors of surgical outcome. Spine. 1992;17:S176-83.
10. Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar
intervertebral discs. Journal of Anatomy. 1981;132:39-56.
11. Furman MB, Lee TS, Mehta A, et al. Contrast flow selectivity during
transforaminal lumbosacral epidural steroid injections. Pain Physician. 2008;
11:855-61.
 Lumbar Disc Herniation
with Radiculopathy:
Lumbar Transforaminal 3
Epidural Steroid Injection
Natacha Falcon, Jeremy Simon

CHIEF COMPLAINT
The patient complains about low back pain with left leg pain.

HISTORY OF PRESENT ILLNESS

This patient is a 32-year-old right-handed male with a history of lower
back pain for 2 years. He has a history of an L5-S1 microdiscectomy
6 months ago for recalcitrant low back and left lower extremity pain. The pain
reoccurred 1 month ago while lifting a heavy piece of equipment at work.
After the event, he began experiencing lower back pain with radiation into
the left lower extremity. He rated the back pain as 4/10, and the left radicular
symptoms as an 8/10. He describes the pain as an achy and sharp pain in
the lower lumbar area with a burning pain into the posterior lateral aspect of
his thigh and leg. The pain is constant and aggravated by sitting, bending and
twisting. Standing and changing positions frequently help reduce his pain. The
pain is similar to the pain he experienced previously prior to his surgery.
The patient has had an epidural steroid injection with transient relief of
his pain prior to his left L5-S1 microdiscectomy. The surgery did provide the
patient with resolution of his symptoms, until the above mentioned work
injury.
He denies any weakness, bowel or bladder incontinence. He takes anti-
inflammatories occasionally with mild pain relief. He attended physical
therapy for 2 weeks without relief of his symptoms.

REVIEW OF SYSTEMS
Denies
18 Interventional Spine ProceduresA Case-based Approach

PAST MEDICAL HISTORY

The patient denies any past medical history.

SURGICAL HISTORY
Left L5-S1 microdiscectomy 6 months prior.

MEDICATIONS
Ibuprofen

ALLERGIES
No known drug allergies.

FAMILY HISTORY
Noncontributory

SOCIAL HISTORY
Alcohol socially, no tobacco, or drug use. He works in construction but admits
he does not follow his lifting restrictions as outlined after surgery.
The pain diagram of the patient is shown in Figure 3.1.

PHYSICAL EXAMINATION
General: Pleasant, cooperative, alert and oriented, no acute distress.
Inspection: No asymmetry, no evidence of scoliosis, well-healed scar
consistent with prior lumbar surgery.
Gait: Non-antalgic, able to ambulate on heels, toes and tandem without
difficulty.
Range of Motion: Limitations in flexion with more pain reproduction in flexion
than extension.
Neurological:
Strength: Manual muscle testing 5/5 with exception of left dorsiflexion
and extensor hallucis longus 4/5
Sensation: Decreased light touch and pinprick over dorsum of foot on the
left
Reflexes: Symmetrical bilateral patellae and Achilles reflex
Provocative: Straight leg raise and sitting dural tension signsnegative.
Musculoskeletal: Hip internal and external with pain free normal range
of motion, FABER (Flexion, abduction, external rotation) test: negative
bilaterally.
 Lumbar Disc Herniation with Radiculopathy 19

Fig. 3.1: Pain diagram

IMAGING
Lumbar spine X-rays: Normal segmentation. No scoliosis. No evidence for
fractures or spondylolisthesis. There is evidence of a prior laminotomy on the
left at L5-S1. Reduced disc space height is noted at L5-S1.
Lumbar spine MRI with and without Gadolinium: Recurrent left paracentral
disc herniation at L5-S1. Loss of lumbar lordosis is noted, likely secondary
to muscle spasms. Moderate degenerative disc disease at L5-S1 and interval
left L5-S1 hemilaminectomy. Postcontrast images show enhancing scar
and granulation tissue at the left paraspinal region without abnormal fluid
collection.

DIAGNOSIS
Lumbar radiculopathy; Left L5-S1; secondary to recurrent left paracentral
disc herniation.
20 Interventional Spine ProceduresA Case-based Approach

NONINTERVENTIONAL TREATMENT OPTIONS

Conservative management of radicular pain begins with activity modifi
cations and physical therapy. The focus of physical therapy is improvement
in functional abilities, centralization of pain, body mechanics education,
and instruction in individualized home exercise program (HEP). Physical
therapy that emphasizes the McKenzie approach has been shown to aid in
centralization of pain.1,2 Centralization of pain refers to movement of the pain
from the leg or buttock and into the low back.1 Modalities such as ice, heat,
ultrasound and transcutaneous electrical stimulation (TENS) may provide
additional analgesic benefits as well.3,4 Physical therapy aids in return to
function and minimizes the sequela of immobility.
Medication management is used to decrease acute pain, so patients may
better able return to function. Oral corticosteroids are often prescribed for
radicular pain, although there is a lack of evidence supporting its use in this
condition.5 Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for
short-term symptomatic relief in patients with acute low back pain.6 Muscle
relaxants may be used acutely for spasms and pain. Non-narcotic and narcotic
pain medications may be utilized if the patient is not responsive to physical
therapy and NSAIDs alone, or should the patient have a contraindication
to taking NSAIDs. Neuropathic agents such as gabapentin and pregabalin
may be utilized as well for radicular pain. These agents presumably work by
binding to the voltage-gated calcium channels and may serve to stabilize
hyperexcitable axons.7 Some antidepressant medications, such as tricyclic
antidepressants, have been shown to be efficacious with neuropathic pain
as well and are believed to work by increasing the amount of norepinephrine
and serotonin in the presynaptic membrane, as well as other proposed
mechanisms.7,8

INTERVENTIONAL OPTIONS
Lumbar Transforaminal
Epidural Steroid Injection (LTFESI)
Lumbar radicular pain (sciatica) is defined as pain referred from the back into
the dermatome of the affected nerve root along the femoral or sciatic nerve
trunk. Radiculitis implies there are no neurological deficits; radiculopathy
implies there are neurological deficits such as motor or sensory abnormalities.
In the absence of neurologic deficits (progressive weakness, bowel
or bladder incontinence) and failure of conservative measures (physical
therapy and medication management) consideration of an epidural steroid
injection is appropriate. Thus far, evidence is conflicting regarding the
efficacy of epidural steroid injections. In clinical practice, many patients find
relief in epidural steroid injections. There is no one single intervention that
 Lumbar Disc Herniation with Radiculopathy 21
will help all patients with radicular pain. Time since onset of symptoms is one
prognostic indicator of success with epidural steroid injections. Some data
indicates that patients with acute radicular pain (less than 3 months) respond
better to transforaminal injections than those with radicular symptoms
greater than one year.9
Transforaminal injections have been shown to be efficacious for lumbar
radicular pain and may potentially eliminate the need for surgery.10 A
combination of physical therapy and epidural steroid injections are usually
effective for patients with herniated nucleus propulsus (HNP) to avoid
surgery, as indicated in trial of Riew et al.10
Potential complications of lumbar transforaminal epidural steroid
injections have been reported.11-14 The use of fluoroscopy with live
injection of contrast significantly reduces the risk of vascular injection.15
Utilization of digital subtraction angiography, while not available on all
fluoroscopy units, may add additional safety in identifying vascular flow.
A case report showed a resultant paraplegia with a right L5 transforaminal
epidural steroid injection with triamcinolone despite digital subtraction,
however.16 Paraplegia most commonly results from embolization of a
particulate steroid into a vessel that communicates with the spinal cord.14

PATIENT DISCUSSION
The patient has a past medical history significant for a previous left L5-S1
microdiscectomy with complete resolution of his symptoms. He had surgical
intervention following failed conservative measures of physical therapy,
medication management, and an epidural steroid injection.
The patient now has a return of his symptoms with magnetic resonance
imaging (MRI) evidence of a recurrent disc herniation.

PLAN
Patients pain pattern is in the L5-S1 dermatomal distribution. He has motor
weakness in his left dorsiflexion (L4-5) and left extensor hallucis longus (L5). He
has sensory changes over the dorsum of his left foot (L5). He has MRI evidence
of a recurrent left paracentral disc herniation at L5-S1. It is minimally contacting
the left S1 nerve root and is causing significant lateral recess narrowing. There is
also moderate left neural foraminal narrowing, thus explaining the patients L5
pattern of involvement. Given his history, physical examination findings, and
MRI results, a left L5-S1 transforaminal epidural steroid injection (TFESI) was
ordered (Fig. 3.2).
A S1 TFESI could have been considered as well, as a paracentral disc
herniation will likely affect the traversing S1 nerve root, and a far lateral
disc herniation would likely affect the L5 spinal nerve. Due to the patients
22 Interventional Spine ProceduresA Case-based Approach

Fig. 3.2: Left L5 transforaminal epidural steroid injection. Note the flow of contrast
extending medial to the pedicle and extending to the L4-L5 disc space

presentation in the L5 dermatomal distribution, a second level was not

deemed necessary.

Left L5-S1 Transforaminal

Epidural Steroid Injection
The risks, benefits and alternatives of the procedure were discussed
extensively with the patient. Risks discussed included but were not limited
to bleeding, infection, allergic reaction and structural damage. Written
informed consent was obtained from the patient and then the following
procedure was performed.
The patient was placed in the prone position on the fluoroscopy table.
The C-arm was rotated to a slightly oblique and ipsilateral position. The
lumbar area was prepped and draped in the usual sterile fashion. Next, the
left L5-S1 neuroforamen was identified under fluoroscopic guidance. Using
sterile technique, the superficial skin was anesthetized with 1% Lidocaine
(preservative-free) using a 25-gauge, 1-inch needle. Next, a sterile 22-gauge
(5-inch) spinal needle was advanced down to the 6 oclock area of the pedicle
under intermittent fluoroscopic guidance, tar geting the superior, lateral
aspect of the safe triangle. Multiplanar fluoroscopic imaging was used to
further verify needle placement. One cc of Omnipaque-240 contrast was
injected through microbore tubing under live fluoroscopy. There was no
intravascular uptake observed. There was a medial and superior epidural
flow pattern observed. After aspiration was negative for return of blood or
cerebrospinal fluid, a solution of 2 mL of Kenalog (40 mg/mL) and 2 cc of 1%
Lidocaine (preservative-free) was injected into the left neuroforamen at the
L5-S1 level.
 Lumbar Disc Herniation with Radiculopathy 23
The needle was then removed. No blood or cerebrospinal fluid (CSF) was
noted to be draining, and a sterile band-aid was applied after pressure was
applied with a gauze pad. Pulse oximetry was used throughout the procedure
and the patients pulse and oxygen saturation remained within normal limits.
Vital signs remained normal and were monitored for an additional 20 minutes.
The patient tolerated the procedure well. There were no complications noted
and no new neurological complaints.
The patient was instructed to apply local ice over the injected site for 1015
minutes for the next 2448 hours. The patient was instructed by the authors
to contact them if there are any problems. A postprocedure instruction sheet
was given.
Fluoroscopy was utilized to ascertain that the needle was placed as close
as possible to the source of pathology, and that the injectate was not injected
into a blood vessel or into the thecal sac.
Anterior-posterior, oblique and lateral views were checked and it was
ascertained that the Omnipaque is in the epidural space at the L5-S1 level
on the left side. Pictures were taken to document accurate placement of the
medication (see Fig. 3.2).
At the patients follow-up visit, 2 weeks after the left L5-S1 TFESI, he had
marked improvement in his low back and lower extremity pain. His pain
scores had improved to 4/10 in his lower back and 1/10 in his lower extremity.

REFERENCES
1. Wheeler AH. Diagnosis and management of low back pain and sciatica.
American Family Physician. 1995;52:1333-41, 1347-8.
2. Taylor MD. The McKenzie method: a general practice interpretation: the lumbar
spine. Australian Family Physician. 1996;25:189-93, 196-7, 200-1.
3. Brosseau L, Milne S, Robinson V, et al. Efficacy of the transcutaneous electrical
nerve stimulation for the treatment of chronic low back pain: a meta-analysis.
Spine. 2002;27:596-603.
4. Milne S, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation
(TENS) for chronic low back pain. Cochrane database of systematic reviews
2001:CD003008.
5. Haimovic IC, Beresford HR. Dexamethasone is not superior to placebo for
treating lumbosacral radicular pain. Neurology. 1986;36:1593-4.
6. van Tulder MW, Scholten RJ, Koes BW, et al. Non-steroidal anti-inflammatory
drugs for low back pain. Cochrane database of systematic reviews
2000:CD000396.
7. Lipetz JS, Malanga GA. Oral medications in the treatment of acute low back
pain. Occup Med. 1998;13:151-66.
8. Staiger TO, Gaster B, Sullivan MD, et al. Systematic review of antidepressants in
the treatment of chronic low back pain. Spine. 2003;28:2540-5.
9. Slipman CW, Derby R, Simeone FA, et al. Interventional spine: an algorithmic
approach. Philadelphia, PA: Elsevier; 2008.
24 Interventional Spine ProceduresA Case-based Approach

10. Riew KD, Yin Y, Gilula L, et al. The effect of nerve-root injections on the need
for operative treatment of lumbar radicular pain: a prospective, randomized,
controlled, double-blind study. The Journal of Bone and Joint Surgery, American
volume. 2000;82-A:1589-93.
11. Krause D, Guiu B, Lerais J-M, et al. Lumbar transforaminal epidural injections:
evaluation of potential risks and complications. Journal de radiologie. 2010;
91:1086-92.
12. Karaman H, Kavak GO, Tufek A, et al. The complications of transforaminal
lumbar epidural steroid injections. Spine. 2011;36:E819-24.
13. Goodman BS, Posecion LW, Mallempati S, et al. Complications and pitfalls of
lumbar interlaminar and transforaminal epidural injections. Current Reviews
in Musculoskeletal Medicine. 2008;1:212-22.
14. Kennedy DJ, Dreyfuss P, Aprill CN,et al. Paraplegia following image-guided
transforaminal lumbar spine epidural steroid injection: two case reports. Pain
Medicine. 2009;10:1389-94.
15. Furman MB, OBrien EM, Zgleszewski TM. Incidence of intravascular
penetration in transforaminal lumbosacral epidural steroid injections. Spine.
2000;25:2628-32.
16. Chang Chien GC, Candido KD, Knezevic NN. Digital subtraction angiography
does not reliably prevent paraplegia associated with lumbar transforaminal
epidural steroid injection. Pain Physician. 2012;15:515-23.
 Lumbar Spinal Stenosis 4
with Radiculopathy
Michael Molter, Jeremy Simon

CHIEF COMPLAINT
The patient complains about low back pain and pain in both legs.

HISTORY OF PRESENT ILLNESS

The patient is a pleasant 57-year-old male with low back and bilateral lower
extremity pain. The symptoms have been present over the last 6 months. The
axial component is located in the lower lumbar spine and is described as a
constant ache. There are times when it becomes sharp in nature primarily
with moving from a bent position to an erect posture. It radiates across the
lower back region. These symptoms are associated with paresthesias and
pain in the bilateral lower extremities. Both legs affected equally. The leg
pain is constant, located over the anterior thigh to the dorsal aspect of his feet
(Fig. 4.1Pain diagram). He rates the pain level at 7/10 on a numeric scale
today and is anywhere from 59/10 on average. His back pain and leg pain
are equal in regards to their severity and how they affect his regular activities.
Sitting is the only thing that has helped his symptoms. His symptoms are
worse with walking and standing for extended periods of time. Furthermore,
he feels unstable when he has to ambulate any significant distance
secondary to the pain in his legs. He denies any associated bowel or bladder
incontinence/retention, fever, chills, night sweats, unintentional weight loss,
progressive weakness or saddle type anesthesia. The pain does not waken
him at night, but he is often sleeping in a reclining chair due to pain with
lying in bed. He has had no treatments in regards to therapy, injections, or
medications at this time.
26 Interventional Spine ProceduresA Case-based Approach

Fig. 4.1: Pain diagram

PAST MEDICAL HISTORY

Significant for a history of a deep vein thrombosis (DVT), since resolved,
hypertension, osteoarthritis and venous insufficiency.

PAST SURGICAL HISTORY

None

REVIEW OF SYSTEMS
Positive for low back pain as well as bilateral leg pain. Positive for hypertension,
osteoarthritis, as well as swelling in the lower extremities, DVT and reflux
disease.

FAMILY HISTORY
Diabetes mellitus
 Lumbar Spinal Stenosis with Radiculopathy 27

SOCIAL HISTORY
A 40-pack-year of tobacco use. He works as an engineering technician in
Navy yard, prior to that he worked directly in building at the Navy yard. He is
married. Ambulation is limited secondary to pain in his legs. He is only able
to ambulate a half of a block without pain in both legs.

MEDICATIONS
Coumadin, Norvasc, Zestril, Antivert and Omeprazole.

ALLERGIES
Ibuprofen sensitivity, when taken causes him severe vomiting.

PHYSICAL EXAMINATION
A 57-year-old male who appears his stated age, in no apparent distress.
Vital signs: blood pressure: 132/90 mm Hg, pulse: 80/min, height: 6 feet
4 inches, weight: 225 lbs, body mass index (BMI): 27.4.
Cardiovascular examination: Distal pulses intact in the lower extremities at
2/4 bilaterally. Nonpitting edema to level of ankle bilaterally. No calf pain is
noted bilaterally.
Musculoskeletal evaluation: His lower extremity range of motion is normal in
the knee and hip joints. No pain with range of motion testing in bilateral knee
or hip joints. No piriformis muscle, sacroiliac joint or greater trochanteric
tenderness to palpation is noted. He has paraspinal tenderness noted in
the right and left side. No spinous process tenderness is noted. No lumbar
paraspinal spasms are noted. His lumbar spine range of motion demonstrates
flexion to be normal and without pain. He has decreased extension to 10 degrees
secondary to pain in lumbar spine. Negative straight leg, slump, Patricks and
Gaenslens test bilaterally.
His neurologic examination demonstrates his reflexes to be 1+/4 bilaterally
in the lower extremities. There are no cerebellar signs noted. Manual muscle
testing in the bilateral hip flexors, hip extensors, tibialis anterior, extensor
hallucis longus (EHL) and gastrocsoleus is 5/5 bilaterally. He is oriented to
person, place and time. Normal muscle bulk and tone for age. Sensation
is intact to light touch, pinprick and proprioception in the bilateral lower
extremity dermatomes. Babinski reveals downgoing toes and Hoffmans sign
is negative bilaterally.
X-rays lumbar spine: Anterior/posterior, flexion and extension X-rays of the
lumbar spine demonstrate normal segmentation, no significant scoliosis,
28 Interventional Spine ProceduresA Case-based Approach

and mild degenerative changes noted at the L3-L4, L4-L5, and L5-S1 level
without spondylolysis or spondylolisthesis. There is no instability on flexion/
extension views.
Magnetic resonance imaging (MRI) lumbar spine: Multilevel lumbar
spondylosis central disc protrusion at L3-L4 as well as moderate central
stenosis at L4-L5 and L5-S1 levels. No significant neuroforaminal narrowing
is appreciated. No spondylolisthesis or spondylolysis noted.

DIAGNOSIS
Lumbar spinal stenosis with bilateral radiculopathy, L4-L5.

Discussion
His symptoms are consistent with L4 and L5 radiculopathy as the L4 and L5
dermatomes are affected. There is also associated lower back pain, decreased
lumbar spine range of motion, particularly with extension.
The word stenosis is derived from Greek and means narrow.
The prevalence of lumbar stenosis is estimated to be 2.45 million older men
and 3.54 million older women who have symptoms suggestive of central/
lumbar stenosis according to data from the 2000 census.1
This entity remains the number one preoperative diagnosis for adults
older than 65 years to have lumbar spine surgery.2 A long-term study of
lumbar stenosis patients has noted of patients followed 70% were unchanged,
15% improved, 15% worsened.3
Classification of lumbar stenosis is divided into congenital/developmental
which includes idiopathic and achondroplastic. The acquired type includes
degenerative (most common), combination of degenerative and congenital,
spondylytic/spondylolisthesthetic, iatrogenic, post-traumatic, and meta
bolic.4 Kirkaldy-Willis described the pathophysiology involving a three joint
complex of zygapophysial joints and the intervertebral disc. This process
leads to dysfunction, instability and finally stability of vertebral column.
Through a cascade of events, rotation and compression injuries cause
degenerative changes of the described three joint complex. The end result
is degeneration/loss of height of the intervertebral disc, hypertrophy of the
ligamentum flavum, and overgrowth of the lumbar zygapophysial joints,
leading to narrowing in the spinal canal.5
Lumbar spinal stenosis typically can involve lateral or central locations.
Central stenosis is found at the intervertebral level caused by multitude
of factors including ligamentum fla vum hypertrophy or buckling, disc
protrusion, hypertrophic zygapophysial joints and degenerative spondy
lolisthesis. Patients with central stenosis typically present with neurogenic
claudication symptoms.6 Lateral stenosis sympto matology results from
 Lumbar Spinal Stenosis with Radiculopathy 29
compression within the lateral recess area which is medial to pedicle, the
midzone located under the pars interarticularis and pedicle, and the exit
zone/neuroforaminal region.6 Hypertrophy of any of the structures can
result in radicular symptoms. It is believed that the radiating pain in the
lower extremities is caused by neural ischemia from compression of the vasa
nervorum, myelin sheath and axons or venous congestion.7
Patients with lumbar spinal stenosis present with neurogenic claudication,
increasing bilateral leg pain and paresthesias that are exacerbated with
prolonged standing and ambulation, and typically resolved by rest. Flexion
typically alleviates the patients symptomatology, where extension, walking
downhill can flare up the symptoms of patients.8

TREATMENT OPTIONS
Smoking cessation: With the patients noted 40-pack-year history of tobacco
use, he is at risk of increased degenerative changes as well as decreased
amount of blood flow and subsequent nutrition to the intervertebral disc.9
Weight loss: According to CDC specifications, the patients BMI of
27.4 puts him in the overweight category.10 Being overweight is associated
with increased risk of low back pain.11 It is shown that spine mobility and
disc nutrition decreases with increased body weight.12 This also leads to an
increase in compressive force throughout the spine during regular activities.13
A recommendation should be made to seek a nutritional evaluation for
further dietary alterations to alleviate increased axial loading secondary to
his increased body weight.
Due to multiple comorbidities, he was not a candidate for nonsteroidal
anti-inflammatory use. His chronic anticoagulant use in combination with
a nonsteroidals would put him at increased risk of bleeding secondary to
antiplatelet effect as well as gastric mucosal damage.14 Those older than
65 years of age, where patients taking both warfarin and nonsteroidals,
had a thirteen fold risk in hemorrhagic peptic ulcers than those taking
either drug.15 He did not have an interest in other pain medications due to
intolerance of opiates and muscle relaxers. Considerations for him could
include possible use of membrane stabilizing agent to help with some of his
radicular pain. One option for this may include gabapentin which acts to
decrease pain by modifying the excitability of nerve or muscle through effects
of sodium and calcium channels or by promoting the inhibition of gamma-
aminobutyric acid alpha (GABA-a) receptors.16,17 There has been an increased
incidence of lower extremity edema compared to placebo in studies of patients
taking gabapentin.18
Physical therapy: Physical therapy program in this case should be designed
to introduce mechanical changes to lumbar spine to open up neurovascular
30 Interventional Spine ProceduresA Case-based Approach

space through increased flexion as well as restoring intervertebral motion

of lumbar segments.19 Progression to a full flexion based program is tied to
first improving and restoring intersegmental motion. This can involve using
intervertebral glides and distraction techniques.20 The use of education,
awareness and exercises can aid in decreasing compressive loading forces on
the spine and improving posture.21 Finally, a general conditioning program
is essentially to long-term maintenance and improvement in conditioning.22
Recommendations are usually for a program two times a week for 4 weeks
with re-assessment by the physician at that time. After 4 weeks of physical
therapy, the patient noted some improvement in his lumbar spinal range
of motion and a slight improvement in his lower back pain. He also noted
doing a home exercise program on a daily basis as well. His leg symptoms
continued despite this intervention.
It was then decided to proceed with an L4-5 interlaminar epidural
steroid injection with the hope of reducing the patients pain and improving
his overall function. This level and approach was chosen secondary to the
fact that patients noted symptomatology corresponded with the L4 and L5
dermatomes and stenosis noted primarily in a central location.

Lumbar Interlaminar Injections

Indications: Studies are conflicting in the effectiveness of lumbar interlaminar
epidural steroid infections.40
Lumbar spinal stenosis
Lumbar neuroforaminal stenosis23
Interlaminar injections are based on approach to dorsal epidural space
by placing a needle between the laminae. The epidural space surrounds the
thecal sac and is bounded by the posterior longitudinal ligament anteriorly,
ligamentum flavum and periosteum of laminae posteriorly and the pedicles
of spinal column and intervertebral foramina containing their elements
laterally.24
Level injected: L4-L5 paramedian approach using a 20-gauge, 3 -inch Tuohy
needle.
The procedure was performed in block suite with fluoroscopic guidance.
Risks and benefits of the procedure were discussed with the patient. Consent
of the patient was obtained and the following procedure was performed.
The patient was placed in the prone position on the fluoroscopic table.
The back was prepped with Betadine and draped in the usual sterile fashion.
The lumbar spine was visualized in anterior-posterior (AP) view. The L4-L5
interlaminar space was identified. The skin insertion site was anesthetized
with a combination of 3 cc 1% Xylocaine and 1cc bicarbonate using a 25-gauge,
1-inch needle. Using a 20-gauge, 3-inch Tuohy was inserted via a paramedian
 Lumbar Spinal Stenosis with Radiculopathy 31

Fig. 4.2: A posterior-anterior image of a right paramedian L5-S1

interlaminar epidural steroid injection

Fig. 4.3:A lateral image of an L5-S1 interlaminar epidural steroid injection. Note the
needle at the spinolaminar line and the flow of contrast appearing as a straight line
(bound by the ligamentum flavum posteriorly and the thecal sac anteriorly) indicating
epidural placement

approach. The needle was directed in a bulls eye approach until it contacted
the inferior lamina. The lumbar spine was visualized in AP and lateral views
(Figs 4.2 and 4.3). The needle was then redirected cephalad and medial.
The needle was advanced into the ligamentum flavum (Fig. 4.4). A loss of
32 Interventional Spine ProceduresA Case-based Approach

Fig. 4.4: Spinolaminar line

resistance to normal saline technique was then used. There was good frank
loss of resistance. There was no cerebrospinal fluid (CSF) or heme aspirated.
There were no paresthesias.
Two milliliters of Omnipaque 240 was injected under live fluoroscopy
and flow of contrast was noted. There was good epidural spread (see Fig. 4.3).
There was no intrathecal or intravascular uptake. Therapeutic injection
consisted of 3 ml preservative-free sodium chloride and 1 cc of 6 mg/cc beta
metha sone.
The needle was flushed and removed intact. The patient was taken to
recovery in stable condition.

COMPLICATIONS/PITFALLS
Dural punctures have a rate of approximately 0.55%.25 This occurs secondary
to the needle passing beyond into the spinal space. Variables affecting this
can be severity of stenosis with possible adherence of layers or redundancy
of the ligamentum flavum. Increased risk factors include women during
pregnancy, low BMI, age between 18 years and 30 years with declines in
percentage in children younger than age 13 and adults older than 60 years
of age.26 Symptoms may include positional headaches, most notably worse
 Lumbar Spinal Stenosis with Radiculopathy 33
when going from a laying to standing or a seated position. The headache can
be quite severe, dull, nonthrobbing and fronto-occipital in nature.27 Initial
treatment includes having the patient increase their fluid intake.28 Caffeine
may also be utilized. Should symptoms fail to improve, consideration may be
given to an autologous blood patch. This involves drawing a patients blood
and injecting it into epidural space to seal the area of puncture. Epidural
blood patch remains the invasive of treatment of choice with success
rates of approximately 70% after initial injection.28,29 In trying to prevent a
dural puncture, the physician may consider use of smaller gauge, noncutting
needles as well as using lateral views on X-ray to check for depth of needle
placement.28

Subarachnoid Injection
Occurs due to improper depth of needle and penetration of the subarachnoid
space. The resultant symptoms are secondary to the amount of anesthetic
directly injected.30 Symptoms associated with this included disorientation,
lightheadedness, complete motor and sensory block, respiratory depression
and seizures.30 If a high spinal were to occur, fluid resuscitation for hypo
tension and maintaining the airway are of paramount importance.
IV access should be obtained prior to the procedure and a certification
by the interventional physician should be obtained in cardiopulmonary
resuscitation and advanced cardiac life support. A crash cart should be
available and medications/equipment periodically checked for expiration
and function. Use of lateral view to assess depth as well as assessment of the
contrast pattern.24

Epidural Abscess
Typically a rare complication with a single shot epidural injection.31
Symptoms include back pain, fever, chills, progressive weakness in lower
extremities, etc.24 Labs may demonstrate an elevated white blood cell count.
Imaging may demonstrate increased enhancement in area of the epidural
space. Treatment involves hospitalization, appropriate antibiotics as well as
surgical evaluation. Preventative aspects include use of a sterile technique,
using single-use vials, as well as appropriate skin prep.

Epidural Hematoma
This complication is an expansion of blood compressing the epidural region
and structures of the spinal canal. It has been reported to occur in less than
1:150,000 patients.32 Epidural hematomas are rare in patients with normal
clotting factors. The presentation is often progressive neurologic dysfunction
in the lower extremities as well as possible cauda equina syndrome.33
Magnetic resonance imaging typically demonstrates an expanding space
34 Interventional Spine ProceduresA Case-based Approach

compressing lesion. Treatment involves emergent laminectomy for decom

pression of the lesion. It is imperative to have patients evaluated if a
hematoma is suspected as surgical outcome is improved with quicker surgical
decompression.34 Preventing this complication includes close monitoring
of high-risk patients both pre- and post-procedure. Preprocedure lab work
should be done on those patients with platelets needing to be greater than
100,000 and International Normalized Ratio (INR), not prothrombin time,
less than 1.2-1.5, depending on the reference35 prothrombin time (PT) less
than 1.2. Furthermore, communication with the prescribing physician on
blood thinners in regards to high-risk patient and risk benefit ratio on a case-
by-case basis. They must always be consulted in regards to the holding of
anticoagulants.35

Intravascular Injection
Intravascular injection is more common with needle placement in the lateral
portion of the spinal canal than midline due to the dorsolateral location of
the vertebral venous plexus.24,36 Intravascular uptake in lumbar epidural
steroid injections can be up to 1.9%.37 Severity of symptoms is usually dose
dependent in the absence of allergic reaction.38 Symptoms range from
dizziness, tinnitus, and disorientation to seizures, unconsciousness and
coma.24 Treatment remains supportive in these cases. Preventions include
injection of nonionic contrast with use of live fluoroscopy as well as digital
subtraction, if available.24

Anatomical
Bony landmarks include both the superficial and deep oss. The superficial
oss that may be encountered is the spinous process. Deep oss is consistent
with the lamina proper. If proper technique is used with fluoroscopy,
contact of spinous process should be limited. It is possible to get a false loss
of resistance secondary to adipose and connective tissues. One method of
differentiating between soft tissue and epidural space is to inject saline with a
small air bubble in the syringe. Saline in the epidural space will not compress
the bubble, but if it is in soft tissue it will compress.39 Use of lateral X-ray for
depth guidance can also assist in this matter.

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3. Johnsson KE, Rosen I, Udeu A. The natural course of lumbar spinal stenosis. Clin
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4. Arnoldi CC, Brodshy AE, Cauchoix J. Lumbar spinal stenosis and nerve root
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5. Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, et al. Pathology and pathogenesis
of lumbar spondylosis and stenosis. Spine.1978;3:319-28.
6. Botwin KP, Gruber RD. Lumbar spinal stenosis: anatomy and pathogenesis.
Physical Medicine Rehabilitation Clinics of North America. 2003; 14(1):1-15.
7. Rydevik B, Brown MD, Lundberg G. Pathoanatomy and pathophysiology of
nerve root compression. Spine. 1984;9(1):7-15.
8. Barr KP, Harrast MA. Low back pain. In: Braddom R (Ed). Physical Medicine and
Rehabilitation. 3rd edition. Philadelphia: Elsevier; 2007.pp.918-9.
9. Porter SE, Hanley EN Jr. The musculoskeletal effects of smoking. J Am Acad
Orthop Surg. 2001;9(1):9-17.
10. Maggard-Gibbons M, Maglione M, Livhits M, et al. Bariatric surgery for weight
loss and glycemic control in nonmorbidly obese adults with diabetes: a
systematic review. JAMA, 2013;309(21):2250-61.
11. Rahman Shiri, Karppinen Jaro, Leino-Arjas Paivi, et al. The association between
obesity and low back pain: a meta analysis. American Journal of Epidemiology.
2010;171:135-54.
12. Mellin G. Correlation of spinal mobility with degree of chronic low back pain
after correction for age and anthropometric factors. Spine. 1987; 12(5):464-8.
13. Hu HY, Chou Y, et al. Association between obesity and injury among Tiawanese
adults. Int J Obesity. 2009;33(8):878-84.
14. Ament PW, Bertolino JG, Liszewski JL. Clinically significant drug interactions.
Am Fam Physician. 2000;61(6):1745-54.
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16. Yildrim K, Deniz O, Gureser G, et al. Gabapentin monotherapy in patients with
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Musculoskeletal Rehabilitation. 2009;22(1):17-20.
17. Rogawski MA, Loscher W. The neurobiology of antiepileptic drugs for treatment
on nonepileptic conditions. Nat MED. 2004;10(7):685-92.
18. Moore RA, Wiffen PJ, Derry S, McQuay HJ. Gabapentin for chronic
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19. Maitland GD. Vertebral Manipulation. 5th edition. London: Butterworths; 1986.
20. Rademeyer I. Manual therapy for lumbar spinal stenosis: a comprehensive
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21. Fritz J, Erhard R, Vignovic M. A non-surgical approach for patients with lumbar
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22. De Rosa CP, Porterfield JA. A physical therapy model for treatment of low back
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23. Manchikanti L, Staats PJ, Vijay S, et al. Evidence based practice guidelines
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24. Goodman BS, Dosecian Lyle WF, Mallenpati S. Complications and pitfalls of
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 5
Coccygodynia
Michael J Mehnert, Ferheen Shamim, Patrick M Foye

CHIEF COMPLAINT
The patient complains about tailbone pain.

HISTORY OF PRESENT ILLNESS

The patient is a 24-year-old female with no significant past medical history,
who presents to the office. She reports the onset of tailbone pain approximately
18 months ago after she slipped on ice and landed on her tailbone. Initially
she noted some bruising and soreness over the area but was told that she
did not break anything after X-rays in the emergency room. She had severe
pain with sitting and walking initially, though this has improved significantly
with time and use of anti-inflammatories. She has had a persistent aching
sensation of pain that is 2 out of 10 and mainly occurs when sitting in her
car. She recently switched occupations and is now sitting and driving more,
with pain that has now escalated to 810 out of 10. She has tried using a
donut style tailbone cushion without relief. She also has pain with changing
position from sitting to standing, and with sitting on softer surfaces more than
firm ones. Sex and bowel movements reproduce some of her pain as well,
and as per the patient, the area is actually tender. She has no genitourinary
complaints and no changes in stool or bright red blood per rectum. There
are no constitutional symptoms and no reports of radicular pain, numbness,
tingling or weakness in the lower limbs.
She continues on occasional usage of Tylenol or nonsteroidal antiinfla
mmatory drugs (NSAIDs) for pain. She is interested in additional information
about her condition and other treatment options. She has also considered
seeing a pelvic therapist.
38 Interventional Spine ProceduresA Case-based Approach

PAST MEDICAL/SURGICAL HISTORY

Appendectomy as a teenager

REVIEW OF SYSTEMS
As above. In addition the patient has no history of pregnancy or childbirth.
She reports normal menstrual periods for 5 days with a regular 28-day cycle
and normal flow. She does not describe painful menses and has no history of
endometriosis or other pelvic pathology. No prior urinary tract infections are
described. She reports no vaginal discharge or dysuria.

