Interventional

Pain Management
A Practical Approach

Under the aegis

of
Bombay Hospital Institute of Medical Sciences
and
Pain Management and Research Foundation (India)
 Interventional
Pain Management
A Practical Approach

Editors
DK Baheti MD
Chief of Anaesthesiology and
Pain Management Clinic
Bombay Hospital Institute of Medical Sciences, Mumbai, India

Sanjay Bakshi MD
Interventional Pain Management
Lenox Hill Hospital, New York, USA
Beth Israel Hospital, New York, USA
Spine and Pain Medicine
899 Park Avenue, NY 10021, USA

Sanjeeva Gupta MD, Dip. NB, FRCA, FIPP

Consultant in Pain Management and Anaesthesia
Bradford Teaching Hospitals NHS Foundation Trust
Department of Anaesthesia, Pain Management and Critical Care,
Field House, Bradford Royal infirmary, Duckworth Lane,
Bradford, BD9 6RJ, United Kingdom

RP Gehdoo MD, DA
Professor of Anaesthesia,
Tata Memorial Hospital, Parel, Mumbai (India) 400 012

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Interventional Pain Management—A Practical Approach

© 2008, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
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First Edition: 2008

ISBN 978-81-8448-319-2
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 Dedicated
to
All Pain Patients
 Contributors

Abrahemsen Gerard W, RPA-C Dalvie Samir MS (ORTH), D ORTH FCPS,

Interventional Pain Management DNBE
Lenox Hill Hospital, New York, USA Spine Surgeon
Beth Israel Hospital, New York, USA Bombay Hospital and Medical
Spine and Pain Medicine Research Centre, Mumbai 400020
899 Park Avenue, NY 10021, USA Email:[email protected]
Website-www.spineandpain.com
Das Gautam MD
Baheti DK MD Director of Pain Clinic,
Chief of Anaesthesiology and Daradia: The Pain Clinic
Pain Management Clinic 92/2A Bidhannagar Road
Bombay Hospital Institute of Medical Kolkata -700067
Sciences, 12, New Marine Lines India
Mumbai-400 020, India Email: [email protected]
[email protected]/ Website: www.painindia.net
[email protected]
Website-painmanagementindia.com Diwan Sudhir MD
Director, Division of Pain Medicine
Bakshi Sanjay MD Director, Pain Medicine Fellowship
Interventional Pain Management Program
Lenox Hill Hospital, New York, USA New York Presbyterian Hospital
Beth Israel Hospital, New York, USA Weill Medical College of Cornell
Spine and Pain Medicine University
899 Park Avenue, NY 10021, USA 525 East 68th Street, New York
[email protected] NY 10021, USA
Website-www.spineandpain.com [email protected]

Boswell Marks V MD, PHD Doshi Preeti MD, MDDA [UK], FRCAII [LON]
Professor of Anaesthesiology Consultant Pain Specialist and
Interim Department Chair and Director Incharge of pain Clinic
of the Messer Racz Pain Center Jaslok Hospital and Research Centre
Department of Anesthesiology, Texas 15, Dr G Deshmukh Road
Tech University Health Sciences Center Mumbai-400026, India
3401 4th Street STOP 8182, Lubbock, [email protected]
Texas 79430 Website-www.jaslokhospital.net
viii Interventional Pain Management—A Practical Approach

Doshi Paresh K MS MCH Jhankaria Bhavin MD

Incharge, Stereo tactic and Functional Director, Jhanakaria Imaging Centre
Neurosurgical Program Bhaveshawar Vihar, 383, Sardar VP
Jaslok Hospital and Research Centre Road, Mumbai-400 004
15, Dr G Deshmukh Marg
Mumbai - 400016 Kothari Kailash MD
[email protected] Pain Physician, Wockhard Hospital
www.parkinsonsdiseasesurgery.net Mumbai, India
[email protected]
Gehdoo RP MD, DA
Krishnan Pradeep MBBS
Professor of Anaesthesia
Jhanakaria Imaging Centre
Tata Memorial Hospital
Bhaveshawar Vihar, 383, Sardar VP
Parel, Mumbai- 400 012
Road, Mumbai-400 004
India
[email protected]
Manchikanti Laxmaiah, MD
Medical Director, Pain Management
Gupta Sanjeeva, MD, DIP NB, FRCA, FIPP Center of Paducah
Consultant in Pain Management and Associate Clinical Professor
Anaesthesia Anesthesiology and Perioperative
Bradford Teaching Hospitals NHS Medicine
Foundation Trust University of Louisville, Kentucky
Department of Anaesthesia 2831 Lone Oak Road, Paducah,
Pain Management and Critical Care KY 42003
Field House, Bradford Royal E-mail: [email protected]
infirmary, Duckworth Lane,
Bradford, BD9 6RJ, United Kingdom. Mangeshikar Tilottama MD
Email: [email protected] Consultant Anesthesiologist and
Interventional Pain Physician
Heavner James DVM, PHD Cumballa Hill Hospital, Madhav
Professor, Department of Niwas, 8 Laburnum Rd, Gamdevi
Anesthesiology Mumbai 400007
Texas Tech University Health Sciences [email protected]
Center website-
Lubbock, TX www.totalpainmanagementclinic.com
[email protected] Pathak Sachin MBBS
Jhanakaria Imaging Centre
Jain Jitendra MD Bhaveshawar Vihar, 383, Sardar V.P.
Pain Physician, Spine and Pain Clinic, Road, Mumbai-400 004
Diamond palace, opposite Bandra Patrick F Annello MD
Police station, Hill Road, Bnadra west,
Pain Management Fellow
Mumbai 400050, Maharashtra, India
New York Presbyterian Weill-Cornell
Website: www.spineandpain.org
University Medical Center
[email protected]
Jain PN MD MNAMS
Professor, Anaesthesiology, Piparia Vishal DMRD
Tata Memorial Hospital Jhanakaria Imaging Centre
Mumbai 400 012 Bhaveshawar Vihar, 383, Sardar VP
[email protected] Road, Mumbai-400 004
 Contributors ix

Rai Sarvendra MBBS Shah Rinoo V MD

Registrar, Dept. of Neurosurgery. Assistant Professor, Interventional
Jaslok Hospital and Research Centre Pain Management
15, Dr. G. Deshmukh Marg, Mumbai – Department of Anesthesiology
Guthrie Clinic, Sayre, PA
India-400016
[email protected]

Richardson Jonathan MD, FRCA, FRCP, FIPP Sharma Anil K MD, DABPM
Consultant in Pain Management Director of Pain Management
Bradford Teaching Hospitals NHS Monmouth Medical Center
Foundation Trust Long Branch, NJ USA
Department of Anaesthesia, Pain
Management and Critical Care, Tarcatu Dana MD
Fellow, Pain and Palliative Care
Field House, Bradford Royal infirmary,
Memorial Sloan-Kettering Cancer
Duckworth Lane,
Center, Department of Neurology
Bradford, BD9 6RJ, United Kingdom. 1275 York Avenue, NY, NY 10021
Email: [email protected] [email protected]
 Foreword

•
Dr. B.K. Goyal DIRECTOR INTERVENTIONAL
CARDIOLOGY & HON. DEAN
FAMS (IND), FRCP (EDIN), FSCAI, FACC (USA), B.Sc., MB, DTM & Bombay Hospital & Medical Research Centre
H (LIV), FICP, FICC, FICA (NY), FIMSA, MICTD (BER), FCCP (USA),
FRSTM (LOND) • VISITING CARDIOLOGIST
Breach Candy Hospital

INTERVENTIONAL CARDIOLOGIST • HON. CONSULTANT CARDIOLOGIST

Lotus House, Marine Lines, Mumbai 400 020 Texas Heart Institute, Housecon, Texas, USA
Tel.: 2203 7777 / 2201 0000 • AWARDED BY PRESIDENT OF INDIA
Bom Hos: 2203 2222 • 2206 7676 • Mobile : 98201 54445 Padma Vibhushan, Padma Bhushan & Padma Shri
Residence : 2367 9999 • Fax : 91-22-2201 0000
e-mail : [email protected]
• EDITOR
Journal of American College of Cardiology
(S.E. Asian Edition)
• FORMER SHERIFF OF BOMBAY

Pain is an integral part of the sufferings of human life. One can only realize
agony when one suffers from it. Pain especially a chronic one, is not a mere
symptom, it itself is a disease. Chronic pain not only disturbs various systems
of the body, but also is responsible for emotional disturbances and can lead
to loss of working hours.
Pain management is fast growing as superspeciality of anaesthesiology
in India. In USA and other western countries pain management is already
established as a superspeciality subject.
At Bombay Hospital, Dr DK Baheti, Chief of Anaesthesiology, realized the
need for development of pain clinic. He visited Cleveland Clinic and Memorial
Sloan-Kettering Cancer Centre for the first hand training.
For the last 17 years he has been successfully managing the Pain
Management clinic at Bombay Hospital. During this period he organized
international conferences like Global Update on Pain, conducted live
demonstrations and hands on cadaver workshops for training young
anaesthesiologists at Bombay Hospital.
Interventional pain procedures are important modalities for relief of pain.
Dr DK Baheti, along with Dr Sanjay Bakshi (USA), Dr Sanjeeva Gupta (UK),
xii Interventional Pain Management—A Practical Approach

and Dr RP Gehdoo (Mumbai) have joined hands to bring out a comprehensive

book on Interventional Pain Management.
I am confident that this book will be very useful as a reference book for the
medical students and will also provide practical tips to practicing physicians
and young anaesthesiologists whose mission is to relieve humanity from the
agony of sufferings.

(Dr B K Goyal)
 Preface

Interventional pain management is one of the most important components of

managing chronic intractable pain. It is mandatory that interventional
procedures need to be performed correctly right from the time of diagnosis to
the relief of pain, so as to provide the best possible results.
Many universities in India as well as abroad do not have appropriate
pain training program in their curriculum not only at the undergraduate
but, also at postgraduate levels. There are very few pain certification programs
or pain specialists or pain training facilities across the world.
Even in the countries where such programs exist, there are significant
inadequacies and lacunae in teaching of the techniques. Although there are
courses run by various organizations, they only incorporate a few common
techniques and hence can never be comprehensive.
Many pain physicians are enthusiastic to learn the art of interventional
techniques for managing pain, but do not have an access to appropriate
reference books. The availability and cost of the books adds to further
constraints.
We, the practicing pain physicians, have recognized the problem and
realized the need for a book on Interventional Pain Management techniques,
which can be both comprehensive and affordable.
It is our sincere attempt to come out with a book on interventional pain
procedures due to existing vacuum in this field.
We express our heartfelt gratitude to all the contributors, without whose
support this Herculean task would have been impossible.
We have taken utmost care to bring out this book with an international
quality at an affordable price.
We sincerely hope that our efforts to come out with this book will benefit
the pain physicians as well as the chronic pain patients.

DK Baheti, Sanjay Bakshi

Sanjeeva Gupta, RP Gehdoo
 Contents

SECTION - A
Basics in Interventional Pain Management

1. Basis of Radiological Imaging ............................................................ 3

B Jhankaria, Vishal Piparia
2. Spinal Radioanatomy Revisited ....................................................... 19
S Pathak, P Krishnan, V Piparia, B Jhankaria
3. Neurolytic Agents and Neurodestructive Techniques ................. 27
RP Gehdoo
SECTION - B
Documentation and Protocol
4. Informed Consent for Interventional Pain Procedures ................ 39
DK Baheti
5. Role of Investigations in Interventional Pain Procedures ............ 42
DK Baheti
6. Protocol for Interventional Pain Procedures: .................................. 50
A Suggested Format
DK Baheti
7. Evaluation of Pain Patient ................................................................. 54
Jitendra Jain, DK Baheti
8. Stimulation Guided Pain Mapping ................................................. 62
Sanjeeva Gupta, Jonathan Richardson

SECTION - C
Head and Neck
9. Trigeminal Nerve Block .................................................................... 69
Jitendra Jain
10. Maxillary Nerve Block ....................................................................... 77
Jitendra Jain
11. Mandibular Nerve Block................................................................... 82
Jitendra Jain
12. Sphenopalatine Ganglion Block ...................................................... 87
Jitendra Jain
xvi Interventional Pain Management—A Practical Approach

13. Glossopharyngeal Nerve Block ....................................................... 92

PN Jain
14. Stellate Ganglion Block ..................................................................... 97
Preeti Doshi
15. Nerve Blocks for the Scalp and Injections ................................... 109
Tilottama Mangeshikar
SECTION - D
Chest and Thorax

16. Suprascapular Nerve Block ............................................................ 121

Jitendra Jain
17. Intercostal Nerve Block ................................................................... 126
Jitendra Jain
18. Intrapleural Block............................................................................. 130
DK Baheti
SECTION - E
Abdomen and Pelvis

19. Celiac Plexus Block .......................................................................... 137

DK Baheti
20. Lumbar Sympathetic Block ............................................................ 145
DK Baheti
21. Hypogastric Plexus Block ................................................................ 150
DK Baheti, RP Gehdoo
22. Ganglion of Impar Block ................................................................. 156
DK Baheti
SECTION - F
Spine and Back

23. Cervical Epidural Block ................................................................... 163

H Bram
24. Cervical Facet, Median Branch Blocks .......................................... 173
H Bram
25. Lumbar and Caudal Epidural Blocks ............................................ 179
S Bakshi, GW Abrahamsen
26. Lumbar Facet and Median Branch Block ..................................... 190
S Bakshi, GW Abrahamsen
27. Sacroiliac Joint Block ....................................................................... 198
S Gupta, J Richardson
 Contents xvii

SECTION - G
Advanced Pain Management

28. Percutaneous Adhesiolysis for Failed Back Surgery Syndrome and

Other Applications ........................................................................... 207
L Manchikanti, Mark V Boswell, Rinoo V Shah, James E Heavner
29. Epiduroscopy for Chronic Low-Back Pain and ............................ 233
Radiculopathy
S Gupta, J Richardson
30. Spinal Cord Stimulation .................................................................. 244
Sanjay Bakshi, GW Abrahamsen
31. Neuromodulation for Chronic Pain ............................................... 257
Sarvendra Rai, Paresh K Doshi
32. Discography ...................................................................................... 268
Sudhir Diwan, P Annello
33. Intradiscal Electrothermal Therapy (IDET) ................................. 281
A Sharma
34. Percutaneous Lumbar Discectomy ................................................ 292
Sudhir Diwan, D Tarcatu
35. Vertebroplasty ................................................................................... 300
Samir Dalvie
36. Ozone and its Applications in Pain Management ...................... 308
Gautam Das
37. Radiofrequency Coagulation .......................................................... 314
Anil Sharma
38. Intrathecal Implantable Devices ................................................... 333
DK Baheti
SECTION - H
What’s New in Interventional Pain Management?
39. Blunt Tip Needle .............................................................................. 343
DK Baheti
SECTION - I
Alternate Therapies
40. Intramuscular Stimulation .............................................................. 347
K Kothari
Index .................................................................................................... 361
 One

Basis of
Radiological Imaging
Bhavin Jhankaria, Vishal Piparia

HISTORY
Wilhelm Conrad Roentgen, a German physicist discovered X-rays on
November 8, 1895. Roentgen was investigating the behavior of cathode
rays (electron) in high energy cathode ray tube. The tube consisted of glass
envelope from which most of the air is removed. A short platinum electrode
was fitted into each end and when a high voltage discharge was passed
through the tube, ionization of remaining gas produced a faint light.
Roentgen had enclosed his cathode ray tube in black card board to prevent
this light from escaping the tube. On passing a high voltage discharge
through the tube, he noticed a faint light glowing on a work bench 3 feet
away. Because electrons could not escape the glass envelope.
Roentgen concluded that some unknown type of ray was produced,
when the tube was energized. He began placing the tube and the fluorescent
screen: a book, a block of wood and a sheet of aluminum. The brightness of
the fluorescence differed with each, indicating that the ray penetrated some
objects more easily than others. Finally he held his hand between the tube
and screen, and the outline of his skeleton appeared.
Till December 28, 1895, he thoroughly experimented and he was
awarded the first Nobel Prize for physics in 1901 for discovery of X-rays.