FAMILY HISTORY
None significant

SOCIAL HISTORY
She consumes 12 drinks over the course of a weekend but no daily alcohol
use. She denies any tobacco or other drug use. She works as a pharmaceutical
sales representative.

CURRENT MEDICATIONS
Tylenol Extra-Strength, rarely over-the-counter Advil.

ALLERGIES
No known drug allergies.
The pain diagram of the patient is shown in Figure 5.1.

PHYSICAL EXAMINATION
Height: 58, Weight: 124 lbs, Body mass index (BMI): 18.9, Pulse: 70/min
Blood pressure (BP): 118/72 mm Hg Respirations: 10/min.
This is an alert, awake and cooperative female. Nutrition and hygiene are
well-maintained. She is in no acute distress. She ambulates with a normal
gait and station and can do heel-and-toe walking. Coordination is intact.
Thoracolumbar spine examination demonstrates normal overlying skin
without erythema, edema, or surgical scar. Range of motion is full and the
area is nontender above the waist, including the lumbar paraspinals, facet
joints and the quadratus lumborum. The spinous processes are nontender.
On inspection of the sacrum and coccygeal area, there is again normal
overlying skin without erythema or bruising. There is focal tenderness to
palpation over the distal coccyx that reproduces her usual pain. Pelvis/genital
 Coccygodynia 39

Fig. 5.1: Pain diagram of the patient

examination was not performed. There was no tenderness to palpation of the

bilateral sacroiliac joints, piriformis muscles, or ischial bursae.
Neurological examination demonstrates 5/5 strength in the upper and
lower limbs in all key myotomes tested. Sensory testing to light touch and
pinprick is normal in the upper and lower limbs in all key dermatomes tested.
Reflexes are 2+ and symmetric in the upper and lower limbs at the biceps,
triceps, brachioradialis, patella and the Achilles.
Dural tension signs are negative in the lower limbs.

IMAGING
X-rays: Anterior-posterior (AP), lateral, flexion and extension views of the
lumbar spine were normal. Disc height was well-maintained with normal
lumbar lordosis. No instability is noted on flexion or extension.
Anterior-posterior and lateral views of the sacrum and coccyx were also
obtained. There are three coccyx segments without evidence of fracture.
Alignment is well-maintained.

DIAGNOSIS
Coccygodynia (coccyx pain) was diagnosed. The patients symptoms are
compatible with tailbone pain, or coccygodynia (also known as coccydynia).
Though her X-rays are unremarkable, the patient has pain that occurs with
prolonged sitting and with position changes, and she has focal tenderness
to palpation over the coccyx.1 She has symptoms that will occasionally
occur with bowel movements or sexual activity. There is also a history of
a preceding tailbone trauma, and though no discrete fracture has been
identified, the patient did have a direct trauma that had reportedly caused
40 Interventional Spine ProceduresA Case-based Approach

temporary ecchymoses over this area. Post-traumatic instability or luxation

of the coccygeal segments has been well-defined, and comparison of sitting
and standing X-ray films may be useful in eliciting radiographic evidence of
instability.1-3

DIFFERENTIAL DIAGNOSIS
The differential diagnosis would include other spinal causes of pain, such as
perhaps a sacral fracture. Referred pain from the lumbar spine is less likely as
the patient has no complaints of low back pain or radicular pain and there is
a normal neurological examination. It may be prudent for this patient to be
evaluated by her primary doctor or obstetrician/gynecologist (OBS/GYN) to
rule-out intrapelvic pathology (ovarian cysts or perhaps endometriosis) but
again, these diagnoses would be unlikely given that she is focally tender over
the coccyx area and also when the history of her prior tailbone injury is taken
into consideration. Possible malignancy should be considered, and if there is
a reasonable suspicion an MRI should be obtained.4,5

COCCYGODYNIA
Coccyx pain has been well-documented.1,6 The coccyx is named after a
cuckoo, as it can be said to resemble a birds beak in appearance.7 It exists
as the most inferiorly-located bony spinal segments, articulating with
the sacrum (at the sacrococcygeal junction) and with each other (via the
intercoccygeal junctions). Often, the segments of the coccyx are connected
with a thin vestigial or fibrocartilage disc space. Range of motion of the
coccyx exists in only one plane with flexion and extension (or, in some cases,
no mobility)2,3 occurring during the process of sitting as weight is distributed
among the ischial tuberosities and the pelvic support structures.
Coccyx pain can occur from direct trauma or injury. Though a true bony
fracture is a rare entity,1 luxation or instability can result with or without
a direct trauma or from repetitive microtrauma from sitting, abnormal
mechanics with sitting, or anatomic variability in the coccyx itself.
Just anterior to the upper coccyx or the lower sacrum (within the
retrorectal space)8-10 lies the midline ganglion impar (unpaired ganglion).
Also known as the ganglion of Walther, it is the most inferiorly-located
ganglia of the sympathetic nervous system. Much like the stellate ganglion
and the lumbar sympathetic ganglion, this structure is postulated to cause
sympathetic pain, though in the pelvic area. A mechanism of hyperactivity
or hypersensitivity of the ganglion impar has been postulated as a cause for
sympathetically maintained tailbone pain that will respond to treatment
directed at the ganglion.11 Blockade of the ganglion impar has been reportedly
effective in controlling pelvic pain and coccygodynia.8,9,12-14
 Coccygodynia 41

TREATMENT OPTIONS
The patient has already trialed a donut style coccyx cushion. A wedge
type of cushion with a coccyx relief cutout could also be trialed. She has taken
acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) with
some relief, though this is incomplete.
Unfortunately, this patient has increased her driving as a result of a
change in her occupation. She may benefit from trying to avoid sitting on
softer surfaces if possible, as this seems to increase her pain as well.
Physical therapy options exist, both in the form of pelvic therapy
with an experienced and skilled therapist, and also in the form of manual
manipulation. These options could be discussed with the patient prior to
pursuing interventional management.15
Coccygectomy has also been described as a treatment option, with
some success in carefully selected patients. This generally should be
considered a last resort only after other interventional treatments fail, and the
literature supports better outcomes in patients who are severely debilitated
by their pain.16

INTERVENTIONAL OPTIONS
From an interventional standpoint, a ganglion impar injection has been
described as being useful for treatment of pelvic pain, particularly when
it is thought to be sympathetically mediated. A reliable approach includes
accessing the ganglion impar by inserting a needle through the vestigial
disc space (intercoccygeal or sacrococcygeal) (Fig. 5.2) and applying local
anesthetic to the ganglion.8,12
Various injection techniques have been described, including an initial
blind injection. Modern techniques via a variety of approaches employ
fluoroscopic guidance with usage of contrast media for accurate medication
place ment and to minimize the risk of adverse reactions.9,10,17-20 Much
like a cervical or lumbar sympathetic ganglion blockade, the structure is
anesthetized with short- and/or long-acting anesthetic. The patient should
report immediate relief of pain with provocative activity (generally sitting)
after the injection.
A published case series of ganglion impar blocks for patients diagnosed
with persistent coccygodynia demonstrated that all injections provided some
level of relief in these patients, with results varying from 20% to 75% pain relief
and most patients responding with 5075% relief. Repeat injections were
often helpful for patients with incomplete relief.13 A patient with complete,
lasting relief after one block has also been reported.14
Radiofrequency neurotomy of the ganglion impar has also been explored,21,22
and may be an option for recalcitrant pain that responds temporarily to
42 Interventional Spine ProceduresA Case-based Approach

Fig. 5.2: Lateral view of the needle traversing the inter-coccygeal junction and placed
just beyond the anterior margin of the coccyx, prior to contrast injection

sympathetic blocks. The procedure is challenging both due to the proximity of

the ganglion to delicate visceral structures such as the rectum, bowel, and anus,
and also due to the difficulty of placing a probe at the target site. Chemodener
vation with phenol or neurotoxic agents has also been established but is not in
wide use.6
Some practitioners have also advocated for the use of caudal epidural
steroid injections for tailbone pain, though little published data exist to
support their use.23

PLAN
The above treatment options were discussed in detail with the patient. She
expressed a lack of interest in surgery and frustration with her increasing
pain and resulting functional deficits, particularly with regard to her recent
job change and the need to drive longer distances. A plan was made to move
forward with a fluoroscopically-guided ganglion impar block (sympathetic
nerve block) for better pain control and sitting tolerance.

PROCEDURE
Coccyx injection/ganglion impar sympathetic block with fluoroscopic
guidance.
 Coccygodynia 43

Indications
Please refer to prior office notes for details. The patient is being treated for a
diagnosis of coccygodynia (tailbone pain). The patient has failed to respond
to oral anti-inflammatory medications and use of pressure-relief cushions
to relieve pain over the coccyx area. A decision was made to proceed with a
fluoroscopically-guided ganglion impar injection for diagnostic and possibly
therapeutic purposes.
The patient was informed of the risks and benefits of the procedure, as well
as alternative treatments. All questions were answered prior to proceeding.
The patient expressed understanding and gave informed written consent.

Preoperative Diagnosis
Coccygodynia (tailbone pain)

Postoperative Diagnosis
Same as preoperative diagnosis

Procedure Performed
Sympathetic nerve block at the anterior coccyx (ganglion impar block)
Fluoroscopic guidance/localization.
The patient was taken into the fluoroscopy suite and was placed prone
on the examination table. The overlying skin was prepped and draped in the
usual sterile fashion. Under AP and intermittent fluoroscopic guidance, the
sacrococcygeal junction was identified, and a lateral view was used to begin
the procedure. The overlying skin was marked using a metal pointer for
radiographic guidance. Local anesthetic (1% lidocaine without preservative
buffered) was administered to anesthetize the skin and subcutaneous tissues.
Next, a 25-gauge, 3-inch sterile spinal needle was inserted via the
(sacrococcygeal, 1st intracoccygeal, etc.) junction using intermittent
fluoroscopic guidance under AP and lateral views. The needle was then
placed appropriately just at the anterior aspect of the coccyx and this was
confirmed by lateral fluoroscopy. Next, aspiration revealed no return of blood
or other fluid. Then, a solution of 2 mL of water-soluble nonionic contrast
media was then injected via the spinal needle. Fluoroscopy on the lateral
view once again confirmed that the needle tip was located at the anterior
aspect of the coccyx/coccygeal junction and there was longitudinal spread
of the contrast just anterior to the sacrum and coccyx, thus covering the
ganglion impar. There was no evidence of contrast filling in the rectum.
Under live fluoroscopy, no evidence of vascular uptake was noted. Proper
placement was also confirmed in the AP view. Next, a solution of 4 mL of
44 Interventional Spine ProceduresA Case-based Approach

1% lidocaine without preservative and 6 mL of 0.25% bupivacaine without

preservative was injected via the spinal needle. Fluoroscopy showed contrast
washout, further confirming good placement of the injected solution. The
needle was withdrawn and good hemostasis was noted.
Immediately upon sitting up from the procedure, the patient reported
____% relief. The patient understands that when the nerve blocks wear off,
the coccygodynia may return, but usually it is less severe than prior to the
injections. If additional relief is still needed, the blocks can be repeated for
additional benefit.
The patient tolerated the procedure well and without complications.
The patient was instructed to apply ice over the injection site for 1015
minutes for the next 2448 hours. A postprocedure instruction sheet was
given.
Ganglion impar injection images are shown in Figures 5.3 to 5.8.

CONCERNS, PITFALLS AND TIPS

Care should be taken to advance the needle gently and slowly through
the sacrococcygeal junction or intercoccygeal space. Remember that the
rectum and visceral bowel structures are in close proximity to and just
anterior to the bony structures; avoiding perforation should obviously be
a paramount concern.
The lateral coccyx view is ideal to begin the procedure, however, may
sometimes be a difficult fluoroscopy view to optimize. The bony sacrum

Fig. 5.3: A-P view of needle in place for a ganglion impar injection. Note the difficulty
identifying detailed bony anatomy given the viceral structures and bowel gas
 Coccygodynia 45

Fig. 5.4: A-P view of the needle in place after contrast injection

Fig. 5.5: A-P view of the needle in place after contrast injection
(rendering to show bony anatomy)

and coccyx exist as a thin plane between a top layer of skin and overlying air
and the bottom layer of gaseous visceral structures such as the rectum and
bowel. In addition, the larger nearby bony structures in the pelvis and the
spine may limit visibility of the relatively small coccyx segments. Also,
the majority of the field will often contain air above and below the bony
46 Interventional Spine ProceduresA Case-based Approach

Fig. 5.6: Initial contrast injection showing appropriate

spread of injectate in the retroperitoneal space

Fig. 5.7: Additional injection of contrast showing injectate spreading along the anterior
aspect of the coccyx in the retroperitoneal space, thus covering the ganglion impar

structures and may result in washing out of the image. As a result, extra care
should be taken to optimize the lateral view with coning down the field and
localizing/marking the injection site with a metal pointer prior to beginning
the procedure.
 Coccygodynia 47

Fig. 5.8: Washout image of the contrast being diluted as

madication is injected and further covers the target location

Sterile gauze may be placed at the top of the patients gluteal fold to help
distract the soft tissue and better visualize the injection site and also to
prevent betadine or other antiseptic solution from flowing beyond the target
sterile area.
In addition, it is often beneficial to direct the needle for the local
anesthetic right down to the posterior aspect of the bony sacrum/
coccyx superior to the target injection junction to administer local
anesthetic over the traversing posterior fibers of the somatic coccygeal
nerve. This may make the remainder of the procedure less painful for the
patient.
It is recommended that the operator attempts to access the ganglion impar
by traversing the vestigial disc space with a small gauge needle, optimally a
25-gauge, 3.5-inch or 2.0-inch needle. If the target junction is significantly
degenerative or sclerotic, a larger gauge needle could be attempted prior
to attempting access at a different level. Alternatively, gentle pressure
downward on the distal coccyx may also theoretically help to distract the
posterior entry to the sacrococcygeal or intracoccygeal junction. Foye
et al. have also described an alternate corkscrew paracoccygeal
injection approach10 if the fibrocartilage junction cannot be penetrated.
At times, if the target sacrococcygeal or intracoccygeal junction appears to be
significantly degenerative or arthritic, one could also inject corticosteroid
into the vestigial disc space/junctional space (Fig. 5.9). Efficacy of this
intervention has not been well established.
48 Interventional Spine ProceduresA Case-based Approach

Fig. 5.9: Coccygeal discography

REFERENCES
1. Maigne JY. Coccydynia. In: Slipman CW, Derby R, Simeone FA, Mayer TG (Eds).
Interventional Spine: An Algorithmic Approach. Philadelphia, PA: Saunders
Elsevier; 2008. pp.1289-97.
2. Maigne JY, Molinie V, Fautrel B. Anatomie des disques sacro et inter-coccygiens.
Revue de Medecine Orthopedique. 1992;28:34-5.
3. Maigne JY, Lagauche D, Doursounian L. Instability of the coccyx in coccydynia.
J Bone Joint Surg. 2000;82B:1038-41.
4. Maigne JY, Pigeau I, Roger B. Magnetic resonance imaging findings in the
painful adult coccyx. Eur Spine J. Published online February 2012.
5. Foye PM. Coccyx pain diagnostic workup: necessity of MRI in detecting
malignancy present with tailbone pain. Am J Phys Med Rehabil. 2002; 89:S33.
6. Howorth B. The painful coccyx. Clin Orthop. 1959;14:145-50.
7. Sugar O. Coccyx, the bone named for a bird. Spine. 1995;20:379-83.
8. Plancarte R, Amescua C, Patt RB, et al. Presacral blockade of the ganglion of
Walther (ganglion impar). Anesthesiology. 1990;73(3A):A751.
9. Toshniwal GR, Dureja GP, Prashanth SM. Trans-sacrococcygeal approach to
ganglion impar block for management of chronic perineal pain: a prospective
observational study. Pain Physician. 2007;10:661-6.
10. Foye PM, Patel SL. Paracoccygeal corkscrew approach to ganglion impar
injections for tailbone pain. Pain Pract. 2009;9(4):317-21.
11. Oh CS, Chung IH, Ji HJ, et al. Clinical implications of topographic anatomy on
the ganglion impar. Anesthesiology. 2004;101(1):249-50.
12. Foye PM, Kirschner JS, Furman MB. Ganglion impar injection. In: Furman MB,
Lee TS, Berkwits L (Eds). Atlas of Image-Guided Spinal Procedures. Philadelphia,
PA: Elsevier Saunders; 2013. pp. 63-71.
 Coccygodynia 49
13. Buttaci CJ, Foye PM, Stitik TP. Coccydynia successfully treated with ganglion
impar blocks: a case series. Am J Phys Med Rehabil. 2005;84(3):218.
14. Foye PM, Buttaci CJ, Stitik TP, et al. Successful injection for coccyx pain. Am J
Phys Med Rehabil. 2006;85:783-4.
15. Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments:
a pilot study. Spine. 2001;26:479-84.
16. Balain B, Eisenstein SM, Alo GO, et al. Coccygectomy for coccydynia: case series
and review of literature. Spine. 2006;31(13):E414-E420.
17. Foye PM. Ganglion impar blocks via coccygeal versus sacrococcygeal joints. Reg
Anesth Pain Med. 2008;33(3):279-80.
18. Foye PM. New approaches to ganglion impar blocks via coccygeal joints. Reg
Anesth Pain Med. 2007;32(3):269.
19. Kuthuru M, Kabbara AI, Oldenburg P, et al. Coccygeal pain relief after trans-
sacrococcygeal block of the ganglion impar under fluoroscopy: a case report.
Arch Phys Med Rehabil. 2003;84(9):E24.
20. Kabbara AI. Trans-sacrococcygeal ganglion impar block for postherpetic
neuralgia. Anesthesiology. 2005;103(1):211-2.
21. Atim A, Ergin A, Bilgi S, et al. Pulsed radio-frequency in the treatment of
coccygodynia. Agri. 2011;23(1):1-6.
22. Reig E, Abejn D, Del Pozo C, et al. Thermocoagulation of the ganglion impar or
ganglion of Walther: description of a modified approach. Preliminary results in
chronic, nononcological pain. Pain Pract. 2005;5(2):103-10.
23. Foye PM, Buttaci CJ, Sorensen MK, et al. Coccyx PaineMedicine Online
Publication. Accessed online 2013 at http://emedicine.medscape.com/
article/309486-overview.
 6
Lumbar Facet Syndrome
Jeremy Simon, Kelly Williams

CHIEF COMPLAINT
The patient complains about lower back pain.

HISTORY OF PRESENT ILLNESS

A 61-year-old right-handed male presents with a 10 year history of mild
intermittent lower back pain, progressively worsening over the last 3 years
without an inciting event. It is predominantly midline and slightly to the
lower right side of his back with occasional radiation to the buttock and right
thigh, never below the knee. Extension, prolonged standing, twisting and
lifting aggravate the pain. It is worse in the morning with associated stiffness
in the lower back, but has become a constant deep, dull ache throughout the
day and a tight feeling in the muscles in the lower back. The pain is reduced
with sitting and forward flexion. It can be sharp when extending, twisting and
lifting. There is no associated unintentional weight loss or weight gain, fevers,
chills or night sweats, weakness, numbness, tingling, or night pain. There
is no radiating pain down either leg. He is employed as a plumber and has
worked for 40 years.
Treatments to date include nonsteroidal anti-inflammatory medications
and muscle relaxers with mild relief, physical therapy with a flexion bias
and core strengthening with mild relief, transcutaneous electrical nerve
stimulation (TENS), heating pads, chiropractic, acupuncture, trigger point
injections, and massage therapy with modest relief. He is coming to your
office for a more complete understanding of his problem and to explore the
possibility of interventional treatments for his pain.
 Lumbar Facet Syndrome 51

PAST MEDICAL HISTORY

Hypertension, hyperlipidemia

PAST SURGICAL HISTORY

None

REVIEW OF SYSTEMS
Otherwise negative

FAMILY HISTORY
Parents alive with no medical issues.

SOCIAL HISTORY
Drinks 12 glasses of beer at night, smokes one pack of cigarettes/day, denies
illicit drugs. Employed as a plumber, full time, no workmens compensation
claims.

CURRENT MEDICATIONS
Ibuprofen 200 mg bid prn, cyclobenzaprine 10 mg qhs prn, lisinopril 10 mg
qDay.

ALLERGIES
None
The pain diagram of the patient is shown in Figure 6.1.

PHYSICAL EXAMINATION
Height: 510, Weight: 270 lbs, Pulse: 82/min, BP: 145/85 mm Hg, Respirations:
16/min.
General: Pleasant, cooperative, looks stated age, obese, in no distress.
Gait and tandem gait stable, with slight forward flexion. Romberg sign
is negative. Able to heel walk and toe walk without difficulty. Pulses are 2+
in the radial and dorsalis pedis arteries. Babinski testing reveals downgoing
toes bilaterally. Slump test and supine straight leg raise to 90 are negative
bilaterally. Negative femoral nerve stretch test bilaterally. No palpable step-
off in the lumbar spine. No tenderness over the lumbar spinous processes.
No palpable scoliotic curve. There is palpable muscle spasm in the lumbar
52 Interventional Spine ProceduresA Case-based Approach

Fig. 6.1: Pain diagram of the patient

paraspinals and tenderness. Patricks test is negative bilaterally, but provokes

some mild reproduction of pain in the lower back on the right. Internal rotation
of the hips does not cause pain. No tenderness to palpation over the bilateral
trochanteric bursae. Negative Gaenslens sign, negative Thomas test, negative
Obers test bilaterally. No tenderness over the sacroiliac joints. Manual muscle
testing in the lower limbs reveals 5/5 bilateral hip flexors, quadriceps, tibialis
anterior, extensor hallucis longus, and gastrocsoleus. Sensory examination
to light touch and pinprick is normal in the lower extremity dermatomes.
Proprioception is intact at the great toes bilaterally. Normal muscle tone.
Reflexes are 2+ in patellae, medial hamstrings and Achilles tendons. No ankle
clonus bilaterally. Lumbar range of motion is reduced in extension and the
end limits of flexion. There is reproduction of typical pain with extension and
extension/rotation to the right. Posterior-anterior pressure over the L4-L5 and
L5-S1 segments on the right cause reproduction of pain.

IMAGING
Lumbar spine X-rays: Anterior-posterior, lateral, flexion and extension lumbar
X-rays reveal moderate disc space narrowing at L4-L5 and L5-S1. Normal
segmentation, no spondylolisthesis or scoliosis.
 Lumbar Facet Syndrome 53
Magnetic resonance imaging: Disc degeneration at L4-L5, L5-S1. Broad-based
disc bulge at L5-S1 without neural compression. Prominent facet arthropathy,
right greater than left, at L4-L5 and L5-S1.

DIAGNOSIS
Lumbar zygapophysial joint (facet) syndromelikely involving the right
L4-L5 and L5-S1 zygapophysial joints.

TREATMENT OPTIONS
Lifestyle modifications should be emphasized. Obesity adds load to the spine
and may contribute to his pain. Poor conditioning and lack of adequate core
strength can also play a role.1,2 Smoking cessation and healthy lifestyle should
be promoted.3-5
Proper ergonomics and lifting mechanics should be emphasized. Potential
referral for back school is indicated due to the physicality of his work.6
Job satisfaction and the amount of strain on his lower back may impact his
outcome and the potential for reoccurrence.7
One might consider increasing the ibu profen dose to 600800 mg
to achieve the anti-inflammatory affects not seen at 200 mg, as well as
increasing the frequency to three times a day. Prior to suggesting this, a
clearance from the patients primary care physician would be advisable due
to the elevated blood pressure. This may be a spurious reading, but if he has
hypertension, increasing the nonsteroidal anti-inflammatory drugs (NSAIDs)
may contribute to higher blood pressures.8
Conflicting data exists regarding the role of spinal manipulation in the
setting of lumbar facet syndrome.9,10 Possible mechanisms of pain relief
include restoration of normal motion through physiological barriers, the gait
theory of pain, endorphin release, and stimulation of joint mechanoreceptors
that reflexively alters alpha motor neuron excitability.11 Neurophysiologic
studies of facet joint strain during manipulation suggest its safety.12 Some
studies see a greater benefit in particular subgroups like facet syndrome as
opposed to spinal stenosis or radiculopathy.11 Potential techniques include
myofascial release, soft tissue, strain-counterstrain, muscle energy, and
high-velocity low amplitude maneuvers.13 Overall, in experienced hands,
manipulation is an accepted and safe treatment option in the setting of
benign low back pain and may be considered in this case.
His symptoms are consistent with lumbar zygapophysial joint syndrome.
Pain associated with extension and extension-rotation are typical findings.
Physical examination is neither sensitive nor specific for this entity.14
Midline lower back pain with a lack of a radicular component also makes
this diagnosis more likely. It is not unusual for pain to radiate into the
posterior thigh or the flank.14 Pain maps have been described corresponding
54 Interventional Spine ProceduresA Case-based Approach

Fig. 6.2: Medial branch anatomy of

the lumbar zygapophysial joint

to different joints involved.15,16 Sacroiliac joint dysfunction is less likely. This

is due to the primary location in the midline and not the buttocks as well as
the lack of a groin component. Discogenic low back pain is also unlikely as
the pain is relieved with sitting and aggravated with extension; the reverse is
usually the case with internal disc disruption syndrome.17
The nerve supply to the lumbar zygapophysial joint is well described.18,19
Two medial branch nerves emanating from the dorsal ramus supply each
joint. The nomenclature can be confusing as the superior aspect of the joint
is supplied by the nerve from above and the inferior by that below (Fig. 6.2).
For example, the L4-L5 zygapophysial joint is supplied by the L3 and L4
medial branch nerves. The L5-S1 zygapophysial joint is supplied by the
L4 medial branch nerve and the L5 dorsal ramus.

INTERVENTIONAL OPTIONS
The lumbar zygapophysial joints may be addressed by injection via an intra-
articular approach or by blocking (anesthetizing) the nerves that supply
them (Figs 6.3 to 6.5). Long-term benefit has not been proven with intra-
injections of steroid and anesthetic.20,21 Consideration to an intra-articular
injection may be given, as medial branch blockade in theory does not offer
therapeutic affects. In cases with severe osteoarthritis, an intra-articular
injection may not be possible and medial branch block may be the only
option. Some authors have noted up to 3 months of relief with medial branch
blocks, but the primary indication for blocks is diagnostic.22
 Lumbar Facet Syndrome 55

Fig. 6.3: L3 medial branch block

Fig. 6.4: L4 medial branch block

The International Spine Intervention Society (ISIS) recommends a

two positive block paradigm for confirmation of the diagnosis.23,24 Some
practitioners may include one intra-articular injection and one medial branch
block; two medial branch blocks are considered the standard. The injections
are performed in conjunction with a pain diary. The patients typical pain
should be reduced between 50% and 100% depending on the criteria the
physician uses to be considered positive.23,25 The relief should correspond to
the duration of the anesthetic used if the effects are temporary. There should
56 Interventional Spine ProceduresA Case-based Approach

Fig. 6.5: L5 dorsal ramus block

be significantly less pain or no pain with typical aggravating activities while

the anesthetic is on board and documentation should be made of these
activities in the pain diary.
Lumbar medial branch radiofrequency abla tion is a method for
potentially giving longer-term relief of zygapophysial joint mediated pain.
Relief is typically 12 months or more.26,27 The procedure is performed in the
outpatient setting with the use of special insulated radiofrequency needles
with exposed active tips placed under fluoroscopic guidance over the regions
where the medial branch nerves reside. The inner cannula (stylet) is replaced
with a heating electrode that makes contact with the active tip. A grounding
pad is placed on the patient and the probes are connected to a radiofrequency
generator. This device also monitors impedance and temperature. It allows
the delivery of radiofrequency energy directly to the needle tips.
Once the needles are in the correct position, the medial branch nerves
should be stimulated one by one to assure that no radicular spread is
obtained. This is performed by first using a sensory stimulation at 50 Hz,
which may cause reproduction of typical low back pain in the absence of
radicular spread. It is then followed by a motor stimulation at 2 Hz, which
should cause contraction of the multifidii in the absence of contraction of
lower limb muscles.
Once all impedances, pictures and stimulations are ideal, a lesioning
protocol is then performed. The ideal temperature should be at 80C for
90 seconds. Many authors advocate rotating the needles after the first cycle
and repeating the lesioning 12 more times for an additional 6090 seconds
to assure maximal damage to the nerve. Up to four medial branch nerves may
be lesioned at once with many of the newer machines.
 Lumbar Facet Syndrome 57

SAMPLE PROCEDURE NOTES

Lumbar Intra-articular Zygapophysial Joint Injection
Informed consent for the procedure was obtained. The risks, benefits and
alternative options were discussed. The risks include, but are not limited to,
death, paralysis, allergic reaction, syncope, arrhythmia, cardiac or respiratory
arrest, spinal cord injury, worse pain, scar formation, bleeding, epidural
hematoma and infection. The patient was prepped and draped in a sterile
fashion while in the prone position. All vital signs and oxygen saturation were
monitored prior to, during and after the procedure.
The C-arm was positioned so that the region overlying the right L4-L5 and
L5-S1 zygapophysial joints were visualized. The soft tissues overlying these
structures were infiltrated with 46 cc of 1% lidocaine without epinephrine.
A 25-gauge spinal needle was inserted into the superior aspect of each of the
above mentioned zygapophysial joints. After negative aspirate for blood or
cerebrospinal fluid (CSF), a small amount of nonionic contrast was injected
and flow of contrast was noted. Radiographs were obtained for documentation
purposes. The injectate consisting of steroid and lidocaine was administered
into both joints.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
was instructed by the authors to call them. The patient is to follow up with the
physician as noted above within 23 weeks.

Lumbar Medial Branch Block

(Zygapophysial Joint Nerve Block)
The C-arm was positioned so that the L5 vertebrae and sacral ala were
identified. The soft tissues overlying these structures were anesthetized with
46 cc of 1% lidocaine without epinephrine.
At the L5 vertebrae, a 25-gauge spinal needle was advanced down under
oblique view to the junction of the superior articular process and transverse
process of the vertebra. This corresponds to the L4 medial branch nerve.
At the sacral ala, a 25-gauge spinal needle was advanced down to the
junction of the sacral ala and the superior articular process of S1. This
corresponds to the dorsal ramus of L5.
An anterior-posterior (AP) projection was used to confirm the positions.
After negative aspirate for blood or CSF, a small amount of nonionic contrast
was injected and flow of contrast was noted at each level, care given to assess
for vascular flow. Radiographs were obtained for documentation purposes.
The anesthetic was administered at both levels.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
58 Interventional Spine ProceduresA Case-based Approach

was instructed by the authors to call them. The patient is to follow up with the
physician as noted above within 12 weeks.
The patient was also given a pain diary and was instructed to note the pain
level and activities at the time of entering the data for the day of the procedure.
The patient will have to bring this data to the follow-up appointment for
diagnostic purposes.
Informed consent for the procedure was obtained. The risks, benefits
and alternative options were discussed. The risks include, but are not
limited to, death, paralysis, allergic reaction, syncope, arrhythmia, cardiac or
respiratory arrest, spinal cord injury, worse pain, scar formation, bleeding,
epidural hematoma and infection. The patient was prepped and draped in
a sterile fashion while in the prone position. A grounding pad was placed
on the patient. All vital signs were monitored prior to, during and after the
procedure. Oxygen saturation was also monitored and noted to be greater
than or equal to 94% throughout the procedure. Cardiac monitoring revealed
normal sinus rhythm.
The C-arm was positioned so that the appropriate vertebral levels for the
above mentioned zygapophysial joint nerves were visualized. The soft tissues
overlying these structures were infiltrated with 46 cc of 1% lidocaine without
epinephrine.
For L4 medial branch nerve, the radiofrequency needle was advanced
down to the junction of the superior articular process and the transverse
process via an oblique approach.
For the L5 dorsal ramus, the radiofrequency spinal needle was advanced
down to the junction of the sacral ala and the superior articular process of S1.
Lateral and AP views were obtained to confirm safe and accurate
placement. Then at each level, the radiofrequency needle stylet was replaced
by the radiofrequency heating electrode. Sensory and motor test stimulation
at 50 Hz and 2 Hz respectively was performed at both levels to ensure no
radicular sensations and to obtain maximal multifidii contractions. After
confirmation, 1 cc of 1% lidocaine without epinephrine was injected at both
levels. Subsequently at each level, lesioning was done for approximately
90 seconds at 80C. The lesioning was repeated two times at each level for
approximately 90 seconds. Radiographs were obtained for documentation
purposes.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
was instructed by the authors to call them. The patient is to follow up with
the physician as noted above within 23 weeks.
 Lumbar Facet Syndrome 59

REFERENCES
1. Willemink MJ, van Es HW, Helmhout PH, et al. The effects of dynamic isolated
lumbar extensor training on lumbar multifidus functional cross-sectional area
and functional status of patients with chronic nonspecific low back pain. Spine.
2012;37:E1651-8.
2. Heuch I, Hagen K, Heuch I, et al. The impact of body mass index on the
prevalence of low back pain: the HUNT study. Spine. 2010;35:764-8.
3. Behrend C, Prasarn M, Coyne E, et al. Smoking cessation related to improved
patient-reported pain scores following spinal care. The Journal of Bone and Joint
Surgery, American volume; 2012.
4. van Oostrom SH, Monique Verschuren WM, de Vet HC, et al. Ten year course
of low back pain in an adult population-based cohortthe Doetinchem cohort
study. European Journal of Pain. 2011;15:993-8.
5. Bjorck-van Dijken C, Fjellman-Wiklund A, Hildingsson C. Low back pain,
lifestyle factors and physical activity: a population based-study. Journal of
Rehabilitation Medicine: Official Journal of the UEMS European Board of
Physical and Rehabilitation Medicine. 2008;40:864-9.
6. Sahin N, Albayrak I, Durmus B, et al. Effectiveness of back school for treatment
of pain and functional disability in patients with chronic low back pain: a
randomized controlled trial. Journal of Rehabilitation Medicine : Official
Journal of the UEMS European Board of Physical and Rehabilitation Medicine.
2011;43:224-9.
7. Courvoisier DS, Genevay S, Cedraschi C, et al. Job strain, work characteristics
and back pain: a study in a university hospital. European Journal of Pain.
2011;15:634-40.
8. Aljadhey H, Tu W, Hansen RA, et al. Comparative effects of non-steroidal anti-
inflammatory drugs (NSAIDs) on blood pressure in patients with hypertension.
BMC cardiovascular disorders. 2012;12:93.
9. Haigh R, Clarke AK. Effectiveness of rehabilitation for spinal pain. Clinical
Rehabilitation. 1999;13 (Suppl 1):63-81.
10. Hadler NM, Curtis P, Gillings DB, et al. A benefit of spinal manipulation as
adjunctive therapy for acute low-back pain: a stratified controlled trial. Spine.
1987;12:702-6.
11. Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of
low-back pain. Canadian family physician Medecin de famille canadien.
1985;31:535-40.
12. Ianuzzi A, Khalsa PS. Comparison of human lumbar facet joint capsule strains
during simulated high-velocity, low-amplitude spinal manipulation versus
physiological motions. The Spine Journal: Official Journal of the North American
Spine Society. 2005;5:277-90.
13. Cyriax J. Manipulation trials. British Medical Journal. 1980;280:111.
14. van Kleef M, Vanelderen P, Cohen SP, et al. Pain originating from the lumbar
facet joints. Pain Practice: the Official Journal of World Institute of Pain. 2010;10:
459-69.
15. Marks R. Distribution of pain provoked from lumbar facet joints and related
structures during diagnostic spinal infiltration. Pain. 1989;39:37-40.
16. Windsor RE, King FJ, Roman SJ, et al. Electrical stimulation-induced lumbar
medial branch referral patterns. Pain Physician. 2002;5:347-53.
17. Rengachary SS, Balabhadra RS. Black disc disease: a commentary. Neurosurgical
Focus. 2002; 13:E14.
60 Interventional Spine ProceduresA Case-based Approach

18. Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. Journal of
Anatomy. 1982; 134:383-97.
19. Bogduk N. The innervation of the lumbar spine. Spine. 1983;8:286-93.
20. Falco FJ, Manchikanti L, Datta S, et al. An update of the effectiveness of
therapeutic lumbar facet joint interventions. Pain Physician. 2012;15:E909-53.
21. Datta S, Lee M, Falco FJ, et al. Systematic assessment of diagnostic accuracy
and therapeutic utility of lumbar facet joint interventions. Pain Physician.
2009;12:437-60.
22. Manchikanti L, Singh V, Falco FJ, et al. Lumbar facet joint nerve blocks in
managing chronic facet joint pain: one-year follow-up of a randomized,
double-blind controlled trial: Clinical Trial NCT00355914. Pain Physician. 2008;
11:121-32.
23. Derby R, Melnik I, Lee JE, et al. Correlation of lumbar medial branch neurotomy
results with diagnostic medial branch block cutoff values to optimize therapeutic
outcome. Pain Medicine. 2012;13:1533-46.
24. Bogduk N. Spinal Diagnostic and Treatment Procedures: Practice Guidelines,
1st edition. San Francisco, CA: International Spine Intervention Society; 2004.
25. Klessinger S. Zygapophysial joint pain in post lumbar surgery syndrome. The
efficacy of medial branch blocks and radiofrequency neurotomy. Pain Medicine;
2012.
26. Speldewinde GC. Outcomes of percutaneous zygapophysial and sacroiliac joint
neurotomy in a community setting. Pain Medicine. 2011;12:209-18.
27. Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency
neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000;25:1270-7.
 7
Sacroiliac Joint Pain
Ari Greis, Melissa Guanche

CHIEF COMPLAINT
The patient complains of right buttock pain.