ATOMIC STRUCTURE
In 1987, JJ Thompson discovered a negatively charged particle called as
electron. Based on the work of Rutherford and Bohv, a model of atom was
made. Thus an atom consists of positively charged nucleus and surrounded
by electrons in orbit.
The nucleus consists of mainly protons and neutrons. The proton has
positive charge while neutron has zero electrical charge. The no. of protons
in the nucleus is called atomic no. (Z). the total no. of protons and neutrons
in the nucleus of atom is called as mass number (A) (Fig. 1.1).
4 Interventional Pain Management—A Practical Approach

FIg. 1.1: Basic atom

ELECTRON ORBITS AND ENERGY LEVELS

The electrons are negatively charged particles revolving around the nucleus.
An electrically neutral atom contains equal no. of protons and neutrons.
The electron move in orbit of shells with 2 in 1st orbit, 8 in 2nd and 18 in 3rd
and so on. Three orbits are designated as K, L, M, N, and O and so on.
The attractive force between the positively charged nucleus and
negatively charged electron is called as binding force. This force is inversely
proportional to the square of distance between the nucleus and electron.
This attractive force keeps the electron moving in circular path.
To free an electron from an atom, the energy must be raised to zero to a
positive value. The energy that an electron in shell needs to rise to zero or a
positive value is called as binding energy of the electron. Ex. To free a ‘K’
electron from tungsten the electron must be given 70 KeV of energy while
only 11 KeV is required to free ‘L’ electron. The binding energy of electron
shells varies from one element to other. The electron can jump from one
shell to other shells. The electron moving to lower energy shell results in
emission of energy.

ELECTROMAGNETIC SPECTRUM
X- rays belong to a group of radiation called electromagnetic radiation. It is
the transport of energy through space as combustion of electric and
magnetic fields. The electromagnetic radiation is made up of an electric
field and a magnetic field that naturally support each other.
The wave concept of Electromagnetic radiation (EM): The EM radiation
is propagated through the space in the form of waves. The no. of waves
passing a particular point of time is called as frequency. The wavelength of
diagnostic X-rays is extremely short and it is expressed in Angstrom
Units (A).
 Basis of Radiological Imaging 5

The particle concept of EM radiation: Short EM waves like X-rays react

with matter, as if they are particles and not waves. These particles are actually
discrete bundles of energy and each of these bundles of energy is called
“Photon”. The actual amount of energy of Photon is calculated by multiplying,
it’s frequency by a constant.
E= hv
E= photon energy
H= pluck’s constant
V= frequency
The unit used to measure the energy of photon is called as electron volt
(eV).

PRODUCTION OF X-RAYS
X-ray Tube (Fig. 1.2)
X-rays is produced by energy conversion when a fast moving stream of
electrons is suddenly decelerated in the target anode of X-ray tube. The X-ray
tube is made of Pyrex glass that encloses a vacuum containing two electrode
(diode tube).
The electrons are produced at the cathode end (filament), which are
accelerated by a high potential difference towards the anode end (positive/
target) where X-rays are produced.

Glass Enclosure
The glass tube encloses two electrodes in vacuum. If gas is present inside the
tube, the electrons which are accelerated towards the anode would collide
with the gas molecules, loose energy and cause secondary electrons to be
ejected from gas molecule by a process of ionization. Thus there is vacuum in

Fig. 1.2: Basic X-ray tube

6 Interventional Pain Management—A Practical Approach

modern X-ray tube. The connecting wires must be sealed into glass wall of X-
ray tube. These are made up of special alloys to prevent the breaking of glass
metal seal.

CATHODE
Cathode is a negative terminal of X-ray tube. In addition to this filament,
there are connecting wires which supply both the voltage and amperage.
The X-ray tube current is measured in milli amperes MA, refers to the no. of
electrons flowing per second from cathode to anode. The cathode end, i.e. the
filament is made up of tungsten wire 0.2 mm in diameter that is coiled to form
a vertical spiral about 0.2 cm in diameter and 1cm or less in length. When
this filament is heated, it connects electron by the process of thermion
emission. The electron cloud surrounding the filament by thermion emission
is called as “Edison effect”. The filament must be heated to 2200 degree to
emit useful no. of electrons. Because the electrons are negative charged and
they repel each other, they bombard unacceptably large area of anode, and
this is prevented by the cathode focusing cup which surrounds the filament.
This focusing cup is made of nickel. Most of the X-ray tubes are now provided
with two filaments; the larger filament is used for larger exposures. The
filament should be never heated for long periods as it shortens the life of X-
ray tube. Many X-ray circuits are supplied with automatic filament boosting
circuit. When the X-ray circuit is made on but no exposure is being made, a
“stand by” current heats the filament. This amount of filament heating is all
required for fluoroscopy.
Tungsten vaporized from the filament gets deposited on the inner
surface of glass wall of X-ray tube giving bronze colored “Sunburn”.

LINE FOCUS PRINCIPLE (FIG. 1.3)

The focal spot is the area of tungsten anode that is bombarded by electrons
from cathode. Most of the energy of electrons is converted into heat, with
less than 1% being converted into X-rays. The heat is uniformly distributed
over the focal spot; a large focal spot allows larger accumulation of heat
leading to damage of target anode. For this reason, Line Focus Principle
was introduced in 1918. The size and shape of electron streams are
determined by dimensions of tungsten filament wire coil, the construction of
focusing cup and position of filament in focusing cup. The electron stream
bombards the target; the surface of Cup is inclined to form an angle. This is
anode angle. It ranges from 6 to 20 degree. Thus as the angle of anode is made
smaller, the apparent focal spot also becomes smaller.

THE ANODE
It is the positive electrode. It may be stationary or rotating. The tungsten is
used as target material because of high atomic no. and high melting point.
The small tungsten target must be bonded to much larger copper portion of
the anode to facilitate heat dissipation and speed up its rate of cooling.
 Basis of Radiological Imaging 7

Fig. 1.3: The line focus principle

ROTATING ANODE
The ability of the X-ray tube to achieve high X-ray output is limited by the
heat generated at the anode. The rotating anode principle is used to produce
X-ray tubes capable of withstanding the heat generated by the large exposures.
The rotating anode rotates at the speed of 3600 RPM. The purpose of rotating
anode is to spread the heat produced during an exposure over a large area of
anode. The heat generated in a solid tungsten disc is dissipated by radiating
through the vacuum to the wall of tube, and then to surrounding oil and then
the tube housing.

HEEL EFFECT
The intensity of X-ray beam that leaves the X-ray tube is not uniform
throughout all the portions of the beam. The intensity of the beam depends
on the angle at which the X-rays are emitted from the focal spot.
A. The intensity of film exposure on the anode side of X-ray tube is
significantly less than that on the cathode side of tube, e.g. In X-ray of
thoracic spine AP view the upper thoracic spine is focused under anode
end where body is less thick. The cathode end of tube is over the lower
thoracic spine where the thicker body structures will receive the increased
exposure.
B. The heel effect is less noticeable when larger film focus distance is used.
C. For equal target film distances, the heel effect will be less for smaller
films. This is concluded the intensity of the X-ray beam nearest the central
ray is more uniform than that towards the periphery.

TUBE SHIELDING
The X-rays are scattered in all directions following collisions with various
structures in and around the tube. The tube housing is lined with lead
which absorbs primary and secondary X-rays. The effectiveness of full
housing in limiting leakage radiation must meet the specifications listed in
National Council on Radiation Protection. The leakage radiation measured
8 Interventional Pain Management—A Practical Approach

at a distance of 1 meter from the source should not exceed 100 MR in an hour,
when tube is operated at its maximum continuous rated current for the
maximum rated tube potential. To prevent short circuiting between grounding
wires and the tube, the space between them is filled with thick mineral oil.
This oil has good electrical insulating and thermal cooling properties.

TUBE RATING CHARTS

It is necessary to speak of the total load that can be applied to an X-ray tube
in terms of kilo voltage, milli amperes and exposure time. The load that can
be safely accepted by X-ray tube is a function of heat energy produced during
the exposure. The maximum temperature to which tungsten can be safely
raised is generally considered to be 3000 degrees. The heat unit is defined as
the product of current (MA) and KVP and time (sec) for single phase power
supply. The term “Watt” is unit of power and it is the product of 1V times 1A.
1 W = 1V × 1A
The term Kilowatt rating of an X-ray tube is commonly used to express
the waiting of the tube to make single exposure of 0.1 sec. In considering
tube rating, three characters are encountered.
1. The ability of the tube to withstand a single exposure.
2. The ability of the tube to function despite multiple rapid exposures.
3. The ability of the tube to withstand multiple exposures during several
hours of heavy use.
The safe limit within which an X-ray tube can be operated for a single
exposure can be easily determined by the tube rating chart supplied with
all X-ray tubes.

METAL/CERAMIC X-RAY TABLES (FIG. 1.4)

Here instead of glass, metal or ceramic is used to insulate the high voltage
parts of X-ray tube. Aluminum oxide is used as a ceramic insulator. The
metal, when used in spite of glass for construction of X-ray tuber serves three
purposes:
1. Less off focus radiation
2. Long tube life
3. Higher tube loading.

PROCESS OF X-RAY GENERATION

X-rays are produced by energy conversion when fast moving electrons interact
with the tungsten anode. The X-rays are generated by two processes:

General Radiation/Bremsstrahlung
Here the high speed electrons lose energy in the target of X-ray tube.
 Basis of Radiological Imaging 9

Fig. 1.4: Model of super ceramic X-ray tube

Characteristic Radiation
It involves collision between high speed electrons and electrons in the shell
of target. Tungsten atoms producing characteristic radiation.

X-RAY GENERATORS
It is the device that supplies electric power to the X-ray tube. The X-ray
generator modifies the energy to meet the needs of X-ray tube. The tube requires
electrical energy for two reasons:
1. To boil the electrons from the filament.
2. To accelerate these electrons from cathode to anode.
The mechanism of X-ray generator is usually continued in two separate
compartments.
A. Control panel/console
B. Transformer assembly.
The control panel allows the operator to select the appropriate KVp,
MA and exposure time for a particular X-ray. One exposure button (standby)
readies the X-ray tube for exposure by heating the filament and rotating the
anode and the other button starts the exposure. The timing mechanism
terminates the exposure.
The second component is transformer assembly. It is a grounded metal
box filled with oil. It contains a low voltage transformer for filament circuit
and a high voltage transformer and a group of rectifier for the high voltage
circuit.
10 Interventional Pain Management—A Practical Approach

The potential difference in these circuits may be as high as 150,000 V, so

the transformers and rectifiers are immersed in oil. The oil serves as an
insulator and prevents sparking between various components. Finally a
transformer is a device that either increases or decreases the voltage in
circuit. A rectifier changes alternating current into direct current.
A transformer consists of two wire coils wrapped around a closed core.
The core is a simple rectangle with the wirings wound around opposite
sides of rectangle (Fig. 1.5).
The circuit containing the first coil which is connected to the available
electrical energy source is called as Primary circuit. The circuit containing
the second coil from which comes the modified electric energy is called as
Secondary circuit. When current flows through the primary coil, it creates a
magnetic field within the core and this magnetic field induces a current in
the secondary coil. Current only flows through the secondary circuit when
magnetic field is changing, i.e. either increasing or decreasing.
For this reason, steady direct current in the primary coil cannot be used to
produce a continuous current through the secondary coil.
Alternating current is used for a transformer because it is produced by
a potential difference (voltage) that changes continuously in magnitude
and periodically in polarity.
The most important characteristic of alternating current is that its voltage
changes continuously, so it produces a continuously changing magnetic
field. Therefore an alternating current in the primary cell of a transformer
produces an alternating current as the secondary coil.

Fig. 1.5: Grid and its utility

 Basis of Radiological Imaging 11

LAWS OF TRANSFORMER
1. The voltage in two circuits is proportional to the no. of turns in the two
coils.
Np Vp
Ns Vs
Np= No. of turns in primary coil
Ns= No. of turns in secondary coil
Vp= Voltage in primary coil
Vs= Voltage in secondary coil
2. The second law is simply a restatement of the law of conservation of
energy. A transformer cannot create energy. An increase in voltage must
be accompanied by a corresponding decrease in current. The product of
voltage and current in the two circuits must be equal.
Vp Ip= Vs Is
Vp= Voltage in primary Cell
Ip= Current in primary cell
Vs= Voltage in secondary cell
Is= Current in secondary cell
The product of voltage and current is power.
W = V x I Where W= Watt; I= Current in ampere; V= Volts
A transformer with more turns in the secondary coil than primary coil
increases voltage of the secondary circuit and it is a step up transformer. The
other with few turns in secondary coil decreases the voltage and it is step
down transformer. A transformer called as autotransformer supplies the
supply voltage for both these circuits.

RECTIFICATION
It is the process of changing the alternating current into direct current. Device
which produce this change is called Rectifier. When cathode is negative
with respect to anode, electrons flow at high speed from cathode to anode
and X-rays are produced. During the next half of the electrical cycle the
anode is negative and the filament is positive, so electrons would flow away
from target anode towards the cathode filament. This is not acceptable because
such electrons would not produce X-rays and such electrons would heat the
filament and reduce its life. By blocking the current flow in the inverse half of
electrical cycle, the X-ray tube changes an alternating current into direct
current. Because only half of the electrical wave is used to produce X-rays,
this is half wave rectification.

RECTIFIER
A rectifier is a device that allows an electric current to flow in one direction
but does not allow current to flow in other direction. Rectifiers are
12 Interventional Pain Management—A Practical Approach

incorporated into X-ray circuit in series with the X-ray tube. High voltage
rectifiers are of vacuum tube type or they can be of solid state composition. In
1965, high voltage silicon rectifiers were introduced and today most of
X-ray generators use silicon rectifiers. The heart of solid state rectifier is a
semiconductor, which is usually a piece of crystalline silicon. They are of
two types the N type semiconductors and P type semiconductors.
Basic interaction between X-rays and matter: Only two interactions are
important in diagnostic radiology, the photoelectric effect and Compton
scattering. The photoelectric effect is the predominant interaction with low
energy radiation and with high atomic no. absorber. It does not generate
scatter radiation and reduces high contrast in the X-ray image but
unfortunately exposes the patient great radiation. Compton scattering is
responsible for almost all scatter radiation. The X-ray image contrast is less
with computer reaction than with photoelectric effect.

ATTENUATION
It is the reduction in the intensity of X-ray beam as it traverses matter by enter
the absorption of deflection of photons from the beam. The photons of X-ray
beam enter a patient with a uniform distribution and emerge out in a specific
pattern of distribution. The transmitted and attenuated photons are equally
important. If all the photons are transmitted the film will be black and if all
the photons were attenuated the film would be uniformly white. The image
formation depends on differential attenuation between the tissues. Some
tissues attenuate more X-ray than other tissues and the size of this differential
determine the X-ray image. In human body, the X-ray attenuation is greater
in bone than other parts.

SCATTER RADIATION
It detracts the film quality and contributes no useful information. There are
three factors determining the quantity of scatter radiation.
1. Kvp
2. Body Part thickness
3. Field size
The scatter radiation is maximum with high Kvp techniques, large field
and thick body parts. We don’t have control over body part thickness and
field size. The only variable we can control is Kvp.

FILTERS
Filtering is the process of shaping the X-ray beam to increase the ratio of
photons useful for imaging to those photons that decrease image contrast.
Filters are usually sheets of metal which reduces the patient’s radiation
dose. In a radiological examination the X-ray beam is filtered by absorber at
three different levels:
 Basis of Radiological Imaging 13

1. The X-ray tube and its housing (inherent filtration)

2. Sheets of metal placed in the path of beam (added filtration)
3. The patient.
Aluminum is usually placed as the filter material for diagnostic
radiology. Most high energy photons are transmitted through aluminum
while low energy photons are absorbed by photoelectric interactions. National
council on radiation for protection and measurement has recommended an
equivalent of 2.5 mm of aluminum permanent filtration for diagnostic X-ray.

COLLIMATORS
There are three types of X-ray beam restrictors- aperture diaphragms; cones
and collimators. Their basic function is to regulate the size and shape of
X-ray beam. Closely collimated beams have two advantages- first a smaller
area of patient is exposed and because area is a square function, a decrease
of one half in X-ray beam diameter affects a fourfold decrease in patient
exposure. Second well collimated beams generate less radiation and thus
improve film quality.

GRIDS
It consists of a series of lead foil strips separated by X-ray transparent spaces.
It was invented by Dr Gustave Bucky in 1913 and it is still most effective way
of removing scatter radiation from large radiographic field. Primary radiation
is oriented in the same axis as the lead strips and passes between them to
reach the film unaffected by the grid. Scatter radiation arises from many
points within the patient and it is multidirectional so most of it is absorbed
by the lead strips and only a small amount passes between. Grid ratio is
defined as the ratio between the height of the lead strips and the distance
between them. Grids are mainly used to improve contrast by absorbing
secondary radiation/scatter radiation before it reaches the film.
The primary disadvantage of grids is that they increase the amount of
radiation that the patient receives. Another disadvantage is that they require
careful centering of the X-ray tube because of the danger of grid cut off. Grid
cut off is the loss of primary radiation occurs when the images of lead strips
are projected wider then double width.

MOUNTING GRIDS
It was invented by Dr Hollis E Potter in 1920 and it was called as Potter
Bucky grid. Grids are moved to blur out the shadows cast by the lead strips.
Three grids move continuously back and forth or 1 to 3 cm throughout the
exposure. These grids eliminate grid lines from the film. The disadvantages
of moving grids are:
1. They are expensive
2. Subject to failure
3. Vibrates the X-ray tube
14 Interventional Pain Management—A Practical Approach

4. Puts a limit on the minimum exposure time so they move slowly

5. It increases patient’s radiation dose.
The other way of reducing the scatter radiation without increasing the
patient radiation is air gap technique. The closer the patient is to film, the
greater is the concentration of scatter per unit area. With air gap the
concentration decreases therefore more scattered photons miss the film.

FLUOROSCOPIC IMAGING
X-rays were discovered because of their ability to cause fluorescence and
first X-ray image observed fluoroscopically. Initial fluoroscope consisted of
X-ray tube, X-ray table and fluoroscopic screen. The fluorescent material
was copper automated zinc cadmium sulfide that emitted the light on
yellow green spectrum. A sheet of lead glass covered the screen so the
radiologist could stare directly into the screen without having the X-ray
beam striking his eyes. Screen fluoroscopy was so faint that the examination
was carried out in dark room by radiologist who had dark adopted his
eyes by wearing goggles, for 10 to 30 minutes prior to examination. The
solution came to above problem in the form of X-ray image intensifier
developed in 1950s.

The Design of Image Intensifier

The X-ray tube is a vacuum tube which contains:
1. Input phosphor and photocathode
2. Electrostatic focusing lens
3. Accelerating anode
4. Output phosphor.
After an X-ray beam passes through the patient, it enters the image
intensifier tube. The input fluorescent screen absorbs X-ray photons and
converts their energy into light photons. The light photons strike the
photocathode, causing it to emit photoelectrons. These electrons are
immediately draws away from photocathode by high potential difference
between it and the accelerating anode. As the electrons flow from the
cathode towards the anode they are focused by an electrostatic lens which
guides them to the output fluorescent screen without distracting their
geometric configuration.
The electrons strike the output screen which emits the light photons
that carry the fluoroscopic image to the eye of the observer. Thus in the
intensifier tube, the image is carried first by X-ray photons, then by light
photons next by electrons and finally by light photons. The input fluorescent
screen in image intensifies due to cesium iodide which is deposited in a thin
aluminum substrate by a process called vapor deposition. The image quality
is better with cesium iodide input screen that’s why of vertical orientation
of crystals, a greater packing density and a more favorable atomic number.
The thickness of phosphor layer is 0.1 mm. The principal advantage of
thinner phosphor layer combined with needle shaped crystals is improved
 Basis of Radiological Imaging 15

resolution. The resolution of cesium iodide image intensifier will be about

four lines per mm.
The photocathode is photosensitive metal commonly combination of
antimony and cesium compounds. When light from the flavescent screen
strikes the photocathode, photoelectrons are emitted in number
proportional to the brightness of the screen. The photocathode is directly
applied to the cesium iodide input phosphor.

ELECTROSTATIC FOCUSING LENS

The lens is made up of a series of positively charged electrodes that are
usually plated on the inside surface of the glass envelope. These electrodes
focus the electron beam from photocathode toward the output phosphor.
Electron focusing inverts and reverses the image. This is called point
inversion that’s why all the electrons pass through a common focal point
on their way to the output phosphor.

ACCELERATING ANODE
It is located in the neck of image intensifier tube. Its function is to accelerate
the electrons emitted from photocathode toward the output screen. The
anode has a positive potential of 25 to 35 Kv relative to the photocathode,
so it accelerates electrons to a tremendous velocity.

OUTPUT PHOSPHOR
It is silver activated zinc cadmium sulfide. The crystal size and layer
thickness are reduced to maintain resolution in magnified image. A thin
layer of aluminum is plated on to the fluorescent screen to prevent light from
moving retrograde through the tube and activating the photocathode. The
glass tube of IIT is about 2 to 4 mm thick enclosed in a lead lived container.
The output phosphor image is viewed either directly through a series of
lenses and mirror or indirectly through closed circuit television. Large field
of view image intensifier tubes- the development of digital angiography was
associated with a need for large image intensifier tubes that could image a
large area of patient. Those image intensifier tubes with diameter of 12, 14
and 16 inches are now available to meet this need. The magnification factor
with the small field can be helpful when fluoroscopy is used to guide delicate
invasive procedures such as percutaneous biliary and nephrostomy.

CLOSED CIRCUIT TELEVISION

Here the signals are transferred from one component to the next through
cables and not through the air. A lens system or a fiber optic system conveys
the fluoroscopic image from the output phosphor of the image intensifier to
the video camera, where it is converted into a series of electrical pulses called
the video signal. This signal is transmitted through a cable to the camera
control unit, where it is amplified and then forwarded through another cable
16 Interventional Pain Management—A Practical Approach

to the TV monitor. The monitor converts the video signal back into the original
image for direct viewing.
The TV image is made up of thousand tiny dots of different brightness
each contributing a minute bit to the total picture.

RADIATION PROTECTION
In 1928, the second international congress of radiology appointed a
committee to define the Roentgen as a unit of exposure. The harmful effects
of radiation fall in two categories:
1. Somatic- Harmful to the person being irradiated.
2. Genetic- Those harmful to future generations.
In actual practice radiation level should be kept at the lowest practicable
level and one should not think of permissible doses as being perfectly safe.
The most important somatic effect of radiation is carcinogenesis and
leukoderma. The genetic effects of radiation are more frightening than
somatic ones because they may manifest themselves for several generations.

RADIATION UNITS
There are three units the Roentgen, the Rad and the Rem.
The roentgen is defined as a unit of radiation exposure that will liberate
a charge of 2.5 × 10 – 4 coulombs per kilo = gram of air.
The rad is the unit of absorbed dose. One rad is equal to the radiation
necessary to deposit energy of 100 ergs in 1 gram of irradiated material
(100 erg/gm).
The Gray (Gy) is the SI unit of absorbed dose. One Gray is defined as to be
radiation necessary to deposit energy of one joule in 1 kg of tissue. One Gray
is equivalent to 100 rads.
The rem is a unit absorbed dose equivalent. The rem is a unit used only
as radiation protection. Its SI unit is Sievert.
All individuals exposed to radiation in low doses. In an attempt to make
some comparison in the risk assessment for all types of exposure, the concept
of effective dose equivalent (HE) has been developed.

Medical Radiation
The concept of effective dose equivalent is particularly useful while
describing medical X-ray exposures. There are two categories of medical
radiation: diagnostic medical X-rays and nuclear medicine. The estimated
annual effective dose equivalent from diagnostic X-ray examination is 0.39
MSV.

DOSE LIMITING RECOMMENDATIONS

There are four classes of individuals:
1. Occupationally exposed individuals
2. The general public
 Basis of Radiological Imaging 17

3. Trainees under 18 years of age

4. Embryo fetus.

Occupational Exposure
It is knowledgeable group, who knows risk involved and their no. are relatively
small. So his exposure does not contribute appreciably to genetically
significant dose. The maximum permissible does is larger for this group
than other people. The stochastic effect of radiation exposure is defined as
air effect in which the probability of occurrence increases with increasing
absorbed dose, but the severity of effect does not depend on the magnitude to
the absorbed dose, e.g. Cancers and genetic effects.
A no stochastic effect of radiation exposure is defined as a somatic effect
that increases in severity with increasing absorbed dose. These are
degenerative effects severe enough to be clinically significant such as organ
atrophy and fibrosis, e.g. Lens opacification, blood changes and increased
sperm production.
For occupational exposures, the NCRP recommends an annual effective
dose equivalent limit of 5 rem (50 MSV). For avoidance of non stochastic
effects recommended annual dose equivalent limits are 15 rem (150 MSV) for
the lens of eye and 50 rem (500 MSV) for other organs.
An individual lifetime effective dose equivalent in rems should not
exceed the value of his/her age in years.

Public (Non-occupational) Exposure

They have no knowledge of the risk involved, receives no compensation for
taking a risk. When a member of general population enters a radiating area,
he becomes an occasionally exposed individual. Large number of individuals
could be involved which would have a greater impact on the genetically
significant dose. For all these reasons, the dose limit for the occasionally
exposed is 0.5 rem/year or 1/10 if maximal permissible dose for the
occupationally exposed.

Trainees Under 18 years of Age

The NCRP recommends that exposure to these trainees should result in an
annual effective dose equivalent of less than 0.1 rem.

Embryo Fetus Exposure

The NCRP recommends a total dose of 0.5 rem (50 MSV) for the embryo
fetus. Once pregnancy becomes known exposure of embryo fetus should
be no greater than 0.05 rem (0.5 MSV) in any month.

PROTECTIVE BARRIERS
The distance, time and barriers are used to control radiation exposure levels.
18 Interventional Pain Management—A Practical Approach

Distance is obviously an effective method that’s why beams intensity is

governed by inverse general law. Exposures can be controlled with time in
various ways.
Barriers are designated as either primary or secondary depending on
whether they protect from primary radiation of stray radiation.
The exposure from primary beams can be calculated by multyplying the
workload, use factor, occupancy factor and inverse square of the distance by
an R output at 1 m for each MA of workload. If this exposure exceeds
permissible levels, then a barrier is required. Barrier thickness is calculated
in two ways:
1. With precalculated tables
2. With half value layer of lead or concrete.
The half value layer (HVL) is the thickness of a specific substances that
when introduced into the path of a beam of radiation, reduces the exposure
by one half.
A secondary barrier is required only when the useful beam cannot be
directed at particular wall. Secondary barrier protect against scatter and
leakage radiation. For scatter radiation the exposure is assumed to the
attenuated by a factor of 1000 (i.e. reduced to 0.001 at a distance 1 ms each for
each right angle scattering).

RECOMMENDED FOR FURTHER READING

1. David Sutton- Textbook of Radiology
 Two

Spinal Radioanatomy
Revisited
Sachin Pathak, Pradeep Krishnan, Vishal Piparia, Bhavin Jhankaria

INTRODUCTION
• Selective nerve block for pain management requires injection of a local
anesthetic into a desired nerve/branch of nerve under image guidance
[fluoroscopy/ultrasound/CT scan].
• Fluoroscopy is commonly used in spinal nerve blocks and for cervical/
thoracic/lumbar discographies. Fluoroscopy guided nerve block is
performed as a diagnostic as well as a prognostic procedure.
• This involves guiding the needle under fluoroscopic guidance towards a
target point specific for the type of block.
• For this, knowledge of spinal radio anatomy and orientation of AP/
lateral and oblique views of the spine is essential.
• The vertebral column is composed of a series of 31 vertebrae. There are 7
cervical, 12 thoracic, and 5 lumbar vertebrae. The sacrum is composed of
5 fused vertebrae, and 2 coccygeal vertebrae which are sometimes fused.
• In the normal adult there are four curvatures in the vertebral column in
an anteroposterior plane. These serve to align the head with a vertical
line through the pelvis. In the thoracic and sacral regions, these curves
are oriented concave anteriorly and each is known as a kyphosis.
• In the lumbar and cervical regions the curves are convex anteriorly and
each is known as a lordosis.
• A curvature of the vertebral column in the mediolateral plane can occur
pathologically and is known as a scoliosis.

STRUCTURE OF A TYPICAL VERTEBRA (FIGS 2.1 TO 2.4)

• Each vertebra is composed of a body anteriorly and a neural arch
posteriorly. The arch encloses an opening, the vertebral foramen, which
helps to form a canal in which the spinal cord is housed.
• Protruding from the posterior extreme of each neural arch is a spinous
process and extending from the lateral edges of each arch are transverse
processes.
20 Interventional Pain Management—A Practical Approach

Fig. 2.1: Diagrammatic representation of typical vertebrae

Fig. 2.2: Cervical spine-lateral view- Fig. 2.3: Cervical spine-lateral view-parts of
showing neural foramina and pedicle vertebrae
 Spinal Radioanatomy Revisited 21

Fig. 2.4: Cervical spine-AP view-parts of vertebrae

• The neural arch of each vertebra is divided into component parts by these
processes. The parts of the neural arch between the spinous and transverse
processes are known as the lamina and the parts of the arch between the
transverse processes and the body are the pedicles.
• At the point where the lamina and pedicles meet, each vertebra contains
two superior articular facets and two inferior articular facets. The former
pair of facets form articulations, which are synovial joints, with the two
inferior articular facets of the vertebra immediately above (or the skull,
in the case of the first cervical vertebra).
• The pedicle of each vertebra is notched at its superior and inferior edges.
Together the notches from two contiguous vertebras form an opening,
the intervertebral foramen, through which spinal nerves pass.
The first and second cervical vertebrae are atypical. The first cervical
vertebra is known as the atlas, and it is remarkable for having no body. It
contains an anterior tubercle instead. Its superior articular facets articulate
with the occipital condyles of the skull and are oriented in a roughly
parasagittal plane. The head thus moves forward and backwards on this
vertebra.
• The second cervical vertebra contains a prominent odontoid process,
or dens, which projects superiorly from its body. It articulates with the
anterior tubercle of the atlas, forming a pivotal joint. Side to side
movements of the head take place about this joint.
• The seventh cervical vertebra is sometimes considered atypical since it
lacks a bifid spinous process.
22 Interventional Pain Management—A Practical Approach

Thoracic Vertebrae (Figs 2.5 and 2.6)

• The unique characteristic of thoracic vertebrae is articular facets for the
ribs. Each vertebra contains two pairs of these costal demifacets on its
body and one on each transverse process. Typical ribs articulate with
the inferior demifacet and transverse process of a thoracic vertebra and
the superior demifacet of the vertebra below it.
• The 11th and 12th thoracic vertebrae are sometimes considered atypical
because they lack a superior costal demifacet. The 11th and 12th ribs
thus articulate only with the 11th and 12th thoracic vertebrae, respec-
tively.