HISTORY OF PRESENT ILLNESS

A 29-year-old right-handed female presents with an 8-week history of
constant achy right buttock pain after a fall at a concert, landing directly
on the right buttocks. The pain radiates to her lateral hip and occasionally
down her posterior thigh, not past the knee. There is occasional radiation to
the right groin. It is worse with sitting and standing, and somewhat relieved
with changing positions and anti-inflammatories. She has been unable to
run secondary to pain and states that long distance walking has become
uncomfortable. She denies any associated bowel or bladder incontinence,
unintentional weight loss or weight gain, fever, chills, night sweats, numbness,
tingling, or weakness in the lower extremities. She has no history of low back
pain, hip pain or known herniated nucleus pulposis.
She is employed as a librarian.
Treatments to date include over the counter nonsteroidal anti-inflammatory
medications and acetaminophen with mild relief. She completed 4 weeks
of physical therapy with core strengthening and lower limb conditioning
with little improvement in pain. She is coming to your office for a more
complete understanding of her problem and to explore other options for pain
management.

PAST MEDICAL HISTORY

None
62 Interventional Spine ProceduresA Case-based Approach

PAST SURGICAL HISTORY

Right inguinal hernia repair 10 years ago.

REVIEW OF SYSTEMS
Otherwise negative

FAMILY HISTORY
Parents alive with osteoarthritis, hypothyroidism and hypertension.

SOCIAL HISTORY
One to two glasses of wine most nights of the week, denies smoking, denies
illicit drugs.

CURRENT MEDICATIONS
Naprosyn 220 mg twice a day, occasional acetaminophen.

ALLERGIES
None

PHYSICAL EXAMINATION
Height: 58
Weight: 135 lbs
Pulse: 62/minute
Blood Pressure: 110/70 mm Hg
Respirations: 16/minute

General Appearance
Pleasant, cooperative, looks stated age, in no distress.
Gait and tandem gait stable. Romberg sign is negative. Able to heel walk
and toe walk without difficulty. Pulses are 2+ in the radial and dorsalis pedis
arteries. Babinski testing reveals downgoing toes bilaterally. No palpable
step-off in the lumbar spine. No palpable scoliotic curve. No tenderness
over the lumbar spinous processes. No lumbar segmental tenderness.
No palpable muscle spasm in the lumbar paraspinals. Pain with palpation
 Sacroiliac Joint Pain 63

Fig. 7.1: Pain diagram

over the sacral sulcus on the right. No tenderness to palpation over the
bilateral trochanteric bursae. Positive Fortin Finger Test. Slump test and
supine straight leg raise to 90 are negative bilaterally. Internal rotation of
the hips does not cause pain. No pain with extension or rotation. Negative
femoral nerve stretch test bilaterally. Pain in the buttock area with Patrick
test on right. Negative Gaenslens sign, negative Thomas test, negative
Obers test bilaterally. Manual muscle testing in the lower limbs reveals 5/5
bilateral hip flexors, quadriceps, tibialis anterior, extensor hallucis longus,
and gastrocsoleus. Sensory examination to light touch and pinprick is
normal in the lower extremity dermatomes. Proprioception is intact at the
great toes bilaterally. Normal muscle tone. Reflexes are 2+ in patellae, medial
hamstrings and Achilles tendons. No ankle clonus bilaterally (Fig. 7.1).

IMAGING
X-rays lumbar spine and pelvisnormal.
Magnetic resonance imaging lumbar spineminimal bulge at L4-5
without herniated nucleus pulposus or neural compression.
64 Interventional Spine ProceduresA Case-based Approach

DIAGNOSIS
Sacroiliac Joint Pain
Sacroiliac joint (SIJ) pain is defined as pain localized to the region of the
SIJ, reproducible by provocation tests of the SIJ, and reliably relieved by
infiltration of the SIJ with a local anesthetic.1 The prevalence of intra-articular
SIJ pain is approximately 1026.6% in patients with chronic back pain.2 Its
incidence may be overestimated as most studies on the prevalence of SIJ
pain focus on patients already suspected of having SIJ pain (pain in the sacral
region, SIJ tenderness and positive provocative maneuvers).3 Manchikanti
et al. found the overall incidence of SIJ pain to be only 2% in patients with
chronic low back pain.2 Conversely, some argue it is underestimated as
current diagnostic blocks fail to include extra-articular causes (enthesopathy,
fractures, ligamentous injuries and myofascial).
The innervation of the SIJ is predominantly dorsal, encompassing a
wide range of sensory fiber types from the L5 dorsal ramus and the S1-S4
dorsal rami.4 Anatomic dissection has illustrated marked variability in the
location and number of lateral branch (LB) nerves innervating the dorsal SIJ
complex between cadavers and also within individual cadavers.4 The use of
sensory stimulation-guided radiofrequency (RF) to identify symptomatic (pain
transmitting) branches demon strated symptomatic branches stemming
predominantly from the L5 dorsal sensory branch (distinct from medial
branch of L5 dorsal ramus) and S1 LB, with common symptomatic LBs at S2
and S3.4 An understanding of the structure and function of the SIJ is necessary
in order to successfully design a treatment plan.
The SIJ is a diarthrodial synovial joint that primarily functions as a stress
relieving joint for the pelvic ring.5 It supports the lumbar spine and transmits
forces from the vertebral column to the pelvis and lower limbs and vice
versa. Its design allows for a small range of movement necessary to counter
the torsional stresses encountered with ambulation and postural changes.
There are no muscles spcecifically designed to produce active, physiologic
movement of the SIJ. Movement occurs passively as a result of muscle
contraction at the hip, pelvis and lumbar spine. Consequently, the stability of
the SIJ is subject to the integrity of the various SIJ ligaments and surrounding
muscle groups. These include the gluteals, hamstrings, hip external rotators,
psoas, abdominals, latissimus dorsi, quadratus lumborum and erector
spinae.6
The biomechanics of the SIJ are complex. The axes of movement of the SIJ
have been described to occur in an oblique plane across the pelvis, consistent
with its role as a stress-relieving joint.7 Numerous studies have examined the
movements of the SIJ in a variety of postures and movements and found the
range of motion is essentially only 1.4 Therapeutic manipulation has also
been examined and found not to alter joint position.8
 Sacroiliac Joint Pain 65
The presentation of SIJ pain is similar to other causes of low back pain
and clinical evaluation requires a thorough musculoskeletal examination of
the low back, pelvis, hips, and the lower limbs. Additionally, a full neurologic
assessment is necessary to rule out a neurologic source of pain. The most
common presenting symptom in patients with SIJ pain is pain or tenderness
over the region of the posterior superior iliac spine (PSIS).9 The Fortin Finger
test is commonly used as a simple diagnostic aid and is considered positive
when the patient points inferomedial to the PSIS within 1 cm, when asked to
indicate the region of pain.9 Pain is commonly described as being unilateral and
localized predominantly below the L5 spinous process.10 A retrospective study
conducted to determine the pain referral patterns in patients with injection-
confirmed SIJ pain found radiation into the buttock (94%), lower lumbar region
(72%), groin (14%) and upper lumbar region (6%).11 In the same study, 28% of
patients experienced pain radiating below the knee.
Radiologic imaging is inconclusive for diagnosing SIJ pain. Plain films
can demonstrate degenerative SIJ changes in at least 24.5% of asymptomatic
individuals over age 50.12 No correlation has been consistently demonstrated
between imaging findings and injection-confirmed SIJ pain.13 SIJ imaging is
useful in excluding red flags, but contributes poorly to the diagnosis.
Physical examination maneuvers are designed to either depict asym
metric movement or provoke SIJ pain. The Standing Flexion and Gillet test
are commonly used in assessment of the SIJ motion. A study of the standing
flexion test demonstrated asymmetric motion in 20% of asymptomatic
individuals.14 Similarly, evaluation of the Gillet test concluded that there was
no statistically significant association between it and patients who responded
to fluoroscopically guided anesthetic injections.15
A number of provocative SIJ maneuvers have been described. The more
commonly utilized maneuvers include the distraction test, compression
test, thigh thrust test, Patrick maneuver and Gaenslen test. A study from
Slipman showed little value in comparing physical examination findings and
diagnostic block.16 Individually, they have weak predictive value, but when
used in combination can suggest the diagnosis of SIJ pain. A study comparing
the diagnostic accuracy of a multitest regimen of 5 SIJ pain provocation tests
with fluoroscopically controlled double SIJ blocks found that when three or
more provocation tests are positive, it is probable that the pain is related to the
SIJ.17 Conversely, SIJ pain is less likely if fewer than three tests are positive.17
To confirm the diagnosis of SIJ pain, the International Association for the
Study of Pain (IASP) criteria mandates that pain should resolve after intra-
articular SIJ infiltration with a local anesthetic.18 The length of time that the
pain is relieved also should correspond to the duration of the anesthetic.
Controversy exists over the use of a single versus confirmatory (double)
second diagnostic block using two different local anesthetics containing
different durations of action. A single diagnostic SIJ block has been reported
to have a false-positive rate of approximately one-third12 and studies have
66 Interventional Spine ProceduresA Case-based Approach

found using a double-block paradigm to be more specific and reliable for

diagnosing SIJ pain.15 False-positive blocks may occur secondary to
extravasation of local anesthetic to surrounding pain-generating structures
such as muscles, ligaments, and lumbosacral nerve roots.10 Similarly, false-
negative blocks may occur with failure to obtain adequate local anesthetic
spread to the anterior and cephalad portions of the SIJ.10 Image-guided
needle placement is strongly recommended when performing intra-articular
SIJ blocks as one study illustrated only 22% intra-articular injectate spread
in blind procedures.19 Some authors advocate diagnostic dorsal ramus and
lateral branch blocks to confirm the diagnosis of SIJ pain.20

TREATMENT OPTIONS
Successful treatment of SIJ pain is challenging and best performed in the
context of a multidisciplinary approach. Conservative treatments are directed
at correcting the underlying biomechanical abnormalities and interventional
treatments aim to alleviate symptoms.
Conservative treatment for SIJ pain resulting from postural and gait
disturbances include physical therapy and manipulation. Both have been
suggested to reduce pain and improve mobility, however, there are no
controlled studies evaluating patients with injection-confirmed SIJ pain.
Correction of leg length discrepancy with the use of shoe inserts and
nonsurgical stabilization with pelvic belts and exercise-induced pelvic
stabilization programs are also utilized.21

INTERVENTIONAL OPTIONS
Patients with SIJ pain refractory to conservative treatment are candidates
for interventional management with intra-articular injections and/or RF
treatment.
Intra-articular injections with local anesthetic and steroid can serve the
dual function of aiding in confirming the diagnosis and being therapeutic.
Studies vary with regard to primary outcome measures and method of
diagnosis of SIJ pain, however, most have found image-guided SIJ injections
to provide good pain relief lasting from 6 months to 1 year.10 One study found
a significant reduction in Oswestry disability score and visual analog scale
pain score (both at the time of discharge from treatment and at almost 2-year
follow-up) following one or more therapeutic SIJ injection.

Classical Sacroiliac Joint Infiltration Technique

Informed consent was signed and all the patients questions were answered.
The risks, benefits, and alternative treatment options were explained. The
risks include but are not limited to increased pain, superficial or deep
 Sacroiliac Joint Pain 67

Fig. 7.2: Sacroiliac joint with contrast

infection, allergic reaction, nerve damage, paralysis, syncope, increased

blood sugar, headache, respiratory or cardiac arrest, and scar formation. All
vital signs, cardiac rhythm and oxygen saturation were monitored prior to,
during, and after the procedure.
The C-arm was positioned so that the SIJ was visualized. The soft tissues
overlying this structure were infiltrated with a small amount of 1% lidocaine
without epinephrine. A 22- or 25-gauge spinal needle was advanced down
to the inferior portion of the SIJ and then inserted into the fluoroscopically
hyperlucent region within the joint. After negative aspirate for blood F, a
0.51 cc volume of nonionic contrast was injected and flow of contrast was
noted. An injectate consisting of steroid and 1% lidocaine (variable) was
administered.
An alternative approach is to visualize the sacroliac joint as medial and
lateral projections. This will represent the posterior and anterior aspects
of the joint, respectively. The physician will then place the needle into the
inferior portion of the medial projection (Fig. 7.2).

Radiofrequency Treatment of the

Sacroiliac Joint
Radiofrequency denervation procedures have become increasingly popular
over recent years in attempt to provide prolonged pain relief to patients
with refractory SIJ pain. There are three main types of radiofrequency ablation
(RFA): low-intensity RFA, cooled RFA and pulsed RFA. Studies evaluating
68 Interventional Spine ProceduresA Case-based Approach

Fig. 7.3: Sacroiliac joint radiofrequency ablation

the use of RFA are limited and differ in the combination of nerves lesioned
no standards have been established for the specific nerves to ablate, type of
technique, or type of RFA.22 The available literature has reported successful
outcomes, defined as greater than a 50% consistent decrease in pain, at 6
months4 and 9 months22 after the procedure. Newer studies have evaluated
cooled RF, in which electrodes are internally cooled to produce larger
thermal lesions and have shown favorable results at 3, 6 and 9 months follow-
up.13,23 There is also literature supporting the use of local anesthetic to the
LBs of the sacrum, without intra-articular injection, to determine a good
response to SIJ RFA (Fig. 7.3).

Radiofrequency Technique
The patient lies prone and the C-arm is obliqued to view the sacral foramen.
An RF lesion generator and an insulated needle with an exposed active tip,
either curved or straight is used. The RF needles are placed under fluoroscopic
guidance to the regions where the respective nerves supplying the SIJ are
known to reside. The electrodes are individually directed under fluoroscopic
imaging toward the superior aspect of the sacral ala, approximately 57 mm
lateral to the S1 superior articular process (location of presumed L5 posterior
sensory branch distinct from dorsal ramus medial branch nerve) and the
lateral edge of the dorsal sacral foraminal apertures of S1S3 (sacral dorsal
rami LB nerves). At each location, 50 Hz, 1 ms stimulation is applied at 0.4
0.7 V (searching voltage). The RF electrodes are finely manipulated under
fluoroscopic imaging around the target structures until either reproduction
 Sacroiliac Joint Pain 69
of concordant/usual pain or paresthetic somatic or cutaneous sensation
(benign stimulation, described by patients as tingling, buzzing, or
vibration) is elicited with electrical stimulation. Stimulation is performed
through the 26 oclock zone on the right or 610 oclock zone on the
left (if the dorsal sacral foramen is viewed as a clock face). If the patient
experiences precise reproduction of concordant ipsilateral pain, stimulation
voltage is decreased to a threshold of 0.10.2 V and the electrodes are finely
maneuvered to maximize and maintain stimulation at the minimal threshold
voltage. This is also utilized to confirm no radicular sensory stimulation.
Motor stimulation may be utilized to ensure that there is no radicular spread
of current at 2 Hz. Before RF lesioning, 0.51.0 mL of lidocaine is injected to
anesthetize the target area. A single LB RF lesion is created at each level (L5,
S1, S2). RF lesions are created at 80C for a period of 6090 seconds. Lesions
are normally repeated one to two times for an additional 6090 seconds
with some slight repositioning of the RF needles. This is to allow for a more
complete lesion. Some practitioners may elect to place an alequot of steroid
and anesthetic at the end of the case to reduce local inflammation created by
the lesioning procedure.
Potential complications can be site soreness, local hematoma, cellulitis,
or inadvertent lesioning of a radicular nerve.24

REFERENCES
1. Vanelderen P, Szadek K, Cohen SP, et al. 13. Sacroiliac joint pain. Pain Pract.
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2. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the relative contributions
of various structures in chronic low back pain. Pain Physician. 2001;4(4):308-16.
3. Hansen HC, McKenzie-Brown AM, Cohen SP, et al. Sacroiliac joint interventions:
a systematic review. Pain Physician. 2007;10(1):165-184.
4. Yin W, Willard F, Carreiro J, et al. Sensory stimulation-guided sacroiliac joint
radiofrequency neurotomy: technique based on neuroanatomy of the dorsal
sacral plexus. Spine. 2003;28(20):2419-25.
5. Bogduk N. Clinical and radiological anatomy of the lumbar spine, 5th edition.
Philadelphia; 2012.
6. Prather H, Hunt D. Conservative management of low back pain, part I. Sacroiliac
joint pain. Dis Mon. 2004;50(12):670-83.
7. Lavignolle B, Vital JM, Senegas J, et al. An approach to the functional anatomy of
the sacroiliac joints in vivo. Anat Clin. 1983;5(3):169-76.
8. Tullberg T, Blomberg S, Branth B, et al. Manipulation does not alter the position
of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine.
1998;23(10):1124-8; discussion 1129.
9. Fortin JD, Falco FJ. The Fortin finger test: an indicator of sacroiliac pain. Am J
Orthop. 1997; 26(7):477-80.
10. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis,
and treatment. Anesth Analg. 2005;101(5):1440-53.
11. Slipman CW, Jackson HB, Lipetz JS, et al. Sacroiliac joint pain referral zones.
Arch Phys Med Rehabil. 2000;81(3):334-8.
70 Interventional Spine ProceduresA Case-based Approach

12. Chou LH, Slipman CW, Bhagia SM, et al. Inciting events initiating injection-
proven sacroiliac joint syndrome. Pain Medicine. 2004;5(1):26-32.
13. Patel N, Gross A, Brown L, et al. A randomized, placebo-controlled study to
assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain.
Pain Med. 2012;13(3):383-98.
14. Dreyfuss P, Dryer S, Griffin J, et al. Positive sacroiliac screening tests in
asymptomatic adults. Spine. 1994;19(10):1138-43.
15. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and
value of sacroiliac pain provocation tests in 54 patients with low back pain.
Spine. 1996;21(6):1889-92.
16. Slipman CW, Sterenfeld EB, Chou LH, et al. The predictive value of provocative
sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome.
Arch Phys Med Rehabil. 1998;79(3):288-92.
17. van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests
as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures.
Arch Phys Med Rehabil. 2006;87(1):10-4.
18. Merskey H, Bogduk N (Eds). Chronic pain: descriptions of chronic pain
syndromes and definitions of pain terms, 2nd edition. Seattle, WA: IASP Press;
1994. pp. 39-43.
19. Rosenberg JM, Quint TJ, de Rosayro AM. Computerized tomographic localization
of clinically-guided sacroiliac joint injections. Clin J Pain. 2000;16(1):18-21.
20. Cohen SP, Abdi S. Lateral branch blocks as a treatment for sacroiliac joint pain:
A pilot study. Reg Anesth Pain Med. 2003;28(2):113-9.
21. Mooney V, Pozos R, Vleeming A, et al. Exercise treatment for sacroiliac pain.
Orthopedics. 2001; 24(1):29-32.
22. Aydin SM, Gharibo CG, Mehnert M, et al. The role of radiofrequency ablation for
sacroiliac joint pain: a meta-analysis. PM & R. 2010;2(9):842-51.
23. Cheng J, Pope JE, Dalton JE, et al. Comparative outcomes of cooled versus
traditional radiofrequency ablation of the lateral branches for sacroiliac joint
pain. Clin J Pain. 2013;29(2):132-7.
24. Abbott Z, Smuck M, Haig A, et al. Irreversible spinal nerve injury from dorsal
ramus radiofrequency neurotomy: a case report. Arch Phys Med Rehabil.
2007;88(10):1350-2.
 Cervical Disc Herniation 8
with Radiculopathy
Theodore Conliffe, Jeremy Simon, Zachary Broyer

CHIEF COMPLAINT
The patient complains of neck and left arm pain.

HISTORY OF PRESENT ILLNESS

The patient is a 33-year-old right-hand dominant professional football player
who presented to our office with a chief complaint of neck pain radiating into
his left arm for approximately 4 weeks. His injury occurred while making a
tackle on a running back during practice. He tackled the ball carrier with
his left shoulder and violently drove the player to the ground. He initially
was without discomfort but developed a burning ache in his neck and left
shoulder over the next few days. His symptoms have persisted despite use of
nonsteroidal anti-inflammatory drugs, heat and ice by his trainers. He has
also tried to remedy his symptoms with therapeutic massage and chiropractic
adjustments without benefit thus far.
The patient informed our staff that he had a similar episode about
3 years ago and frequently complains of neck stiffness and soreness after
games. He recalls one episode that his entire left arm went numb for about
5 minutes and he was told that he had a stinger but the symptoms resolved
quickly without further incident.
The patient describes his current symptoms as a constant dull ache in his
neck with associated pain in his left shoulder and scapula with numbness
into his left hand (Fig. 8.1). He quantifies his level of pain as a 7/10 on a
visual analog scale. The symptoms are not accompanied by motor weakness,
clumsiness, or loss of control of bowel or bladder. There is no balance or fine
motor deficits. The symptoms are exacerbated by neck flexion and lateral
72 Interventional Spine ProceduresA Case-based Approach

Fig. 8.1: Pain diagram

flexion of his neck to his right shoulder, as well as reaching overhead. His
symptoms are not relieved by anything presently.

PAST MEDICAL HISTORY

Cervical strain, right shoulder dislocation.

PAST SURGICAL HISTORY

Right anterior cruciate ligament reconstruction, left meniscectomy.

FAMILY HISTORY
Unremarkable

MEDICATIONS
Ibuprofen 600 mg taken with food, metaxalone (skelaxin) 800 mg QHS.
 Cervical Disc Herniation with Radiculopathy 73

ALLERGIES
Penicillin

SOCIAL HISTORY
Patient is a nonsmoker. Drinks alcohol socially.

REVIEW OF SYSTEMS
Neck pain, left arm pain/numbness.

PHYSICAL EXAMINATION

Vital Signs
Height: 6 2
Weight: 225 lbs
Pulse: 56/minute
Blood pressure: 120/74 mm Hg

General Appearance
Well-developed, well-nourished male in no apparent distress at time of
examination.
The patients gait and station are normal and his coordination is intact for
rapid alternating movements. Inspection and palpation revealed tenderness
over the left cervical paraspinal muscles and trapezius.
Motor strength was normal and 5/5 in all extremities. There was mildly
diminished sensation to light touch in the first digit of the left hand.

Reflexes
Left biceps reflex was 1 + otherwise, all other reflexes were intact. There were
no upper motor neuron signs, including Hoffmans and Babinski signs.
Provocative tests: Spurlings maneuver was positive for reproduction of pain
into his left arm.
Range of motion was normal in flexion/extension and lateral rotation of
C-spine, however, pain was reproduced with neck flexion past 10.
There were normal movements observed in the patients shoulders, hips
and knees. There were negative provocative maneuvers for shoulder pain.
No other abnormalities were observed on physical examination.
74 Interventional Spine ProceduresA Case-based Approach

IMAGING STUDIES
X-Rays
Anteroposterior, lateral, flexion and extension X-rays of cervical spine were
obtained and revealed moderate cervical spondylosis with narrowing of
the cervical zygapophyseal joints bilaterally from C4 to C7. There was no
spondylolisthesis, fracture or instability observed with dynamic imaging.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) of the cervical spine revealed a moderate
broad-based disc osteophyte complex at C5/6 with mild narrowing of the
neuroforamen on the left. There was no spinal cord impingement or signal
changes within the spinal cord. All other levels had mild degenerative
changes without significant neural encroachment.

DIAGNOSIS
Cervical disc herniation with left C6 radiculopathy.

TREATMENT OPTIONS
The patients occupation as a professional football player requires that he
returns to play as soon as possible without missing any games necessitating a
fairly aggressive approach.
The patient was receiving physical therapy with emphasis on cervical
stabilization exercises as prescribed by his team physicians and training staff.
He referred himself to a local chiropractor for adjustments and received
four to six sessions without benefit, and this treatment could be continued.
While not conclusive, some data suggests that manipulation in disorders
of the cervical spine may be beneficial.1,2 Complications with manipulation
are rare, but reported.3-9 Cervical traction can be considered as an
adjunctive, nonmedication, noninvasive treatment. Studies on its benefit are
conflicting.10-12
Medication options include nonsteroidal anti-inflammatories, muscle
relaxants and/or membrane stabilizing medications. Opiates in the setting
of radiculopathy should not be considered as a first line agent. This patient
declined additional medications.
The patient also had the option of therapeutic massage and electrical
stimulation that may provide some benefits with this condition. The studies
on these modalities are also conflicting.13,14 In addition, there are currently
no well-controlled randomized controlled studies proving the benefits of
massage therapy in neck pain or cervical radiculopathy.15
 Cervical Disc Herniation with Radiculopathy 75

Fig. 8.2: Left cervical transforaminal epidural steroid injection

At the time of his evaluation it was too soon to consider surgical

intervention and this option would have ended the patients season. The
absence of progressive neurologic dysfunction or overt signs of myelopathy
allow for nonsurgical management. The indications for cervical spine surgery
include but are not limited to progressive neurological deficits, intractable
arm pain, loss of bladder or bowel function, and other symptoms and signs
of myelopathy.16,17 The absence of cord edema and severe cord impingement
allow for the consideration of a cervical epidural steroid injection (Fig. 8.2).
The decision was made to proceed with a cervical transforaminal epidural
steroid injection targeting the C6 nerve root on the left.

INDICATIONS
Pain radiates into the left upper extremity corresponding to the cervical
symptoms of C6 radiculopathy. A cervical MRI prior to considering the
procedure supported the diagnosis. The patient attempted to control his
symptoms with 4 weeks of conservative treatments including physical
therapy, medications and chiropractic manipulations without success.
The patients symptoms of predominant arm versus neck pain made us
choose a transforaminal versus interlaminar approach, although there is no
definitive evidence that one approach is superior to the other.18,19

Cervical Epidural Steroid Injection:

Transforaminal Approach
Following informed consent the patient was brought to the fluoroscopy
suite and placed in the supine position. An intravenous catheter was
76 Interventional Spine ProceduresA Case-based Approach

inserted into the patient forearm for administration of fluids and mild
conscious sedation.
The patients neck was sterilely prepped and draped in the usual fashion.
C-arm fluoroscope was positioned in the oblique position to identify the
neuroforamen of the targeted nerve root (Left C6). The target position is the
posterior aspect of the cervical intervertebral foramen of the exiting spinal
nerve. A sterile spinal needle is directed through the skin over the target and
the needle is inserted using the axis of the fluoroscope into the posterior
aspect of the intervertebral foramen. Needle positioning is confirmed by
oblique view demonstration of needle placement in the posterior aspect of
the foremen and anterior posterior view lateral placement of the needle.
Confirmation of the needle placement in the epidural space is made
by injection of 1.0 cc of iodinated contrast. Live fluoroscopic images are
obtained in the anterior posterior view to confirm placement of contrast
spread along the nerve root and to ensure no vascular spread specifically
within the vertebral artery.
After needle placement is confirmed 12 cc of preservative-free 1%
lidocaine is injected and the patient is monitored briefly to ensure no seizure
activity. Finally, 1 cc of corticosteroid, dexamethasone equivalent to 10 mg, is
injected and the needle is removed.
The patient is then taken to the recovery room and monitored for
approximately 30 minutes to 1 hour prior to discharge. The patient is
provided with discharge instructions about contacting the physician after the
procedure and follow-up appointments are scheduled.

DISCUSSION
The proposed theory behind epidural steroid injection is that the
corticosteroids diminish inflammation caused by the disc herniation. Saal
et al. described high levels of inflammatory phospholipase A2 in lumbar
disc herniation.20
Cervical epidural steroid injections were first described in medical
literature in the 1960s to treat radiculopathy.21 Since that time, these
procedures have become a widespread treatment for cervical radiculopathy.
The evidence supporting efficacy of epidural steroid injections is limited by
the absence of randomized controlled trials.
Slipman et al.22 retrospectively analyzed selective nerve root blocks
in scientific literature for the cervical spine and reported there were clear
benefits and improved pain control. The evidence surrounding efficacy
of cervical epidural steroid injections for axial neck pain is limited.
A recent small randomized controlled study by Manchikanti et al. in 2010
for discogenic neck pain showed benefits of pain relief and improved
functional status.23
 Cervical Disc Herniation with Radiculopathy 77
A retrospective analysis by Benyamin et al. found there to be moderate
evidence that cervical interlaminar epidural injections provided relief of
chronic neck and radicular pain.24 Presently, there is some controversy
regarding the application of cervical transforaminal epidural steroids in the
use of radicular pain. The relative safety of these procedures has been debated
due to the potential for catastrophic injury. The potential for paralysis,
stroke and death exists by accidental injection into a vertebral artery despite
fluoroscopic imaging in expert hands.25-27 Many clinicians have stopped
performing these procedures because of the risk and instead perform only
cervical interlaminar injections.

CLINICAL OUTCOME
The patient received a left C6 transforaminal epidural injection without
complications and was able to return to practice and play in the game within
a week of his injection. Thus far he has avoided further injury to his cervical
spine and hopes to avoid surgical intervention in the future.

REFERENCES
1. Eriksen K, Rochester RP, Hurwitz EL. Symptomatic reactions, clinical outcomes
and patient satisfaction associated with upper cervical chiropractic care:
a prospective, multicenter, cohort study. BMC Musculoskeletal Disorders.
2011;12:219.
2. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the
cervical spine. A systematic review of the literature. Spine. 1996; 21(15):1746-59;
discussion 1759-60.
3. Lopez-Gonzalez A, Peris-Celda M. Acute paraplegia after chiropraxis. European
spine journal: official publication of the European Spine Society, the European
Spinal Deformity Society, and the European Section of the Cervical Spine
Research Society. 2011;20 (Suppl 2):S143-6.
4. Chakraverty J, Curtis O, Hughes T, et al. Spinal cord injury following chiropractic
manipulation to the neck. Acta Radiol. 2011;52(10):1125-7.
5. Solheim O, Jorgensen JV, Nygaard OP. Lumbar epidural hematoma after
chiropractic mani pulation for lower-back pain: case report. Neurosurgery.
2007;61(1):E170-1; discussion E171.
6. Whedon JM. Lumbar epidural hematoma after chiropractic manipulation for
lower-back pain: case report. Neurosurgery 2008;63(2):E376; author reply E376.
7. Soragna D, Montalbetti L, Bo P, et al. Chiropractic complications. Another case
report. Acta Neurol. 1993;15(2):145-50.
8. Stuart PJ, Bernstein T. A case of subdural hematoma and temporal bone fracture
as complications of chiropractic manipulation. J Emerg Med. 1989;7(6):615-7.
9. Huff L. Chiropractic manipulation and incidence of complications. Am Fam
Physician. 1996; 54(5):1467, 1470.
10. Zylbergold RS, Piper MC. Cervical spine disorders. A comparison of three types
of traction. Spine. 1985;10(10):867-71.
78 Interventional Spine ProceduresA Case-based Approach

11. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phy Med
Rehabil. 1994; 75(3):342-52.
12. Thoomes EJ, Scholten-Peeters W, Koes B, et al. The Effectiveness of Conservative
Treatment for Patients with Cervical Radiculopathy: A Systematic Review. Clin J
Pain. 2013.
13. Chiu TT, Hui-Chan CW, Chein G. A randomized clinical trial of TENS and
exercise for patients with chronic neck pain. Clinical Rehabil. 2005; 19(8):
850-60.
14. Frieden RA. Conservative management of neck pain. Mt Sinai J Medicine.
1994;61(3):197-203.
15. Gam AN, Warming S, Larsen LH, et al. Treatment of myofascial trigger-
points with ultrasound combined with massage and exercisea randomised
controlled trial. Pain. 1998;77(1):73-9.
16. Nesterenko SO, Riley LH, Skolasky RL. Anterior cervical discectomy and fusion
versus cervical disc arthroplasty: current state and trends in treatment for
cervical disc pathology. Spine. 2012; 37(17):1470-4.
17. Dreyer SJ, Boden SD. Nonoperative treatment of neck and arm pain. Spine.
1998;23(24):2746-54.
18. Smuck M, Rosenberg JM, Akuthota V. The use of epidural corticosteroids for
cervical radiculopathy: an interlaminar versus transforaminal approach. PM R.
2009;1(2):178-84.
19. Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical epidural
injections in the management of chronic neck and upper extremity pain. Pain
Physician. 2012;15(4):E405-34.
20. Saal JS, Franson RC, Dobrow R, et al. High levels of inflammatory phospholipase
A2 activity in lumbar disc herniations. Spine. 1990;15(7):674-8.
21. Thierry-Mieg J. [Cervical epidural injections of corticoids in hyperalgic cervico-
brachial neuralgias. 1st cervical epidurographical pictures]. Rev Rhum Mal
Osteoartic. 1961;28:451-3.
22. Slipman CW, Lipetz JS, Jackson HB, et al. Therapeutic selective nerve root block
in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: a
retrospective analysis with independent clinical review. Arch Phy Med Rehabil.
2000;81(6):741-6.
23. Manchikanti L, Cash KA, Pampati V, et al. Cervical epidural injections in chronic
discogenic neck pain without disc herniation or radiculitis: preliminary results
of a randomized, double-blind, controlled trial. Pain Physician. 2010;13(4):
E265-78.
24. Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of
cervical epidurals in the management of chronic neck pain. Pain Physician.
2009;12(1):137-57.
25. Huston CW, Slipman CW, Garvin C. Complications and side effects of cervical
and lumbosacral selective nerve root injections. Arch Phy Med Rehabil.
2005;86(2):277-83.
26. Scanlon GC, Moeller-Bertram T, Romanowsky SM, et al. Cervical transforaminal
epidural steroid injections: more dangerous than we think? Spine. 2007;32(11):
1249-56.
27. Rozin L, Rozin R, Koehler SA, et al. Death during transforaminal epidural steroid
nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic
Med Pathol. 2003;24(4):351-5.
 Cervical Disc Herniation 9
without Radiculopathy
Gautam Kothari, Jeremy Simon

CHIEF COMPLAINT
The patient complains of neck pain.

HISTORY OF PRESENT ILLNESS

A 39-year-old gentleman with a 3-year-history of intermittent axial neck
pain presents with 6 months of worsening symptoms. He describes
symptom exacerbation after going to an amusement park and going on
multiple rollercoaster rides. He noted that a week following the rides, he
began experiencing worsening neck pain which was associated with spasm
(Fig. 9.1). The symptoms are also described as sharp and burning and are
exacerbated by prolonged neck flexion/extension and rotation, which is a
requirement of his job as an electrician. He has no significant history of neck
pain or radiating arm pain. His pain level is currently an 8/10. He does not
describe any associated falling, fine-motor deficits, clumsiness, loss of bowel
or bladder control, or any other constitutional symptoms.
Treatments to date have been conservative and include 6 weeks of
physical therapy to the cervical spine including stabilization, range of
motion exercises, modalities with cervical traction and strengthening of
the upper extremities and paraspinal musculature. He was given a Medrol
Dosepak initially and has been more recently been taking nonsteroidal anti-
inflammatory medications twice daily and a muscle relaxer at night time
for sleep and spasm. His primary care physician recently started him on
tramadol for his pain. He has noticed minimal relief with these treatments.
He has also tried a few chiropractic treatments with no significant benefit.
80 Interventional Spine ProceduresA Case-based Approach

Fig. 9.1: Pain diagram

He is presenting to your office for a more complete evaluation of his

problem and to explore the possibility of spinal intervention. He brings with
him a recent cervical spine MRI ordered by his primary care physician.