Fig. 2.5: Thoracic spine-lateral view- Fig. 2.6: Thoracic lumbar spine-AP
showing articular process view-various parts

Lumbar Vertebrae (Figs 2.1 and 2.6)

Lumbar vertebrae are characterized by massive bodies and robust spinous
and transverse processes.
• Their articular facets are oriented somewhat parasagittally, which is
thought to contribute to the large range of anteroposterior bending
possible between lumbar vertebrae (Fig. 2.7).

SCOTTY DOG (FIGS 2.8 AND 2.9)

Oblique Radiograph of the Lumbar Spine
“The Scotty Dog” Appearance
On oblique radiographs, the posterior elements form the appearance of a
“Scotty dog”, where the superior articular process resemble the ear, the pedicle
 Spinal Radioanatomy Revisited 23

Fig. 2.7: X-ray thoracolumbar spine- Fig. 2.8: Diagrammatic representation-scotty

lateral view showing parts of vertebrae dog: A-Sup. art. process (ear of dog); B-Eye of
dog-pedicle; C-Transverse process-(Nose of
dog); D-Inf. art. process-(Lower leg of dog)

Fig. 2.9: X-ray-lumbar spine-lateral view-showing parts of scotty dog:

Sup. art. process, transverse process; Inf. art. process
24 Interventional Pain Management—A Practical Approach

forms the eye, the transverse process forms the nose and the inferior articular
process forms the lower leg of the dog. The pars interarticularis forms the
neck of the dog.

Sacrum (Fig. 2.10)

• The sacrum consists of five fused vertebrae. It articulates with the fifth
lumbar vertebra above and the coccyx below, and with the iliac bones
on either side.
• In addition to its characteristic shape, it contains both anterior and
posterior foramina through which the anterior and posterior rami of
the spinal nerves pass.

Intervertebral Joints
• Adjacent vertebrae are connected by three types of intervertebral
articulations. Synovial joints are formed between the inferior articular
facets of one vertebrae and the superior articular facets of the vertebrae
below.
• These joints are extensively re-enforced by different ligaments.
• These ligaments connect the tips of the spinous processes (supraspinous
ligaments), the base of the spinous processes (interspinous ligaments),
and the transverse processes (intertransversalis ligaments).
• In addition the laminas of adjacent vertebrae are bound together by a
ligamentum flavum.

Fig. 2.10: Sacrum and coccyx

 Spinal Radioanatomy Revisited 25

• The bodies of adjacent vertebrae are connected by specialized cartilagi-

nous joints known as intervertebral discs. Each disc is composed of a
central core of gelatinous material, known as the nucleus pulposus, and
a surrounding series of fibrous rings known as the annulus fibrosis. In
most individuals, the fibers of the annulus fibrosus effectively resist this
load, but in some people they do not and the nucleus pulposus is forced
out of the disc, or is herniated.
• A herniated nucleus pulposus can have a profound effect on the adjacent
spinal nerves.
• Two ligaments connect the vertebral bodies anteriorly and posteriorly
and thereby re-enforce the intervertebral disc. The anterior longitudinal
ligament is strong and robust throughout but the posterior longitudinal
ligament becomes thin and narrow in the lumbar region.
• This change in structure of the posterior longitudinal ligament is part
of the reason that the overwhelming majority of disc herniations occur
posteriorly in the lumbar region.

The Spinal Cord

• The spinal cord proper begins at the level of the foramen magnum of the
skull and ends at the level of the L1/L2 intervertebral joint. There it tapers
to a cone-shaped ending known as the conus medullaris. A stalk of pia
mater, the filum terminale attaches it to the end of the dura mater at S2.
All of the roots of the spinal nerves from L2 to the lowest coccygeal nerve
pass caudal to the conus medullaris to exit at their respective intervertebral
foramina. This mass of spinal roots within the spinal canal (in the
subarachnoid space) is known as the cauda equina. Thus, the area of the
subarachnoid space below the L2 vertebra (typically L4) is considered a
safe place to insert a needle to sample cerebrospinal fluid, since only
nerve roots and not spinal cord are found there.
• Likewise, the posterior protrusion of a herniated lower lumbar
intervertebral disc, while not pressing on the spinal cord, can compress
a lumbar nerve root, causing severe pain or physical dysfunction in
distinct areas of the lower limb.

The Intervertebral Canal

• It is situated between adjacent pedicles which form its upper and lower
boundaries. The intervertebral canal is widest superiorly, narrowing
inferiorly. The intervertebral canal narrows with extension as the facets
slide over each other.
• The cervical intervertebral canal is oriented anterolaterally at 45 degrees
to the sagittal plane and is best demonstrated using the oblique
radiographic projection.
• Lateral radiographs are appropriate for demonstrating the cervical
neural foramina (Fig. 2.11).
26 Interventional Pain Management—A Practical Approach

Fig. 2.11: X-ray cervical spine-lateral view-showing neural foramina

• The dorsal root ganglia, epidural fat, the spinal nerves and the blood
vessels are found in the intervertebral canal.
• In the thoracic and lumbar regions the neural elements traverse the
superior part of the intervertebral canal. The superior part of the cervical
neural canal contains foraminal veins, while the nerve root ganglia lie
in the inferior part.

RECOMMENDED FOR FURTHER READING

1. David Sutton- Textbook of Radiology
 Three

Neurolytic Agents and

Neurodestructive Techniques
RP Gehdoo

INTRODUCTION
Injection of neurolytic agents to destroy nerves and interrupt pain pathways
as well as neurodestructive techniques have been extensively used to achieve
‘permanent’ analgesia in the cases of advanced chronic pain patients by the
pain practitioners since the early part of the 20th Century. The results of
such injections are essentially the same as nerve sectioning, although the
effect is usually seen for only 3 to 6 months. Schloesser, in 19031, used alcohol
for the first time in the cases of trigeminal neuralgia. A neurolytic sympathetic
block was used for providing the anginal and abdominal pain relief by
Swetlow2 in 1926. Intrathecal alcohol neurolysis for the intractable pain
relief was used for the first time by Digliotti3 in 1933. However, the use of
neurolysis has decreased significantly in recent years due to advances in
spinal analgesia and increased life expectancies in patients with cancer. In
1851, Arnott4 reported the application of cold in relieving cancer pain. Smith
and Fay5 in 1939 reported finding regression of tumor following localized
freezing. But still, neurolysis continues to be an attractive option for pain
control in many cancer patients. Neurolysis is indicated inpatients with
severe, intractable pain in whom less aggressive maneuvers are ineffective
or intolerable because of either poor physical condition or the development
of side effects.
Various chemical agents used for the purpose of neurolysis are alcohol,
phenol, glycerol, chlorocresol, ammonium salts and hypertonic saline. For
the neurodestruction techniques, cryoablation and of late, radiofrequency
lesioning has been used in the pain practice.

MECHANISM OF ACTION
As soon as the neurolytic agents like alcohol or phenol come in contact with
the nerve fiber, there is an increase in the endoneurial fluid pressure
secondary to the mast cell degranulation and release of vasoactive substances.
This elevated pressure causes stretching of the perineurium and compression
of perineurial vessels. This leads to ischemia of nerve fiber and interruption
28 Interventional Pain Management—A Practical Approach

of nerve impulses. Adequate amount of wallerian degeneration should be

accompanied to get good results.

Types of Neurolytic Agents and Neurodestructive

Techniques are as follows
A. Chemical Neurolytic Agents: Alcohol, Phenol, Glycerol, Ammonium salts,
and Hypertonic saline
B. Cryoablation
C. Radiofrequency Lesioning

Chemical Neurolytic Agents

The neurolytic agents commonly used for chemical neurolysis include Ethyl
alcohol, phenol, chlorocresol, ammonium salts and hypertonic saline etc.
1. Ethyl alcohol: It is a clear, colorless solution. It absorbs water on exposure
to air. It is stable at room temperature and hypobaric to CSF. It spreads
quite rapidly from the injection site and requires 12 to 24 hours before the
effects of the injection can be assessed. Ninety to ninety-eight percent of
the injected alcohol is rapidly metabolized by oxidation in the liver
principally by the enzyme alcohol dehydrogenase.
This is available in various concentrations from 50 to 97%. The
minimum concentration required for neurolysis has not been established.
However, Labat G6 reported in 1933 that an injection of 33.3% alcohol
produced satisfactory analgesia in the treatment of painful disorders.
Its mechanism of nerve destruction is similar to phenol. It extracts
cholesterol, phospholipids and cerebrosides from the nervous tissue and
causes precipitations of lipoproteins and mucoproteins.7 This initiates
Wallerian degeneration and neurolysis. Whenever intrathecal alcohol is
given, similar changes are noted in the nerve rootlets. There can be a
minimal focal inflammation of meninges and patchy areas of demyeli-
nation in the dorsal column, Lissauer’s tract and dorsal root.8 When
sympathetic chain comes in contact with alcohol, the ganglion cells get
destroyed.9-11 This blocks all postganglionic fibers to all effector organs.
Following its injection, the patient complains of severe burning pain
along the nerve’s distribution which may last for a minute and is
subsequently replaced by a warm, numb sensation. To overcome this
pain, an injection of local anesthetic agent prior and following the alcohol
injection should be done.
It is used for neurolysis at cranial nerves, intrathecal injection,
sympathetic chain and chemical hypophysectomy.
Usually it is given at a dose of 20 to 25 ml of 50% alcohol on either side
in case of advanced upper GI malignancy cases, while in the varying
doses of 0.25 to 2 ml of absolute (97%) alcohol in all other cranial and
sympathetic nerves or ganglions.
2. Phenol: Phenol is a chemical composite containing carbolic acid, phenic
acid, phenylic acid, phenyl hydroxide, hydroxybenzene, and oxyben-
 Neurolytic Agents and Neurodestructive Techniques 29

zene. In its pure state, it is colorless and poorly soluble. Shelf life exceeds
one year when the solution is refrigerated and not exposed to light. Phenol
turns red on exposure to sunlight and air because of oxidation. A reddish
tinge. It is available as a sterile solution and can be prepared as a 6.7%
solution in water.
Usually it is available in concentrations ranging from 4 to 10%. Since
phenol is hyperbaric, it will settle if injected into a liquid medium such as
the cerebrospinal fluid-containing subarachnoid space. It is highly soluble
in organic solvents such as alcohol and glycerine. The addition of small
amounts of glycerol or water soluble radiopaque contrast material may
increase the concentration to 15%. The solution can be diluted with saline
and is compatible when mixed with radio-contrast dyes. The glycerine
mixed phenol is thick solution and needs to be injected through a needle
not less than 20 Gz. When mixed with glycerine, it slowly diffuses from
the solution. This property of phenol can be taken into advantages, when
injected intrathecally because it allows for limited spread and is localized
in the area that needed to be destroyed. When mixed with water, it has a
wider spread, causing a bigger area of nerve destruction. Aqueous solution
of phenol is more potent than the glycerine solution. The choice of diluents
depends upon the extent of neurolysis desired. The use of higher
concentrations of phenol might predispose to a higher incidence of
vascular injury. It is metabolized in the liver by conjugation to
glucuronides and oxidation to equinol compounds or to carbon dioxide
and water. Excretion of metabolites is via the kidneys.
Phenol causes non-selective neurolysis by denaturing proteins of
axons and perineural blood vessels.12 There is loss of cellular fatty
elements, separation of the myelin sheath from the axon, and axonal
edema.13 The degeneration after contact with solution takes about 14
days and regeneration is completed in about 14 weeks. However, phenol
is not as effective as alcohol at destroying the nerve cell body and its
blocking effect tends to be less profound and of shorter duration than
alcohol. At a concentration of 2 to 3% in saline, phenol seems to spare
motor function. The efficacy of 3% phenol in saline is comparable to that
of 40% alcohol. It acts as a local anesthetic in lower concentrations and
as a neurolytic in higher concentrations. The effects of the block cannot
be evaluated until after 24 to 48 hours, to allow time for the local anesthetic
effect to dissipate. The neurolytic effect may be clinically evident only
after 3 to 7 days. If inadequate pain relief is obtained after two weeks, this
may indicate incomplete neurolysis and requires repetition of the
procedure. The subsequent fibrosis that occurs following phenol injection
makes nerve regeneration more difficult, but not impossible. Nerve
regeneration can occur as long as the nerve cell body is intact, at a rate of
1 to 3 mm per day. Nerve arborization and neuroma formation can occur
at the site of nerve disruption and can be a focus of a neuropathic type of
pain. Phenol can be injected intrathecally and epidurally. Phenol in
glycerine is hyperbaric compared to the CSF. It can be used also for
30 Interventional Pain Management—A Practical Approach

paravertebral somatic block, peripheral nerve blocks, in epidural,

peripheral nerve roots, intrathecal and cranial nerves and sympathetic
blocks.
Phenol has systemic side effects including central nervous system
stimulation, cardiovascular depression, nausea, and vomiting. Systemic
doses of more than 5 grams can cause convulsive seizures and central
nervous system depression. Doses less than 100 mg are less likely to
cause serious side effects.
3. Glycerol: It is a mild neurolytic agent used preferably for the Gasserian
ganglion block, as it was found to preserve the facial sensations in most
of the cases. It is usually used as 100% solution in 0.5 to 2 ml dose. Due to
a poor control of spread in the area close to the subarachnoid space, it is
not used in the intrathecal injection.
The mechanism of it’s action is not completely understood. However,
it appears to affect primarily damaged myelinated axons. Injection in the
vicinity of the nerve causes perineural damage, while intra-neural
injection results in Schwann cell edema, axonolysis, and Wallerian
degenarion. Intra-neural injection destroys all the fibers.
4. Ammonium salts: Ammonium salts used for long-term pain relief. It is
usually available at a concentration of 10%. At this concentration, a
neuronal degeneration, including C-fibers neurolysis, appears with a
success of 40%. Interestingly, it has been found that a 10% solution
provides adequate analgesia without a significant motor block.
These salts produce an acute degenerative neuropathy with
obliteration of C-fibers and with a very small effect on A-fibers. However,
the degeneration is nonselective and may affect all types of fibers.
Complications due to ammonium salts injection are transient and
include nausea and headache. Paresthesia and burning sensation may
occur in 30% of patients at doses 500 mgs of ammonium salts, lasting 2 to
14 days.
5. Hypertonic saline or normal saline: The use of hypertonic saline by
intrathecal injection to treat intractable pain was first reported by
Hitchcock14 in 1967. The most commonly used solution is the 10%
aqueous solution and it is readily available. It is usually given intra-
thecally as 40 to 60 ml of normal saline injection, after withdrawing an
equal amount of CSF (a very distressing procedure).
Its mechanism of neurolysis is not well elaborated. Normal saline
usually is thought to act specifically on C-fibers, sparing larger fibers of
sensory, motor, and autonomic functions. Cold hypertonic saline
produces C-fiber neurolysis with a success of 30%. It causes severe pain
on injection and local anesthetic is first injected before the saline solution.
When injected intrathecally, it seems to produce it’s action by an
intrathecal shift of water with extracellular change in osmolarity. Intra-
thecal injection of hypertonic saline can cause an increase in the
intracranial pressure, increase in blood pressure, heart rate and
respiratory rate.
 Neurolytic Agents and Neurodestructive Techniques 31

Duration of the pain relief is normally short-lived, may be from 10 to

25 days. Rarely, one may find a relief extending to a couple of months.
Cardiac complications have been seen during and after saline
injection. Complications consists of tachycardia, premature ventricular
contractions and myocardial infarction, localized paresis (which may
last for many hours), paresthesia (which may last for many weeks),
hemiplegia, pulmonary edema, pain in the ear, vestibular disturbances,
and loss of sphincter control with sacral anesthesia.