PAST MEDICAL/SURGICAL HISTORY

None

FAMILY HISTORY
Parents alive, both healthy.

SOCIAL HISTORY
Currently employed as an electrician, drinks: two drinks/week, denies
tobacco, denies illicit drug use, no workmans compensation claim or
autoclaim.
 Cervical Disc Herniation without Radiculopathy 81

MEDICATIONS
Ibuprofen 800 mg PO TID PRN, cyclobenzaprine 10 mg PO QHS PRN,
tramadol 50 mg PO BID PRN.

ALLERGIES
None

REVIEW OF SYSTEMS
Negative

PHYSICAL EXAMINATION
Height: 57
Weight: 175
Pulse: 80/minute
Respirations: 16/minute

General Appearance
Pleasant, cooperative, looks stated age in no acute distress.
Affect is unremarkable. Coordination is normal. Reflexes are 2/4 right
biceps, triceps and brachioradialis. Left biceps and brachioradialis are 1/4
and left triceps at 2/4. Hoffmann is negative. Inspection and palpation do
not identify significant misalignment, atrophy, or asymmetry in the head,
neck, shoulders, upper limbs or thoracolumbar spine. There is no evidence
of acute dislocation, instability or fracture in the neck, thoracolumbar spine
or either upper limb. The pelvis is level without obvious scoliotic deformity.
The patient has a normal tandem gait. Cervical flexion and extension are
painful, rotation and side bending to the left side also painful, pain free toward
the right. Spurlings maneuver reproduces left axial neck pain. Bilateral
shoulder forward flexion, abduction, internal and external rotation range of
motion is grossly functional and symmetric. Strength testing is 5/5 in the right
upper extremity. Left upper extremity strength demonstrates 5/5 muscle
strength testing with the exception of left elbow flexion and wrist extension
which is 4/5. Sensation to light touch is normal in the right upper extremity,
diminished in the left proximal outer arm and distal radial forearm. Distal
pulses are within normal limits in the bilateral upper limbs, neck and trunk
without evidence of lymphadenopathy, edema, or rash in these regions.
There is no ankle clonus.
82 Interventional Spine ProceduresA Case-based Approach

Fig. 9.2: Lateral radiograph of the cervical spine

Fig. 9.3: Anterior-posterior (AP) radiograph of the cervical spine

IMAGING
X-ray cervical spine (anteroposterior/Lat/obl/flex/ext) demonstrated normal
alignment and contour (Figs 9.2 to 9.4). Reduced lordosis. No instability on
flexion/extension. No evidence of fracture or dislocation. No evidence of
spondylolisthesis.
 Cervical Disc Herniation without Radiculopathy 83

Fig. 9.4: Lateral flexion-extension radiographs of the cervical spine

Fig. 9.5: Sagittal MRI showing a C5-6 disc herniation

Magnetic imaging of the cervical spine without contrast demonstrates

a moderate-sized central disc herniation at C5C6 with effacement of the
ventral aspect of the spinal cord (Fig. 9.5).
84 Interventional Spine ProceduresA Case-based Approach

DIAGNOSIS
Axial neck pain in the setting of cervical disc herniation C5C6.

TREATMENT OPTIONS
The patient presents with axial neck pain appearing to be largely discogenic
in nature. His symptoms have been minimally responsive to physical therapy,
manual therapies, and medication management. Consideration should certainly
be given to continuation of cervical spine stabilization and strengthening as the
patients job requires a significant amount of cervical flexion/extension.
The patient is currently on ibuprofen 800 MG PO TID as well as
cyclobenzaprine and tramadol. Although the patient is otherwise healthy, he
should be counseled with regards to long-term effects of anti-inflammatory
medications and should certainly have a H2 blocker or proton pump inhibitor
added to his regimen for gastric protection.1 The dosage of tramadol could be
increased, but a frank discussion is necessary regarding the addiction and
tolerance potential of this drug.2
The symptoms, physical exam findings and imaging studies correlate with
a discogenic neck pain. Cervical facet syndrome is less likely as he does not
have evidence of cervical facet disease on imaging.

INTERVENTIONAL OPTIONS
Axial neck pain has a typical 12-month prevalence of 3050%.3 In recent years
chronic neck pain has reached epidemic proportions with an explosion in
diagnostic and therapeutic measures. There is, to date, no consensus on
the cause and/or treatment. The pain generators can range from soft tissue
to symptomatic facet disease to symptomatic discogenic pain. It has been
postulated that the presence of discogenic pain can be wide ranging because
of the multi-segmental innervation of the intervertebral disc. Dorsal root
ganglia, sympathetic ganglia and parasympathetic ganglia can all contribute
to innervation of the disc. This may explain the prevalence of discogenic pain
that can occur via different arms of the nervous system.4 Advanced diagnostic
imaging offers an anatomic road map of degenerative disc disease and
potential pain generators, but does not necessarily correlate with subjective
complaints. For this reason, patients with recalcitrant axial neck pain who
have not responded to conservative management may be candidates for
diagnostic discography.5 Serious complications including discitis can occur6
and the true utility of the procedure is in question.7
Cervical epidural steroid injections can be considered for the treatment
of axial neck pain in the setting of a disc herniation not responding well to
other conservative measures.3 The proposed mechanism of epidural steroid
 Cervical Disc Herniation without Radiculopathy 85
injections is a reduction in axial and radicular pain by administration of a
concentrated mixture of localized steroid/anesthetic in close proximity
to the site of pathology, thereby reducing the inflammatory reaction likely
responsible for symptoms. The efficacy of epidurals is considered greater
in those patients with radicular pain, in the presence of disc herniation or
stenosis, and is less predictable for patients with axial pain without radicular
symptoms with similar anatomic abnormalities.8
The approach that is commonly considered is through the interlaminar
approach (Figs 9.6 to 9.8). This procedure is carried out with the use of
fluoroscopic guidance. The target entry point is (generally) the C7T1
interspace as this is considered the safest entry point. It has the largest
epidural space relative to the dura and spinal cord in the cervical spine
thereby allowing more room to work.9 Similar to lumbar interlaminar
injections, the paramedian approach is what is most commonly used to avoid
traversing the interspinous ligament. Biplanar imaging is advocated for safe
needle placement and assessment of depth of needle insertion. Commonly,
the patients shoulders obscure the needle image on lateral view. In this
scenario, the 60 contralateral oblique view may be the only view available
for safely identifying depth. If the needle tip is midline, the oblique may be
in either direction (i.e. right or left). When the lateral or contralateral view is
used, stepping off lamina is not necessary.10,11

Cervical Interlaminar Epidural Steroid Injections

The patient was prepped and draped in a sterile fashion in the prone position
after informed consent was signed and all patient questions were answered

Fig. 9.6: AP fluoroscopy image showing the Tuohy needle in the C7-T1 interspace
86 Interventional Spine ProceduresA Case-based Approach

Fig. 9.7: AP fluoroscopy image showing the flow of contrast

epidurally and lateralizing to the left

Fig. 9.8: Contralateral oblique image showing the

flow of contrast into the epidural space

including the risks, benefits, alternative treatment options and prognosis. The
risks include but are not limited to infection, allergic reaction, nerve damage,
stroke, paralysis, epidural hematoma, syncope, headache, respiratory or
cardiac arrest, spinal cord injury, and scar formation.
 Cervical Disc Herniation without Radiculopathy 87
Using a paramedian approach from the side mentioned above, the region
overlying the inferior lamina was localized under fluoroscopic visualization and
the soft tissues overlying this structure were infiltrated with 4 cc. of 1% lidocaine
without epinephrine. A #18 gauge, Tuohy needle was inserted into the epidural
space using a paramedian approach. The epidural space was localized using
loss of resistance after negative aspirate for air, blood, and CSF. A 2 cc volume of
omnipaque 300 was injected into the epidural space and the flow of contrast was
observed. Radiographs were obtained for documentation purposes.
The injectate was administered into the level noted above. The patient
tolerated the procedure well and was discharged after an appropriate
period of observation.
If there are any complications, the patient was instructed to call us.
The patient is to follow-up with the requesting physician in 12 weeks.

REFERENCES
1. Taha AS, Hudson N, Hawkey CJ, et al. Famotidine for the prevention of gastric
and duodenal ulcers caused by nonsteroidal antiinflammatory drugs. N Engl J
Med. 1996;334(22):1435-9.
2. Raffa RB, Friderichs E, Reimann W, et al. Complementary and synergistic
antinociceptive interaction between the enantiomers of tramadol. J Pharmacol
Exp Ther. 1993;267(1):331-40.
3. Manchikanti L, Cash KA, Pampati V, et al. Cervical epidural injections in chronic
discogenic neck pain without disc herniation or radiculitis: preliminary results
of a randomized, double-blind, controlled trial. Pain physician. 2010; 13(4):
E265-78.
4. Fujimoto K, Miyagi M, Ishikawa T, et al. Sensory and autonomic innervation
of the cervical intervertebral disc in rats: the pathomechanics of chronic
discogenic neck pain. Spine. 2012; 37(16):1357-62.
5. Schellhas KP, Smith MD, Gundry CR, et al. Cervical discogenic pain. Prospective
correlation of magnetic resonance imaging and discography in asymptomatic
subjects and pain sufferers. Spine. 1996;21(3):300-11; discussion 311-2.
6. Kapoor SG, Huff J, Cohen SP. Systematic review of the incidence of discitis after
cervical discography. Spine J. 2010;10(8):739-45.
7. Onyewu O, Manchikanti L, Falco FJ, et al. An update of the appraisal of the
accuracy and utility of cervical discography in chronic neck pain. Pain Physician.
2012;15(6):E777-806.
8. Bush K, Hillier S. Outcome of cervical radiculopathy treated with periradicular/
epidural corticosteroid injections: a prospective study with independent clinical
review. European spine journal: official publication of the European Spine
Society, the European Spinal Deformity Society, and the European Section of
the Cervical Spine Research Society. 1996;5:319-25.
9. Lieberman R, Dreyfuss P, Baker R. Fluoroscopically guided interlaminar cervical
epidural injections. Arch Phy Med Rehabil. 2003;84:1568-9; author reply 1569.
10. Furman M, Jasper NR, Lin HW. Fluoroscopic contralateral oblique view in
interlaminar interventions: a technical note. Pain Med. 2012; 13(11):1389-96.
11. Landers MH, Dreyfuss P, Bogduk N. On the geometry of fluoroscopy views for
cervical interlaminar epidural injections. Pain Med. 2012;13(1):58-65.
 10
Cervical Facet Syndrome
Matthew McAuliffe, Jeremy Simon

CHIEF COMPLAINT
The patient complains of neck pain.

HISTORY OF PRESENT ILLNESS

A 37-year-old right-handed male with a 2-year history of neck pain presents
to your office. Onset began immediately after he was in a motor vehicle
accident where he was a restrained passenger in a rear-end collision. The
pain has been a constant dull ache since the accident, worsening over the last
2 weeks. The pain limits his neck motion when looking to the right, looking
up and with looking up and to the right. It is now constant, unilateral and
located on the right posterior and lateral aspect of the neck beginning from
approximately C4 spinous process and radiates down to around the scapula
intermittently but does not radiate past the shoulder or acromioclavicular
(AC) joint. In addition, patient complains of intermittent headaches over this
same time period that starts over the back of his neck and radiate up over
his head, occasionally extending to his forehead with an associated band-
like pressure across his temples. There is no associated numbness or tingling
in the arms or hands. There is no associated weakness, fine motor deficits,
falls or balance problems. He denies symptoms of unintentional weight
loss, fevers, incontinence, nausea, vomiting, trouble swallowing, history of
malignancy, pain occurring at night or any other symptoms.
He explains he has attempted many different therapies in an attempt to
relieve his neck pain including nonsteroidal anti-inflammatory medications,
muscle relaxers with modest relief. He briefly tried physiotherapy but quit after
a few sessions because he felt it did nothing to improve his pain. In addition
 Cervical Facet Syndrome 89

Fig. 10.1: Pain diagram

he has also tried TENS and K-Pads that were prescribed by his primary care
physician with moderate relief. He has also sought the advice of a massage
therapist and a chiropractor with no relief. He is coming to your office to
seek another opinion and to consider the possibility of interventional
treatment for his pain.
Patient has aching pain in the right side of the neck and into the trapezius
(Fig. 10.1).

PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

Hypertension (HTN), gastroesophageal reflux di
sease, history of gastric
ulcer 5 years previous.

REVIEW OF SYSTEMS
As above, otherwise negative.

FAMILY HISTORY
Mother and father have history of HTN, high-density lipoprotein. No family
history of malignancy.
90 Interventional Spine ProceduresA Case-based Approach

SOCIAL HISTORY
Denies alcohol use other than an occasional glass of wine when out with
friends, denies tobacco abuse and denies intravenous or illicit drug use.
Employed as an accountant, full time, no workmens compensation claims.

CURRENT MEDICATIONS
Naprosyn 500 mg BID PRN, cyclobenzaprine 10 mg QHS PRN, hydro
chlorothiazide 12.5 mg daily, pantoprazole 40 mg QAM.

ALLERGIES
Penicillinpatient believes he developed hives as a kid.

PHYSICAL EXAMINATION
Height: 61
Weight: 225 lbs
Body mass index: 29.7
Pulse: 76/minute
BP: 129/77 mm Hg
Respirations: 12/minute
He is a pleasant, cooperative man. Looks his stated age, is overweight,
and appears in no distress. There are no gait abnormalities and tandem gait
is negative for any posterior column or cerebellar signs. Reflexes are 2+ in
patellae, Achilles tendons, biceps tendons, pronator teres tendons, and
triceps tendons. Babinski is down going, and Hoffmans sign is negative
bilaterally. Sensory exam to light touch and pinprick are normal in the upper
and lower extremity dermatomes. Manual muscle testing in lower extremities
reveals 5/5 strength in bilateral hip flexors, quadriceps, tibialis anterior,
extensor halluces longus and gastrocsoleus. Manual muscle testing in upper
extremities reveals 5/5 strength in bilateral deltoids, rotator cuff muscles,
biceps, extensor carpi radialis, triceps, flexor digitorum profundus and in
the intrinsic hand muscles. On shoulder exam, Hawkins test and empty can
test are negative bilaterally. There is no AC joint tenderness. Patient has full
passive and active range of motions in all four extremities. There is tenderness
to palpation along the right C5C6 lateral mass. Pain is exacerbated when
patient actively and passively rotates neck to the right when cervical spine is
in a neutral and extended position. There is palpaple muscle tenderness along
cervical paraspinal muscles. Patient has no pain when active or passive
rotation to the left occurs. Spurlings test is negative.
 Cervical Facet Syndrome 91

IMAGING
X rays cervical spine AP, lateral, flexion, extension: Normal segmentation, no
fracture or spondylolisthesis, reduced lordosis, mild disc desiccation at C45
and C56.
Magnetic resonance imaging cervical spine disc degeneration at C45, C56.

DIAGNOSIS
Cervical zygapophysial joint (facet) syndrome at C5C6.
His symptoms are consistent with cervical zygapophysial joint syndrome.
While sometimes difficult to diagnose on history and physical exam alone,
the syndrome is characterized by axial neck pain that rarely radiates past the
shoulder, tends to be unilateral, and an absence of neurological symptoms
to suggest myelopathy or radiculopathy.1-3 In addition the syndrome is also
often characterized by pain on passive and active stretch on neck extension
and rotation that limits motion.4
Other diagnoses in the differential are less likely. Following a motor
vehicle accident with significant neck pain, the cervical spine should be
cleared of fracture or dislocation via dynamic (flexion and extension) X-rays.5
The X-rays on this patient were negative, thus pointing to a benign cause for
the pain. It is important to always rule out shoulder pathology in patients
with a chief complaint of neck pain, and the two may coexist. However, the
shoulder exam here is normal and no pain can be elicited. Discogenic neck
pain is more likely to have pain on flexion of the neck. With the absence of
neurological signs on history or exam, radiculopathy or myelopathy can
essentially be ruled out. Due to the length of time and the severity of pain,
additional imaging can help confirm this. If an interventional procedure is to
be considered, an MRI or CT scan with axial cuts should be obtained prior to
injection into the cervical spine.
If the diagnosis remains in doubt, a diagnostic medial branch block can
be performed as described below. A block is considered the gold standard for
diagnosis.

Treatment Options
An initial recommendation to the patient could be keeping a pain journal as
to the time and frequency of neck pain exacerbations. This could help identify
activities that make his pain worse and help with lifestyle modifications.
In addition he works as an accountant, and desk jobs are known to
promote poor posture which can cause or aggravate neck pain. Good
sitting posture should be encouraged. He should also be advised to avoid
long periods of sitting and to make efforts to walk around or exercise
intermittently during the day. An ergonomic evaluation of his workstation
92 Interventional Spine ProceduresA Case-based Approach

may be ordered. Proper ergonomics may also be emphasized at the time of

visit and literature may be provided for patient education.
The importance of physical therapy should be emphasized when treating
neck pain and preventing recurrence. Gentle range of motion exercises, light
aerobic exercise, and stretching should be advised to the patient. For long-
term pain relief, the patient should focus on isometric muscle strengthening
which has shown to be beneficial for sources of axial neck pain.6 In general,
the above activities should make patients more involved in their care;
however, he has already shown a history of not participating actively in
physical therapy.
He already has been taking nonsteroidal anti-inflammatory drugs
(NSAIDs) in the form of naprosyn as well as muscle relaxer for pain. A concern
for continued NSAID use is his previous history of a gastric ulcer. According
to the American College of Gastroenterology patients who are at high risk for
gastrointestinal complications, if possible, should consider an alternative to
a nonselective NSAID considered such as a selective COX-2 inhibitor used
concomitantly with a proton pump inhibitor.7 Selective COX-2 inhibitors
have been shown to have lower risk of gastrointestinal side effects. Evidence
for the use of muscle relaxers suggests they are also beneficial, though they
are not as strong as they are for NSAIDs.8
Other therapeutic alternatives include transcutaneous electrical nerve
stimulation, electromagnetic therapy, manual manipulation and massage
therapy. However, the evidence that any of these modalities are effective is
currently inconclusive.9-13

Interventional Options
Cervical zygapophysial joint pain may be addressed in one of three ways:
Injection via an intra-articular (Fig. 10.2) approach, injection that blocks
(anesthesizes) the nerves that supply them (Fig. 10.3), or with radiofrequency
neurotomy (Fig. 10.4).
Before each interventional option is discussed it is important to
understand the basic anatomy of the cervical zygapophysial joints. Cervical
vertebrae C2C7 have superior and inferior articulating facet joints. The
C2C3 zygapophysial joint is innervated by the dorsal ramus of the third
occipital nerve. The remaining cervical zygapophysial joints are innervated
by medial branches of the dorsal rami whose roots originate one level
rostral and one level caudal to the corresponding joint.13 For example, the
C3C4 zygapophysial joint is innervated by medial branches of the third and
fourth cervical rami, the C4C5 zygapophysial joint is innervated by medial
branches of the fourth and fifth cervical rami, and so on. The following figure
illustrates the innervation of the cervical zygapophysial joints. They are taken
from Lord et al.14 and are representation of the variation of the position of the
 Cervical Facet Syndrome 93

Fig. 10.2: Cervical intra-articular zygapophysial joint injection

Fig. 10.3: Cervical medial branch block (zygapophysial joint nerve block)

cervical dorsal rami; the lateral view shows the nerves as lines, the antero
posterior view shows them as dots (Fig. 10.5).
Some practitioners advocate trying an intra-articular zygapophysial
injection first as steroid can be delivered to the joint itself. If the patient
benefits, radiofrequency ablation may be avoided. Unfortunately, studies fail
to demonstrate the effectiveness of intra-articular steroid injections.16 Intra-
articular zygapophysial injections are also technically more difficult and
may, in cases of significant arthritis, not be possible. There is also a concern
94 Interventional Spine ProceduresA Case-based Approach

Fig. 10.4: Cervical zygapophysial joint radiofrequency ablation of the third occipital
nerve for the right C2-3 zygapophysial joint (anterior posterior view)

Fig. 10.5: Cervical medial branch anatomy (mb: medial branch nerve)

from a diagnostic standpoint that the anesthetic medicine may extravasate

to surrounding tissue and thus reduce the reliability of the diagnostic
component.
As recommended by the International Spine Intervention Society (ISIS)
and generally accepted as the gold standard for diagnosis of facet joint pain,
a two positive block paradigm is required for confirming zygapophysial joint
pain.17 The ISIS guidelines say this may include one intra-articular injection
and one medial branch block or two medial branch blocks.
Similarly, medial branch block of the dorsal ramus is also predominately
used as a diagnostic aid. However, one 2-year trial with follow-up has
noted improvement of pain following injection with local anesthetic over a
 Cervical Facet Syndrome 95
1719 weeks period, although the addition of a steroid showed no added
benefits of pain relief.18
The most studied and most effective interventional technique for
short-term relief for cervical zygapophysial joint pain is radiofrequency
neurotomy. The landmark study that demonstrated the effectiveness of this
procedure demonstrated a mean duration of pain relief defined as a return
to 50% of a patients original pain level of 263 days following radiofrequency
neurotomy.15,19 Since that study was done, there have been several studies
to support pain relief from radiofrequency neurotomy in a significant
number of patients ranging from months to years.15,20 Furthermore, evidence
suggests that if a patient responds to the first radiofrequency neurotomy well,
subsequent procedures will produce a similar satisfaction with pain and a
similar duration as the initial injection.20-22

Cervical Intra-articular Facet Injection

The patient was prepped and draped sterilely in the prone position with the
head rotated to the left after informed consent was signed and all the patients
questions were answered. The risks, benefits, alternative treatment options
and prognosis were explained to the patient in the preprocedure area. The
risks include, but are not limited to infection, nerve damage, paralysis,
allergic reaction, spinal cord injury, epidural hematoma formation, syncope,
headache, respiratory or cardiac arrest, death, worse pain and scar formation.
All vital signs were monitored prior to, during, and after the procedure.
Oxygen saturation was also monitored and noted to be greater than or equal
to 94% throughout the procedure. Cardiac monitoring revealed normal sinus
rhythm.
The C-arm was positioned so that the region overlying the C5C6
zygapophysial joint was visualized. The soft tissues overlying these structures
were infiltrated with 35 cc of 1% lidocaine without epinephrine. A 25-gauge
spinal needle was inserted into the superior aspect of the joint. After negative
aspirate for blood or CSF, a small volume of nonionic contrast was injected
and flow was noted. Radiographs were obtained for documentation purposes.
The injectate was administered into the levels noted.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
was instructed to call us. The patient is to follow-up with the physician as
noted above within 2 weeks. The patient was provided with a pain diary
noting the preprocedure pain level and asked to bring it to the follow-up
appointment.

Cervical Medial Branch Block

The patient was prepped and draped sterilely in the prone position with
the head rotated to the left after informed consent was signed and all the
96 Interventional Spine ProceduresA Case-based Approach

patients questions were answered. The risks, benefits, alternative treatment

options and prognosis were explained to the patient in the preprocedure
area. The risks include, but are not limited to infection, nerve damage,
paralysis, allergic reaction, spinal cord injury, epidural hematoma formation,
syncope, headache, respiratory or cardiac arrest, death, worse pain and
scar formation. All vital signs were monitored prior to, during, and after the
procedure. Oxygen saturation was also monitored and noted to be greater
than or equal to 94% throughout the procedure. Cardiac monitoring revealed
normal sinus rhythm. The patient was lightly sedated prior to and during
the procedure via IV infusion with the anesthesia noted above. The patient
remained communicative throughout the procedure.
The C-arm was positioned so that the regions where the C5 and C6
zygapophysial joint nerves are known to reside were visualized. The soft
tissues overlying these structures were infiltrated with 35 cc of 1% lidocaine
without epinephrine for local anesthesia.
For the C3C7 medial branch nerves, the 25-gauge spinal needle was
advanced down to the trough of the lateral masses of each appropriate
vertebral level.
An AP projection was used to confirm the positions. After negative
aspirate for blood or CSF, a small amount of nonionic contrast was injected
and flow of contrast was noted at each level. Radiographs were obtained for
documentation purposes. The injectate was administered at the levels noted
above.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
was instructed to call us. The patient is to follow-up with the physician as
noted above within 12 weeks.
The patient was also given a pain diary and was instructed to note the
pain level and activities at the time of entering the data for the day of the
procedure. The patient will bring this data to the follow-up appointment for
diagnostic purposes.

Cervical Medial Branch Radiofrequency Ablation

The patient was prepped and draped sterilely in the prone position with
the head rotated to the left after informed consent was signed and all the
patients questions were answered. The risks, benefits, alternative treatment
options and prognosis were explained to the patient in the preprocedure
area. The risks include, but are not limited to infection, nerve damage,
paralysis, allergic reaction, spinal cord injury, epidural hematoma formation,
syncope, headache, respiratory or cardiac arrest, death, worse pain and
scar formation. All vital signs were monitored prior to, during, and after the
procedure. Oxygen saturation was also monitored and noted to be greater
than or equal to 94% throughout the procedure. Cardiac monitoring revealed
 Cervical Facet Syndrome 97

Fig. 10.6: Cervical zygapophysial joint radiofrequency ablation of the third

occipital nerve for the right C2-C3 zygapophysial joint (lateral view)

normal sinus rhythm. The patient was lightly sedated prior to and during
the procedure via IV infusion with the anesthesia noted above. The patient
remained communicative throughout the procedure. A grounding pad was
placed on the patient.
The C-arm was positioned so that the appropriate vertebral levels for the
above mentioned zygapophysial joint nerves were visualized. The soft tissues
overlying these structures were infiltrated with 26 cc of 1% lidocaine without
epinephrine.
At the C5 and C6 medial branch nerves, the radiofrequency needle
was advanced down to the trough of the lateral masses of each vertebral
level. A lateral projection was used to confirm the positions. At both levels,
the radiofrequency needle stylets were replaced with the radiofrequency
probes. Impedance was noted to be less than 300 at both levels. Sensory
stimulation at 50 Hz and motor stimulation at 2 Hz were performed at each
level to ensure no radicular stimulation and to observe maximal multifidus
contractions. An additional 12 cc of 1% lidocaine without epinephrine was
infiltrated into the soft tissues. Subsequently at each level, lesioning was
performed at 80C for approximately 90 seconds. The lesioning was repeated
two times at each level for 90 seconds. At the cessation of the procedure,
a small mixture of betamethasone and 1% lidocaine without epinephrine
was injected and the needles removed. Radiographs were obtained for
documentation purposes.
The patient tolerated the procedure well, was taken to the recovery room
and then discharged after an appropriate period of observation. If there are
any complications, the patient was instructed to call us. The patient is to
follow-up with the physician as noted above within 23 weeks (Fig. 10.6).
98 Interventional Spine ProceduresA Case-based Approach

REFERENCES
1. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A
study in normal volunteers. Spine (Phila Pa 1976). 1990;15(6): 453-7.
2. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med.
2007;8(4):344-53.
3. Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: A
clinical evaluation. Spine (Phila Pa 1976). 1990;15(6):458-61.
4. van Eerd M, Patijn J, Lataster A, et al. 5. Cervical facet pain. Pain Pract.
2010;10(2):113-23.
5. Clancy MJ. Clearing the cervical spine of adult victims of trauma. J Accid Emerg
Med. 1999; 16(3):208-14.
6. Ylinen J, Takala EP, Nykanen M, et al. Active neck muscle training in the
treatment of chronic neck pain in women: a randomized controlled trial. JAMA.
2003;289(19):2509-16.
7. Lanza FL, Chan FK, Quigley EM, et al. Guidelines for prevention of NSAID-
related ulcer complications. Am J Gastroenterol. 2009;104(3):728-38.
8. Deyo RA. Drug therapy for back pain. Which drugs help which patients? Spine
(Phila Pa 1976). 1996;21(24):2840-9; discussion 2849-50.
9. Kroeling P, Gross A, Houghton PE, et al. Electrotherapy for neck disorders.
Cochrane Database Syst Rev. 2005;(2):CD004251.
10. Patel KC, Gross A, Graham N, et al. Massage for mechanical neck disorders.
Cochrane Database Syst Rev. 2012;9:CD004871.
11. Gross AR, Hoving JL, Haines TA, et al. A Cochrane review of manipulation and
mobilization for mechanical neck disorders. Spine (Phila Pa 1976). 2004;29
(1-4):1541-8.
12. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain:
noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task
Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;
33(4 Suppl):S123-52.
13. Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine. 1982;7(4):
319-30.
14. Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in
the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery.
1995;36(4):732-9.
15. Lord SM, Barnsley L, Wallis BJ, et al. Percutaneous radio-frequency neurotomy
for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996;335(23):
1721-6.
16. Falco FJ, Erhart S, Wargo BW, et al. Systematic review of diagnostic utility and
therapeutic effectiveness of cervical facet joint interventions. Pain Physician.
2009;12(2):323-44.
17. Bogduk N. Spinal Diagnostic and Treatment Procedures: Practice Guidelines,
1st edition. San Francisco, CA: International Spine Intervention Society; 2004.
18. Manchikanti L, Singh V, Falco FJ, et al. Cervical medial branch blocks for chronic
cervical facet joint pain: a randomized, double-blind, controlled trial with one-
year follow-up. Spine (Phila Pa 1976). 2008;33(17):1813-20.
19. Niemisto L, Kalso E, Malmivaara A, et al. Radiofrequency denervation for neck
and back pain. A systematic review of randomized controlled trials. Cochrane
Database Syst Rev. 2003;(1):CD004058.
 Cervical Facet Syndrome 99
20. Falco FJ, Manchikanti L, Datta S, et al. Systematic review of the therapeutic
effectiveness of cervical facet joint interventions: an update. Pain Physician.
2012;15(6):E839-68.
21. Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain:
outcomes in a series of consecutive patients. Pain Med. 2005;6(4):282-6.
22. MacVicar J, Borowczyk JM, MacVicar AM, et al. Cervical medial branch
radiofrequency neurotomy in New Zealand. Pain Med. 2012;13(5):647-54.
 11
Hip Pain
Anupam Sinha, Madhuri Dholakia

CHIEF COMPLAINT
The patient complains of left hip pain.

HISTORY OF PRESENT ILLNESS

A 66-year-old male with no past significant medical history presents
with a 3 month history of insidious left groin and thigh pain. He denies any
trauma or injury. He denies any low back pain but does report some left
buttock discomfort. It is aching at rest, sharp with standing and walking.
His pain is worse with weight bearing on the left leg, walking, and getting
in and out of his car. He reports five out of ten pain radiating from the left
groin into the medial thigh. He denies any lower extremity weakness or
paresthesia. He denies any bowel, bladder or balance disturbance. There is
no unintentional weight loss, fevers, chills or night sweats.
Treatments to date have included over the counter medications, heat and
ice packs, and a trigger point injection into the greater trochanteric region
from his primary physician; he has had no relief with these options.
Note the aching pain in the left groin and buttocks (Fig. 11.1).

PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

None

REVIEW OF SYSTEMS
Otherwise negative
 Hip Pain 101

Fig. 11.1: Pain diagram. Note the aching pain in the left groin and buttocks

FAMILY HISTORY
Parents alive with no medical issues

SOCIAL HISTORY
Does not drink or smoke, married, retired, avid golfer.

CURRENT MEDICATIONS
Ibuprofen 600 mg BID PRN

ALLERGIES
None

PHYSICAL EXAMINATION
Height: 511
Weight: 200 lbs
102 Interventional Spine ProceduresA Case-based Approach

Pulse: 75/minute
BP: 120/80 mm Hg
Respirations: 16/minute

General Appearance
Pleasant, cooperative, looks stated age, in no distress.
Gait and tandem gait stable. Able to heel walk and toe walk without
difficulty. Pulses are 2+ in the radial and dorsalis pedis arteries. Babinski
testing reveals downgoing toes bilaterally. Slump test and supine straight leg
raise to 90 are negative bilaterally. No tenderness over the lumbar spinous
processes. Patricks test is positive on the left. Internal rotation of the left hip
reproduces groin and thigh pain. Stinchfields test is positive on the left. No
tenderness to palpation over the bilateral trochanteric bursae. No tenderness
over the sacroiliac joints. Manual muscle testing in the lower limbs reveals
5/5 bilateral hip flexors, quadriceps, tibialis anterior, extensor hallucis
longus, and gastroc soleus; however, there is trace weakness in the left hip
flexor due to pain. Sensory examination to light touch and pinprick is normal
in the lower extremity dermatomes. Proprioception is intact at the great
toes bilaterally. Normal muscle tone. Reflexes are 2+ in patellae, medial
hamstrings and Achilles tendons. No ankle clonus bilaterally.

IMAGING
X-rays of the pelvis reveal moderate degenerative joint disease in the left hip
without evidence of fracture.

DIAGNOSIS

Left Hip Degenerative Joint Disease

Osteoarthritis of the hip is one of the most common causes of gait dysfunction
among older adults in the United States (knee osteoarthritis being the other).1
Risk factors that may increase the likelihood of developing hip osteoarthritis
include: genetic predisposition, childhood developmental hip dysplasia,
avascular necrosis, femoral acetabular impingement, prior hip trauma or
fracture, and obesity.1 Early symptoms of hip osteoarthritis may include:
groin, buttock, and/or thigh pain, pain with weight bearing, hip joint stiffness,
and referred knee pain. As the arthritis becomes more severe, the patient may
develop an antalgic gait pattern, joint deformity, hip girdle weakness, and
leg length discrepancy.2 The classic radiographic features of osteoarthritis of
the hip are joint space narrowing, osteophyte formation, subchondral cyst
formation and subchondral sclerosis.2
 Hip Pain 103

Treatment Options
Physical therapy and exercise for strengthening of the hip girdle muscles
may improve overall hip joint stability and increase flexibility.3 Heat and
cold modalities may also help reduce hip joint pain and inflammation.4 Anti-
inflammatories (nonsteroidal anti-inflammatory drugs) and acetaminophen
may be used to reduce symptoms of arthritic joint pain.4 While helpful in knee
osteoarthritis, glucosamine chondroitin has been found to have no impact
on pain, disease progression, or functional status for hip osteoarthritis.5
Ultimately, total hip arthroplasty (THA) may provide the most relief in
patients with moderate to severe osteoarthritis.6
Image-guided intra-articular injections of steroid and anesthetic
may also alleviate discomfort from mild to moderate hip osteoarthritis.7
These injections may be done under fluoroscopy or musculoskeletal
ultrasound. Care must be taken when injecting to avoid the femoral
vessels (nerve, artery and vein) which course along the proximal anterior
thigh. There is limited data on how frequently it is safe to administer steroid
injections to patients with hip osteoarthritis. Repeat injections more than
four times annually are generally not recommended.7 Previous studies have
suggested avoiding the use of intra-articular steroids injected in the hip for
at least 2 months before total hip arthroplasty due to an increased risk of
postoperative infection.8,9 A more recent study suggests an intra-articular
steroid injection through a lateral approach to the hip is safe when performed
using strictly aseptic technique. However, caution is still advised when
planning a THA within 2 months after an intra-articular steroid injection
(Fig. 11.2).10

Fig. 11.2: Intra-articular hip injection. Note the flow of contrast into the
capsule and the characteristic ring sign of contrast in the joint
104 Interventional Spine ProceduresA Case-based Approach

The patient was prepped and draped in a sterile fashion in the supine
position after informed consent was signed and all the patients questions
were answered, including the risks, benefits, alternative treatment options
and prognosis. The risks include but are not limited to infection, allergic
reaction, nerve damage, paralysis, syncope, and worsening pain. All vital signs
were monitored prior to, during, and after the procedure. Oxygen saturation
was also monitored and noted to be greater than or equal to 94% throughout
the procedure. Cardiac monitoring revealed normal sinus rhythm.
The C-arm was positioned so that the region overlying the femoral
acetabular junction was visualized. The femoral pulse was palpated. Staying
lateral to the pulse, the soft tissues overlying the joint were infiltrated with
35 cc of 1% lidocaine without epinephrine. A 22-gauge spinal needle was
inserted and directed toward the femoral neck until bony contact. After negative
aspirate for blood, a total volume of 3.5 cc of nonionic contrast was injected
and flow of contrast was noted. Radiographs were obtained for documentation
purposes. The injectate was administered.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient was
instructed to call us. The patient is to follow-up with the physician as noted above
within 23 weeks.

REFERENCES
1. Suri P, Morgenroth DC, Hunter DJ. Epidemiology of osteoarthritis and associated
comorbidities. PM R. 2012;4(5 Suppl):S10-9.
2. JF Sarwark (Ed). Essentials of Musculoskeletal Care, fourth edition. Rosemont,
IL, American Academy of Orthopaedic Surgeons; 2010.
3. Fransen M, McConnell S, Hernandez-Molina G, et al. Does land-based exercise
reduce pain and disability associated with hip osteoarthritis? A meta-analysis of
randomized controlled trials. Osteoarthritis Cartilage. 2010;18(5):613-20.
4. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology
2012 recommendations for the use of nonpharma-cologic and pharmacologic
therapies in osteo arthritis of the hand, hip, and knee. Arthritis Care Res
(Hoboken). 2012;64(4):465-74.
5. Reichenbach S, Sterchi R, Scherer M, et al. Meta-analysis: chondroitin for
osteoarthritis of the knee or hip. AnnIntern Med. 2007;146(8):580-90.
6. Grayson CW, Decker RC. Total joint arthroplasty for persons with osteoarthritis.
PM R. 2012;4(5 Suppl):S97-103.
7. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the
management of hip and knee osteoarthritis, Part II: OARSI evidence-based,
expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137-62.
8. McIntosh AL, Hanssen AD, Wenger DE, et al. Recent intraarticular steroid
injection may increase infection rates in primary THA. Clin Orthop Relat Res.
2006;451:50-4.
9. Kaspar S, de V de Beer J. Infection in hip arthroplasty after previous injection of
steroid. J Bone Joint Surg Br. 2005;87(4):454-7.
10. Meermans G, Corten K, Simon JP. Is the infection rate in primary THA increased
after steroid injection? Clin Orthop Relat Res. 2012;470(11):3213-9.
 Complex Regional
Pain Syndrome 12
Lower Extremity
Jeremy Simon, Matthew McAuliffe

CHIEF COMPLAINT
The patient complains of pain and cold feeling in the left foot (Fig. 12.1).

Fig. 12.1: Pain diagram

106 Interventional Spine ProceduresA Case-based Approach

HISTORY OF PRESENT ILLNESS

This patient is a very pleasant, 10-year-old right-handed female who injured
her left foot 2 months ago. She twisted her left foot and ankle while playing
volleyball. She was placed in an air cast and diagnosed with a bone contusion
by a local sports medicine doctor. When she was at school, another student
stepped on it and then she developed the above pain syndrome. The pain
has been constant and severe. It is associated with a cold feeling in the entire
left foot. It has been also been changing colors and is blue/purplish looking.
She never had symptoms like this prior to these incidents. She went to an
orthopedic surgeon who had performed X-rays as well as an MRI of the left foot
and a whole-body bone scan. The X-rays were negative for fracture. The MRI
demonstrated bone contusions and edema without fracture or ligamentous
injury. The bone scan was consistent with complex regional pain syndrome
(CRPS). The symptoms have not gotten any better. She rates her pain about
7/10 and it is constant. It is aggravated with walking. Light touch increases
pain and even sheets touching the foot or wearing socks aggravate it. It is
described as burning and cold in quality. She is presently using crutches
to walk. There are no similar symptoms on the right side. There is no back
pain and no radiating pain from the proximal limb. She denies weakness.
She denies any bowel or bladder incontinence, unintentional weight loss or
weight gain, fevers, chills, or night sweats. She denies any history of cancer,
tuberculosis, infections, autoimmune disorders or other significant medical
problems.

TREATMENTS TO DATE
Ibuprofen 200 mg TID PRN, crutches, attempted physical therapy, but
discontinued due to severe pain after one attempt.

PAST MEDICAL HISTORY

None; normal development, normal intelligence

PAST SURGICAL HISTORY

None

REVIEW OF SYSTEMS
Positive for pain and temperature changes in the right foot
 Complex Regional Pain SyndromeLower Extremity 107

FAMILY HISTORY
Significant for blood clots in her father. Both her parents are alive. Her mother
accompanies her today.

SOCIAL HISTORY
She denies tobacco, alcohol, or illegal drugs. She is a fourth grade student at
a local elementary school; Lives with both of her parents. She is an only child.

CURRENT MEDICATIONS
Ibuprofen 200 mg TID PRN

ALLERGIES
Penicillin

PHYSICAL EXAMINATION
Height: 41
Weight: 80 pounds
Blood pressure: 108/60 mm Hg
Pulse: 88/minute
Respirations: 16/minute
Gait and tandem gait stable. Romberg sign is negative. She has an antaegic gait
with the inability to bear weight on the left foot. Pulses are 2+ in the radial and
dorsalis pedis arteries. Babinski testing reveals downgoing toes bilaterally.
Slump test and supine straight leg raised to 90 are negative bilaterally;
Negative femoral nerve stretch test bilaterally. No palpable step-off in the
lumbar spine. No pain with extension or rotation. No tenderness over the
lumbar spinous processes. No palpable scoliotic curve. No lumbar segmental
tenderness. No palpable muscle spasm in the lumbar paraspinals. Patricks
test is negative bilaterally. Internal rotation of the hips does not cause pain.
No tenderness to palpation over the bilateral trochanteric bursae. Negative
Gaenslens sign, negative Thomas test, negative Obers test bilaterally. No
tenderness over the sacroiliac joints. Manual muscle testing in the lower
limbs reveals 5/5 bilateral hip flexors, quadriceps, tibialis anterior, extensor
hallucis longus and gastroc soleus. There is pain limited strength in the left
tibialis anterior, extensor hallicus longus and flexor hallicus longus. Decreased
sensation to light touch and allodynia in the dorsal, lateral, plantar and medial
aspects of her foot on the left side. Active range of motion in the left ankle is
markedly reduced in all directions; passive range of motion is exquisitely
painful. Proprioception is intact at the great toes bilaterally. Normal muscle
108 Interventional Spine ProceduresA Case-based Approach

tone. Reflexes are 2+ in patellae, medial hamstrings and Achilles tendons. No

ankle clonus bilaterally.
She has a mottled appearing foot with dystrophic changes in the entire
left foot.

IMAGING
X-rays left foot: negative for fracture, dislocation.
Whole body bone scan: demonstrates markedly reduced flow and uptake in
the left foot.
Magnetic resonance imaging left foot: Marrow edema of the medial sesamoid
bone at the first metatarsophalangeal joint due to contusion/stress response.
Diffuse subcutaneous edema.

DIAGNOSIS
Complex regional pain syndrome Type I: Left foot.

Complex Regional Pain Syndrome

The first descriptions of sympathetically mediated pain (SMP) were from
Claude Bernard in the mid 1800s.1 Silas Weir-Mitchell first described
causalgia in American Civil War veterans. Formerly known as reflex
sympathetic dystrophy (RSD) and causalgia, in 1994, the International
Association for the Study of Pain (IASP) changed the names of these entities
to CRPS, Types I and II. They are treated as the same condition, but Type II is
distinguished by a documented injury to a nerve.1
The clinical characteristics of CRPS Type I typically occurs secondary to
a crush injury, tight fitting casts, soft tissue injury and immobilization. CRPS
Type II occurs with a documented nerve injury such as a penetrating injury or
iatrogenic disruption, as in a surgical procedure. A series of symptoms then
develop including pain that is much more severe than to be expected from
the event, avoidance of weight-bearing or use of the extremity, allodynia/
hyperesthesia of the affected area, temperature changes, swelling, skin color
changes and/or sudomotor changes.2
The pathophysiology of CRPS types I and II remain elusive and are not
completely understood. Current research suggests that both central and
peripheral sensitization of nerves occurs.3 The mechanism may involve
chronic activation of the afferent C-fibers from a noxious stimulus and
subsequent reduction in the threshold for activation.4
Evidence supporting the central sensitization theory of CRPS includes
a study which showed reorganization of cortical somatosensory repres
entation as demonstrated by magnetoencephalography.5 Furthermore, it
 Complex Regional Pain SyndromeLower Extremity 109
was found that the cortical reorganization was reversible with resolution of
symptoms in patients with CRPS.6,7
N-methyl D-aspartate (NMDA) receptors are believed to play a pivotal
role in central sensitization via plasticity of neural substrates.8 When afferent
nerves are more sensitive to neurotransmitter release, action potentials are
produced at lower levels of stimulation.8 This makes nerves more sensitive
to neurotransmitter release and as a result nociceptive transmission is
enhanced through increased NMDA receptor activation.8
It is thought that peripheral sensitization may be related to chronic
neurogenic inflammation. Often patients will complain of signs of inflam
mation including erythema or skin color changes and pain. Evidence that
supports this theory includes a study showing higher skin blister fluid levels
of IL-6 and TNF- found in CRPS patients on the side of the affected limb.9
Another study supporting neurogenic inflammation showed increased
serum levels of substance P in patients with CRPS.10
As the earlier term RSD implied, the sympathetic nervous system is still
believed to play a role in the condition. Some advocated a subcategory for
CRPS involving sympathetic hyperactivity as SMP. This subset of CRPS is
diagnosed after a positive response to sympathetic blockade.11 This subset
refers to the presumed mechanism of continued pain, not the clinical
picture.12
The early autonomic-type symptoms may be the result of effects on the
ability of the vessels to constrict or dilate.13 The symptoms early on may
be warmth in the affected body part, but later coolness often develops. In
addition, other symptoms of autonomic dysfunction are frequently present in
CRPS such as hyperhidrosis and differences in skin blood flow in the affected
body part.14
The diagnosis of CRPS is largely clinical. Criteria exist as described by the
IASP in 1994.3,12 For CRPS Type I, this includes:
Presence of noxious event/immobilization
Ongoing pain, allodynia/hyperesthesia out of proportion to event
Evidence at some time of edema, vascular changes (reduced or increased
skin temperature), or abnormal sudomotor changes
Exclusion of other explanations
Budapest criteria as taken from Harden RN, Bruehl S, Stanton-Hicks M,
et al. for making a diagnosis of CRPS type I:15
To make the clinical diagnosis, the following criteria must be met:
Continuing pain, which is disproportionate to any inciting event
Must report at least one symptom in three of the four following categories:
Sensory: Reports of hyperesthesia and/or allodynia
Vasomotor: Reports of temperature asymmetry and/or skin color
changes and/or skin color asymmetry
Sudomotor/edema: Reports of edema and/or sweating changes and/or
sweating asymmetry
110 Interventional Spine ProceduresA Case-based Approach

Motor/trophic: Reports of decreased range of motion and/or motor

dysfunction (weakness, tremor, dystonia) and/or trophic changes
(hair, nail, skin)
Must display at least one sign at time of evaluation in two or more of the
following categories:
Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia
(to light touch and/or temperature sensation and/or deep somatic
pressure and/or joint movement)
Vasomotor: Evidence of temperature asymmetry (> 1C) and/or skin
color changes and/or asymmetry
Sudomotor/edema: Evidence of edema and/or sweating changes and/
or sweating asymmetry
Motor/trophic: Evidence of decreased range of motion and/or motor
dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair,
nail, skin)
There is no other diagnosis that better explains the signs and symptoms
For Type II, the criteria are the same, but a documented nerve injury has
occurred.
A triple-phase bone scan may show homogeneous hypoperfusion in the
perfusion and blood-pool phases. There may also be increased periarticular
uptake in the delayed images.

TREATMENT OPTIONS
There is no single cure for CRPS and it is often managed with multiple
approaches. Typically, a combination of physical therapy and medications
in different classes are prescribed. Sympathetic nerve blocks and rarely
surgery or chemical sympathectomy may be employed. The ultimate goal is
to improve a patients functional status.
Although there is no single cure for CRPS, there is evidence that in some
cases it can be prevented. One study demonstrated early mobilization and
physical therapy significantly decreased the incidence of CRPS in patients
with hemiplegia.16 Therefore it is important to begin early physical therapy in
patients who have limbs that may be at risk of developing CRPS.
Physical therapy with desensitization and forced weight bearing is an
essential element in the treatment of CRPS. The primary goal is to improve the
function of the affected part. Altering modalities are utilized to desensitize the
painful area. This may involve exposing the skin to soft or silken to gradually
rougher materials. Varying degrees of pressure are also employed. The goal
is to diminish, and hopefully extinguish, allodynia and hyperesthesia. There
is mixed evidence supporting the benefits of physical therapy in CRPS, and
the evidence suggests as the symptoms of CRPS progress, physical therapy
is less likely to benefit.17,18 However, it should be stressed, that the risks of
 Complex Regional Pain SyndromeLower Extremity 111

Fig. 12.2: Lateral view confirming contrast placement along the

region of the sympathetic chain without vascular flow

implementing a physical therapy program in patients is low, and should be a

first line consideration in treatment of CRPS.
Medications are often used in a variety of classes with limited data on
their true benefit in CRPS.19 Oral steroids may be considered early in the
diagnosis.20 Nonsteroidal anti-inflammatory medications may also provide
some analgesic benefit. Neuropathic pain medications such as the tricyclic
antidepressants (e.g. amitriptyline, nortriptyline) may be considered and the
mechanisms of action are described elsewhere in this book. Bisphosphonate
medications are often used in CRPS.21 The mechanism of action is to reduce
bone turnover, which is often overactive in this condition.22
The practice of infusing ketamine under monitored conditions is under
investigation.23 Intravenous ketamine is believed to inhibit the sympathetic-
mediated pain via ketamines blockade of NMDA-receptors.24 This treatment
has been utilized in the outpatient as well as inpatient setting and is employed
in refractory cases.25,26
Blockade of the sympathetic chain via the injection of bupivacaine may
be considered, especially early in the acute phase of CRPS (Fig. 12.2). This
procedure is normally performed under fluoroscopic guidance for safety
and specificity. The temperature of the affected extremity is monitored,
often with a transdermal thermometer. After the injection of anesthetic, a
positive response will result in vasodilation and thus a significant increase in
temperature in the treated limb. The patient should also exhibit a significant
decrease in their pain.
If a lumbar sympathetic block is performed, it is ideally followed imme
diately or within 30 minutes by a physical therapy program. As previously
112 Interventional Spine ProceduresA Case-based Approach

mentioned, the goals are to promote weight-bearing and desensitization of

the affected limb while the sympathetic nerve fibers are anesthetized.
Positive results with sympathetic block are directly correlated with
symptom duration, younger age. A recent study suggests that allodynia and
hypoesthesia were negative predictors for a good result with sympathetic
block and that no factors were indicative of who would respond to this
injection.27
Risks associated with lumbar sympathetic blockade include bleeding into
the retroperitoneum and psoas muscles, puncture of the inferior vena cava
or aorta, infection/abscess formation, kidney or ureteral puncture, direct
neural injury, seizure, arrhythmia, syncope, death and paralysis. Patients
with a bleeding diathesis or who are on blood thinning medications require
particular attention as they may be at increased risk for severe bleeding
complications. Vital signs should be monitored prior to, during and after the
procedure.
Other invasive strategies are in use for CRPS. Some advocate a sympath
ectomy for refractory cases. This may be accomplished surgically via open
resection of the lumbar sympathetic chain on the affected side, chemically
via injection of alcohol or phenol, or with percutaneous radiofrequency
ablation.27,28 Results of these treatments are variable and are typically
considered in very refractory and debilitating cases of CRPS with SMP.5,29,30

PLAN
Due to the duration of symptoms, the classic signs and symptoms of CRPS,
the significant debility, and lack of tolerance to a therapy program and other
conservative treatments, it was mutually decided with the patient and her
family to go forward with a left L3 sympathetic block under fluoroscopy.
Arrangements were made in advance to the procedure with the in-house
physical therapists to begin an immediate desensitization and forced weight-
bearing program following the injection.

SAMPLE DICTATION
A skin thermometer was placed on the affected limb prior to the procedure
and informed consent was signed. All the patients questions were answered,
including the risks, benefits, alternative treatment options and prognosis. The
risks include but are not limited to infection, retroperitoneal bleed, kidney
or ureteral puncture, nerve damage, paralysis, epidural hematoma, syncope,
headache, allergic reaction, cardiac arrest, and scar formation. The patient
was placed in the prone position and the target area was sterilely prepped.
Vital signs and oxygen saturation were monitored pre and periprocedurally.
Cardiac monitoring revealed normal sinus rhythm.
 Complex Regional Pain SyndromeLower Extremity 113
The C-arm was positioned so that an oblique view of the region overlying
the inferior portion of the L2 or L3 vertebral body was visualized. The soft
tissues overlying this structure were anesthetized with an injection of
1% lidocaine without epinephrine. A 22-gauge spinal needle was inserted
down to the inferior anterolateral aspect of the L2 or L3 vertebral body. After
negative aspirate for blood or CSF, a 2-4 cc volume of contrast dye was injected
into the region where the sympathetic chain is known to reside and flow of
contrast was noted, ensuring nonvascular and proper spread. Radiographs
were obtained for documentation purposes. An injectate consisting of 10 cc
of 0.25% bupivacaine was slowly injected. The needle was then removed and
an occlusive dressing was placed on the insertion site.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the
patient was instructed to call us. The patient is to follow-up with the physician
as noted above within 23 weeks.

REFERENCES
1. Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome:
practical diagnostic and treatment guidelines, 4th edition. Pain Med.
2013;14(2):180-229.
2. Field J. Complex Regional Pain Syndrome: a review. J Hand Surg Eur Vol.
2013;38(6):616-26.
3. Marinus J, Moseley GL, Birklein F, et al. Clinical features and pathophysiology of
complex regional pain syndrome. Lancet Neurol. 2011;10(7):637-48.
4. Pappagallo M, Rosenberg AD. Epidemiology, pathophysiology, and management
of complex regional pain syndrome. Pain Pract. 2001;1(1):11-20.
5. Straube S, Derry S, Moore RA, et al. Cervico-thoracic or lumbar sympathectomy
for neuropathic pain and complex regional pain syndrome. Cochrane Database
Syst Rev. 2010;(7):CD002918.
6. Maihofner C, Handwerker HO, Neundorfer B, et al. Cortical reorganization during
recovery from complex regional pain syndrome. Neurology. 2004;63(4):693-701.
7. Pleger B, Tegenthoff M, Ragert P, et al. Sensorimotor retuning [corrected]
in complex regional pain syndrome parallels pain reduction. Ann Neurol.
2005;57(3):425-9.
8. Zhou HY, Chen SR, Pan HL. Targeting N-methyl-D-aspartate receptors for
treatment of neuropathic pain. Expert Rev Clin Pharmacol. 2011;4(3):379-88.
9. Wesseldijk F, Huygen FJ, Heijmans-Antonissen C, et al. Six years follow-up of the
levels of TNF-alpha and IL-6 in patients with complex regional pain syndrome
type 1. Mediators Inflamm. 2008;2008:469439.
10. Leis S, Weber M, Isselmann A, et al. Substance-P-induced protein extravasation
is bilaterally increased in complex regional pain syndrome. Exp Neurol. 2003;
183(1):197-204.
11. Stanton-Hicks M, Janig W, Hassenbusch S, et al. Reflex sympathetic dystrophy:
changing concepts and taxonomy. Pain. 1995;63(1):127-33.
12. Loeser. Bonicas Management of Pain; 2001.
114 Interventional Spine ProceduresA Case-based Approach

13. Wasner G, Schattschneider J, Heckmann K, et al. Vascular abnormalities in

reflex sympathetic dystrophy (CRPS I): mechanisms and diagnostic value.
Brain. 2001;124(Pt 3):587-99.
14. Wasner G. Vasomotor disturbances in complex regional pain syndrome--a
review. Pain Med. 2010;11(8):1267-73.
15. Harden RN, Bruehl S, Stanton-Hicks M, et al. Proposed new diagnostic criteria
for complex regional pain syndrome. Pain Med. 2007;8(4):326-31.
16. Braus DF, Krauss JK, Strobel J. The shoulder-hand syndrome after stroke: a
prospective clinical trial. Ann Neurol. 1994;36(5):728-33.
17. Oerlemans HM, Goris JA, de Boo T, et al. Do physical therapy and occupational
therapy reduce the impairment percentage in reflex sympathetic dystrophy?
American journal of physical medicine & rehabilitation / Assoc Acad Physiatrists.
1999;78:533-9.
18. Oerlemans HM, Oostendorp RA, de Boo T, et al. Pain and reduced mobility
in complex regional pain syndrome I: outcome of a prospective randomised
controlled clinical trial of adjuvant physical therapy versus occupational
therapy. Pain. 1999;83(1):77-83.
19. Rowbotham MC. Pharmacologic management of complex regional pain
syndrome. Clin J Pain. 2006;22(5):425-9.
20. Kalita J, Vajpayee A, Misra UK. Comparison of prednisolone with piroxicam in
complex regional pain syndrome following stroke: a randomized controlled
trial. QJM. 2006;99(2):89-95.
21. Varenna M, Adami S, Rossini M, et al. Treatment of complex regional pain
syndrome type I with neridronate: a randomized, double-blind, placebo-
controlled study. Rheumatology (Oxford). 2013;52(3):534-42.
22. Abe Y, Iba K, Takada J, et al. Improvement of pain and regional osteoporotic
changes in the foot and ankle by low-dose bisphosphonate therapy for complex
regional pain syndrome type I: a case series. JM Case Rep. 2011;5:349.
23. Schwartzman RJ, Alexander GM, Grothusen JR, et al. Outpatient intravenous
ketamine for the treatment of complex regional pain syndrome: a double-blind
placebo controlled study. Pain. 2009;147(1-3):107-15.
24. Schwartzman RJ, Alexander GM, Grothusen JR. The use of ketamine in
complex regional pain syndrome: possible mechanisms. Expert Rev Neurother.
2011;11(5):719-34.
25. Koffler SP, Hampstead BM, Irani F, et al. The neurocognitive effects of 5 day
anesthetic ketamine for the treatment of refractory complex regional pain
syndrome. Arch Clin Neuropsychol. 2007;22(6):719-29.
26. Goldberg ME, Torjman MC, Schwartzman RJ, et al. Pharmacodynamic profiles
of ketamine (R)- and (S)- with 5-day inpatient infusion for the treatment of
complex regional pain syndrome. Pain Physician. 2010;13(4):379-87.
27. van Eijs F, Geurts J, van Kleef M, et al. Predictors of pain relieving response to
sympathetic blockade in complex regional pain syndrome type 1. Anesthesiology
2012;116(1):113-21.
28. Asik ZS, Orbey BC, Asik I. Sympathetic radiofrequency neurolysis for unilateral
lumbar hyperhidrosis: a case report. Agri. 2008;20(3):37-9.
29. Mailis A, Furlan A. Sympathectomy for neuropathic pain. Cochrane Database
Syst Rev. 2003; (2):CD002918.
30. Furlan AD, Lui PW, Mailis A. Chemical sympathectomy for neuropathic
pain: does it work? Case report and systematic literature review. Clin J Pain.
2001;17(4):327-36.
 Complex Regional
Pain Syndrome 13
Upper Limb
Michael J Mehnert, Jeremy Simon, Matthew McAuliffe

CHIEF COMPLAINT
The patient complains of severe burning pain and swelling of the wrist and
hand.

HISTORY OF PRESENT ILLNESS

A 45-year-old right-handed male presents to the outpatient clinic with
complaints of severe right arm pain (Fig. 13.1). He reports that approximately
6 months ago he fell off of a ladder and went through the glass ceiling
of a greenhouse 6 feet below him. The patient describes landing on an
outstretched right arm. He initially was seen in the emergency room for a
right forearm laceration, a scalp laceration, and wrist pain and swelling. His
scalp injury was closed with staples and the right medial forearm wound was
closed with sutures. Subsequently he was diagnosed with a displaced right
scaphoid fracture for which he underwent surgical fixation.
On follow-up from his scaphoid fixation the patient complained of new
onset epicritic, burning pain in the right forearm, wrist and hand. He reported
symptoms of warmth and swelling in the right hand as well. He was prescribed
pregabalin for pain control. On re-evaluation successful scaphoid fixation
was appreciated on imaging; however, the patient described worsening of
right arm pain with the sensation that it had spread to the entire forearm,
wrist and hand. He described constant, severe pain in the forearm and the
lateral digits of the right hand. He also stated that he had abnormal sensation
in the right hand and felt as though he was wearing a glove on just one
hand. Increased erythema was reported in the right arm with swelling of
the fingers and stiffness. Pregabalin was continued at an increased dosage,
116 Interventional Spine ProceduresA Case-based Approach

Fig. 13.1: Pain diagram

and occupational therapy was prescribed for mobilization along with

modalities and desensitization techniques. Electrodiagnostic testing was
ordered but could not be completed due to the patients pain and limited
tolerance.
Ultimately the patient was sent for a bone scan, and findings compatible
with complex regional pain syndrome (CRPS) were appreciated. No evidence
of scaphoid nonunion or avascular necrosis was noted. On re-evaluation
the patient continued to complain of pain and limited function of the right
upper limb. He reported problems with dressing and handwriting due to pain
with closing his right hand for fine motor activities. Constant, 9/10 pain was
reported with hypersensitivity. No left upper limb symptoms were reported
and no neck pain or shoulder/upper arm pain were described. The patient
reported no prior history of similar symptoms and no fevers, chills, or other
constitutional symptoms.

TREATMENTS TO DATE
Hydrocodone/APAP 5/325 mg q4 hours PRN, pregabalin 150 mg BID,
occupational therapy and desensitization techniques.
 Complex Regional Pain SyndromeUpper Limb 117

PAST MEDICAL HISTORY

Gastroesophageal reflux disease, seasonal allergies.

PAST SURGICAL HISTORY

Right inguinal hernia repair.

REVIEW OF SYSTEMS
Insomnia, depressed mood, and right-hand weakness.

FAMILY HISTORY
Remarkable for type II diabetes, osteoarthritis and maternal thyroid disease.

SOCIAL HISTORY
He reports no illegal drug use and that he quit smoking 6 years ago. Rare
alcohol use is described. The patient is an electrician by trade.

CURRENT MEDICATIONS
Pregabalin: 150 mg BID.

ALLERGIES
No known drug allergies.

PHYSICAL EXAMINATION
Height: 510
Weight: 205 lbs
Afebrile.
This is an alert, awake and cooperative male. He is in visible distress and
appears anxious. Nutrition and hygiene are well-maintained. He ambulates
with a normal gait and station and can do heel-and-toe walking. He cradles
his right arm during most of the interview and exam.
Cervical spine exam demonstrates normal overlying skin. No tenderness
is appreciated. Range of motion is full and Spurlings maneuver is negative
bilaterally for any upper limb pain.
Pulses are 2+ and symmetric in the upper and lower limbs.
Reflexes are 2+ and symmetric at the biceps, triceps and brachioradialis
with pain and guarding during testing on the right. Lower limb reflexes are
118 Interventional Spine ProceduresA Case-based Approach

1+ and symmetric at the patella and Achilles. Long tract signs are absent in
the lower limbs with a downgoing Babinski and in the left upper limb with a
negative Hoffmans sign. This maneuver could not be tested on the right due
to guarding.
Strength is 5/5 in the upper and lower limbs in all key myotomes tested on
manual muscle testing, except in the right upper limb where biceps, triceps,
wrist flexion and wrist extension were pain limited. He put forth minimal
effort due to pain on hand intrinsic testing and active range of motion. Passive
range of motion could not be performed.
A 2C temperature difference is evident on upper limb skin temperature
testing (with the right hand warmer than the left). No focal muscle atrophy is
appreciated on inspection. Right scaphoid open reduction internal fixation
(ORIF) scar is well-healed without erythema or drainage. Nail growth appears
symmetric with no evidence of abnormal sweating or abnormal hair growth.
Visible redness and swelling of all digits in the right upper limb is noted with
the appearance of shiny skin over the right hand and digits.
Sensory testing to light touch and pinprick is normal in the upper and
lower limbs in all key dermatomes tested, again except for the distal right
upper limb where allodynia and paresthesias are appreciated with light touch
in the entire hand and all digits.

IMAGING
Three-Phase Bone Scan, Right Upper Limb
Decreased uptake in the right forearm, wrist and hand with no evidence of
avascular necrosis or fracture of the right scaphoid.

Right Forearm, Wrist and Hand X-rays

Pin fixation of the right scaphoid is noted without evidence of nonunion.
Suspected diffuse soft-tissue swelling in the right hand is noted.

DIAGNOSIS
Complex regional pain syndrome type II involving the distal right upper limb.

DIFFERENTIAL DIAGNOSIS
Given the evaluation and testing that has already been done in this case,
other diagnoses would be less likely. In fact, the criterion standard for CRPS
includes ensuring that there is no other diagnosis that would better account
for the patients symptoms.1 This patient seems to have recovered from
an acute orthopedic injury, but has persistent and progressive symptoms.
A com-petent electrodiagnostician should have been able to rule-out
 Complex Regional Pain SyndromeUpper Limb 119
persistent nerve injury, however this patient could not tolerate the exam.
The provided history and physical exam are not compatible with a cervical
radiculopathy, though often a patient such as this would undergo a cervical
spine MRI. The bone scan findings correlate with a diagnosis of CRPS and
help to further rule-out nonunion, infection and other post-traumatic structural
injury.

Complex Regional Pain Syndrome

Complex regional pain syndrome (previously known as reflex sympathetic
dystrophy) was first described in injured soldiers under yet another name,
causalgia.2 As discussed in the lower limb CRPS chapter, the nomenclature
for sympathetic pain syndromes has evolved and is now complex regional
pain syndrome, types I and II. Type II CRPS is differentiated by a documented
penetrating injury or trauma, even if it is a surgical or iatrogenic event.2 The
widely accepted, recent Budapest Criteria1 utilize the same model for
diagnosis of CRPS I and II, and the conditions are treated as a single medical
entity. The hallmark of this disease process is pain that is disproportionate to
what should be expected from the injury, along with atypical symptoms that
include disuse, hypersensitivity, temperature abnormalities, swelling and
skin or sudomotor changes.1 Even in cases of Type II CRPS with a documented
peripheral nerve injury, the symptoms may not be isolated to that same
peripheral nerve distribution, as sympathetically-mediated pain does not
follow the same peripheral nerve pattern.2,3 A triple-phase bone scan may
be beneficial in diagnosing this condition, with homogenous hypoperfusion
appreciated in the perfusion and blood-pool phases, along with increased
periarticular uptake on the delayed images.4,5 Changes are more prominent in
early CRPS on bone scan imaging.6 Plain films may demonstrate osteopenia
as the disease persists due to disuse, with some evidence of soft tissue
swelling.6,7
Though multiple theories as to the exact mechanism of CRPS development
exist, widely accepted dogma includes a central sensitization component as
well as a peripheral neural sensitization component.3 There appears to be a
role for sympathetic-mediated pain (or sympathetically maintained pain),
in certain subtypes of CRPS.8 Not all sympathetically maintained pain will
meet the criteria for CRPS, and by definition response to sympathetic blocks
will determine if a patient with CRPS has sympathetically-mediated pain or
sympathetically-independent CRPS.9

TREATMENT OPTIONS
Complex regional pain syndrome treatments include palliative measures
to control symptoms with modalities, medications, injection therapies and
120 Interventional Spine ProceduresA Case-based Approach

sympathectomy.10-13 There may be a role for neuromodulation and dorsal-

column stimulation for pain control as well. Many of these treatment options
have been explored in the lumbar sympathetic block discussion of this
book. Earlier intervention is preferred, and may result in recovery or slowed
progression of symptoms.
The upper limb sympathetic innervation system includes the stellate
ganglion, a structure that includes both the C7 and T1 ganglion in most
patients.14 Preganglionic fibers from the first and second thoracic spine
segments travel along the ventral roots of T1 and T2 and join the sympathetic
chain, synapsing at the inferior, middle or superior cervical ganglion. The
inferior cervical ganglion is known as the stellate ganglion, and is generally
found at the level of the first rib, spanning the C7 and T1 vertebral bodies.15,16
All preganglionic fibers will either synapse at or pass through this ganglion.15
Postganglionic fibers will continue on cranially to innervate neck structures.
The preganglionic fibers that will innervate the upper limb originate in T2 and
T8 or T9 spine segments and travel with the ventral roots of T2 to T8 to join
the sympathetic chain. As they pass cephalad they also synapse at the second
thoracic, first thoracic, stellate ganglion or the middle cervical ganglion.
Most of these fibers travel to the anterior spinal nerves of C5-T1 and join the
brachial plexus. The ganglion generally is positioned on the lateral border of
the longus colli muscle.17
Blockade of this structure may be beneficial, particularly for newly-
diagnosed CRPS in the upper limb and for certain variants or subtypes
of CRPS.18,19 The injection is now almost exclusively performed with
fluoroscopic guidance and use of contrast media for safety and accuracy.
Sufficient medication should be injected to bathe the C7-T1 interspace
as noted above. A successful blockade of the ganglion (suggesting accurate
delivery of anesthetic to the target stellate ganglion) will be heralded by a
resulting increase in skin temperature in the upper limb on the injected side,
along with increased vasodilation in the arm and temporary induction of a
Horners syndrome on the affected side. The patient should rapidly develop
the classic triad of ptosis, miosis and anhidrosis with possible increased
nasal congestion and skin temperature on the ipsilateral face.20,21 The
criteria for a positive diagnostic block would involve pain relief during the
duration of administered anesthetic.
As with a lumbar sympathetic block, after administration of the medication
immediate (occupational) therapy with range of motion, desensitization and
functional retraining of the limb should be instituted.
Associated risks include bleeding, infection/abscess formation, direct
neural injury, seizure, arrhythmia, syncope, death and paralysis. Potential
pneumothorax and carotid or vertebral artery puncture are complications
more specific to this procedure that should be discussed.15,17 Coagulopathy is
 Complex Regional Pain SyndromeUpper Limb 121
considered a contraindication if it cannot be corrected. Patients with a history
of cardiac conduction block deserve careful consideration as blockade of the
ganglion may affect cardiac regulation. Vital signs should be monitored prior
to, during and after the procedure.

PLAN
The patient has not had relief with a therapy program and other interventions,
including a trial of low-dose opiates and medications to target neuropathic
pain. Given the patients progressive pain and disability in his dominant
hand, a decision was made to proceed with a right cervical stellate ganglion
block with fluoroscopic guidance.

PROCEDURE NOTE
Procedure: Cervical/stellate ganglion block

INDICATIONS
Please refer to prior office notes for details. The patient is being treated for
a diagnosis of complex regional pain syndrome. The patient has failed to
respond to conservative measures including oral medications, modalities
and physiotherapy. A decision was made to proceed with a fluoroscopically-
guided cervical stellate ganglion block for diagnostic and therapeutic
purposes.
The patient was informed of the risks and benefits of the procedure, as well
as alternative treatments. All questions were answered prior to proceeding.
The patient expressed understanding and gave informed written consent.

PREOPERATIVE DIAGNOSIS
Complex regional pain syndrome, right upper extremity.