Indications for Chemical Neurolysis

1. Management of chronic, intractable, non-terminal pain that are not
responsive to other modalities.
2. Treatment of cancer pain in those patients who have short life expectancy
(less than a year).
3. Alternative management to treat spasticity in order to improve balance,
gait, self-care, and global rehabilitation. An important difference between
neurolytic blocks for pain relief versus spasticity is that motor or mixed
nerves are targeted preferentially in the management of spastic disorders.

Complications of Chemical Neurolysis

i. Skin and other tissues: There is a necrosis and sloughing of the skin
and other non-target tissues, mainly due to damage of the vascular
supply, and subsequent chronic trauma to denervated tissue. Necrosis
of muscles, blood vessels, and other soft tissues has also been reported.
ii. Neuritis: The incidence of neuritis is up to 10%. It is caused by partial
destruction of somatic nerve and subsequent regeneration. It is clinically
manifested as hyperesthesia and dysesthesia that may be worse than
the original pain problem. It is one of the limiting factors in the use of
chemical neurolysis.
iii. Anesthesia dolorosa: This is a poorly understood condition whereby
the patient complains of distressing numbness caused by an imbalance
in afferent input. It is caused by long-term loss of afferent input and the
resultant CNS changes. Management of this problem is
pharmacotherapy with the use of tricyclic antidepressants, major
antipsychotic tranquilizers, and anticonvulsants.
iv. Prolonged motor paralysis: This can be a major complication, that
occurs infrequently and is usually temporary.
v. Perineal and sexual dysfunction: This is another fearsome complication
that can occur temporarily. About 1.4% and 0.2% of patients will have
bowel or bladder dysfunction at one week and one month, respectively.
vi. Systemic complications: These include hypotension secondary to
sympathetic block and systemic toxic reactions, heart rate and rhythm
disturbances, blood pressure changes, and CNS excitation and
depression.
32 Interventional Pain Management—A Practical Approach

Cryoablation
Pain relief from the destruction of nerves following exposure to extreme cold
is called cryoanalgesia. Smith and Fay15 in 1939 reported a tumor regression
following localized freezing. Lloyd and coworkers16 in 1976 used this method
for pain relief and coined the term “cryoanalgesia”.
The major advantage of this procedure is the absence of neuritis or
neuroma formation, and prolonged analgesia with reversible effect unlike
chemical neurolysis17 and to a certain extent, radiofrequency lesioning.18,19
It has no systemic side effects and produces minimal tissue damage. It can be
performed as an outpatient procedure. The pain relief might last from 2
weeks to 5 months.
Cryoablation involves inducing profound hypothermia over nerve fiber
(at the contact point). A prolongation of action potentia is seen, when nerve
is cooled to 5° C. Unmyelinated fibers require a lower temperature.
Cryolesioning is done by freezing of a small nerve segment with a 2 mm
probe cooled at – 60° C by rapid expansion of pressurized nitrous oxide from
its tip. The probe is left in contact with the nervous tissue for 60 to 90 seconds
and then allowed to thaw for another 45 to 60 seconds before being removed.
An ice ball 2 to 4 mm in diameter is formed that freezes the nerve and
completely damages the nerve fiber. Endoneurial fluid pressure is elevated
up to 20 mm Hg within 90 minutes. It reduces over next 24 hours and then
increases again, to reach a plateau after 6 days secondary to changes of
wallerian degeneration.
It is particularly useful in the management of chronic pain syndrome,
when other modalities of pain relief are unacceptable to patients such as
surgery or device implantation, too difficult to perform, have a high inci-
dence of complications or side effects, or has been ineffective. The techniques
has been utilized in the treatment of various types of neuralgias (fascial,
intercostal, post-therapeutic, post-traumatic), myofascial trigger point pain,
post-surgical pain, cancer pain, neuroma, phantom limb pain, cervicogenic
headache, cervicalgia, thoracic, lumbar and coccygeal pain. These can be
usually done as an outpatient procedure, readily acceptable to patients,
minimal complications, and an effective alternative to pharmacologic pain
killers.
The therapeutic effectiveness of cryoablation is difficult to predict. There
is wide patient to patient variability depending upon the site of lesioning,
nature of the pain problem, psychologic make up of the individual, and
experience of the operator. Across the board, the effectiveness may vary from
3 to 1000 days.
It has a special N2O delivery system that allows safe delivery of the gas
up to 850 psi to the gas expansion orifice in the tip of the cryoprobe (14, 16, 18
gauge). Generally, the gas is delivered at an operating pressure of 600 psi.
The minimum temperature at the tip of the probe can rapidly reach to
– 60° C.
 Neurolytic Agents and Neurodestructive Techniques 33

The commonly encountered complications are Frostbite and depigmen-

tation of skin, sensory and motor damage and damage to the adjacent
structures due to movements or mal-positioning of the probe.

Radiofrequency Lesioning
Radiofrequency lesioning is the application of electrical current to promote
the thermocoagulation, leading ultimately to the nerve destruction. It is used
to ablate pain pathways in the trigeminal ganglion, spinal cord, dorsal root
entry zone, dorsal root ganglion, sympathetic chain, facet joints, failed back
pain syndrome and peripheral nerves.20-24 Since it causes nerve destruction,
this technique is utilized only as end of the line therapeutic modality when
other measures have failed. Fluoroscopic guidance is a requirement for proper
needle placement. The patient should also be informed of the risks and benefits
of the procedure and a written informed consent must be signed in front of a
witness.
The mechanism of action of RF lesioning is as follows: Frictional heat is
generated by molecular movement in a field of alternating electrical current
at radiofrequency. An electromagnetic field is created around an active
electrode when the frequency is set above 250 kHz. The active electrode is
placed at the site for lesioning and an indifferent electrode is placed to
minimize passage of current through the myocardium. Heat is generated in
the tissues, which conducts to the active electrode. Heat is generated as
current flows through a probe with a built in thermocouple needle. The heat
is not emitted from the probe itself but from the current movement which
generates the heat as it passes through the tissues. The lesion is formed once
the neural temperature exceeds 45° C. Temperature above 90° C can cause
boiling and tissue tearing with electrode removal. The temperature is
monitored and wattage is adjusted to the desired level, which in turn
determines the size of the lesion. Lesion plateaus with time. After 60 seconds
at a certain temperature, lesion growth is minimal. The lesion is spheroidal
and may extend several millimeters beyond the active electrode tip, but the
majority of the lesion volume surrounds the axis of the active electrode. Prior
to the lesioning, pain is first replicated using higher frequencies and lower
voltages. Once the target tissue is localized, then only the thermocoagulation
is instituted.
Technique proper: Once the needle or cannula position is perfectly placed at
the desired site and level, the RF electrode is introduced via the cannula.
With older systems, the electrode itself needed to be touching bone. With
newer systems, utilizing a cannula sheathed with plastic or Teflon with an
exposed metal tip of varying length, the electrode need not actually touch the
bone, although the exposed tip must. Stimulation is then carried out, using a
frequency of 50 Hz and a current up to 1 mA for sensory detection, and a
frequency of 2 Hz with current between 3 to 5 mA for motor stimulation. A
positive stimulation is that which reproduces the patient’s pain, without
producing other sensory or motor findings in the lower extremity or buttocks.
34 Interventional Pain Management—A Practical Approach

Negative stimulation may be failure to produce the patient’s pain, or obvious

stimulation of motor and sensory structures arising from the spinal nerve. In
such cases, denervation should not be performed, and the cannula should
be repositioned, followed by repeat stimulation.
Once the stimulation pattern is acceptable, a RF lesion is created by
passing current through the electrode to raise the tissue temperature to 60 to
80° C for 60 to 90 seconds. This portion of the procedure may be quite
uncomfortable, and judicious use of sedation and analgesics may be
appropriate. Once the lesion is completed, the next level(s) can be treated in
a similar fashion.
The usual complications encountered are as follows:
1. Neuritis/neuralgia – (Incidence -10%). Pain may be worse than the
original pain.
2. Numbness; Motor paralysis.
3. Pneumothorax; Horner’s syndrome.
4. Incomplete pain relief.

CONCLUSION
Chemical neurolysis or destruction of nerves either by the application of
chemical neurolytic agents, which is an age-old accepted technique of
achieving a pain relief in the chronic intractable pain patients, still continues
to be one of the main armamentarium. Newer techniques like Radiofrequency
lesioning and Cryoprobe have taken a front seat in the patient care recently
and these are getting further improvized to produce effective prolonged
analgesia for chronic pain syndromes. But, these techniques require
specialized training, in depth knowledge of neural anatomy and
understanding of chronic pain physiology. So, there application should be
reserved only in painful conditions where conventional conservative pain
management fails.

REFERENCES
1. Scholoesse. Heilung peripharer reizzustande sensibler and motorischer nerven
klin Monatsbl Augenhilkd 1903;41:244.
2. Swetlow GI. Paravertebral alcohol block in cardiac pain. Am Heart J
1926;1; 393.
3. Digliotti AM. A new method of block anesthesia: Segmental peridural spinal
anesthesia. Am J Surg 1933;20:107.
4. Arnott J. On the treatment of cancer by the regular application of an anesthetic
temperature. London G Churchill 1851.
5. Smith LW, Fay T. Temperature factors in cancer and embryonal cell growth.
JAMA 1939;113:60.
6. Labat G. Action of alcohol on the living nerve. Curr Res Anesth Analg
1933;12:190.
7. Myers RR, Powell HC. Galacose neuropathy: Impact of chronic endoneurial
edema on the nerve blood flow. Ann Neurol 1984;16:587.
 Neurolytic Agents and Neurodestructive Techniques 35

8. Gallagher HS, Yonezawa T, Hoy RC, Derrick WS. Subarachnoid alcohol block-
II. Histological changes in the central nervous system. Am J Pathol 1961;35:679.
9. Mayo. Functional and histological effects of intraneural and intraganglionic
injection of alcohol. Br Med J 1912;2:365.
10. Rumbsy MG, Finean JB. The action of the organic solvents on the myelin
sheath of peripheral nerve tissue-II (short chain aliphatic alcohol). J Neurochem
1966;13:1509.
11. Myers RR, Katz J. Neural pathology of neurolytic and semidestructive agents.
In Cousins MJ, Bridenbaugh PO (Eds). Neural blockade in clinical anesthesia
and management of pain, (2nd Edn). Philadelphia, JB Lippincott 1988, 1031-
1951.
12. Felsenthal G. Pharmacology of phenol in peripheral nerve blocks: A review.
Arch Phys Med Rehabil 1974;55:13-16.
13. Smith MC. Histological findings following intrathecal injection of phenol
solutions for the relief of pain. Anesthesia 1964;36:387.
14. Raj PP, Denson DD. Neurolytic Agents. In Raj PP (Ed): Clinical practice of
regional anesthesia. New York, Churchill Livingston 1991.
15. Bonica JJ. Management of pain (2nd Ed.) Philadelphia, Lea and Febiger 1990,
1980-2039.
16. Lloyd JW, Barnard JDW, Glynn CJ. Cryoanalgesia, a new approach to pain
relief Lancet 1976; 2:932-4.
17. Swerdlow M. Intrathecal neurolysis. Anaesthesia 1978; 33:733-40.
18. Paintal AS. Block of conduction in mammalian myelinated nerve fibers by low
temperature. J Physiol 1965;180:1.
19. Myers RR, Powell HC, Costello ML, et al. Biophysical and pathologic effects of
cryogenic nerve lesions. Ann neurol 1981;10:478.
20. Koning HM, Mackie DP. Percutaneous radiofrequency facet denervation in
low back pain. The Pain Clinic 1994;7(3):199-204.
21. Sluijter ME. The use of radiofrequency lesions for pain relief in failed back
patients. International Disability Studies 1988; 10(1): 37-42.
22. Wilkinson HA. Stereotactic radiofrequency sympathectomy. The Pain Clinic
1995; 8(1): 107-115
23. Shealy CN. Percutaneous radiofrequency denervation of spinal facets.
J Neurosurgery 1975; 43:448-51.
24. Shealy CN. Facet denervation in the management of back and sciatic pain.
Clin Orthop 1976; 115:157-64.
 Four

Informed Consent for

Interventional Pain Procedures
DK Baheti

Interventional procedure for treatment pain remains an important modality

for relief of pain. All care is taken to make it simpler, free of stress and
complications, cost effective however it is an invasive one so untoward
effect or complications are unpredicted.
The scenario of practice of medicine has changed due to the internet
explosion, medicolegal awareness and accountability. The information about
the details of procedure to the patient and assuring him of successful outcome
is necessary as we are dealing with a live person. The patient has every right
to know the details of the procedure he is to undergo.
So it is mandatory for pain physician to inform the patient and his
relatives the condition of patient, procedure to be performed its effects,
outcome and unforeseen complications if any.
Following is the sample draft of informed consent form used by the
author for interventional pain procedures, in more than 2000 pain relief
procedures at Pain Management Clinic of Bombay Hospital and Medical
Research Center and other centers nationally and internationally for more
than fifteen years.
The same form is used by many pain physicians in India and abroad
after obtaining the written consent from the author.
A word of caution for the pain physician who wants to use this form
must check about the certain objectionable clause if any with notary or
lawyer in their country.
40 Interventional Pain Management—A Practical Approach

Informed Consent for Pain Management Procedure Sample Form

Patient Name: __________________________________________________

Age: ______________ Sex: Male/Female Date: _______________

Address: ________________________________________________________

________________________________________________________

I hereby authorize Dr. _____________________ to perform a Pain Management

Procedure Known as _____________________.

This procedure has been explained to me by Dr._________________ and I completely

understand the nature and consequences of the said procedure. The following points have
been made particularly clear.

1. Complications that may follow a procedure with/without relief of pain are same as
those that may follow any other type of surgical procedure, such as infection, haematoma
formation etc. These complications are enhanced in those cases where the patient is
old and infirm, those with Diabetes and hypertension as also with those who have
previous cardiac ailments and decompensation.

2. The drugs that are being used in this procedure are used generally in pain relief
procedure alone. A patient may be allergic/idiosyncratic to this drug and may react
to the drug in an unpredictable fashion and rarely with unpredictable results.

3. Rarely in some procedures may the procedure be followed with paralysis of one or
more limbs? The risk of this has been explained to me.

4. In some procedures, specially prepared long needles have to be used. It is not always
possible to use totally disposable needles in such cases. Though they are fully autoclaved
the possibility of AIDS and B Virus hepatitis cannot be excluded.