POSTOPERATIVE DIAGNOSIS
Same

PROCEDURE PERFORMED
Sympathetic nerve block, cervical spine (stellate ganglion block), right
side
Fluoroscopic guidance/localization.
122 Interventional Spine ProceduresA Case-based Approach

A skin thermometer was placed on the affected limb prior to the

procedure and informed consent was signed. All questions were answered,
including the risks, benefits, alternative treatment options and prognosis.
The risks include but are not limited to bleeding, infection, allergic reaction,
nerve injury and structural damage.
The patient was taken to the fluoroscopy suite and then placed in a supine
position on a fluoroscopy table with a shoulder roll in place with the cervical
spine in a slightly extended position, as much as tolerated. The affected side
was prepped with antiseptic solution and draped in the usual sterile fashion.
Vital signs and oxygen saturation were monitored pre- and periprocedurally.
Cardiac monitoring revealed normal sinus rhythm.
The cricoid cartilage was palpated and the figertips were moved laterally,
displacing the sterno -cleidomastoid and the carotid sheath laterally.
Chassaignacs tubercle, the transverse process of the sixth cervical vertebra,
was identified under fluoroscopic guidance, palpated, and then isolated
between two palpating fingertips. Once the carotid sheath was out of the
way, a 22-gauge needle was inserted perpendicularly to all planes and placed
on the anterior lateral border of the C-6 vertebral body. Aspiration was then
attempted. After aspiration was negative for return of blood or other fluid,
35 mL of nonionic radio-opaque contrast media were injected (Figs 13.2
and 13.3) and noted to flow over the lateral borders of the ipsilateral cervical
vertebral bodies, thus covering the stellate ganglion. Live fluoroscopy was
utilized to ensure the absence of vascular flow of contrast. A test dose of
0.5 mL of 1% lidocaine was then injected, and the patient was monitored
for 6090 seconds to ensure no adverse effects to suggest intravascular
injection. Next, a solution of 10 mL of marcaine 0.25% in aliquots of 2 mL with
negative aspirations between injections was administered, with intermittent
fluoroscopy utilized to ensure further washout of the contrast. The patient
tolerated the procedure well without any evidence of complications or
problems. Post-procedure they experienced the following:
Evidence of a Horners sign after the block was established: YES
Pain relief: 80%
Skin temperature change was greater than 10 degrees.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
was instructed to call us. The patient is to follow-up with the physician as
noted above within 23 weeks.
The patient was instructed to apply ice over the injection site for 1015
minutes for the next 2448 hours. A postprocedure instruction sheet was
given.
 Complex Regional Pain SyndromeUpper Limb 123

STELLATE GANGLION BLOCK (Figs 13.2 and 13.3)

Fig. 13.2

Fig. 13.3
Figs 13.2 and 13.3: Anterior posterior views of a right stellate ganglion block after
contrast administration
124 Interventional Spine ProceduresA Case-based Approach

REFERENCES
1. Harden RN, Bruehl S, Stanton-Hicks M, et al. Proposed new diagnostic criteria
for complex regional pain syndrome. Pain Med. 2007;8(4):326-31.
2. Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome:
practical diagnostic and treatment guidelines, 4th edition. Pain Med.
2013;14:180-229.
3. Marinus J, Moseley GL, Birklein F, et al. Clinical features and pathophysiology of
complex regional pain syndrome. Lancet Neurol. 2011;10(7):637-48.
4. Mailis A. How are bone scans used in the diagnosis and treatment of CRPS?
RSDSA Review. 2005;18:11.
5. Intenzo CM, Kim SM, Capuzzi DM. The role of nuclear medicine in the evaluation
of complex regional pain syndrome type I. Clin Nucl Med. 2005;30(6):400-7.
6. Schurmann M, Zaspel J, Lohr P, et al. Imaging in early posttraumatic complex
regional pain syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;
23(5):449-57.
7. Cappello ZJ, Kasdan ML, Louis DS. Meta-analysis of imaging techniques for
the diagnosis of complex regional pain syndrome type I. J Hand Surg.
2012;37(2):288-96.
8. Stanton-Hicks M, Janig W, Hassenbusch S, et al. Reflex sympathetic dystrophy:
changing concepts and taxonomy. Pain 1995;63(1):127-33.
9. Raja SN, Treede RD, Davis KD, et al. Systemic alpha-adrenergic blockade
with phentolamine: a diagnostic test for sympathetically maintained pain.
Anesthesiology. 1991;74(4):691-8.
10. Rowbotham MC. Pharmacologic management of complex regional pain
syndrome. Clin J Pain. 2006;22(5):425-9.
11. Mailis A, Furlan A. Sympathectomy for neuropathic pain. Cochrane database
Syst Rev. 2003; (7):CD002918.
12. Braus DF, Krauss JK, Strobel J. The shoulder-hand syndrome after stroke: a
prospective clinical trial. Ann Neurol. 1994;36(5):728-33.
13. Oerlemans HM, Goris JA, de Boo T, et al. Do physical therapy and occupational
therapy reduce the impairment percentage in reflex sympathetic dystrophy? Am
J Phys Med Rehabil/Assoc Acad Physiatr. 1999;78:533-9.
14. Benzon HT Raja SN, Molloy RE, et al. Essentials of Pain Medicine and Regional
Anesthesia, 2nd edition. Philadelphia, PA: Elsevier; 2005.
15. Haspeslagh S VKM. Sympathetic System. Philadelphia, PA: Saunders Elsevier;
2008.
16. Fox M. Stellate ganglion block. Philadelphia, PA: Elsevier-Saunders; 2013.
17. Hogan QH, Erickson SJ. MR imaging of the stellate ganglion: normal appearance.
AJR Am J Roentgenol. 1992;158(3):655-9.
18. Blain A 3rd. Cervical sympathetic and stellate ganglion block in apoplexy;
preliminary note on indications and technique. Alexander Blain Hosp Bull.
1949;8(1):42-6.
19. van Eijs F, Stanton-Hicks M, Van Zundert J, et al. Evidence-based interventional
pain medicine according to clinical diagnoses. 16. Complex regional pain
syndrome. Pain Pract. 2011;11(1):70-87.
20. Abdi S, Zhou Y, Patel N, et al. A new and easy technique to block the stellate
ganglion. Pain Physician. 2004;7(3):327-31.
21. van Eijs F, Geurts J, van Kleef M, et al. Predictors of pain relieving response to
sympathetic blockade in complex regional pain syndrome type 1. Anesth
esiology. 2012;116(1):113-21.
 Dural Puncture 14
Headache
Jeremy Simon

CHIEF COMPLAINT
The patient complains of severe headache.

HISTORY OF PRESENT ILLNESS

This patient is a 52-year-old female with a past medical history significant
for 10 years of gradually increasing lower back and bilateral buttock pain.
She underwent 2 nonfluoroscopically-guided L5-S1 interlaminar epidural
steroid injections approximately 2 weeks apart as part of a series of three.
The first of these injections was performed 3 weeks ago, the second less than
1 week ago. She is unsure if the first injection helped and had no significant
side effects or complaints. Upon awakening the following day after the
second injection, she experienced a severe headache. It has persisted and
not improved over the last 2 days. She rates the pain a 10/10 with standing
or sitting and a 4/10 with lying flat. It is located in the temples, associated
with nausea and dizziness. She has never had a headache like this before. It
is significantly worse with sitting upright, standing, and relieved somewhat
with lying flat. There are no fevers, chills or night sweats. She has not started
any new medications and the headache is not responsive to ibuprofen 800
mg PO TID. There are no new sensory or motor symptoms.

PAST MEDICAL HISTORY

None
126 Interventional Spine ProceduresA Case-based Approach

PAST SURGICAL HISTORY

None

REVIEW OF SYSTEMS
Positive for headache, photophobia, nausea, lower back and buttock pain

FAMILY HISTORY
Hypertension

SOCIAL HISTORY
Denies tobacco, alcohol or illegal drugs. Manager of a retail store. Has not
worked since onset of symptoms. No workers compensation claims.

CURRENT MEDICATIONS
Ibuprofen: 800 mg TID, multivitamin

ALLERGIES
None

PHYSICAL EXAMINATION
BP: 140/90 mm Hg
Pulse: 90/minute
Respirations: 14/minute
Height: 54
Weight: 100 lbs

General Appearance
Pleasant, cooperative, looks stated age, in obvious distress, lying on exam table
flat on her back with knees bent.
Gait and tandem gait stable, with slight forward flexion. Romberg
sign is negative. Able to heel walk and toe walk without difficulty. Pulses
are 2+ in the radial and dorsalis pedis arteries. Babinski testing reveals
downgoing toes bilaterally. Slump test and supine straight leg raised to
90 are negative bilaterally. Negative femoral nerve stretch test bilaterally.
No palpable step-off in the lumbar spine. No tenderness over the lumbar
spinous processes. No palpable scoliotic curve. There is palpable muscle
spasm in the lumbar paraspinals and tenderness. Patricks test is negative
 Dural Puncture Headache 127
bilaterally. Internal rotation of the hips does not cause pain. No tenderness
to palpation over the bilateral trochanteric bursae. Negative Gaenslens
sign, negative Thomas test, negative Obers test bilaterally. No tenderness
over the sacroiliac joints. Manual muscle testing in the lower limbs reveals
5/5 bilateral hip flexors, quadriceps, tibialis anterior, extensor hallucis
longus and gastrocsoleus. Sensory examination to light touch and pinprick
is normal in the lower extremity dermatomes. Proprioception is intact at
the great toes bilaterally. Normal muscle tone. Reflexes are 2+ in patellae,
medial hamstrings and Achilles tendons. No ankle clonus bilaterally. Lumbar
range of motion is reduced in extension and the end limits of flexion. There
is reproduction of typical pain with extension and extension/rotation to the
right. Posterior-anterior pressure over the L4-5 and L5-S1 segments on the
right cause reproduction of pain.
Cranial nerves II-XII were intact. Upright posture causes severe headache
and nausea.

IMAGING
Magnetic resonance imaging lumbar spine from 2 months ago demonstrates
moderately severe spinal stenosis at L4-5, facet arthropathy at L4-5 and L5-S1.

DIAGNOSIS
Post-dural puncture headache (PDPH) (spinal headache).

DISCUSSION
Post-dural puncture headache most likely occurs as result of a needle piercing
the dura mater covering the thecal sac and a resultant leakage of spinal fluid.1
This results in reduced intracranial pressure and a postural headache.1,2 Why
the headache occurs is postulated to be a result of the loss of cushion of the
meninges through loss of cerebrospinal fluid (CSF) through the hole created
by the needle.3,4
The characteristics of PDPH are typically bilateral and temporal and
may occur anywhere from immediately following or up to 12 days after
a lumbar puncture.3 It is classically worse with upright posture. They are
often self-limited, but may result in significant morbidity including nausea,
vomiting and neck pain.3 Patients experiencing these symptoms may visit the
emergency room, undergo diagnostic testing and take analgesic medications
and miss work, resulting in significant direct and indirect medical costs.
Risk factors reported for the development of PDPH include female
gender, younger age and low body mass index.5,6 A smaller-size needle has
also shown to play a role in reduction of the development of PDPH.7 The use
of fluoroscopy in epidural steroid injections should also play a role reducing
128 Interventional Spine ProceduresA Case-based Approach

risk of PDPH, as well as other potential serious complications.8,9 One study

recently showed a lower incidence of PDPH in cigarette smokers.10 Certainly,
this is not meant to encourage smoking, but in the diagnosis of PDPH
in our patient, the low BMI, female gender, blind-epidurals performed,
characteristics of the headache (positional, frontal/temporal) and the non
smoking status paint an obvious clinical picture.
Fluoroscopy for placement of epidural steroid injections is not
universally utilized. Studies have shown inaccurate injection in 830% of
nonfluoroscopically-guided lumbar epidural steroid injections11 and up to
53% in blind cervical epidural steroid injections.12 Many practitioners also
perform epidurals in a series despite the lack of evidence in a clear benefit
of repetition.

TREATMENT
Most PDPHs will resolve on their own.13 Conservative treatment consists of
increasing oral fluid intake, caffeine and nonsteroidal anti-inflammatory
medications. Caffeine has shown efficacy for treating this condition over
placebo.14 Bed rest is often recommended and shown to have mixed results.15,16
An epidural blood patch can be considered for recalcitrant headache
resulting from dural puncture. This procedure involves injecting the patients
blood into the epidural space, with or without fluoroscopic guidance
(Figs 14.1 and 14.2). The use of fluoroscopy in this procedure improves the
accuracy and are likely safer than using a blind approach.17
The success rate is reported to be between 70% and 100%.13,18 The
proposed mechanism of action is to form a clot over the hole in the dura and
thus stop the CSF from leaking.3 The volume of blood injected may range
from 7 mL to 30 mL.13 Risks of the procedure include compressive epidural
hematoma, meningitis, dural puncture, death, subdural hematoma,19,20
stroke,21 blindness, arachnoiditis,22 fever,23 and scar formation.
This patient underwent an epidural blood patch and her symptoms
completely resolved in 2 days.

Sample Dictation
Informed consent was signed prior to the procedure. The risks, benefits,
alternative treatment options, prognosis and questions were discussed.
The risks include, but not limited to, epidural hematoma, meningitis, dural
puncture, new or worsening pain, subdural hematoma, arachnoiditis, fever,
scar formation and nerve damage.
The patient was then prepped and draped in a sterile fashion in the prone
position. Vital signs and oxygen saturation were monitored throughout the
procedure.
 Dural Puncture Headache 129

Fig 14.1: Anterior and posterior view of contrast extending into the epidural space

Fig 14.2: Lateral view with contrast extending into the epidural space

Around 1020 cc of the patients blood was withdrawn in a sterile fashion

via an intravenous needle placed at the start of the procedure.
The C-arm was positioned so that an AP view of the L5-S1 interlaminar
space was visualized. The soft tissues overlying the area were infiltrated
with 3 cc of 1% lidocaine without epinephrine. An 18-gauge Tuohy needle
130 Interventional Spine ProceduresA Case-based Approach

was inserted under intermittent fluoroscopy to just superior to the inferior

lamina via a paramedian approach. A lateral image was then obtained and
the needle advanced to just superficial to the spinolaminar line. The epidural
space was localized with a loss of resistance technique. After negative
aspiration for blood or CSF, a 1 cc volume of nonionic iodinated contrast
was injected and flow of contrast was noted. Radiographs were obtained for
documentation purposes. Initially, 2 cc of 1% lidocaine was injected as a test
dose. No adverse reaction was noted. The patients autologous blood was
then administered slowly through the needle. After the blood was injected,
the needle was flushed with 1% lidocaine and removed. A bandage was
placed over the injection site. The patient laid prone for an additional minute
and then was taken to the recovery area.

REFERENCES
1. Serpell MG, Rawal N. Headaches after diagnostic dural punctures. BMJ.
2000;321(7267):973-4.
2. Grant R, Condon B, Hart I, et al. Changes in intracranial CSF volume after lumbar
puncture and their relationship to post-LP headache. J Neurol Neurosurg
Psychiatry. 1991;54(5):440-2.
3. Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and
management. Postgrad Med J. 2006;82(973):713-6.
4. Hatfalvi BI. Postulated mechanisms for postdural puncture headache and
review of laboratory models. Clinical experience. Reg Anesth. 1995;20(4):
329-36.
5. Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches:
experience in 501 consecutive procedures. Neurology. 1992;42(10):1884-7.
6. Leibold RA, Yealy DM, Coppola M, et al. Post-dural-puncture headache:
characteristics, management, and prevention. Ann Emerg Med. 1993; 22(12):
1863-70.
7. Stendell L, Fomsgaard JS, Olsen KS. There is room for improvement in the
prevention and treatment of headache after lumbar puncture. Dan Med J.
2012;59(7):A4483.
8. Johnson BA. Image-guided epidural injections. Neuroimaging Clin N Am.
2000;10(3):479-91.
9. Furman MB, OBrien EM, Zgleszewski TM. Incidence of intravascular
penetration in transforaminal lumbosacral epidural steroid injections. Spine.
2000;25(20):2628-32.
10. Dodge HS, Ekhator NN, Jefferson-Wilson L, et al. Cigarette smokers have
reduced risk for post-dural puncture headache. Pain Physician. 2013;16(1):
E25-30.
11. Bartynski WS, Grahovac SZ, Rothfus WE. Incorrect needle position during
lumbar epidural steroid administration: inaccuracy of loss of air pressure
resistance and requirement of fluoroscopy and epidurography during needle
insertion. AJNR Am J Neuroradiol. 2005;26:502-5.
12. Stojanovic MP, Vu TN, Caneris O, et al. The role of fluoroscopy in cervical
epidural steroid injections: an analysis of contrast dispersal patterns. Spine.
2002;27(5):509-14.
 Dural Puncture Headache 131
13. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis,
prevention and treatment. Br J Anaesth. 2003;91(5):718-29.
14. Basurto Ona X, Martinez Garcia L, Sola I, et al. Drug therapy for treating post-
dural puncture headache. Cochrane Database Syst Rev. 2011;(8):CD007887.
15. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing
more careful evaluation. Lancet. 1999;354(9186):1229-33.
16. Teece S, Crawford I. Towards evidence based emergency medicine: best BETs
from the Manchester Royal Infirmary. Bed rest after lumbar puncture. Emerg
Med J. Emerg Med J. 2002;19(5):432-3.
17. Cho KI, Moon HS, Jeon HJ, et al. Spontaneous intracranial hypotension: efficacy
of radiologic targeting vs blind blood patch. Neurology. 2011;76(13):1139-44.
18. Kawaguchi M, Hashizume K, Watanabe K, et al. Fluoroscopically guided
epidural blood patch in patients with postdural puncture headache after spinal
and epidural anesthesia. J Anesth. 2011;25(3):450-3.
19. Schott M, Gehrke A, Gaab M, et al. [Subdural hematoma after dural puncture:
fateful complication of epidural anesthesia]. Anaesthesist. 2013;62(5):392-5.
20. Verduzco LA, Atlas SW, Riley ET. Subdural hematoma after an epidural blood
patch. Int J Obstet Anesth. 2012;21(2):189-92.
21. Ng MD, Manikappa S. Postpartum seizure and ischaemic stroke following dural
puncture and epidural blood patch. Anaesth Intensive Care. 2012;40(2):347-51.
22. Al Maach N, Vogels OJ, Bollen TL, et al. Arachnoiditis and communicating
hydrocephalus as a complication of epidural blood patch. J Neurol. 2010;
257(4):672-3.
23. Hunyady AI, Anderson CT, Kuratani JD, et al. Fever following an Epidural Blood
Patch in a Child. Case Rep Anesthesiol. 2012;2012:753875.
 Adverse Reactions to 15
Medications
Jeremy Simon

CHIEF COMPLAINT
Low back and left lower extremity pain.

HISTORY OF PRESENT ILLNESS

A 26-year-old male with no significant medical history was moving out of his
medical school apartment and lifted a couch 10 weeks ago. He was taking it
down the steps with his fianc and maneuvering in the hallway. He almost
dropped it, twisted and felt a pop in the left side of his low back. He felt
immediate pain, 10/10, followed by pain radiating to the left lower limb.
Now the leg pain is 9/10 and the back pain 6/10, worse with sitting and
bending, better with standing with his left leg extended. It is dull and aching
in the left low back, sharp in the left buttock and electric-like and sharp in the
posterior left thigh, calf and lateral left foot. There are associated paresthesias
in the left outer foot and fifth toe. He notices slight weakness. The pain is
constant. He has tried ibuprofen 800 mg PO TID, cyclobenzaprine 10 mg PO
TID, heat/ice, and five sessions of physical therapy with very little benefit.
He started internship in 4 weeks.

PAST MEDICAL HISTORY

None

PAST SURGICAL HISTORY

None
 Adverse Reactions to Medications 133

REVIEW OF SYSTEMS
Positive for above otherwise negative.

FAMILY HISTORY
Diabetes type II

SOCIAL HISTORY
Denies tobacco or illegal drugs, drinks occasional alcohol. Finished medical
school and is starting internship in general surgery.

CURRENT MEDICATIONS
None (discontinued 2 weeks ago due to lack of benefit).

ALLERGIES
No known drug allergies

PHYSICAL EXAMINATION
Height: 60
Weight: 180 lbs
BP: 110/70 mm Hg
Pulse: 70/minute

General Appearance
Pleasant, cooperative, alert and oriented, no acute distress.
Inspection: No asymmetry, no evidence of scoliosis.
Gait: nonantalgic, able to ambulate on heels, and tandem without difficulty,
difficulty with toe walking.
Range of motion: Limitations in flexion with more pain reproduction in flexion
than extension.

Neurological
Strength: Manual muscle testing 5/5 with exception of left plantar flexion and
flexor hallucis longus 4+/5.
Sensation: Decreased light touch and pinprick over lateral aspect of foot on the
left.
134 Interventional Spine ProceduresA Case-based Approach

Reflexes: Symmetrical bilateral patellae and Achilles reflex.

Provocative: Straight leg raise and sitting dural tension signs positive on the
left.
Musculoskeletal: Hip internal and external with pain-free normal range of
motion, FABER negative bilaterally.

IMAGING
X-rays: Patient brings lumbar X-rays from his family physician AP/lateral/
oblique/flexion and extension showing normal segmentation, no spondy
lolisthesis, spondylolysis and normal disc height.
Magnetic resonance imaging lumbar spine demonstrates a moderate size
left paracentral disc extrusion at L5-S1 in contact with the left S1 nerve root.

DIAGNOSIS
Acute left S1 radiculopathy secondary to L5-S1 disc herniation.

Plan
It was recommended for this patient to undergo a left S1 transforaminal
epidural steroid injection under fluoroscopy due to the severe limb greater
than back pain and his failure of conservative treatment at 10 weeks. He is
also to start internship and wants the opportunity to reduce his pain quickly.
Surgical options of microdiscectomy were also discussed and a referral was
given for an orthopedic spine surgeon if the conservative treatments were to
fail.

Method of Procedure
Left S1 transforaminal epidural steroid injection under fluoroscopy.
Informed consent was signed and all questions were answered prior
to procedure. The risks, benefits and alternative treatment options were
explained. The risks include, but are not limited to, infections, epidural
hematoma, nerve damage, spinal cord infarction, paralysis, spinal headache,
new or worsening pain, and scar formation. The patients vital signs and
oxygen saturation were monitored prior, during and after the procedure.
The C-arm was positioned so that an AP view of the S1 foramen was
visualized. The soft tissues and skin were anesthetized with 3 cc of 1%
lidocaine without epinephrine. A 22-gauge spinal needle was inserted toward
the posterior aspect of the sacrum just lateral and inferior to the S1 pedicle.
The needle was advanced under a lateral projection into the sacral canal at
the S1-2 level.
 Adverse Reactions to Medications 135

Fig. 15.1: Patient symptom diagram. Patient describes a whole body rash with itching

After negative aspirate for blood or CSF, approximately a total volume

of 1 cc of nonionic contrast was injected and flow of contrast was noted.
Radiographs were obtained for documentation purposes. An injectate of
4 cc consisting of 2 cc of 6 mg/cc betamethasone, 1 cc of 1% lidocaine
without epinephrine and the remainder of normal saline was then injected.
Following the procedure, the patient was taken to the recovery area and
vital signs were repeated.
Postprocedure: As the discharge instructions were discussed approximately
10 minutes after the procedure, the patient felt itching in the throat and a
raised rash on the trunk began to develop. There was also a full feeling in
the tongue and mouth (Fig. 15.1).

ADDITIONAL DIAGNOSIS
Anaphylactic reaction, likely secondary to medication administered during
epidural steroid injection.

Plan
The patient was placed on the cardiac monitor and given a bolus of 50 mg of IV
diphenhydramine and 0.5 mg IM epinephrine. Emergency medical services
(EMS) were called, as well. Oxygen via mask was placed at 10 L/minute and
vital signs were repeated. The patients heart rate and blood pressure were 100
bpm and 140/90 mm Hg. The patients oxygen saturation remained at 98% on
masked oxygen. His rash began to fade in 5 minutes and he was breathing
better and less labored when EMS arrived.
136 Interventional Spine ProceduresA Case-based Approach

DISCUSSION
Anaphylactic and pseudo-anaphylactic reactions appear as clinically
identical entities.1 The two are distinguished only by whether or not antibodies
are involved in the mediation of histamine release.1 Prior exposure to an
antigen is necessary for a true anaphylactic reaction. When the antigen is
reintroduced, the antigen binds to IgE or IgG, which then binds to a mast
cell and basophils and releases histamine, leukotrienes, prostaglandins, and
other chemicals causing a systemic-anaphylactic reaction.1
The possibility of severe anaphylactic reaction is one that the interventionist
need be prepared for in the injection suite. This patient developed the rapid
onset of shortness of breath, angioedema and urticaria while in the recovery
room. All patients should be consented for the possibility of an anaphylactic
reaction for an interventional spine procedure and equipment should be
readily available was the need to arise.
While the medications utilized during an epidural steroid injection
are minimal, recognition of the potential for any of them to cause an
allergic reaction should be noted. Allergies to local anesthetics have been
documented.2,3 Side effects should be differentiated from true allergies as
many patients will report increased heart rate with epinephrine containing
anesthetics used in dental and other procedures.
Reports of allergy to steroid compounds are also documented.4 The
symptoms should also be clarified as common side effects from steroids
may be misinterpreted as allergy. The common side effects include a facial
or truncal flushing reaction, dizziness, headache, pruritus, increased blood
sugar in diabetics, menstrual cycle changes, jitteriness and insomnia.3
Mood changes and rarely psychosis may also occur.5,6
The use of contrast agents is also a significant potential source of allergy.
Most of the contrast agents utilized in epidural steroid injections are iodine-
containing. While the newer agents are nonionic, closer to physiologic
osmolality and contain a smaller amount of free-iodine, patients with a
known iodine allergy should be premedicated with anti-histamines, both
H1 and H2 blockers, and steroid.7 Some practitioners advocate utilizing
gadolinium in cases of severe allergy,8 although this material is not as
radiodense and subtle vascular flow may be missed. Cases of allergy to
gadodiamide have also been reported.9 While not as common, allergies to
topical iodine-povidine and chlorhexidine have been reported, as well.10-14
Treatment of the anaphylactic reaction should begin immediately.
Autoinjectors of epinephrine should be readily available.15 Epinephrine
has been shown to be the most effective treatment in the treatment of
anaphylaxis.15,16 Supportive treatment with supplemental oxygen should also
 Adverse Reactions to Medications 137
be provided. Emergent care also includes administration of antihistamine,
typically diphenhydramine, an H2 blocker such as ranitidine and steroids.
Resuscitation equipment should be available in the procedure suite as severe
anaphylactic reactions may result in cardiac and pulmonary arrest. EMS
should be called immediately if the reaction is occurring as a precaution.
After the patient is stabilized and the reaction is abated, a consultation
with an allergy specialist is recommended. Skin prick or patch testing may
provide the answer as to which agent or agents caused the anaphylactic
reaction.17

REFERENCES
1. Ring J, Behrendt H, de Weck A. History and classification of anaphylaxs. Chen
Immunol Allergy. 2010;95:1-11.
2. Caron AB. Allergy to multiple local anesthetics. Allergy and asthma procee
dings: the official journal of regional and state allergy societies. 2007;28:600-1.
3. Goodman BS, Posecion LW, Mallempati S, et al. Complications and pitfalls
of lumbar interla minar and transforaminal epidural injections. Curr Rev
Musculoskelet Med. 2008;1(3-4):212-22.
4. Kamm GL, Hagmeyer KO. Allergic-type reactions to corticosteroids. Ann
Pharmacother. 1999;33(4):451-60.
5. Milgrom H, Bender BG. Psychologic side effects of therapy with corticosteroids.
Am Rev Respir Dis. 1993;147(2):471-3.
6. Brown ES, Khan DA, Nejtek VA. The psychiatric side effects of corticosteroids.
Ann Allergy Asthma Immunol. 1999;83(6 Pt 1):495-503.
7. Meth MJ, Maibach HI. Current understanding of contrast media reactions and
implications for clinical management. Drug Saf. 2006;29(2):133-41.
8. Safriel Y, Ali M, Hayt M, et al. Gadolinium use in spine procedures for patients
with allergy to iodinated contrast-experience of 127 procedures. AJNR Am J
Neuroradiol. 2006;27(6):1194-7.
9. ODonnell CJ, Cano WG. Allergic reactions to gadodiamide following inter
ventional spinal procedures: a report of 4 cases. Arch Phys Med Rehabil.
2007;88(11):1465-7.
10. Aliagaoglu C, Turan H, Uslu E, et al. Iododerma following topical povidone-
iodine application. Cutan Ocul Toxicol. 2013.
11. Cheng CE, Kroshinsky D. Iatrogenic skin injury in hospitalized patients. Clin
Dermatol. 2011;29(6):622-32.
12. Masse M, Falanga V, Zhou LH. Use of topical povidone-iodine resulting in an
iododerma-like eruption. J Dermatol.2008;35(11):744-7.
13. Keni NN, Aras MA, Chitre V. Chlorhexidine allergy due to topical application.
Indian J Dent Res. 2012;23(5):674-6.
14. Liippo J, Kousa P, Lammintausta K. The relevance of chlorhexidine contact
allergy. Contact Dermatitis. 2011;64(4):229-34.
138 Interventional Spine ProceduresA Case-based Approach

15. Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010;125(2 Suppl):S161-181.

16. Simons FE, Ardusso LR, Bilo MB, et al. 2012 Update: World Allergy Organization
Guidelines for the assessment and management of anaphylaxis. Curr Opin
Allergy Clin Immunol. 2012;12(4):389-99.
17. Rive CM, Bourke J, Phillips EJ. Testing for drug hypersensitivity syndromes. Clin
Biochem Rev. 2013;34(1):15-38.
 Discogenic Low Back
Pain/ Lumbar Disc
Herniation without 16
Radiculopathy
Jeremy Simon, Zachary Broyer, Theodore Conliffe

CHIEF COMPLAINT
The patient complains of constant lower back and buttock pain (Fig. 16.1).

HISTORY OF PRESENT ILLNESS

This patient is a 45-year-old construction worker with a past medical history
significant for two previous lumbar sprain/strain injuries at work over the
last 6 years. These episodes resolved after approximately 34 weeks with the
help of nonsteroidal anti-inflammatory medications and relative rest. Three
months ago, he was lifting several bags of concrete at work and felt a pop in
his lower back. He had immediate lower back pain, sharp in nature. The pain
has become constant with intermittent radiation to the bilateral buttocks,
but not all the way down the legs. There is a constant ache and he rates the
pain an average of 6/10, worse with sitting, bending, twisting and standing
for extended periods of time. There is pain with bowel movements, coughing
and sneezing. Lying flat and arching his back helps slightly. Nonsteroidal
anti-inflammatory medications and cyclobenzaprine have not helped
substantially. The patient tells you he wants to go back to work, but the pain
is preventing him from going back and enjoying life. He denies associated
numbness, tingling, or weakness in the lower extremities and there is no
saddle anesthesia. He denies fevers, chills or night sweats, unintentional
weight loss or weight gain, or hip pain. This is a workers compensation claim.
Treatments to date include anti-inflammatory medications, muscle
relaxers, eight sessions of physical therapy, one L5-S1 interlaminar epidural
steroid injection and one bilateral S1 transforaminal epidural steroid injection
without significant relief.
140 Interventional Spine ProceduresA Case-based Approach

Fig. 16.1: Pain diagram

PAST MEDICAL HISTORY

As above

PAST SURGICAL HISTORY

Wisdom teeth removed

REVIEW OF SYSTEMS
As above otherwise negative

FAMILY HISTORY
Parents alive with hypertension

SOCIAL HISTORY
Smokes half pack of cigarettes a day for 20 years, occasional alcohol, no illicit
drugs. He works as a construction laborer, but is currently out of work due to
pain since this injury. There is no light duty.
 Discogenic Low Back Pain/ Lumbar Disc Herniation without Radiculopathy 141

CURRENT MEDICATIONS
Cyclobenzaprine 10 mg PO BID PRN, naprosyn 500 mg PO BID

ALLERGIES
None

PHYSICAL EXAMINATION
Height: 60
Weight: 190 lbs
Blood pressure: 120/70 mm Hg
Pulse: 62/minute

General Appearance
Pleasant, cooperative, alert and oriented, in obvious discomfort

Inspection
No asymmetry, no evidence of scoliosis

Gait
Nonantalgic, able to ambulate on heels, toes and tandem without difficulty

Range of Motion
Pain reproduction in flexion and less pain with extension

Neurological
Strength: Manual muscle testing 5/5 in the bilateral lower limbs
Sensation: Intact to light touch and pin prick in the bilateral lower limbs
Reflexes: Symmetrical bilateral patellae and Achilles reflex
Provocative: Straight leg raise and sitting dural tension signs negative;
however, there is reproduction of pain in the buttocks and back bilaterally
Musculoskeletal: Hip internal and external with pain-free normal range of
motion, FABER negative bilaterally
Waddells signs are negative.

IMAGING
Lumbar Spine X-Rays
Normal segmentation. No scoliosis. No evidence for fractures or spondy
lolithesis. Reduced disc-space height is noted at L5-S1.
142 Interventional Spine ProceduresA Case-based Approach

Lumbar Spine Magnetic Resonance

Imaging without Gadolinium
Mild disc space narrowing at L4-5 and moderate disc narrowing at L5-S1.
There is an area of increased signal intensity on T2-weighted images in the
posterior aspect of the L5-S1 disc and a central protrusion.

DIAGNOSIS
Likely discogenic low back pain secondary to annular tear at L5-S1.

Plan
The patient was counseled on discogenic lower back pain. It was explained
that the treatments for this entity are not as predictably successful as with
disc herniations associated with mostly limb pain. Options for treatment
were discussed as well as the benign nature of his pain (i.e. that it is not life-
threatening). Recommendations were made for continued physical therapy,
avoidance of aggravating factors, and pain-coping strategies. The patient
was also counseled to stop smoking as there is a negative association with
smoking and pain, as well as disc healing.1 Surgical options were discussed as
well as the possibility of discography should he wish to pursue this option. The
patient was placed on light duty work and a functional capacity evaluation
was considered. The patient wished to discuss the options with his wife and
to return for assessment in 4 weeks.
The patient returned for follow-up 4 weeks later with his wife. They both
expressed that the pain had become unbearable and was affecting almost
every aspect of their lives. They could not have sexual intercourse due to the
severity of the pain. They requested a surgical consultation (Fig. 16.2). It was
explained to the patient that prior to the surgical consultation, confirmation
of the diagnosis need be made by a provocative lumbar discogram. The risks,
benefits, and alternative treatment options were discussed with them and
they expressed understanding.

Lumbar Provocative Discography Method of Procedure

Informed consent for the procedure was obtained. The risks, benefits and
alternative options were discussed. The risks include, but are not limited to,
death, paralysis, allergic reaction, syncope, arrhythmia, cardiac or respiratory
arrest, spinal cord injury, worse pain, scar formation, bleeding, epidural
hematoma and infection. The patient was prepped and draped in a sterile
fashion while in the prone position. All vital signs and oxygen saturation
were monitored prior to, during, and after the procedure. All personnel in the
operating room were wearing masks, head and foot protection to reduce the
 Discogenic Low Back Pain/ Lumbar Disc Herniation without Radiculopathy 143

Fig. 16.2: Lumbar discogram with contrast noted in the discs at L3-4, L4-5 and L5-S1

possibility of infection. The patient received 1gm of cefazolin intra-venously

prior to the procedure.
The C-arm was properly positioned toward the side noted above using
an extradural approach. The soft tissues overlying the above levels were
infiltrated with 46 cc of 1% lidocaine without epinephrine. An 18-gauge
introducer needle was placed under fluoroscopic guidance to just posterior
to each disc studied. A 22-gauge discography needle was then inserted into
the center of the each lumbar disc. A mixture of 20 cc of omnipaque-240 and
200 mg of cefazolin was made sterilely. After confirmation of needle position
on AP and lateral views, the contrast and antibiotic mixture was injected into
each disc with a manometer. A nurse recorded the pressures, pain responses
and nucleograms for each tested disc. Sham injections were also performed.
Repeat confirmation for all levels pain responses were done prior to cessation
of the procedure.
Following the procedure, once the patient was confirmed to be stable, he
was taken to the radiology suite for a post-discogram CT scan of the lumbar
spine.
The patient tolerated the procedure well and without ill effects. He was
provided our contact number and a small prescription for post-procedure
discomfort. He was discharged with his wife at the end of the procedure.