5. Specially prepared needles are known sometimes, though rarely to break and if this
happens a foreign body remains within the body and will require surgery to remove it.
If such a procedure need be done then I permit Dr. _________________ to get such
operation performed a surgeon of his choice. Blood transfusions may be required during
or after surgery. Though the blood is fully tested it may give rise to mismatch, B virus,
Malaria as well as AIDS.
6. I understand that the Dr. _________________ relies on the qualified staff provided by
the hospital or nominated by him for postoperative care of the patient. He personally
may not be able to visit the patient everyday.
I am aware that during the course of the procedure unforeseen condition may necessitate
additional or different procedures that those set forth above. I therefore authorize and
request that Dr.. _________________ to perform such procedures as are, in this professional
judgment, necessary; these includes but are not limited to, procedures stated above. The
 Informed Consent for Interventional Pain Procedures 41

Authority granted therein, shall extend to remedying conditions that were unknown
before the start of the operation.

I understand the risks of Local and General anaesthesia. I consent to the

administration of anaesthesia under the supervision of Dr _________________ or
such anaesthesiologist that he shall select, and to the use of such anaesthesia as he may
deem advisable.
The approximate recuperation time and the interval before I can return to work have
been discussed with me. There is no guarantee when I shall be able to resume normal
activities.
I consent to be photographed or filmed before, during and after treatment, and that
these pictures will be property of Dr _________________ and may be published inn
scientific Journals and/or shown for scientific purpose.
I am known/not known allergic to any drug.

I agree to keep Dr. _________________ informed of any change of address so that

he can notify me of any late findings, and I agree to cooperate with Dr.
_________________ in the postoperative care until discharged.

I have read the above consent form/I have been explained the contents of this form
in a language I understand ____________________________________________ and
I understand the contents.

I have had sufficient opportunity to discuss my condition with Dr.

_________________ and all my questions have been answered to my satisfaction. I
believe that I have adequate knowledge on which to base an informed consent to the
proposed treatment.

______________________________ ______________________________
Witness Patient

I ______________________________ (Relation _________________________) of

the patient ______________________________ have understood and been explained
the contents of the above form. The patient cannot be explained as he/she is minor/is
tense and can not be explained as he/she is mentally disturbed and I would rather sign
the form.

______________________________ ______________________________

Witness Relative
42 Interventional Pain Management—A Practical Approach

Five

Role of Investigations in
Interventional Pain Procedures
DK Baheti

INTRODUCTION
Interventional procedure can lead to disturbances physiological and
hemodynamic changes into the body, even though it is done with intention
to relieve pain. It amounts to doing any surgical procedure. So it demands
utmost care and precautions in order to make interventional procedure
safe and can be repeated easily.
The investigations play an important role as it not only tells us about
the physical condition of the patient but also leads to correct diagnosis of
pain syndrome its management and therapy. However the investigation
such as, imaging is a supplement to, not a substitute for a thorough history
and physical examination.
Broadly investigations can be classified into biochemical and diagnostic.

Biochemical Investigations
Biochemical investigations are mainly laboratory investigations, such as:
1. Bleeding time, clotting time and INR: During Interventional procedure
the needle can pass through any vessel and may lead to hematoma.
Secondly many patients can be on thrombolytic agents such aspirin,
clopedrogel, so it is vital to know the status of coagulation.
2. HIV and Australia Antigen.
3. Complete Blood Count: It will give us information about anemia and rise
in white blood count indicate underlying infection.

Diagnostic
The diagnostic investigations are further classified as Imaging studies,
Electromyography and Nerve conduction studies, Thermography,

IMAGING STUDIES
Imaging studies are Plane radiography, Computed tomography (CT), MRI,
Myelography, Nuclear Medicine Scanning, Arthrography, and Discography.
 Role of Investigations in Interventional Pain Procedures 43

The choice of modality depends upon tissue type and likely diagnosis.
CT is best for severe, sudden headaches, trauma, and presumed sinusitis.
MRI for chronic headache and temporomandibular joint dysfunction.

Plain Radiography (Figs 5.1 and 5.2 )

It is very commonly available and least expensive modality and reliable one.
It is rapid and portable. It gives the information about musculoskeletal
disorders including trauma, abnormality of joints, bony structure, and
osteophytes.

Computed Tomography (CT)

It will give us additional information of musculoskeletal system in compare
to plain radiography, especially in regard to joint spaces. It is also helps in
accurate placement of needle while celiac plexus block, cervical spine
injections, and cranial nerve blocks.

Magnetic Resonance Imaging (MRI) (Figs 5.3 and 5.4)

It is modality of choice for spines to know the degree, position and extension
of spinal cord compression due to protruding disc; Musculoskeletal,
intracranial.

Fig. 5.1: Dorsolumbar spine-AP view Fig. 5.2: Lateral view of lumbar spine
44 Interventional Pain Management—A Practical Approach

Fig. 5.3: MRI – showing disc protrusion at L5-S1

Fig. 5.4: MRI – showing root compression at L4-5 root

The use of Gadolinium contrast helps to identify early inflammatory and

infectious process such as post-procedural discitis and suspected intrathecal
catheter tip granuloma. The Gadolinium is iodine free, so it scores over other
agents in iodine allergy patients.
 Role of Investigations in Interventional Pain Procedures 45

MRI is contraindicated in ferromagnetic implants such as Cardiac

pacemakers, intracranial clips or claustrophobic patients. One must verify
with manufacturer for MRI compatibility, while performing intrathecal
implants.

Myelography
This is done to visualize spinal canal and thecal sac. Nowadays MRI has
replaced Myelography. However myelography is indicated in absence of
MRI facility, where MRI does not correlate clinical findings and in
claustrophobic patient.

Nuclear Medicine Scanning (Bone Scan) (Figs 5.5A and B)

This is bone scintigraphy with technetium (Tc)-99 phosphate. It indicates
bone turn over in bone metastases and other disorders involving bone
metabolism.

Arthrography
It is an injection of dye into joint space. Not very commonly done as, replaced
by MRI.

Discography (Fig. 5.6)

This is done to localize the disc herniation or degeneration and for diagnostic
purpose to know the cause of pain. It can be done in conjunction with CT

Figs 5.5A and B: Bone scan-Normal

46 Interventional Pain Management—A Practical Approach

Fig. 5.6: Normal discogram- L2, 3

and MRI. Discography is invasive and has a risk of infection and neural
injury so it should be used as confirmatory and not initially diagnostic tool.

Electromyelography (EMG) and Nerve Conduction Studies:

Electrodiagnostic Studies (EDX) (Figs 5.7 and 5.8)
The history, symptoms, signs and physical examination is of prime
importance. Any patient with neurological or muscular symptoms such as
shooting or burning pain, numbness or weakness then EMG and Nerve
conduction studies can be useful in the evaluation and treatment. Peripheral
nervous system lesions such as dorsal root ganglion and distal can be
assessed with these investigations.
In case of neuropathy EDX studies will show type of axonal or
demyelinating; severity; as well as muscle involvement that may be present
as a result of denervation of the muscle. Severe neuropathies may cause
weakness.
The carpel tunnel syndrome may be bilateral, with only one hand clinically
involved. So it is necessary to examine lower extremity as well to rule out
generalized neuropathy.
For suspected neuropathies in tibialis anterior, EMG needle examination
is recommended as it may show enervation. In order to confirm
radiculopathies both EMG and Nerve conduction studies are necessary. As
NCS may be normal, the needle EMG is diagnostic.
The temperature of extremity will significantly alter the nerve conduction
studies.
 Role of Investigations in Interventional Pain Procedures 47

Fig. 5.7: Normal EMG tracings

Fig. 5.8: Large wide triphasic units on needle EMG of Left TA muscle in Left L5 radiculopathy

In myasthenia gravis antibody assays are helpful to confirm the

diagnosis.
The contraindication for EMG studies is uncooperative and unwilling
patient, coagulopathies, lymph edema or anasarca and in patient muscle
biopsy to be performed.
48 Interventional Pain Management—A Practical Approach

THERMOGRAPHY (FIG. 5.9)

Thermography is noninvasive procedure and easy to use. The qualitative
data obtained reflect quantitative temperature difference up to 0.1°C. The
examination room ambient temperature 20°C, carpeted floor, and
examination table in center of room will give more precise information. The
patient should wear light clothing, have not recently exercised, smoked,
taken vasoconstrictor medicines.
Thermography is a sensitive tool to evaluate the dynamic physiological
changes that reflect the underlying pathology. The changes in the pattern
of temperature will help in differential diagnosis of pain due to peripheral
nerve injury, spinal root pathology and CRPS. For example, increase in
sympathetic activity causes vasoconstriction and resultant decrease in skin
temperature. Whereas decreased sympathetic flow causes increase in regional
blood flow which results in rise in skin temperature.
Thermographic images display temperature differentials in the entire
area scanned. These images reflect alterations in blood flow superficially
or up to 27 mm deep.
Colder temperatures are reflected as blue to black hues and warmer
temperatures are pink to red. The difference in temperature provides
important diagnostic information.
The mean temperature differential in peripheral nerve injury is 1.5°C.
In sympathetic dysfunctions (RSD/SMP/CRPS) temperature differentials
ranging from 1 to 10°C depending on severity are not uncommon.
Rheumatologic processes generally appear as “hot areas” with increased
temperature patterns. The pathology is generally an inflammatory process,
i.e. synovitis of joints and tendon sheaths, epicondylitis, capsular and muscle
injuries, etc.

Fig. 5.9: Normal thermography

 Role of Investigations in Interventional Pain Procedures 49

Both hot and cold responses may coexist if the pain associated with an
inflammatory focus excites an increase in sympathetic activity. Also, vascular
conditions are readily demonstrated by DITI including Raynauds, Vasculitis,
Limb Ischemia, DVT, etc.

RECOMMENDED FOR FURTHER READING

1. David Sutton- Textbook of Radiology
50 Interventional Pain Management—A Practical Approach

Six

Protocol for Interventional Pain

Procedures: A Suggested
Format
DK Baheti

An interventional pain procedure remains the main stay in the treatment

protocol for relief of chronic pain and total pain management.
In the era of internet explosion the physician is accountable for his deeds
while providing the pain relief procedure. In addition the insurance agency
requires to be, satisfied before the reimbursement of the claim.
Hence it is mandatory for pain physician, to follow a strict protocol while
performing any interventional procedure. It will not only provide the safety,
minimum or no morbidity but also ensure the credibility of the procedure
and so of the physician.
The suggested protocol is as follows:-
1. Complete evaluation and documentation of pain problem, history,
symptoms, signs and investigations such as X-ray, CT Scan, MRI,
Electromyelography, Nerve Conduction Study.
2. Explain the patient and family members about the procedure details,
side effects, complications, if any.
3. Informed consent- must explain it in the language in which patient
and his relatives understand, so they will sign the informed consent
willingly.
4. Hospital admission for few hours to few days as the need be.
5. Investigations such as Bleeding time, clotting time, INR ratio (if patient
on anticoagulants); HIV and Australia antigen.
6. Interventional pain procedure should be done either in operating room
or procedure room equipped with monitoring and resuscitation
facilities.
7. Pre procedure monitoring of Blood pressure, pulse.
8. Monitoring of the patient- Pulse, NIBP, and SaO2.
9. Secure I.V. line.
10. I.V. antibiotic cover.
11. Sedation if necessary.
12. Anesthesiologist stands by as and when necessary.
 Protocol for Interventional Pain Procedures: A Suggested Format 51

13. Aseptic precaution such as wearing of gown, gloves, preparation of

the area.
14. Lead gowns along with thyroid shield and radiation gloves (if possible)
for all pain physician and lead gown for all staff present in procedure
or operating room.
15. Radiation counter/measure monitor for pain physician.
16. Procedure tips
A. Keep talking to the patient while performing the procedure, to allay
the fear and anxiety.
B. Follow rule of Three D’s, i.e Direction, Depth, Destination while
performing the procedure under fluoroscopy aim. Aim for Tunnel
vision (Fig. 6.1).

Fig. 6.1: Tunnel vision

C. At regular interval push the needle about 1 cm and confirm the

direction depth and destination.
D. Repeated negative aspiration after confirming position of needle,
injection of dye and local anesthetic agent, steroid, neurolytic agent.
E. Confirm the spread of dye (Figs 6.2 and 6.3).
52 Interventional Pain Management—A Practical Approach

Fig. 6.2: Spread of dye- AP view-transforaminal lumbar epidural showing

dye in epidural space with outlining of L4 nerve root sleeve

Fig. 6.3: Injection of dye and local anesthetic agent

F. Before injecting Neurolytic agent put gauze piece or abdominal

sponge around the needle. This will prevent spilling of neurolytic
agent on the skin and will prevent skin burns (Fig. 6.4).
G. Inject local anesthetic agent into the track of needle while with-
drawing of the needle. This will reduce the post procedure pain at
the site of insertion of needles.
 Protocol for Interventional Pain Procedures: A Suggested Format 53

Fig. 6.4: Sponge around needles during celiac plexus block

17. Documentation in the form of print out, CD-one copy for record and
one for patient.
18. Post-procedure monitoring of vital signs.
19. Follow-up advice must include
• Dosage and schedule of medications
• Explain about possible side effects of the drug
• Date and time of next visit
• Driving instruction to the patient if driving by himself.
54 Interventional Pain Management—A Practical Approach

Seven

Evaluation of Pain Patient

Jitendra Jain, DK Baheti

Pain is one of the most fundamental symptoms of human species showing

dysfunction of the body. Once Pain becomes chronic, it could get
complicated. It might be then difficult to diagnose the physical or functional
problem or the combination of both.
In recent years there has been tremendous interest in pain. As result of
these modern researches there is a lot of information available about pain
development at the Molecular, Physiological and Psychological level. As
this information is applied in clinical practice more and more Clinicians
are getting involved in the patient treatment. This is how Multidisciplinary
Clinics are coming to picture.
Multidisciplinary clinics have clinicians from various specialities namely
Pain Specialist, Neurologist, Psychiatrist, Spine specialist, General
Physician, Physical therapist, Occupational therapist, Pain nurse, Social
worker and Counselors and support staff. Depending on the availability
specialist could be taken and group discussion could be held so as to give
best of the multidisciplinary approach to the patient (Flow chart 7.1). Referring
physician also plays an important role in alleviating patient anxiety about
the Pain Clinic. He or she should be able to convince that the center is a pain
centre where his problem would be heard and required treatment options
would be suggested. Before these patients come to specialists for evaluation
of the Pain, a Pain evaluation should be started by Pain nurse or the support
staff.

Multidisciplinary Requirement
• Pain Physician
• Neurologist
• General Physician
• Psychiatrist
• Spine specialist
• Physical therapist
• Occupation therapist
 Evaluation of Pain Patient 55

• Psychotherapist
• Pain Nurse
• Social worker
• Support staff for clinic.

Flow chart 7.1: Showing approach to a pain patient with a multidisciplinary approach

At our Clinic we have a team of specialist. Before patient comes to

specialist he or she fills a pain evaluation form. It is actually a modified
McGill Pain questionnaire with a local modification to suit patients and
staff. It makes job of specialist very easy since almost all parts which could
contribute to patient’s pain are included in this form. Flow chart 7.1 is showing
what should be a pain specialists approach for a pain patients which in
reassessment in case of poor result. It is also important since it gives patient
a sense of being heard and building rapport with the clinic. Patient should
also explained about the steps of evaluation, i.e. after filling evaluation form
there would be interaction with a clinician on the basis of evaluation form
and examination and if required investigations. After all this treatment
options would be suggested. It again helps patient gaining confidence about
the clinician.