Discography Results
Diagnosis: Internal disc disruption (IDD) syndrome
Levels tested: L3-4, L4-5, L5-S1
Approach: Extradural and infraneural, right
144 Interventional Spine ProceduresA Case-based Approach

Discography Findings
L3-4: No pain, opening pressure 15 PSI, nucleogram: cotton ball, max 100
PSI
L4-5: Discordant pain, 2/10, opening pressure 15 PSI location is too
high, nucleogram: fissured, maximum pressure 100 PSI, pain at 50 PSI
above opening pressure, no grimacing.
L5-S1: Concordant pain, 8/10, opening pres sure 10 PSI you have
found the spot, nucleogram: fissured with subligamentous protrusion,
maximum PSI: 30 PSI, concordant pain at 10 PSI, facial grimacing.

Post-Discography Computed
Tomography
L3-4: cotton ball, contrast within the disc
L4-5: Grade 1 tear, contrast within the disc
L5-S1: Grade 3 tear, contrast within the disc and extravasating into
epidural space.

Discography Impression
L3-4: no pain, normal discogram.
L4-5: discordant and mild pain, abnormal nucleogram.
L5-S1: concordant pain at low pressure, abnormal nucleogram.
Impression: The above findings are consistent with IDD syndrome at L5-S1.
All sham injections were negative. The pain findings were repeatable and
consistent. The validity of the study was excellent.

DISCUSSION
Internal disc disruption syndrome (discogenic low back pain) is defined
as pain resulting from a structurally and supportively incompetent lumbar
intervertebral disc.2 This often occurs as a result of injury, such as tears in
the annulus fibrosis. The disc has been shown to contain pain-sensing fibers,
reported first in 1975.3 The outer annulus is innervated by the sinuvertebral
nerves and gray rami communicantes.4,5 These studies have also showed
pain-producing chemicals such as substance P and calcitonin gene-related
peptides and innervation in the outer annulus of damaged discs.4-6 There are
also both Ruffini and Golgi mechanoreceptors in the outer annulus fibrosis.7
This has been demonstrated by pathologic staining of the disc.
Much of the current on chronic low back pain secondary to IDD is based
on the theory of sensitization. The studies from Coppes suggest a neural
ingrowth in individuals suffering from IDD.4,5,8 Studies in rat and rabbit
models have supported this theory.9,10 The belief is that the torn disc may
 Discogenic Low Back Pain/ Lumbar Disc Herniation without Radiculopathy 145
develop sprouting neural fibers that are pain sensing. These fibers may become
hyper-excitable and cause a chronic pain syndrome. Studies of fetal discs and
cadaveric discs have shown that the disc has innervation irrespective of disc
degeneration, but that ingrowth may be a reason for sensitization.11,12 Genetic
factors may also play a role.6
The diagnosis of IDD is mostly clinical. Primarily axial low back pain with
radiation to the buttocks and/or thigh, but not below the knee is common.
This pain is normally provoked by sitting, standing, bending and twisting.
Coughing or sneezing, and Valsalva may also provoke pain. Further support
is made when MRI imaging demonstrates a disc with a high intensity zone
(HIZ) on T2-weighted imaging in the posterior annulus.13 Studies have
shown a high correlation with concordant lower back pain with provocative
lumbar discography and the presence of an HIZ.13-18 Not all patients with an
HIZ have pain, however.15,18,19 Carragee showed a false positive rate of 25% in
asymptomatic individuals.20
Lumbar provocative discography was declared the gold standard for the
diagnosis of IDD syndrome by the North American Spine Society in 1988
and remains the diagnostic test for confirmation of discogenic pain.21-23 It is
a tool that can be utilized to confirm the diagnosis and, arguably, prevent
unnecessary procedures performed for other causes of axial back pain (e.g.
zygapophysial injections, sacroiliac joint injections).2
Internal disc disruption treatment and workup remains a topic of
controversy.24 The role of discography has been questioned since its inception
in 1948.24,25 A study from Holt in prisoners showed a high false positive rate of
36% with injection of noxious stimulus.26 This was later refuted by Simmons
due to the patient population, the use of an irritating contrast agent and
technical approach.27
Several studies have since supported and refuted the utility and safety
of lumbar discography. In the same year as the Holt paper, Wiley reported
on the safety of the procedure showing relatively low complication rate.28
Much controversy has existed on whether the procedure is accurate for in
the assessment of disc pain as the nature of the procedure involves patient
response. A study from Gruber et al. showed harmful effects of radiocontrast
agents on nucleus cells in vitro.29 Carragee et al. followed patients who had
undergone provocative discography over 10 years and demonstrated an
increased rate of degeneration and a higher incidence of far lateral disc
herniations on the ipsilateral side as the disc entry point.30 Carragee also
showed a false positive rate of approximately 25% in low pressure lumbar
discography.31 Carragee also showed a high false positive rate of provocative
discography in patients with chronic backache.32 A study from Willems et al.
did not show a substantial benefit in studying adjacent discs in patients who
underwent fusion.33
146 Interventional Spine ProceduresA Case-based Approach

Other studies support the use of discography in certain clinical situations.

Berg et al. showed that discography has good utility in the surgical decision-
making process.34 Manchikanti et al. showed fair evidence for the use of
discography in a retrospective analysis.35 Manchikanti et al. also showed level
II-2 evidence for the use of lumbar and cervical discography by reproduction
of concordant pain via a best evidence synthesis.36 Resnick et al. purport
utility in using discography to evaluate potential adjacent level disease in
post-fusion patients and in abnormal discs for surgical consideration.37
The biggest risk associated with discography is infection due to the
relatively poor vascular supply of the intervertebral disc as most of its
nutrition occurs via diffusion in a relatively anerobic environment.38 It is
recommended to give preprocedure antibiotics such as cefazolin or clinda
mycin intravenously.2 Sterile technique is a must and a thorough sterile prep
is essential. While not a standard, we recommend a two-needle technique
with an introduce needle through the skin and soft tissues and a spinal needle
through this, which does not touch the skin. This allows the needle entering
the disc to have minimal contact with anything but the disc itself.
The evaluation of the pain response to the studied disc is reported as
no pain, discordant (nontypical) or concordant (identical). Only
concordant pain is considered positive. A numeric pain score may also be
utilized and the patients description of the pain documented to give more
objective information. Facial grimacing is also useful as an indicator of the
pain response.
Pressure recording with the production of pain is also utilized and
important in the interpretation of the discogram. Opening pressure is defined
as the pressure recorded on the manometer when contrast is first observed
to enter the disc. The pressure at which pain is first observed is also recorded,
as well as the pressure at the end of testing, or final pressure. The Derby
Criteria are a well-described method of interpreting discography. The pain
and pressure responses must show a concordant response of greater than
6/10 on a numeric pain scale at a pressure of less than 50 psi above the
opening pressure and a negative control disc.39 Also, the nucleogram must be
abnormal, showing a grade 3 tear on the Dallas discogram scale (described
below).
The nucleogram is also described in the report and lends credence to
positive results. The Dallas discogram scale, described by Sachs et al. grades
the disruption of the intervertebral disc as demonstrated by post-CT pictures
on a scale of 03.40 A normal nucleogram (Grade 0) is described as a cotton-
ball appearance with contrast staying only in the disc. A Grade 1 tear extends
into the inner third of the disc, Grade 2 to the middle third, and a Grade 3
to the outer third.40 The post-discography CT scan also confirms that all
injections are within the nucleus as annular injections are not reliable.
 Discogenic Low Back Pain/ Lumbar Disc Herniation without Radiculopathy 147

TREATMENT OPTIONS
The conservative treatment options for IDD often start with a physical therapy
program with an emphasis on core strengthening. Proper lifting mechanics
are emphasized and avoidance of aggravating factors, particularly sitting
improperly and for extended periods of time should be avoided. The patient
should be counseled to stop smoking as this may have deleterious effects on
his pain, disc healing and overall health.41,42 The patient should be counseled
on the benign nature of the condition as fear-avoidance can significantly
impact their willingness to exercise and glean quality of life.43 Medications
such as muscle relaxants, anti-inflammatories, antidepressants and narcotics
may be considered but have questionable long-term benefits.44-47
Intradiscal procedures of varying types have been trialled. Chemo
nucleolysis with chymopapain, derived from papaya extract had been widely
utilized and shown benefit in several studies,48-50 but the company ceased
its production in 2003. Serious complications including paraplegia and
anaphylaxis have been reported.51-55
Intradiscal electrothermal annuloplasty (IDET) is a procedure where
a catheter is placed into the disc and attached to a thermal generator. The
catheter is then heated to approximately 90C to cauterize the disc and destroy
the pain fibers. It is also postulated to cause the disc tissue to harden.56 The
efficacy of IDET was called into question showing it helped approximately
50% of people attain about 50% reduction in their preprocedure pain.57
Biacuplasty is a procedure in which two radio- frequency probes are
placed fluoroscopically in the left and right posterior disc. A radiofrequency
current is then applied between the probes with a goal to heat the posterior
annulus to 5560C. It has shown benefit in a selected population and has
comparable results to IDET.58-60
While beyond the scope of this text, discography is often utilized in
determining if a patient is a candidate for surgical discectomy and fusion.
A serious conversation is needed with the patient prior to recommending
this procedure, both by the surgeon and the discographer. The success rates
for lumbar fusion for discogenic low back pain are reported to be between
50% and 70%.61 One study showed no difference in outcome with surgery
compared to psychological counseling.62

SUMMARY
The treatment of discogenic low back pain is challenging and research is
currently being performed for disc-preserving, nonsurgical treatments.
A serious discussion should be had with the patient regarding IDD and
realistic goals of treatment explained. A multidisciplinary approach and
conservative care should be maximized. If the patients quality of life is
148 Interventional Spine ProceduresA Case-based Approach

significantly impaired and they are serious about pursuing surgical options
for the pain, consideration of discography can be made. Counseling about
the risks of the procedure including potential for harm to the disc should
be made prior to the discogram. As with other procedures, proper patient
selection is key and exclusion of psychiatric comorbidities should be made
as this may potentially influence surgical outcomes, as well.63-65

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41. Palmer KT, Syddall H, Cooper C, et al. Smoking and musculoskeletal disorders:
findings from a British national survey. Ann Rheum Dis. 2003;62(1):33-6.
42. Alkherayf F, Agbi C. Cigarette smoking and chronic low back pain in the adult
population. Clin Invest Med. 2009;32(5):E360-7.
43. Rainville J, Smeets RJ, Bendix T, et al. Fear-avoidance beliefs and pain
avoidance in low back pain--translating research into clinical practice. Spine J.
2011;11(9):895-903.
44. Wielage R, Bansal M, Wilson K, et al. The Cost-Effectiveness of Duloxetine in
Chronic Low Back Pain: a Quebec Societal Perspective. Spine. 2012.
45. Anastassopoulos KP, Chow W, Tapia CI, et al. Economic study on the impact of
side effects in patients taking oxycodone controlled-release for noncancer pain.
J Manag Care Pharm. 2012;18(8):615-26.
46. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician.
2012;85(4):343-50.
47. Martell BA, OConnor PG, Kerns RD, et al. Systematic review: opioid treatment
for chronic back pain: prevalence, efficacy, and association with addiction. Ann
Intern Med. 2007;146(2):116-27.
48. Wittenberg RH, Oppel S, Rubenthaler FA, et al. Five-year results from
chemonucleolysis with chymopapain or collagenase: a prospective randomized
study. Spine. 2001;26(17):1835-41.
49. Simmons JW, Nordby EJ, Hadjipavlou AG. Chemonucleolysis: the state of the
art. Eur Spine J. 2001;10(3):192-202.
50. Kim YS, Chin DK, Yoon DH, et al. Predictors of successful outcome for lumbar
chemonucleolysis: analysis of 3000 cases during the past 14 years. Neurosurgery.
2002;51(5 Suppl):S123-8.
51. Benoist M, Bex C, Lassale B, et al. [Neurological complications of chemo
nucleolysis with chymopapain. Apropos of a case]. Rev Rhum Mal Osteoart.
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52. Boccanera L, Laus M. Chemonucleolysis: advantages and disadvantages. Chir
Organi Mov. 1990;75(1):25-32.
53. Haag P, Munkel K, Meinck HM. [Late myelopathy after chemonucleolysis. Case
report and review of the literature]. Nervenarzt. 1999;70(10):920-3.
54. Dabezies EJ, Langford K, Morris J, et al. Safety and efficacy of chymopapain
(Discase) in the treatment of sciatica due to a herniated nucleus pulposus.
Results of a randomized, double-blind study. Spine. 1988;13(5):561-5.
 Discogenic Low Back Pain/ Lumbar Disc Herniation without Radiculopathy 151
55. Kitchel SH, Brown MD. Complications of chemonucleolysis. Clin Orthop Relat
Res. 1992;(284):63-74.
56. Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low
back pain: prospective outcome study with a minimum 2-year follow-up. Spine.
2002;27(9):966-73.
57. Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial
of intradiscal electrothermal therapy for the treatment of discogenic low back
pain. Spine J. 2004;4(1):27-35.
58. Kapural L, Vrooman B, Sarwar S, et al. A randomized, placebo-controlled trial of
transdiscal radiofrequency, biacuplasty for treatment of discogenic lower back
pain. Pain Med. 2013;14(3):362-73.
59. Kapural L, Ng A, Dalton J, et al. Intervertebral disc biacuplasty for the treatment
of lumbar discogenic pain: results of a six-month follow-up. Pain Med.
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60. Karaman H, Tufek A, Kavak GO, et al. 6-month results of TransDiscal Biacuplasty
on patients with discogenic low back pain: preliminary findings. Int J Med Sci.
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Food and Drug Administration investigational device exemption study of
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fusion: five-year follow-up. Spine J. 2009;9:374-86.
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instrumented fusion and cognitive intervention and exercises in patients with
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64. Carragee EJ. Psychological and functional profiles in select subjects with low
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65. Derby R, Lettice JJ, Kula TA, et al. Single-level lumbar fusion in chronic discogenic
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 17
Thoracic Facet Pain
Michael J Mehnert, Jesse A Sally, Gary P Chimes

CHIEF COMPLAINT
The patient complains of persistent mid-back pain.

HISTORY OF PRESENT ILLNESS

A 54-year-old man with no significant past medical history presents to the
office with the above complaint. He reports that for the past 18 months he
has had increasing pain in the mid-back area between the shoulder blades,
(Fig. 17.1) and does not recall any specific injury. He has had episodes of
his back going out a few times a year for as long as he can remember, and
believes he has disc problems in his mid- and lower spine. He complains
of an aching and burning pain with tingling right over that spot that occurs
toward the end of the day, in particular when he is on his feet. The pain is
worse with standing and walking and much better with sitting. Sometimes
the area is stiff and sore when he wakes up. Initially he was getting by with
regular use of anti-inflammatories and muscle relaxants, but over the past
2 months his pain has increased to a 78 out of 10 and does not respond
to medications. He has tried physical therapy and exercise, and had to
stop walking on a treadmill for exercise due to increasing pain, but he can
tolerate limited use of a recumbent bike. Heating modalities are helpful but
have given less relief recently. He reports that when his symptoms become
more severe such as when standing at work, he finds that bending forward to
stretch decreases his pain.
He has no history of shingles or constitutional symptoms. He denies night
time pain. The pain does not radiate along the ribcage or into the low back
and he denies numbness, tingling or weakness in the lower limbs.
 Thoracic Facet Pain 153

Fig. 17.1: Pain diagram

PAST MEDICAL HISTORY

Hypertension, reflux disease

PAST SURGICAL HISTORY

Left shoulder rotator cuff repair

REVIEW OF SYSTEMS
As per history of present illness and also remark-able for fatigue, weight gain
and seasonal allergies.

FAMILY HISTORY
None significant
154 Interventional Spine ProceduresA Case-based Approach

SOCIAL HISTORY
He reports no current tobacco use (quit smoking 11 years ago) and no illicit
drug use. He consumes one to two beers per day. He works as an electrical
engineer.

CURRENT MEDICATIONS
Hydrochlorothiazide. Also cyclobenzaprine and ibuprofen as needed.

ALLERGIES
Sulfa medications

PHYSICAL EXAMINATION
Height: 511
Weight: 224 lbs
BMI: 31.2
Pulse: 84/minute
BP: 128/82 mm Hg
Respirations: 9/minute
This is an alert, awake and cooperative male. Nutrition and hygiene are
well-maintained. He is overweight and he appears uncomfortable during the
interview, changing position occasionally.
He ambulates with a normal gait and station and can do heel-and-toe
walking.
Coordination is intact in the upper and lower limbs.
Thoracolumbar spine exam demonstrates normal overlying skin without
erythema, edema, or surgical scar. No zoster skin lesions are appreciated.
Range of motion is full with reproducible pain at end range extension.
Forward flexion is full and painless. Oblique extension is painful bilaterally,
though more so on the right. Prolonged standing in spinal extension provokes
an increase in axial pain between the shoulder blades without complaints of
radiating or claudicating pain. The spinous processes are nontender. Focal
tenderness is noted along the right greater than left thoracic paraspinals and
the facet joints, approximating the T6-T8 levels. No palpable muscle spasm
is appreciated; trigger points are not identified. Scapulohumeral motion is
normal without winging.
Neurological exam demonstrates 5/5 strength in the upper and lower
limbs in all key myotomes tested. Sensory testing to light touch and pinprick
is normal in the upper and lower limbs in all key dermatomes tested. Sensory
testing of thoracic dermatomes demonstrated normal sensation as well to
light touch. Reflexes are 2+ and symmetric in the upper and lower limbs at
the biceps, triceps, brachioradialis, patella and the Achilles.
 Thoracic Facet Pain 155
Long tract signs are absent bilaterally.
Dural tension signs are negative in the lower limbs.

IMAGING
X-Rays
Anteroposterior, lateral, flexion and extension views of the lumbar spine were
normal. Disc height was well-maintained throughout except at L5-S1 where
loss of disc-space height is noted with some endplate changes and facet
arthropathy. Lumbar lordosis is normal and no instability is noted on flexion
or extension.
Anteroposterior and lateral views of the thoracic spine were obtained.
No evidence of fracture is appreciated and no scoliosis is identified. Spur
formation is noted anteriorly at several levels, with loss of disc height at T6-T7
and T7-T8.

Magnetic Resonance Imaging

Magnetic resonance imaging of the thoracic spine without contrast
demonstrates disc desiccation at T6-T7 and T7-T8. Loss of disc height is
appreciated at these same two levels. Facet arthropathy is noted at T6-T7
as well. Spinal cord signal is normal. No nerve root compression or cord
compression is identified.

DIAGNOSIS
Thoracic zygapophysial joint pain (thoracic facet syndrome)likely
involving the right greater than left T6-T7 and T7-T8 zygapophysial joints.
The patient describes axial pain between the shoulder blades in the region
of the thoracic zygapophysial joints. Symptoms are reportedly and demo
nstrably worse with extension-biased activities and maneuvers and
extension-rotation movements. A lack of radicular pain and neuropathic
symptoms is also consistent with this diagnosis.

DIFFERENTIAL DIAGNOSIS
For this patient, the differential diagnosis would also include other causes
of axial spine pain, such as soft-tissue pathology (myofascial pain, muscle
sprain) though this would be less likely given an absence of trigger points or
appreciable muscle spasm on exam. This patient could also be symptomatic
from thoracic degenerative disc disease, but reproduction of pain
with loading of the facet joints with extension and oblique extension along
with tenderness to palpation is more consistent with zygapophysial joint pain
156 Interventional Spine ProceduresA Case-based Approach

or other posterior element pathology. Improvement in pain with sitting and

flexion-biased stretches would also point toward pain from the posterior
zygapophysial joints and would make discogenic pain less likely as well.1
The patients MRI results and lack of sensory deficits and neuropathic pain
symptoms would make a thoracic radiculopathy or zoster infection much
less likely.

Thoracic Zygapophysial Joint Pain

Diagnosis and treatment of thoracic zygapophysial joint pain has evolved as
a clinical entity analogous to cervical and lumbar zygapophysial joint pain.2,3
The thoracic zygapophysial joints are true synovial-lined joints.4,5 Sprains
and contusions of the zygapophysial joints in the thoracic spinal regions,
as well as osteoarthritis, have been postulated as causes of axial thoracic
spine pain mediated by the zygapophysial joints.6 Pain patterns attributable
to the thoracic zygapophysial joints when they are noxiously stimulated to
become pain generators have been described in the literature7,8 (Figs 17.2A
and B). In the lumbar spine, imaging studies have not been shown to be
useful indicators of facet joint pain,9 though there is a role in imaging to rule-
out other causes of pain. Physical exam is also not sufficient to accurately
diagnose facet-mediated pain.10

TREATMENT OPTIONS
As with other conditions that can cause axial spine pain, initial treatment
should be conservative and include medication management, physical
therapy, modalities and potentially spinal manipulation. A regular home
exercise program as well as activity modification should be incorporated.
Weight loss should be encouraged. Anti-inflammatory medications may be
preferred; opioid usage should be avoided if possible.

Interventional Options
Dogmatic interventional treatment approaches for thoracic zygapophysial
joint pain are analogous to those available for cervical and lumbar
zygapophysial joint pain and include corticosteroid/anesthetic injections
intra-articularly, anesthetic blockade of the corresponding medial branches
and sensory innervation, as well as standard radiofrequency neurotomy of
the same medial branches. Pulsed radiofrequency of the thoracic medial
branches lacks sufficient evidence at this time, and other denervation
techniques (chemodenervation) have been described but are less commonly
employed.11
Sensory innervation to the thoracic zygapophysial joints is analogous
to the lumbar zygapophysial joints both in terms of responsible neural
 Thoracic Facet Pain 157

A B
Figs 17.2A and B: Maps of referred pain patterns in normal volunteers elicited by
noxious stimulation of the thoracic zygapophysial joints at the segments indicated
Source: (A) Dreyfuss et al.; (B) Fukui et al.

structures and also the numbering of the individual zygapophysial joints and
their corresponding nerve roots and medial branches.12-14 Two medial branch
nerves originating from two different dorsal rami innervate each joint. Care
must be taken to clearly identify the target joint (often identified as two
levels with a hyphen, i.e. the T3-T4 zygapophysial joint) and the correspon
ding medial branches (often identified with a comma, i.e. the T2, T3 medial
branches). Additionally, the medial branches are often accessed at a vertebral
transverse process one level below the actual name of the originating nerve
root. For example, the T3-T4 zygapophysial joint can be anesthetized by
injecting anesthetic with a needle upon the T2 medial branch as it crosses
the transverse process of the T3 vertebral body and upon the T3 medial
branch as it crosses the transverse process of the T4 vertebral body.2,14,15
There may be a role for intra-articular corticosteroid injections, parti
cularly for osteoarthritic joints.16,17 However, the role of a diagnostic joint
injection is well-established.16-19 The thoracic articulating joints are oriented
in a near-coronal plane and thus access from a direct posterior needle
approach is often prohibited by the overlying vertebral lamina.20 Similarly the
unique anatomy of the thoracic spine with the pulmonary structures in close
proximity precludes needle access to the thoracic facet joints from a lateral
approach.6 Nonetheless, an intra-articular approach accessing the inferior
aspect of a thoracic facet joint has been described.6,21
158 Interventional Spine ProceduresA Case-based Approach

Medial branch blocks are also a diagnostic intervention, utilized to

determine if a given zygapophysial joint can be considered the source
of a patients pain. Comparative medial branch blocks are employed for
diagnostic purposes, in accordance with a validated model for cervical
zygapophysial joint pain.22-24 Data exclusive to thoracic zygapophysial joint
pain are, by comparison to the cervical literature, limited.25 Anesthetic blocks
on at least two separate occasions should be performed; however, the exact
criteria for positive comparative blocks with two different local anesthetics
can be left up to the physician.2 Some authors advocate complete abolition
of pain with diagnostic blockade2 where others have suggested a threshold of
80% pain relief.26 It has been demonstrated that a single-block paradigm for
thoracic medial branches can have a false positive rate of 58%.25
The location of the potential target thoracic medial branches (Figs 17.3
and 17.4) has also been described via cadaver analysis14,15 in a manner similar
to that for the cervical medial branches.27
An initial technique for thoracic medial branch blocks (and subsequent
percutaneous neurotomy) was initially described by Stolker et al.28 Anato
mical studies of the location of the thoracic medial branches by Chua14
conclude that this technique is inaccurate.2
Localization of a target painful thoracic zygapophysial joint with medial
branch blocks should be done only with the expectation that a patient would
be willing to move on to a medial branch neurotomy procedure.2 Thoracic
zygapophysial joint pain must be confirmed with prior diagnostic medial
branch blocks before advancing to a neurotomy procedure for pain control.
Thoracic medial branch radiofrequency neurotomy potentially offers
the advantage of longer-term pain relief from a problematic thoracic
zygapophysial joint. Over 1 year of pain relief can be expected.29-31
The location of the target thoracic medial branches is appreciably different
from that in the cervical and lumbar spine.2,14 Furthermore the thoracic
medial branches demonstrate significant variability (Figs 17.3 and 17.4) in
their location throughout the thoracic levels.14,26 Nonetheless, the equipment,
sensory and motor stimulation, and the radiofrequency lesioning protocol
are otherwise similar to that utilized in the lumbar spine.2,26
The above procedures are indicated for patients who, as a general rule,
have failed to improve with more conservative measures. A reasonable
suspicion of pain mediated by the thoracic zygapophysial joints should exist,
and a target joint for anesthetic blockade or injection of corticosteroid is
often chosen based on clinical exam findings and reported pain patterns.18
Fluoroscopic guidance is necessary for accuracy, and the patient should
keep a written pain diary to assess their level of response and minimize recall
bias.2,32,33
Contraindications include active infection, coagulopathy/bleeding
diathesis, pregnancy or allergy to a given injectate.2
 Thoracic Facet Pain 159

Fig. 17.3: A sketch of the thoracic medial branches from Chua1. Nerves with an atypical
course are marked with an asterisk (*)

Plan/Treatment Course
Given the failure to achieve adequate pain relief with medications, physical
therapy and activity modification, a decision was made to move forward with
right-sided T6-T7 and T7-T8 intra-articular zygapophysial joint injections.
Pain relief of 90% was reported, albeit temporarily. Sub-sequently, an injection
procedure to anesthetize the medial branches that innervate the right-sided
T6-T7 and T7-T8 zygapophysial joints was performed. Again significant,
concordant pain-relief was obtained without complication. Ultimately, a
decision was made to proceed with a radiofrequency neurotomy procedure
to denervate the right T6-T7 and T7-T8 thoracic zygapophysial joints for
better pain control.
160 Interventional Spine ProceduresA Case-based Approach

Fig. 17.4: A composite sketch of a radiograph of cada-veric thoracic spines in which

the medial branches of the thoracic dorsal rami were marked with wires, in order to
depict their relationship to the transverse processes. From Chua1. Note how at middle
thoracic levels, the nerves are suspended in the intratransverse space, whereas at
other levels they cross, and lie on, the transverse processes

Tricks and Tips

During a neurotomy procedure relatively light sedation should be used
so that the patient can be questioned for the perception of radiating or
radicular pain during sensory stimulation and for the perception of
nonmultifidus muscle contraction during motor stimulation. Similarly,
narcotic medications or intravenous opioids should be administered after
the stimulation portion of the neurotomy proce- dure.
The operator should bear in mind that even light sedation and anxiolytics
can potentially impact the patients reporting of their response to a
diagnostic injection.
For intra-articular injections, expected volumes are often quite small
(~1 mL including contrast media) and higher concentrations of cortico
steroid preparations to keep volumes lower may be useful.
The level to be injected and accessed with a needle will need to be
identified by counting the ribs to the target level (being careful that a
cervical rib does not exist).
Anatomic variability with regard to location of the traversing medial
branches over a given thoracic spinous process can be significant; refer
to the above anatomic locations when proceeding with neural blockade
or neurotomy.14,15
 Thoracic Facet Pain 161

Procedure NoteThoracic Intra-articular

Zygapophysial Joint Injection
Procedure
Thoracic facet joint injection (intra-articular injection) with fluoroscopic
guidance

Indications
Please refer to prior office notes for details. The patient is being treated
for a diagnosis of thoracic pain and thoracic facet syndrome. The patient
has failed to respond to conservative measures including physiotherapy,
medications, and activity modification. A decision was made to proceed with
fluoroscopically-guided thoracic facet joint injections for diagnostic and
possibly therapeutic purposes.
The patient was informed of the risks and benefits of the procedure, as
well as alternative treatments. The risks include, but are not limited to, death,
paralysis, allergic reaction, syncope, arrhythmia, cardiac or respiratory arrest,
spinal cord injury, worse pain, scar formation, bleeding, epidural hematoma
and infection. All questions were answered prior to proceeding. The patient
expressed understanding and gave informed written consent.

Preoperative Diagnosis
Thoracic facet pain, thoracic facet syndrome

Postoperative Diagnosis
Same

Procedure Performed
Thoracic intra-articular facet joint injection to the right T6-T7 and T7-T8
facet joints
Fluoroscopic guidance/localization.
The patient was taken into the fluoroscopy suite and was placed prone on
the procedure table. The patient was prepped and draped in a sterile fashion.
All vital signs were monitored prior to, during, and after the procedure.
Oxygen saturation was also monitored and noted to be greater than or
equal to 94% throughout the procedure. Cardiac monitoring revealed normal
sinus rhythm.
The C-arm was positioned so that the region overlying the right T6-T7
and T7-T8 zygapophysial joints was visualized. The soft tissues overlying
these structures were infiltrated with 1% lidocaine without epinephrine
and buffered with sodium bicarbonate for local anesthesia. Then, under
162 Interventional Spine ProceduresA Case-based Approach

Fig. 17.5: A decline view of the needle approaching the target right thoracic facet joint

Fig. 17.6: An AP view of the needle approaching the target joint; note that
the needle is advanced towards the joint from an inferior to superior approach

intermittent fluoroscopic guidance, a 25-gauge spinal needle was inserted

into the inferior aspect of each of the above mentioned zygapophysial
joints (Figs 17.5 and 17.6). Multiplanar fluoroscopic imaging was obtained
to verify correct needle positioning (Figs 17.7 and 17.8).
After aspiration was attempted and was negative for return of blood or
other fluid, a small amount of nonionic contrast was injected and flow of
 Thoracic Facet Pain 163

Fig. 17.7: A lateral view of the target joint with the needle
approaching the target facet joint

Fig. 17.8: A lateral view of the target joint with the needle approaching the joint; note
that compared to the previous image the needle bevel was rotated to better access the
intra-articular space

contrast was noted at each level (Figs 17.9 to 17.11), with care given to assess
for vascular flow. Radiographs were obtained for documentation purposes.
The injectate consisting of steroid and lidocaine was administered into each
joint.
The needles were then withdrawn and hemostasis was achieved.
The patient tolerated the procedure well and was discharged after
an appropriate period of observation. Postprocedure instructions were
given and the patient was advised to call with any questions or concerns.
164 Interventional Spine ProceduresA Case-based Approach

Fig. 17.9: A lateral view of the target joint with the needle in place
and contrast filling the intra-articular space

Fig. 17.10: An AP view of contrast in the target thoracic facet joint

The patient is to follow-up with the physician as noted above within

12 weeks.
The patient was also given a pain diary and was instructed to note the
pain level and activities at the time of entering the data for the day of the
procedure. The patient will bring this data to the follow-up appointment
for diagnostic purposes.
 Thoracic Facet Pain 165

Fig. 17.11: The procedure being repeated to access a second joint

superior to the previously injected facet joint

Procedure NoteThoracic Medial Branch Block

Procedure
Thoracic medial branch block (zygapophysial joint nerve block) with fluoro
scopic guidance.

Indications
Please refer to prior office notes for details. The patient is being treated
for a diagnosis of thoracic pain and thoracic facet syndrome. The patient
has failed to respond to conservative measures including physiotherapy,
medications, and activity modification. A decision was made to proceed
with fluoroscopically-guided thoracic medial branch blocks for diagnostic
purposes.
The patient was informed of the risks and benefits of the procedure, as
well as alternative treatments. The risks include, but are not limited to death,
paralysis, allergic reaction, syncope, arrhythmia, cardiac or respiratory arrest,
spinal cord injury, worse pain, scar formation, bleeding, epidural hematoma
and infection. All questions were answered prior to proceeding. The patient
expressed understanding and gave informed written consent.

Preoperative Diagnosis
Thoracic facet pain, thoracic facet syndrome
166 Interventional Spine ProceduresA Case-based Approach

Postoperative Diagnosis
Same

Procedure Performed
Thoracic medial branch blocks to the right T5, T6 and T7 nerves to
anesthetize the right T6-T7 and T7-T8 thoracic facet joints
Fluoroscopic guidance/localization.
The patient was taken into the fluoroscopy suite and was placed prone on
the procedure table. The patient was prepped and draped in a sterile fashion.
All vital signs were monitored prior to, during, and after the procedure.
Oxygen saturation was also monitored and noted to be greater than or equal
to 94% throughout the procedure. Cardiac monitoring revealed normal sinus
rhythm.
The C-arm was positioned so that the T6, T7 and T8 vertebrae were
identified. The soft tissues overlying these structures were anesthetized with
1% lidocaine without epinephrine and buffered with sodium bicarbonate as
a local anesthetic.
At the T6 vertebrae, a 25-gauge spinal needle was advanced down via an
oblique approach to the site of the traversing medial branch on the transverse
process of the vertebra on the right side. This corresponds to the right T5
medial branch nerve. Needle positioning was done under intermittent
fluoroscopic guidance.
At the T7 vertebrae, a 25-gauge spinal needle was advanced down via an
oblique approach to the site of the traversing medial branch on the transverse
process of the vertebra on the right side. This corresponds to the right T6
medial branch nerve. Needle positioning was done under intermittent
fluoroscopic guidance (Fig. 17.12).
At the T8 vertebrae, a 25-gauge spinal needle was advanced down via an
oblique approach to the site of the traversing medial branch on the transverse
process of the vertebra on the right side. This corresponds to the right T7
medial branch nerve. Needle positioning was done under intermittent
fluoroscopic guidance.
An AP view was obtained to verify correct needle positioning. After
aspiration was attempted and was negative for return of blood or other fluid,
a small amount of nonionic contrast was injected and flow of contrast was
noted at each level, with care given to assess for vascular flow. Radiographs
were obtained for documentation purposes. Next, the selected preservative-
free local anesthetic was administered at each level.
The needles were then withdrawn and hemostasis was achieved.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. Postprocedure instructions were given
 Thoracic Facet Pain 167

Fig. 17.12: Example of an AP view of the needle in place at the

site of the traversing medial branch for a different patient

and the patient was advised to call with any questions or concerns. The
patient is to follow-up with the physician as noted above within 12 weeks.
The patient was also given a pain diary and was instructed to note the
pain level and activities at the time of entering the data for the day of the
procedure. The patient will bring this data to the follow-up appointment for
diagnostic purposes.

Procedure NoteRadiofrequency
Neurotomy of Thoracic Medial Branches
Procedure
Radiofrequency neurotomy of the thoracic medial branches (zygapophysial
joint nerve ablation) with fluoroscopic guidance.

Indications
Please refer to prior office notes for details. The patient is being treated
for a diagnosis of thoracic pain and thoracic facet syndrome. The patient
has failed to respond to conservative measures including physiotherapy,
medications, and activity modification. The diagnosis has been confirmed
with prior injections of local anesthetic. A decision was made to proceed with
fluoroscopically-guided thoracic medial branch radiofrequency neurotomy
for therapeutic purposes.
168 Interventional Spine ProceduresA Case-based Approach

The patient was informed of the risks and benefits of the procedure, as
well as alternative treatments. The risks include, but are not limited to death,
paralysis, allergic reaction, syncope, arrhythmia, cardiac or respiratory arrest,
spinal cord injury, worse pain, scar formation, bleeding, epidural hematoma
and infection. All questions were answered prior to proceeding. The patient
expressed understanding and gave informed written consent.

Preoperative Diagnosis
Thoracic facet pain, thoracic facet syndrome

Postoperative Diagnosis
Same

Procedure Performed
Radiofrequency ablation of the thoracic medial branches of the right
T5, T6 and T7 nerves to denervate the right T6-T7 and T7-T8 thoracic
facet joints
Fluoroscopic guidance/localization.
The patient was taken into the fluoroscopy suite and was placed prone on
the procedure table. The patient was prepped and draped in a sterile fashion.
All vital signs were monitored prior to, during, and after the procedure.
Oxygen saturation was also monitored and noted to be greater than or equal
to 94% throughout the procedure. Cardiac monitoring revealed normal sinus
rhythm. A grounding pad was then placed on the patient.
The C-arm was positioned so that the T6, T7 and T8 vertebrae were
identified. The superficial soft tissues overlying these structures were
anesthetized with 1% lidocaine without epinephrine and buffered with
sodium bicarbonate as a local anesthetic. At the T6 vertebrae, a 20-gauge
10 cm radiofrequency cannula with a curved, sharp 10-mm active-tip was
advanced down via an oblique approach to the site of the traversing medial
branch on the transverse process of the vertebra on the right side. This
corresponds to the right T5 medial branch nerve. Cannula positioning was
done under intermittent fluoroscopic guidance.
At the T7 vertebrae, a 20-gauge 10-cm radiofrequency cannula with a
curved, sharp 10-mm active-tip was advanced down via an oblique approach
to the site of the traversing medial branch on the transverse process of the
vertebra on the right side. This corresponds to the right T6 medial branch
nerve. Cannula positioning was done under intermittent fluoroscopic
guidance.
At the T8 vertebrae, a 20-gauge 10 cm radiofrequency cannula with a
curved, sharp 10-mm active-tip was advanced down via an oblique approach
 Thoracic Facet Pain 169
to the site of the traversing medial branch on the transverse process of the
vertebra on the right side. This corresponds to the right T7 medial branch
nerve. Cannula positioning was done under intermittent fluoroscopic
guidance.
Lateral and AP views were obtained to confirm safe and accurate
placement. Then, at each level, the radiofrequency needle stylet was replaced
by the radiofrequency heating electrode. Impedances were recorded and
were noted to be greater than 300 at each level, with adjustments and
repeat imaging performed if necessary. Sensory and motor test stimulation
at 50 Hz and 2 Hz respectively was performed at each level to ensure no
radicular sensations and to obtain maximal multifidi contractions. After
stimulation-confirmed correct needle placement and after aspiration was
attempted and was negative for return of blood or other fluid, 1 cc of 1%
lidocaine without epinephrine was injected at each level. Repeat imaging
again demonstrated correct needle placement. Subsequently at each level,
standard (nonpulsed) radiofrequency lesioning was done for approximately
90 seconds at 80C at each level. The lesioning was repeated two times at
each level for approximately 90 seconds. At the cessation of the procedure,
a small mixture of betamethasone and 1% lidocaine without epinephrine
was injected and the needles removed. Radiographs were obtained for
documentation purposes.
The patient tolerated the procedure well and was discharged after an
appropriate period of observation. If there are any complications, the patient
was instructed to call us. The patient is to follow-up with the physician as
noted above within 23 weeks.

REFERENCES
1. Rengachary SS, Balabhadra RS. Black disc disease: a commentary. Neurosurg
Focus. 2002;13(2):E14.
2. Bogduk N. Spinal Diagnostic and Treatment Procedures: Practice Guidelines,
1st edition. San Francisco, CA: International Spine Intervention Society; 2004.
3. Wilson PR. Thoracic facet syndromea clinical entity? Pain Supp. 1987;4:S87.
4. Jeffries B. Facet steroid injections. Spine: State of the art review. 1988;2:409-17.
5. Huston CW, Slipman CW, Furman MB, Hasan S, Derby R. Spinal injections. In:
Slipman CW, Derby R, Simeone FA, Mayer TG (Eds): Interventional spine: an
algorithmic approach. Philadelphia, PA: Saunders Elsevier; 2008. pp. 245-73.
6. Falco FJE, Furman MB. Thoracic zygapophysial joint intra-articular injection,
posterior approach. In: Furman MB, Lee TS, Berkwits L (Eds): Atlas of Image-
Guided Spinal Procedures. Philadelphia, PA: Elsevier Saunders; 2013. pp. 213-7.
7. Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophysial joint pain patterns. A
study in normal volunteers. Spine. 1994;19(7):807-11.
8. Fukui S, Ohseto K, Shiotani M. Patterns of pain induced by distending the
thoracic zygapophyseal joints. Regional Anesth. 1997;22(4):332-6.
170 Interventional Spine ProceduresA Case-based Approach

9. Schwarzer AC, Wang SC, ODriscoll D, et al. The ability of computed tomography
to identify a painful zygapophysial joint in patients with chronic low back pain.
Spine. 1995;20(8):907-12.
10. van Kleef M, Vanelderen P, Cohen SP, et al. 12. Pain originating from the lumbar
facet joints. Pain Pract. 2010;10(5):459-69.
11. Weksler N, Klein M, Gurevitch B, et al. Phenol neurolysis for severe chronic
nonmalignant pain: is the old also obsolete? Pain Med. 2007;8(4):332-7.
12. Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. J Anat.
1982;134(Pt 2):383-97.
13. Bogduk N. The innervation of the lumbar spine. Spine. 1983;8(3):286-93.
14. Chua WH, Bogduk N. The surgical anatomy of thoracic facet denervation. Acta
Neurochir (Wien). 1995;136(3-4):140-4.
15. Chua WH. Clinical anatomy of the thoracic dorsal rami. BMedSci Thesis.
University of Newcastle, Newcastle, Australia; 1994.
16. Atluri S, Datta S, Falco FJ, et al. Systematic review of diagnostic utility and
therapeutic effectiveness of thoracic facet joint interventions. Pain Physician.
2008;11(5):611-29.
17. Boswell MV, Colson JD, Sehgal N, et al. A systematic review of therapeutic facet
joint interventions in chronic spinal pain. Pain Physician. 2007;10(1):229-53.
18. Bogduk N, Aprill C, Derby R. Diagnostic blocks of synovial joints. In: White AH
(Ed): Spine Care, Volume One: Diagnosis and conservative treatment. Mosby,
St. Louis; 1995. pp. 298-321.
19. Gray D, Bajwa Z, Warfield C. Facet block and neurolysis. In: Waldman SLR, Ross
A, et al (Eds). Interventional pain management. Philadelphia: WB Saunders;
2001. pp. 446-83.
20. Czervionke LF, Fenton DS. Facet joint injection and medial branch block. In:
Czervionke LF, Fenton DS (Eds): Image-guided spine intervention. Philadelphia,
PA: Saunders Elsevier; 2003. pp. 9-50.
21. Dreyfuss P, Tibiletti C, Dreyer S, et al. Thoracic zygapophysial joint pain: a review
and description of an intra-articular block technique. Pain Digest. 1994;4:46-54.
22. Barnsley L, Lord S, Bogduk N. Comparative local anesthetic blocks in the
diagnosis of cervical zygapophysial joint pain. Pain. 1993;55(1):99-106.
23. Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic blocks
versus placebo-controlled blocks for the diagnosis of cervical zygapophysial
joint pain. Clin J Pain. 1995;11(3):208-13.
24. Mehnert MJ, Freedman MK. Update on the role of z-joint injection and
radiofrequency neurotomy for cervicogenic headache. PM&R. 2013;5(3):221-7.
25. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the prevalence of facet
joint pain in chronic thoracic pain. Pain Physician. 2002;5(4):354-9.
26. Czervionke LF, Fenton DS. Facet denervation. In: Czervionke LF, Fenton DS
(Eds): Image-guided spine intervention. Philadelphia, PA: Saunders Elsevier;
2003. p. 51-71.
27. Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in
the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery.
1995;36(4):732-9.
28. Stolker RJ, Vervest AC, Groen GJ. Percutaneous facet denervation in chronic
thoracic spinal pain. Acta Neurochir (Wein). 1993;122(1-2):82-90.
 Thoracic Facet Pain 171
29. Speldewinde GC. Outcomes of percutaneous zygapophysial and sacroiliac joint
neurotomy in a community setting. Pain Med. 2011;12(2):209-18.
30. Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency
neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000;25(10):
1270-7.
31. Smuck M, Crisostomo RA Trivedi K, et al. Success of initial and repeated medial
branch neurotomy for zygapophysial joint pain: a systematic review. PM&R.
2012;4(9):686-92.
32. Falco FJE, Steinmetz BD, Furman MB. Thoracic zygapophysial joint nerve
(medial branch) radiofrequency neurotomy, posterior approach. In: Furman
MB, Lee TS, Berkwits L (Eds): Atlas of Image-Guided Spinal Procedures.
Philadelphia, PA: Elsevier Saunders; 2013. pp. 225-9.
33. Haspeslagh S, Van Kleef M. Technique of radio frequency denervation.
In: Slipman CW, Derby R, Simeone FA, Mayer TG (Eds): Interventional spine:
an algorithmic approach. Philadelphia, PA: Saunders Elsevier; 2008. p. 275-89.
 18
Thoracic Disc Herniation
Arjang Abbasi, Shounuck I Patel, Gautam Malhotra

Chief Complaint
A 67-year-old right-handed male presents with 2 months of sudden onset,
gradually worsening 8/10 mid-back pain radiating into the left ribs (Fig. 18.1).

Fig. 18.1: Thoracic disc herniation (Pain diagram)

 Thoracic Disc Herniation 173

HISTORY OF PRESENT ILLNESS

He woke up with the symptoms and denies any inciting or traumatic events.
He reports that his primary physician ruled out gastrointestinal, renal, cardiac
and pulmonary causes. He has already tried nonsteroidal anti-inflammatory
medications, acetaminophen, and acupuncture. Chiropractic manipulation
of the ribs and thoracic spine did not provide relief. A neurologist ordered
diagnostic studies summarized below:
X-ray thoracic spine: mild dextroscoliosis. No osteopenia
Magnetic resonance imaging cervical spine with contrast: mild multilevel
degenerative disc disease (DDD)
Magnetic resonance imaging thoracic spine with contrast: multilevel DDD
and herniated nucleus pulposus (HNPs) including a large one at T10-11.
No intrinsic cord changes (Figs 18.2 and 18.3).
Shingles was ruled out. A trial of modalities, manipulation, and lumbar
stabilization in physical therapy provided no significant relief. Gabapentin
provided some relief but the pain persists. There are no other relieving factors.
He denies any identifiable exacerbating factors and specifically denies and
worsening with deep inspiration. He denies any associated numbness,
tingling, awakening from the pain, weakness, gait difficulties, bladder/
bowel dysfunction, unexplained weight loss, fever, chills, night sweats and
significant spine surgical/procedural history. The pain is affecting his daily
function and quality of life.

Fig. 18.2: Sagittal image from thoracic spine MRI study with
disc herniation visualized at T10-T11
174 Interventional Spine ProceduresA Case-based Approach

Fig. 18.3: Thoracic spine MRI axial image demonstrating the T10-T11 disc herniation

Past Medical History

Sinusitis
Colon carcinoma status post-resection
Diabetes type 2 adult
Osteoarthritis
Lysis of adhesions 2005
Reflux
Coronary artery disease
Inguinal hernia status postherniorrhaphy
Hypertension
Melanoma

Allergies
No known allergies

Family History
Mother and father died in their late 80s due to heart disease.
Brother has DDD, herniated disc and osteoarthritis.
Paternal grandmother colon cancer
 Thoracic Disc Herniation 175

Social History
Occupation: Retired bus operator and classified as disabled through
social security/social security disability insurance
Living condition: He is married and has two grown children that have left
the home. He lives with his spouse in a single level ranch house with no
steps to enter
Tobacco: Former pipe smoker. Quit 2 years ago
Alcohol: Drinks a glass of wine daily

Medication History
Omeprazole: 20 mg
Mobic: 15 mg
Gabapentin: 600 mg
Januvia: 100 mg
Livalo: 2 mg
Diovan HCT: 16012.5 mg
Allegra allergy: 180 mg
Aspirin: 81 mg
Metformin HCL
Welchol
Plavix: 75 mg
Singulair: 10 mg

Review of Systems
Constitutional: See history of present illness
HEENT: denies recent double vision or changes in speech
Respiratory: No shortness of breath or cough
Cardiovascular: See past medical history
Gastrointestinal: See past medical history
Genitourinary: No dysuria, hematuria, incontinence
Reproductive: Negative for dysfunction
Metabolic/endocrine: See past medical history
Neurological: See history of present illness
Dermatologic: No rash or itching
Musculoskeletal: See history of present illness
Hematologic: No easy bruising, bleeding or blood clots
Immunologic/allergy: No environmental allergies
Corrective lenses: Wears glasses.
176 Interventional Spine ProceduresA Case-based Approach

Physical examination
Vital Signs
BP: 140/90 mm Hg
Pulse: 74/minute
Height: 72 inches
Weight: 180 pounds
BMI: 24.41
Head/face/eyes/ears/nose/throat: Normocephalic. No exophthalmos or
nasal deformity. Hearing grossly intact
Respiratory: Normal to inspection
Integumentary: No impressive skin lesions present
Psychiatric: No unusual anxiety noted today.

Neurological
Manual muscle testing reveals no gross weakness in lower extremities.
Muscle stretch reflexes are symmetric 2+ in the biceps, triceps, pronator
teres, quadriceps, medial hamstring and triceps surae.
Babinski testing is symmetric and reveals downgoing toes.
Sensation is symmetric and intact in all dermatomes of the thorax,
abdomen, upper and lower limbs.

Thoracic and Lumbar Spine

Inspection
There is a lateral/anterior abdominal surgical scar.
There is no thoracic spinal deformity including scoliosis or excessive
kyphosis.
No atrophy noted in the upper or lower limbs.

Palpation
Mild left-sided paraspinal tenderness without muscle spasm
No tenderness of the ribs
There is no spinous process
No percussive tenderness is elicited.

Range of Motion
Lumbar active range of motion does not produce pain.
Intersegmental spine motion during ROM is preserved.
 Thoracic Disc Herniation 177
Right lateral lumbar flexion is 40, left lateral lumbar flexion is 40
Lumbar flexion is 90, lumbar extension is 35.

Tone
Normal without velocity-dependent increase with passive range of motion

Stability
Hip motion is painless and within normal limits. Knee exam is normal and
painless bilaterally.

Special
Straight leg raise, femoral stretch, Patricks test, distraction testing and
contralateral straight leg raise are negative bilaterally.

Assessment with
differential diagnosis
Mid-Back Pain Radiating into Ribs
Differential includes:
Neuromuscular: imaging evidence of herniated nucleus pulposis without
myelopathy. This could be causing a thoracic radiculopathy which
would explain the symptoms. Diabetes is also a risk factor for thoracic
radiculopathy. Shingles, syrinx, and other cord etiologies are unlikely
given history and imaging.
Musculoskeletal: rib and spine fracture ruled out. There is a myofascial
component but this seems less contributory and more likely a sequelum
of underlying cause.
Visceral: renal, cardiac, pulmonary and gastrointestinal causes ruled
out already. Neoplastic or paraneoplastic causes should be considered;
however, these seem less likely given the presentation and workup thus
far.

Treatment Plan
Education: discussed the relevant anatomy and proposed etiology of his
pain
Physical therapy: one to two sessions with goals of preventing maladaptive
sequelae of pain and providing a home exercise program. This should
include posture training, chin tucks, cervical stabilization, ergonomics,
scapular retractor strengthening, pectoral stretching and education of
modalities to address myofascial pain for home use (e.g. heat, tens, etc.)
178 Interventional Spine ProceduresA Case-based Approach

Transforaminal thoracic epidural steroid injection (ESI) left at T10,

T11. The patient was instructed to discontinue medications prior to
procedure pending clearance from their provider. The risks, benefits,
alternatives and expectations of the proposed procedure were discussed
at length with the patient, as well as the procedure itself and expected
recovery period. The patient was allowed as much time as necessary to
ask all appropriate questions and they were answered to the patients
satisfaction. A medication alert sheet was given to the patient instructing
the patient to stop the listed medications 1 week prior to procedure.
Medication: he will try tramadol 50 mg in the interim to see if it helps.
Follow-up: next available appointment for spine injection.

BACKGROUND
Thoracic back pain can originate from intervertebral disc disease, facet
joints, ligaments, fascia, muscles, and nerves.1 Neuropathic thoracic flank
and/or chest-wall pain can be radicular due to herniated nucleus pulposus,
spinal stenosis, or other mechanical nerve root impingement such as from a
fracture or metastatic disease. Focal or radiating thoracic pain can also stem
from intercostal nerve mononeuropathy.2 Post-thoracotomy pain syndrome
is a possible cause of chronic thoracic pain postoperatively, but is considered
separate from thoracic spinal pain.1
The prevalence of thoracic back pain has been reported as 515%,
compared to 2444% cervical and 3356% lumbar. Thoracic disc injuries
represent 0.250.75% of all disc herniations.3 Although computed
tomography, magnetic resonance imaging and postmortem findings have
suggested incidence as high as 15.2437%,5 it has been stated that more than
70% of thoracic disc herniations are asymptomatic6 with an incidence of one
per million patients.5 However, symptomatic cases of thoracic disc herniation
have been reported at almost all thoracic levels.7
Thoracic disc herniation may manifest as myelopathy, radiculopathy,
back pain5 or flank pain,7 but the presenting symptoms often overlap with
pulmonary, cardiac, gastrointestinal or genitourinary etiologies,8 therefore,
thoracic radiculopathy is often a diagnosis of exclusion.
Although thoracic disc degeneration and endplate irregularities are
common findings, pain attributed to thoracic disc herniation is considered
extremely rare. Since imaging ultimately can only examine anatomy and
not physiology, MRI, CT, myelography and radiographs are expectedly as
ineffective of identifying pain from disc herniation in the thoracic spine as
it is in the lumbar spine.9 Electrodiagnostic examination can help confirm
thoracic radiculopathy as well as differentiate from intercostal nerve
mononeuropathy, and somatosensory evoked potentials can be performed
for suspected thoracic myelopathy.7
 Thoracic Disc Herniation 179

INDICATIONS FOR INJECTION

Thoracic epidural steroid injections for radi culo pathy are indicated in
the presence of image-confirmed disc herniation with or without electro
diagnostic verification, and in the absence of more life-threatening etiologies.
Thoracic epidural steroid injections have also been used for acute post-
thoracotomy pain.1

TREATMENT ALTERNATIVES
Thoracic radiculopathy can be managed conservatively similar to radiculo
pathy at other spinal levels. Pharmacologic treatment includes nonsteroidal
anti-inflammatory, neuropathic, muscle relaxant, and opioid medications.
An oral steroid dose pack may be considered for acute radiculopathy.
Physical therapy can include spinal exten sion, spinal stabilization, and
posture training. Orthotics may be used and modalities may give short-term
symptomatic relief.7
Thoracic epidural steroid injections can have an interlaminar or
transforaminal approach. Interventional treatments for other causes of
thoracic pain may include facet blocks, radiofrequency ablation, intercostal
nerve blocks, and thoracic paravertebral blocks.
Surgical interventions range from laminectomy to thoracoscopic discec
tomy,5 but there is no consensus on optimal surgical approach.10

CONTRAINDICATIONS
There is a relative scarcity of literature regarding epidural steroid injections for
thoracic disc herniations as compared with other levels. Contraindications are
the same as for other spinal levels such as bleeding disorders, uncontrolled
psychiatric disorders, uncontrolled acute or chronic medical illness, pregnant
or lactating women, history of adverse reaction to anesthetic, contrast,
or steroids. Additional contraindications include patients with higher
propensity for pneumothorax including but not limited to those with bullous
lung disease and uncontrolled spasms.

THORACIC TRANSFORAMINAL
EPIDURAL STEROID INJECTION
Preparation
Informed consent is obtained.
Risks and benefits are reviewed with the patient. Risks are similar to other
epidural steroid injections, except for the addition of a pneumothorax
180 Interventional Spine ProceduresA Case-based Approach

Fig. 18.4: Schematic of a left ipsilateral oblique view of the thoracic spine, demonstrating
the target area just below the pedicle of the vertebral body and lateral to the lamina.
Note the location of the radicular arteries anterior to the traversing nerve roots

when performing a transforaminal thoracic ESI. Attention should also be

paid to the artery of Adamkiewicz given that the pain is left sided and in
the thoracic region (Fig. 18.4).

Equipment and Medications

Fluoroscope with a C-arm, preferably with digital subtraction angiography.
The procedure can be done in an outpatient setting or a hospital setting.
The tools include: 25 gm 3.5 inch spinal needle, sterile procedure tray, low
volume connection tube, Appropriate syringes: Two 5 mL syringes; One
3 mL syringe; 18-gauge needle (to draw meds); 25-gauge needle (to inject
anesthetic)
Medication: Dexamethasone 10 mg/mL preservative free; Preservative-
free 1% lidocaine; nonionic contrast-I use omnipaque.

Technique: oblique subpedicular

transforaminal approach
Patient lies prone on a fluoroscopic table with arms above shoulder level.
A true AP view of the thoracic spine is obtained to assess the target level
counting from the first thoracic level. Once the correct level is identified,
the fluoroscope is obliqued ipsilaterally to the point where the lateral
margin of the ribs and pedicles are clearly delineated. The target point is
 Thoracic Disc Herniation 181

Fig. 18.5: Oblique view with the two needles precontrast. Notice at the left T10 level,
the needle was angled a bit more inferiorly due to significant osteoarthritis obstructing
the left T10 foramen

the area just below the pedicle and lateral to the lamina. Once the area is
identified, the area is anesthetized using 1% lidocaine. A 25-gauge 3.5 inch
needle is advanced under live fluoroscopic imaging to the identified area
(Fig. 18.5). If the patient identifies any pain that would mimic the pain
caused by spinal nerve root irritation, the needle should be withdrawn
slightly and reinserted until the optimal position is obtained. The caudal
deviation of the needle would increase the chance of contacting the
target nerve which traverses caudal to the pedicle. Care should be taken
to avoid lateral deviation of the needle to the ribs or medial deviation
past the lamina. Needle should be advanced until the needle contact the
posterior aspect of the foramen. At that point an AP view is obtained to
ensure proper placement of the needle (Fig. 18.6) followed by a lateral
view (Fig. 18.7) to ensure adequate placement of the needle. Once the
needle is in the optimal position, contrast should be injected under live
fluoroscopic guidance to ensure no intravascular or intrathecal flow is
obtained (Figs 18.8 and 18.9). If venous uptake is noted, the needle should
be repositioned to ensure vascular flow is no longer seen. In case of intra-
arterial or intrathecal flow, the procedure should be discontinued. Digital
subtraction angiography is recommended if available followed by a test
dose of 1% lidocaine in order to ensure lack of any significant vascular
uptake. A neurologic exam 90 seconds post-test dose can be done to
further ensure lack of any significant vascular uptake.
182 Interventional Spine ProceduresA Case-based Approach

Fig. 18.6: Anteroposterior view. The needle is slowly adjusted if needed in the AP view

Fig. 18.7: Lateral view. Needle position is confirmed using a lateral

view and adjustments are made if necessary

In this patients case, the injection was performed at the left T10, T11
levels. A mixture of 15 mg dexamethasone /2.5 mL 1% lidocaine was used,
2.0 mL at each level. This patient tolerated the procedure well with no
adverse reactions. Vitals and oxygen saturation were monitored during
the procedure.
 Thoracic Disc Herniation 183

Fig. 18.8: Contrast injected at the left T10 level. Notice the contrast
outlining the exiting nerve root and the pedicle

Fig. 18.9: Contrast injected at the left T11 level. Once again,
the contrast outlines the exiting nerve root

Other techniques
Variable approaches have been described to perform thoracic transfor
aminal ESIs. This author generally uses the subpedicular oblique approach
as described above. Another oblique approach is an infraneural approach
where the target point is slightly medial to the head of the rib opposite the
184 Interventional Spine ProceduresA Case-based Approach

foramenwhich is below the nerve.11 A more recent oblique technique

has also been described where the needle contacts the posterosuperior
aspect of the rib to the lateral aspect of the lamina and then medially,
anteriorly toward the neuroforamen.12 A dorsal approach has also been
described where the target point is dorsal to the spinal nerve and the
procedure is done entirely in the AP view.11 With the oblique view, the
target is a directly visualized bony landmark. Therefore, the chance of a
pneumothorax is theoretically lower compared to the dorsal approach.
For this reason, we prefer the oblique view. In addition, direct view of
the foraminae using the oblique approach makes the procedure less
technically challenging, especially in patients with severe degeneration
and facet arthropathy.
Thoracic interlaminar approach. Alternatively, an interlaminar thoracic
epidural steroid injection can also be considered. The procedure would
be done in a similar fashion to an interlaminar cervical or lumbar epidural
steroid injection where the lamina below the level of entry is first targeted
using a paramedian approach using an AP view. Once the lamina is
contacted, the needle is redirected into the interlaminar space. At this point,
a lateral view is obtained and the needle is slowly advanced using a loss of
resistance technique. Contrast is injected to ensure adequate placement and
then the medication is injected. Below is an example of a T12-L1 interlaminar
epidural steroid injection (Figs 18.10 and 18.11).
In general, we prefer to use the transforaminal approach to more directly
deliver the medication to the affected spinal nerve(s) in the intervertebral
foramen.

COMPLICATIONS
In the authors experience, the complications of thoracic transforaminal
epidural steroid injections (TFESI) are similar to those described for
cervical13 and lumbar TFESI.14 One study of thoracic foraminal nerve blocks
reports a complication rate of 4.1% with minor adverse events such as
light-headedness, local numbness, muscle spasm, vasovagal response and
headache, and one major complication of pneumothorax.15 There are reports
of neurological damage following thoracic TFESI, including paraplegia
due to particulate steroid embolic injury to the radiculomedullary artery
of Adamkiewicz.16 However, overall incidence of intravascular injection in
transforaminal epidural injections is reportedly 8.2% in one study.17
Botwins study of interlaminar thoracic epidural steroid injections
reported no major complications and an adverse effects rate of 20.5%. These
included increased pain at injection site, facial flushing (5.1%), transient non
positional headache, insomnia on the night of the injection, and one episode
 Thoracic Disc Herniation 185

Fig. 18.10: Anteroposterior interlaminar view precontrast. In general, using a para

median approach, the needle enters the interlaminar space in a 4560 angle. More
the cephalad level, the more angle is needed due to the caudad direction of the spinous
process. As we approach the cervical levels, the angle decreases. In this case, the
needle was inserted at an almost 90 approach as the patient was moving during the
procedure secondary to low pain tolerance. The needle was slowly advanced until the
ligamentum flavum was contacted

A
Figs 18.11A
186 Interventional Spine ProceduresA Case-based Approach

B
Figs 18.11A and B: Lateral and anteroposterior viewsinterlaminar T12-L1 ESI post-
contrast. (A) Contrast confirms correct placement of the needle in the epidural space in
the lateral view; (B) Contrast pattern viewed in the AP view

of fever the night of the procedure.18 A more recent prospective evaluation

of 301 thoracic interlaminar epidural injections revealed intravascular
penetration (4%) with return of blood in 2.7% dural punctures (1.3%),
vasovagal reactions (0.33%), facial flushing (0.33%), transient spinal cord and
nerve root irritation (1% and 0.33%).19

EVIDENCE TO SUPPORT THE PROCEDURE

Currently the evidence for thoracic interlaminar and TFESIs in the
management of thoracic disc herniations is scant. There is only one prospective
study in preliminary support of thoracic interlaminar epidural injections.1,9
At the time of this publication, no studies could be found regarding thoracic
TFESIs. It is, however, considered an appropriate step in management if
life-threatening concerns (i.e. neoplasm, infection, rapidly progressive
myelopathy, cardiopulmonary etiology, etc.) and appropriate imaging
have been addressed, especially with chronic thoracic pain (Benyamin, Wang
et al. 2012).14

Coding
64479: thoracic transforaminal injection
64480: additional level/thoracic transforaminal
62310: Thoracic interlaminar
 Thoracic Disc Herniation 187

REFERENCES
1. Benyamin RM, Wang VC, Vallejo R, et al. A systematic evaluation of thoracic
interlaminar epidural injections. Pain Physician. 2012;15(4):E497-514.
2. Santos PS, Resende LA, Fonseca RG, et al. Intercostal nerve mononeuropathy:
study of 14 cases. Arq Neuropsiquiatr. 2005;63(3B):776-8.
3. Stout AHN, Kaufman MS. Spinal injection techniques in Physical Medicine &
Rehabilitation. Braddom RL (Ed). Saunders: Philadelphia, PA; 2011. pp. 541-62.
4. Uribe JS, Smith WD, Pimenta L, et al. Minimally invasive lateral approach for
symptomatic thoracic disc herniation: initial multicenter clinical experience. J
Neurosurg Spine. 2012;16(3):264-79.
5. Wait SD, Fox DJ, Kenny KJ, et al. Thoracoscopic resection of symptomatic
herniated thoracic discs: clinical results in 121 patients. Spine. 2012;37(1):35-40.
6. Ozturk C, Tezer M, Sirvanci M, et al. Far lateral thoracic disc herniation
presenting with flank pain. Spine J. 2006;6(2):201-3.
7. OConnor RC, Andary MT, Russo RB, et al. Thoracic radiculopathy. Phys Med
Rehabil Clin N Am. 2002;13(3):623-44.
8. Papadakos N, Georges H, Sibtain N, et al. Thoracic disc prolapse presenting with
abdominal pain: case report and review of the literature. Ann R Coll Surg Engl.
2009;91(5):W4-6.
9. Manchikanti L, Cash KA, McManus CD, et al. A preliminary report of a
randomized double-blind, active controlled trial of fluoroscopic thoracic
interlaminar epidural injections in managing chronic thoracic pain. Pain
Physician. 2010;13(6):E357-69.
10. Deviren V, et al. Minimal invasive anterolateral transthoracic transpleural
approach: a novel technique for thoracic disc herniation. A review of the
literature, description of a new surgical technique and experience with first 12
consecutive patients. J Spinal Disord Tech. 2011;24(5):E40-8.
11. Bogduk N. Thoracic Transforaminal injections, in Practice Guidelines: Spinal
Diagnostic and Treatment Procedures. Bogduk N (Ed). International Spine and
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 Index
Page numbers followed by f refer to figure.

A intra-articular
facet injection 95
Acetaminophen 62 zygapophysial joint injection 93f
Acromioclavicular joint 88 medial branch
Aggrenox 5 anatomy 94f
Agrylin 5 block 93f, 95
Allegra allergy 175 radiofrequency ablation 96
Allergies 9, 18, 51, 107, 117, 141 zygapophysial joint
Anagrelide 5 radiofrequency ablation of
Anaphylactic reaction 135 third occipital nerve for
Anterior-posterior radiograph of cervical right C2-3 zygapo -
spine 82f physial joint 94f, 97f
Anticoagulants 4 syndrome 91
Apixaban 5 Cilostazol 5
Aspirin 5, 175 Classical sacroiliac joint infiltration
technique 66
B Classification of lumbar stenosis 28
Clopidogrel 5
Bilateral Coccygeal discography 48f
hip flexors 27 Coccygodynia 37, 40
lower extremities 10 Colon carcinoma status post-resection
Blood pressure 9, 38 174
Body mass index 38 Complex regional pain syndrome 105,
108, 115, 116, 118, 119
C Computed tomography scan 3
Coronary artery disease 174
Cerebrospinal fluid 32, 57, 127
Cervical
D
disc herniation 74, 84
with radiculopathy 71 Dabigratan 5
without radiculopathy 79 Deep vein thrombosis 26
epidural steroid injection 75 Diabetes mellitus 26
facet syndrome 88 Diovan 175
interlaminar epidural steroid Dipyridamole 5
injection 85 Discogenic low back pain 139
190 Interventional Spine ProceduresA Case-based Approach

Discography impression 144 Intra-articular

Dural puncture headache 125 hip injection 103f
injection 161
E Intradiscal electrothermal annuloplasty
147
Electromyography 10 Intravascular injection 34
Eliquis 5
Enoxaparin 5 L
Epidural
abscess 33 Lateral
hematoma 33 flexion-extension radiographs of
Extensor hallucis longus 18, 27 cervical spine 83f
radiograph of cervical spine 82f
F Left
biceps reflex 73
Facet syndrome 53, 91 cervical transforaminal epidural
Fondaparinux 5 steroid injection 75f
hip
G degenerative joint disease 102
pain 100
Gabapentin 175 Livalo 175
Gaenslens test 27 Lovenox 5
Gamma-aminobutyric acid alpha 29 Lower back pain 50
Gastroesophageal reflux disease 89 Lumbar
disc herniation 11
H with radiculopathy 8, 17
without radiculopathy 139
Heparin 5
facet syndrome 50
Herniated nucleus pulposus 173
interlaminar injections 30
Hip
internal disc disruption syndrome
extensors 27
11
pain 100
intra-articular zygapophysial joint
Hoffmans and Babinski signs 73
injection 57
Hyperlipidemia 51
medial branch block 57
Hypertension 51, 62, 89, 153, 174
neuroforaminal stenosis 30
Hypothyroidism 62
provocative discography method of
procedure 142
I radiculopathy 10, 19
Inguinal hernia status postherniorrhaphy spinal stenosis 30
174 with radiculopathy 25
Internal disc disruption syndrome 143 spine magnetic resonance imaging
International with gadolinium 19
normalized ratio 34 without gadolinium 19, 142
Spine Intervention Society 55, 94 spine X-rays 19, 52, 141
 Index 191
transforaminal epidural steroid Parallax 3
injection 17 Pentoxifylline 5
zygapophysial joint 53, 54, 54f Persantine 5
Plavix 175
M Post-discography computed tomography
144
Magnetic resonance imaging 3, 10, 53, Post-dural puncture headache 127
74, 155, 173 Posterior superior iliac spine 65
cervical spine disc degeneration 91 Pradaxa 5
left foot 108 Prasugrel 5
lumbar spine 28, 127
Prothrombin time 34
thoracic spine with contrast 173
Provocative tests 73
Medial branch nerve 94f
Melanoma 174
Metformin HCL 175 R
Mild multilevel degenerative disc disease
173 Radiofrequency
Multilevel lumbar spondylosis central neurotomy of thoracic medial
disc protrusion 28 branches 167
Musculoskeletal evaluation 27 treatment of sacroiliac joint 67
Reflex 18, 73, 174
sympathetic dystrophy 108
N
disease 153
Neck Right buttock pain 61
and left arm pain 71 Rivaroxaban 5
pain 79, 88
N-methyl D-aspartate 109
S
Nonsteroidal anti-inflammatory drugs 4,
5, 37, 41, 53, 92 Sacroiliac
denervation 4f
O joint 64
pain 61, 64
Oblique subpedicular transforaminal
radiofrequency ablation 68f
approach 180
with contrast 67f
Omeprazole 175
Selective spinal nerve injection 8
Open reduction internal fixation 118
Sensation 18
Osteoarthritis 62, 174
Sinusitis 174
Slight forward flexion 51
P Spinolaminar line 32f
Pain Spondylolisthesis 28
diagram 19f, 26f, 39f, 52f, 63f, 72f, 80f, Spondylolysis 28
89f, 101f, 105f, 116f, 140f, 153f, Spurlings maneuver 73, 117
172f Stellate ganglion block 123
relief 122 Subarachnoid injection 33
192 Interventional Spine ProceduresA Case-based Approach

Sympathetic Total hip arthroplasty 103

nerve block 43 Transcutaneous electrical nerve
pain 40 stimulation 50
Sympathetically mediated pain 108 Transforaminal thoracic epidural steroid
injection 178
T
V
Tailbone pain 37, 43
Thoracic Vasomotor 109, 110
and lumbar spine 176 Vital signs 27
disc herniation 172, 172f
facet W
joint 161, 162f, 164f
pain 152, 165 Weight loss 29
syndrome 155, 165 Whole body bone scan 108
interlaminar approach 184
intra-articular zygapophysial joint X
injection 161
medial branch block 165 X-ray 74
transforaminal epidural steroid left foot 108
injection 179, 184 lumbar spine 27
zygapophysial joint pain 155, 156 thoracic spine 173
Tibialis anterior 27 Zygapophysial joint 53, 56
Ticagrelor 5 nerve 58
Ticlopidine 5 nerve block 57, 93f