History
It is the most import part of patient management in pain. It gives us a full
insight of patient, his problem, his expectation and possible treatment
option.
56 Interventional Pain Management—A Practical Approach

General
It starts with knowing patient by name and calling him by his name. After
this comes the contact details, age, sex, marital history, occupation, race,
nationality and religion. Then one should start the pain history.

Chief Complain
What is the chief complain of the patient, e.g. is it Pain or Numbness. Because
pain might have a treatment option but numbness might not have any
treatment option. How did the pain start, trauma, accident or previous
surgery, etc. one should note down VAS, i.e. Visual analogue scale of patients
pain (Fig. 7.1).

Fig. 7.1: Visual analogue scale

Pain History
History should revolve around pain, where, when, diurnal variation,
severity, aggravating, relieving factors, referred pain patterns etc. A
characteristic of pain is also important. It could be throbbing might indicate
an inflammatory kind of a pain or a Burning pain which might indicate a
neuropathic pain. Scary pain or fearful pain might give a hint about the
patient personality and his tolerance to pain. Noting down these points is
important since it helps in the treatment of the patient. Pain could be
localized to one place might follow a nerve distribution or might even be
diffuse. Every bit of information is important.

Pain Diagram

Pain diagram (Fig. 7.2) is the next important thing since it denotes the
predominant pain site. If patients have pointed pain in virtually most of his
body or back that might explain about the patient’s mind and his or her
expectation from a pain specialist. Also if in the second visit if patient’s pain
shifts from its original description might need a reassessment or gives us
guide to send the patient to a psychotherapist for analysis.

Past Medical History

Patient’s past medical history might indicate towards an accident or abuse
or previous surgery which might help in treating the patient. Also what
kind of treatment has the patient tried should be mentioned. Has he visited
lots of doctors or hardly any is also helpful in devising treatment strategy.
Associated medical illness which might be contributing to his pain needs
to be attended.
 Evaluation of Pain Patient 57

Fig. 7.2: Pain diagram

Family History
Health of family members, siblings’ relations with them, disputes, family
stress, divorce, financial problems or even abuse history might be helpful.

Personal History
Drug addiction, alcoholism, financial issues, social habits, behavior or sleep
problems gives us an insight about patients pain problem.
Having all above information is important because it helps in under-
standing patients pain problem as well gives us an insight about his per-
sonality, his mental make up and expectations. For example, patients having
pain all over body with numbness all over, giddiness and history of dep-
ression is less likely to respond to an interventional procedure than psychiatry
counseling. History abuse in the patient in childhood or by the husband or a
family member would also need counseling. Patient with a back pain who
doesn’t want surgery could be helped by interventional procedure. So one
can do an overall assessment to see who would need what kind of treatment
to start with.
Following questionnaire shows the General kind of Pain questionnaire.
It mentions about what all kind of leading pain questions to be asked so as to
get best information about patient’s pain. VAS score is very important along
with diurnal variation of pain. It also helps assessing improvement in patients
since the first visit to the clinic. All the points mentioned in type of pain and
disability could also be given score to get a better assessment.
58 Interventional Pain Management—A Practical Approach

Pain Questionnaire (smaller version)

PAIN QUESTIONNAIRE

GENERAL INFORMATION OF PATIENT: INCLUDING NAME, AGE, SEX, HEIGHT,

WEIGHT, MARITAL STATUS, ALLERGIES, OCCUPATION, CHILDREN ETC.

PRESENT VAS SCORE: (VAS from 1-10)

PAIN DIAGRAM:

SITE, ONSET, DURATION AND PROGRESSION OF PAIN:

TYPE OF PAIN: THROBBING/SHOOTING/STABBING/BURNING/CRAMPCURRENT LIKE/

SHARP/ACHE/SPLITTING/SICKENING/FEARFUL/DEADLY/ EXHAUSTING

PAIN IN LAST 24 HRS:

PAIN DAIRY OR DIURNAL VARIATION OF PAIN:

AGGRAVATING FACTORS:
RELIEVING FACTORS:

CONTRIBUTING FACTORS:

DISABILITY:

• PHYSICAL: WALKING/SITTING/STANDING/SLEEPING/SEX/POSITION
CHANGE
• FUNCTIONAL: MOOD SWING/CAN’T WORK OR PERFORM/NOT ENJOYING
LIFE/ AFFECTING RELATIONS

ASSOCIATED PAIN OR REFERRED PAIN:

ANY INVESTIGATIONS:

ATTEMPTED TREATMENT: HOW LONG AND HOW EFFECTIVE

ASSOCIATED ILLNESS AND TREATMENT:

PERSONAL HISTORY: MARITAL/ ADDICTION/DRUGS/SLEEP/DEPRESSION OR OTHER

SIGNIFICANT HISTORY

PAST HISTORY:

FAMILY HISTORY:

Examination
It is usually done to ascertain the cause of pain and its relation to the
underlying disease. Even if it might not be really beneficial in some cases but
still it assures about the competence level of the physician and he feels that
his complains have been taken seriously. Patient should be appropriately
undressed, if situation demands undress fully. It is advisable to have a female
attendant with you while examining a female patient. Specific examination
of various parts of body is beyond the scope of this chapter. Our attempt is to
give you an overview of the examination so one does not neglect an important
aspect of the examination.
 Evaluation of Pain Patient 59

General Examination

Built of the patient, skin color, weight loss signs, weakness, contractures,
deformity, swelling of limbs and posture. Pulse, respiration, blood pressure,
height and weight should be recorded while observing patient for signs of
anxiety, tremors or sweating etc.

Systemic Examination

It is not always needed in depth unless patient has a systemic disease but is
usually required to complete the list.

Localized Examination

One should be careful and warn patient of increased pain while performing
localized area examination. If patient doesn’t want that area to be touched
then kindly make a note of it and report accordingly after inspection of the
local area.
Inspection: It should involve checking the color of skin, surrounding area
skin color, scar, wasting in comparison to opposite side, swelling or loss
creases etc. also range of motion around that area or joint should be observed.
Active and passive movement should be observed.
Palpation: It should include first palpating the painful area, is it tender or
finding a trigger point, consistency feel, presence of allodynia or hyperesthesia
etc. Palpating the surrounding area for pain is also important. Patient’s
reaction while examining him or her should be noted. Shouting or constant
crying while examination indicates about the pain behavior of patient.

Neurological Examination

It is usually a must during examination. It might include cranial nerves if

required otherwise usually include examining the area involved with the
opposite side area or limb. In case of upper limb, lower limb examinations
should be done to see if there is any lower limb involvement and vice versa.
Sensory: Pinprick, light touch, position sense, reflexes, strength and vibration
of the dermatomes or an individual peripheral nerve.
Motor: Muscular atrophy, gait, power, flicker or flutter of localized muscles
etc. of the group of muscles or individual muscle.
Cerebrum: Mood, Memory, Orientation etc.
Sympathetic Function: Sweating, Piloerection to gentle stroking of affected
skin and Skin temperature.

Specific Examinations
Straight leg raising for Lumbar disc prolapse, spine flexion, extension and
rotation with reporting of localized pain and its referring pattern. Breath
60 Interventional Pain Management—A Practical Approach

related pain could be examined in trunk related cases. Specific area related
examination is beyond the scope of this chapter but should be performed so
as to come to a diagnosis.
Sometimes it might be difficult to perform examination due to extreme
pain. Diverting patient’s mind might sometimes decrease pain and allows
examination. It should be tried in difficult cases. There is nothing in having
a shorthand book of examination in the clinic so one can just browse through
before or during examination.
Only after a thorough history and examination one should think of
sending the patient for a laboratory investigation or a scan. One should not
forget that patient’s pain and laboratory report or scan finding might co-
relate. One must always record visual analogue scale of the patient during
interview.

Diagnostic Evaluations
Depending on patient’s history and examinations laboratory tests or scanning
or X-rays are asked for. Depending on clinical impression patient might be
even sent for a proper psychosocial evaluation. If required one might need to
do a differential diagnostic interventional block like in cases of low back
pain.

Commonly Done Diagnostic Tests

• X-ray of respective area.
• Scan either MRI or CT of the respective area. Sometimes it might needed
to be done with contrast so as to enhance scanning as in cases of failed
back surgery. Also in the patients with cancer pain to detect the spread.
• Doppler scan for limb pain.
• Bone scan for back or limb joints or metastasis.
• EMG and Nerve conduction studies.
• HLA B27, RA factor, ANA, Uric acid might be required to rule Immu-
nological arthritic disorders.
Still inspite of all above investigations one needs to correlate these
finding with patients symptom and treat accordingly.

Diagnostic Tests
• Nerve root blocks to assess the level which is causing pain in cases of
confusion about multiple levels
• Median branch block for Facet Syndrome
• Discography in cases with multiple levels Discogenic pain
• Sympathetic block to ascertain Sympathomimetic pain.
These are few blocks mentioned are usually useful in cases where there is
diagnostic dilemma inspite of scans etc. and Pain generator could not be
found. Also before performing a Neurodestructive procedure a diagnostic
 Evaluation of Pain Patient 61

block is a must. Depending on the pain generator, therapeutic modality

needed to treat one particular pain could be applied so as to treat patients
pain.

RECOMMENDED FOR FURTHER READING

1. Bonica’s Management of Pain: (3rd Edn), Chief editor; John D Loeser. Lippincott
Williams and Wilkins.
2. Melzack R. The McGill pain questionnaire: Major properties and scoring
methods. Pain 1975;1:277-99.
62 Interventional Pain Management—A Practical Approach

Eight

Stimulation Guided
Pain Mapping
Sanjeeva Gupta, Jonathan Richardson

INTRODUCTION
Pain is a subjective symptom and expression of pain for the same degree of
nociceptive input can vary between individuals. The nerve roots involved in
carrying the nociceptive impulses can be identified either by looking at the
pain dermatomal maps or by injection of a small amount of local anesthetic
along the nerve roots involved and assessing the patient’s response. There is
always a possibility that the injected local anesthetic can soak adjacent nerve
roots, which can confuse the issue. Stimulation guided steriotactic pain
mapping allows us to identify precisely the nerve roots involved in carrying
the nociceptive impulses and gives us an anatomical diagnosis of the nerve
roots involved. This can help us to target the available treatments precisely.
In our experience we have found this technique useful when patients
complain of symptoms from a wide area of a particular part of the body.

Indications
The procedure is indicated when patients have pain in a particular part of
the body and the nerve roots involved in carrying the nociceptive impulse
needs to be identified to plan further management.

Contraindications
Absolute contraindications: Systemic or localized bacterial infection in the
region of the block to be performed, bleeding diathesis, possible pregnancy.
Relative contraindications: Allergy to contrast medium and local anesthetic.

Equipment
Fluoroscopy is mandatory: The procedure is performed under aseptic conditions.
25G and 21G hypodermic needles, 2ml and 5 ml syringes can be used.
 Stimulation Guided Pain Mapping 63

A 22-gauge, 100 mm long radiofrequency needle, with 5 mm active tip is

used. Intravenous solutions, sedation or antibiotics are not required.
Lignocaine 1% for local anesthesia.

Procedure (Figs 8.1 to 8.4)

The patient is assessed for suitability of the procedure and an informed
consent is obtained. The procedure is done under strict aseptic conditions
and fluoroscopic guidance. A 22G, 100 mm long radiofrequency needle
with 5 mm active tip is placed along the Dorsal Root Ganglion (DRG) in
question using a sub pedicular technique1-4 and sensory stimulation applied
at 50Hz. The stimulation is gradually increased and the patient’s response
assessed. The part of the body where the patient experiences pain and/or
paresthesiae on sensory stimulation is noted. The optimal stimulation at
which the pain and/or paresthesia is reproduced should be between 0.3
and 0.6 V. The same procedure is carried out at the adjacent levels if
appropriate until all the area where the patient experiences pain is covered.
Once the procedure is complete the information obtained is used to identify
the DRG involved in carrying the nociceptive impulses from the painful
area and further treatment planned.
As an example we had a patient who had a degloving injury to his left
lower limb. When the above technique was used we were able to reproduce
the patient’s pain in the left lower limb on stimulating the left L3, L4 and
L5 DRG between 0.3 and 0.5 V. This patient has pulsed radiofrequency
lesioning of the respective DRG and obtained significant pain relief. Similar
procedures to identify the DRGs involved in nociceptive perception have
been carried out at the thoracic levels for patients presenting with chronic
chest pain due to various causes.

Fig. 8.1: Radiofrequency needle in position just below the left

L4 pedicle in left oblique view
64 Interventional Pain Management—A Practical Approach

Fig. 8.2: Tip of the radiofrequency needle in the intervertebral

foramen at L4 level in lateral view

Fig. 8.3: Tip of the needle below the left L4 pedicle in AP view. Note that the
tip of the needle is at about the 6 O’ clock position of L4 pedicle

Fig. 8.4: Injection of contrast medium outlines the left L4 nerve root
along with the dorsal root ganglion
 Stimulation Guided Pain Mapping 65

Discussion
If the needle is appropriately placed, pain and/or paresthesiae is produced
in a dermatomal distribution. If the patient experiences pain and/or
paresthesiae in the area where he/she normally experiences pain this suggests
that the DRG in question is involved in the nociceptive perception. One or
several levels can be tested in a similar manner to come to an accurate
diagnosis to plan further available treatments. The possibility of local
anesthetic spillage to adjacent DRG is avoided by using stimulation technique
to identify the DRGs involved in carrying the nociceptive message.
In the case mentioned above we were able to reproduce the patient’s
symptoms on stimulating the left L3, L4 and L5 DRG. The patient had
DRG block which helped temporarily. Subsequently the patient had Pulsed
Radiofrequency lesion at the same levels and has benefited greatly. In a
patient with chest pain following rib fractures clinical examination
suggested that the pain could be in the T6, T7 and T8 levels but on stimulation
of T7 DRG we were able to reproduce all the patients pain symptoms giving
us the precise DRG involved in carrying the nociceptive impulse to target
future treatments.

Conclusion
In our opinion stimulation guided pain mapping is a very useful technique
in identifying the DRG/Nerve roots involved in carrying the nociceptive
impulses which can help us target available treatments precisely.

REFERENCES
1. N Bogduk (Ed). Lumbar Spinal Nerve Block. In: Practice guidelines for spinal
diagnosis and treatment procedures. International Spin Intervention Society
2004:3-19.
2. Guarino A, Staats P. Diagnostic neural blockade in the management of pain.
Pain Digest 1997;7:194-9.
3. Levy B. Diagnostic, prognostic, and therapeutic nerve blocks. Arch Surg
1997;112:870-79.
4. Kline MT. Radiofrequency techniques in clinical practice. In: Waldman S (Ed).
Interventional Pain Management. Philadelphia, WB Saunders 2001;243-93.
 Nine

Trigeminal Nerve Block

Jitendra Jain

Trigeminal neuralgia (TN) is one of the classical neuropathic pain conditions

that have been known for centuries.1 As far as history is concerned, Absolute
alcohol injection was first described by Hartel2 then in 1965 Hakanson S3
described Radiofrequency lesioning and Fujimaki T4 about the Glycerol
injection for the Trigeminal Neuralgia.
The International Association for the Study of Pain and the International
Headache Society both have diagnostic criteria for trigeminal neuralgia
(TN) that emphasize the severe paroxysmal nature of typical trigeminal
neuralgia. The paroxysms of electric shock like pain that are often triggered
by light mechanical stimulation of a trigger point are extremely painful.
Treatment for it is initial pharmacotherapy with anticonvulsants like Carba-
mazepine, Gabapentine and the latest one Pregabalin. If the symptoms are
not controlled by these medications or have side effects which are not tolerable
then advanced option like Interventions by means of Neurolysis of Trigeminal
nerve5 or Thermocoagulation by Radiofrequency6 current could be attempted
as a minimally invasive safer option.

ANATOMY
Trigeminal nerve is one of the largest cranial nerves. It carries sensory fibers
from Oral Mucosa, Conjunctiva, Tooth pulp, Gingiva and also anterior and
middle cranial fossa. Trigeminal ganglion which is also known as Gasserian
ganglion lies in Meckel’s cave which is close to petrous part of temporal
bone, it is formed by the two roots that exit the ventral surface of the brain-
stem at the mid pontine level. Meckel’s cavity or cave lies in the middle
cranial fossa. Medial to Trigeminal ganglion is bounded by the cavernous
sinus; superiorly by the temporal bone of the brain and posteriorly is the
brainstem. It gives off three branches intracranially namely—Ophthalmic,
Maxillary and Mandibular. The exit of these three nerves is superior-medial
to lateral and inferior respectively. Ophthalmic and Maxillary are sensory
nerves while a small motor root joins mandibular division as it exits the
cranial cavity via the foramen ovale (Figs 9.1 and 9.2).
70 Interventional Pain Management—A Practical Approach

B
Figs 9.1A and B: Showing the trigeminal ganglion, its branches,
foramen ovale and sphenopalatine ganglion
 Trigeminal Nerve Block 71

Fig. 9.2: Showing facial area cover by trigeminal nerve branches V1

(1st Ophthalmic), V2 (2nd Maxillary) and V3 (3rd Mandibular)

Indications
• Trigeminal neuralgia
• Cluster headache
• Intractable facial pain
• Oral or facial cancer
• Postintracranial or microvascular surgery pain
• Ocular pain due to glaucoma.

Contraindications
• Infection
• Sepsis
• Coagulopathy.

Equipment and Drugs

• 25G ¾ inch needle
• 22G 1½ inch needle or spinal needle
• 10 cm radiofrequency needle with 5 mm active tip
• 5 ml and 10 ml syringe
• 1 to 2% lignocaine
• 0.25 to 0.5% bupivacaine
• Depot steroids usually not required
• 6 to 10% phenol 1 ml
• Alcohol 95 to 97%
• Glycerol 40 to 50%
• Radiofrequency generator.
72 Interventional Pain Management—A Practical Approach

Preparation
Preprocedure history and physical examination of the local area before
Trigeminal ganglion block is a must. Coagulation profile and requisite
preoperative blood investigation of the patient could be done depending
on the patient.
For this block usually sedation is required especially when Radio-
frequency Thermocoagulation ablation is planned.
Patient is explained about the nature of the procedure. Patients is also
informed that during the procedure he would be asked about numbness
or current like sensation on face while stimulating the nerve and if it is
covering the area of his pain. Patient should be told that there might be
slight numbness over face after the procedure.

Position
Supine with extension of cervical spine and if needed roll under the shoulder
blade, depending upon the C-arm visualization

Procedure
Preoperative antibiotic and intravenous sedation is supplemented before
starting the procedure. Usually the entry point for the needle for Trigeminal
block is 2.5 to 3 cm from the angle of the mouth. First antiseptic is applied.
Local anesthetic using 1% Lignocaine is given along the skin and possible
track of Radiofrequency needle but well short of foramen ovale with the
spinal needle (Fig. 9.3).

Fig. 9.3: Showing the direction of the needle, to be entering 2.5 to 3 cm from the
angle of mouth and not medial to the center of the pupil

There are few different ways in which C-arm could be placed for doing
Gasserian Ganglion block.
 Trigeminal Nerve Block 73

Fig. 9.4: Showing needle in the foramen ovale in submental view.

Also try to appreciate the foramen ovale on the opposite side

• Submental position of the face and jaw or of the beam of C-arm (Fig. 9.4).
• Caudal and lateral movement of C-arm so as to get the foramen between
the mandibular ramus and maxillary sinus and foramen ovale is then
visible as a slit opening usually near the upper half of Mandibular ramus
• Good old lateral C-arm placement while directing the needle into the
foramen ovale (Figs 9.5 and 9.6).
In first two ways of placing C-arm the needle is directed towards the
foramen ovale with “Tunnel view” and once deep enough and nearing
foramen ovale lateral view is taken so as to check the depth of the needle.
Once the needle enters foramen there might be sharp pain to patient as needle
might be close to the mandibular nerve at the entry point of the foramen
ovale. Needle is pushed till the intersection of petrous part of temporal bone
and clivus. Needle should not be pushed beyond that point (Figs 9.5 and
9.6).
Confirmation is usually by C-arm. If required contrast with iopamide
0.1 ml or 0.5 ml could be injected. There might be CSF flow from needle. Most
confirmatory would be stimulating the required segment of the nerve, either
V1 or V2 (Maxillary) or V3 (Mandibular). V2 or V3 is more common than
ophthalmic division, i.e. V1.

Neurolysis
Usually Glycerol is used for Neurolysis of the Gasserian Ganglion. Alcohol
and Phenol Neurolysis is not recommended for trigeminal ganglion
neurolysis. Contrast injection of iopamide checks the correct placement of
needle and then Glycerol to about 0.1 to 0.5 ml is injected. Patient is warned
74 Interventional Pain Management—A Practical Approach

Fig. 9.5: Shows needle inside the foramen ovale in lateral C-arm view. Needle is just
touching the clivus and not deeper than that, also approximately at the intersection of the
clivus and petrous part of the temporal bone

Fig. 9.6: Showing needle in the foramen ovale under CT guidance

of sudden pain or headache due to glycerol injection. Before injecting glycerol

clear CSF flow is required and patient is place in semi sitting position with
neck flexed for next 2 hours so that neurolysis of V2-V3 only occurs.

Radiofrequency Ablation
Trigeminal ganglion should get stimulated with sensory stimulation at 50 to
100 Hz with 0.1 to 0.5 V. Patient is asked to confirm the numbness or
stimulation over face. Confirmation that numbness covers the painful area
is the prerequisite before starting the Radiofrequency ablation. CSF leakage
is not a must for Radiofrequency but negative aspiration with optimum
 Trigeminal Nerve Block 75

impedance of 150 to 400Ω is desirable. After confirmation either good

intravenous sedation or local anesthesia with 0.25% bupivacaine or 2%
lignocaine at the trigeminal ganglion level is required so as to minimize the
pain of Radiofrequency ablation. One has to make sure that there is no
intracranial leakage before injecting local anesthetic.
Heating could be started at 46°C or at 55°C as test lesion then increase to
about 60 to 70°C for 90 seconds. The conventional setting of 80°C for 60 sec to
90 sec is not recommended so as to decrease incidence of loss of corneal
reflex and risk of anesthesia dolorosa. At least 2 lesions at that level would
be giving a good Thermocoagulation near the ganglion level.
Pulsed Radiofrequency is a good option for Trigeminal neuralgia
patients. The usual setting would be used, i.e. 42°C for 120 sec. again at least
2 cycles should be used. It would help preserve the corneal reflex and also
decrease the incidence of anesthesia dolorosa. Although long-term results
are doubtful but still it remains an attractive mode to be used for these
patients.
Other minimally invasive interventional modalities used for Trigeminal
Neuralgia Treatment:
• Microcompression lesioning
• Gamma Knife Radio-lesioning
• Permanent peripheral electrode stimulation.

Complications
• Anesthesia dolorosa
• Loss of corneal reflex
• Neurolytic keratitis
• Retrobulbar hematoma
• Carotid puncture
• Meningitis
• Intracranial brainstem radiofrequency lesioning
• Motor deficit of mandibular nerve, mastication difficulty
• Cheek hematoma.
Post-procedure it could be advisable to put ice pack over the cheek so as
to decrease the cheek hematoma. Procedure is usually day care and patient
could be discharged after few hours of the procedure unless the attending
doctor feels otherwise.
If one is careful and observant with the point mentioned above for doing
the procedure then one should not observe above listed complications. In
case of V1 sensory deficit one should visit ophthalmologist regularly.
In most cases pain relief is immediate with immediate cessation of
medication. Sometimes relief might take more than 1 to 2 week to be effective.
These procedure are very effective with most patients have pain relief of
usually more than their expected duration of pain relief, i.e. 6 months in case
of radiofrequency ablation or even neurolysis. After recurrence procedure
could easily be repeated. While performing repeat procedure one should be
76 Interventional Pain Management—A Practical Approach

cautious as there might be fibrosis especially after neurolysis or difficult

previous procedure of radiofrequency ablation. In older and edentulous
patients the skin entry point could be made between 3 to 4 cm from the angle
of the mouth so as to enter foramen ovale straight rather then at an angle.

REFERENCES
1. P Prithvi Raj, et al. Radiographic Imaging for Regional Anesthesia and Pain
Management (1st edn). Churchill Livingston 2003.
2. Steven Waldman. Atlas of interventional pain management (2nd edn).
Saunders 2004.
3. Håkanson S. Comparison of surgical treatments for trigeminal neuralgia:
Re-evaluation of radiofrequency rhizotomy. Neurosurgery 1997;40:1106-7.
4. Fujimaki T, Fukushima T, Miyazaki S. Percutaneous retrogasserian glycerol
injection in the management of trigeminal neuralgia: Long-term follow-up
results. J Neurosurg 1990;73:212-6.
5. Fraioli B, Esposito V, Guidetti B, et al. Treatment of trigeminal neuralgia by
thermocoagulation, glycerolization, and percutaneous compression of the
gasserian ganglion and/or retrogasserian rootlets: Long-term results and
therapeutic protocol. Neurosurgery 1989;24:239-45.
6. Taha JM, Tew JM, Buncher CR. A prospective 15-year follow up of 154
consecutive patients with trigeminal neuralgia treated by percutaneous
stereotactic radiofrequency thermal rhizotomy. J Neurosurg 1995;83:989–93.
 Ten

Maxillary Nerve Block

Jitendra Jain

INTRODUCTION
Maxillary nerve is the 2nd division of the Trigeminal nerve, also know as V2
division of Trigeminal nerve. Blocking of Maxillary nerve is useful for nasal,
upper jaw pathologies.

ANATOMY (FIG. 10.1)

It is purely sensory nerve. As 2nd division of the Trigeminal Ganglion it goes
anteriorly and inferiorly along the cavernous sinus through the foramen
rotundum. It continues along the pterygopalatine fossa in the inferior portion
of the infraorbital foramen. It is accompanied by the Maxillary artery in the

Fig. 10.1: Shows the division of trigeminal nerve. Maxillary nerve the V2 division travel
just above the lateral pterygoid plate in the pterygopalatine fossa
78 Interventional Pain Management—A Practical Approach

pterygopalatine fossa. The sensory fibers connect the maxillary nerve to the
sphenopalatine ganglion by way of five branches. Sensory branches of
maxillary nerves which are about 10 in number carry sensation from soft
palate, hard palate, gums, teeth, upper jaw, dura and parasympathetic fibers.

Indications
• Regional anesthesia for maxillofacial surgeries
• Diagnostic and therapeutic block for chronic nasal, upper jaw paiful
conditions such as cancer.

Contraindications
• Local, nasal infection
• Coagulopathies
• Distorted anatomy.

Equipment and Drugs

• 25G ¾ inch needle, for local infiltration
• 22G 1½ inch needle or spinal needle, depending on the built of the patient
• 5 ml and 10 ml syringe
• 1 to 2% lignocaine
• 0.25 to 0.5% bupivacaine
• Depot steroids usually triamcinolone or alphamethyl prednisolone
40 mg
• 10 cm radiofrequency needle with 5 mm active tip
• Radiofrequency generator
• Alcohol 99%
• Phenol 6%.

Preparation
Preprocedure history and physical examination of the local area before
maxillary nerve block is a must. Coagulation profile and requisite preoperative
blood investigation of the patient could be done depending on the patient.
For this block usually no sedation is required unless radiofrequency
thermocoagulation ablation is planned. Patient is explained about the nature
of the procedure. Patients is also informed that during the procedure he or
she might feel numbness or current like sensation in the nose or upper jaw
when needle is maneuvered to target area or while stimulating the nerve.
Patient should be told that there might be slight numbness over nasal, upper
jaw area after the procedure.

Position
• Supine position or sitting if patient is co-operative with head straight
looking at the ceiling.
• Make sure height is comfortable for you to do the block.
 Maxillary Nerve Block 79

Procedure
Preoperative antibiotic is supplemented before starting the procedure. Usual
external approach is from the center of the Coronoid notch, i.e. mandibular
notch of the mandibular bone. Point of entry is just below the zygomatic arch
and anterior to temporomandibular joint. First antiseptic is applied. Local
anesthetic using 1% lignocaine is given along the skin. Needle is then pushed
medially perpendicular to the skin. After about a distance of 3 to 5 cm one
might encounter bone which would be lateral pterygoid plate of sphenoid
bone (Figs 10.2 and 10.3). Once the lateral pterygoidal plate is hit then the
needle is withdrawn and directed anterio-superiorly at about 45 degrees.
One should go past the Lateral pterygoid plate. Needle should not go beyond
1.5 cm after hitting lateral pterygoid plate. Paresthesia might be encountered
if maxillary nerve is hit. Use of peripheral nerve stimulator would be strongly
recommended to place the needle as close to the maxillary nerve as possible.
C-arm could also be used to reassure the placement of the needle by injecting
contrast. Once confirmed the placement then 2 to 4 ml of local anesthetic is
injected. If it is a diagnostic block then 1 to 3 ml is sufficient or else for a
therapeutic block 3 to 5 ml is injected.

Fig. 10.2: Needle hits the lateral pterygoid plate

and then is redirected towards maxillary nerve

Under C-arm guidance the needle is entered in the usual fashion and
directed towards the inverted vas on the C-arm picture (Fig. 10.4A ). Needle
should not go further than lateral border of nose just at the superio-medial
aspect of the maxillary sinus on the AP view of C-arm (Fig. 10.4B).
80 Interventional Pain Management—A Practical Approach

Fig. 10.3: Showing transverse section of the face showing needle hitting the lateral
pterygoid plate and redirected for maxillary nerve. Also note needle direction for blocking
mandibular nerve

Figs 10.4A and B: Showing C-arm picture of needle placement for maxillary
nerve block, A is in the lateral view and B is in the AP view

Neurolysis
Neurolysis is done for chronic pain maxillary, nasal, upper jaw, soft or hard
palate cancers. Volume of the neurolytic solution should be same as the local
anesthetic block, i.e. 3 to 5 ml. Neurolytic solution could be alcohol 99% or
phenol 6%. It should be given slowly in 0.1 to 0.2 ml increaments so as to
prevent accidental orbital, intracranial or vascular injection. One should
keep in mind that as maxillary nerve is blocked in pterygopalatine fossa,
sphenopalatine ganglion would also get blocked.
 Maxillary Nerve Block 81

Radiofrequency Ablation
Radiofrequency ablation of the maxillary nerve is possible. Standard
parameters should be for radiofrequency ablation of the maxillary nerve.
Sensory stimulation of 50 Hz at 0.4 to 0.6 V would be the ideal response.
Conventional radiofrequency is used at 80°C for 90 sec after injecting local
anesthetic with 2 % lignocaine or 0.5% bupivacaine.
Pulsed Radiofrequency or Pulsed Electromagnetic field should be used
for the peripheral nerve like maxillary nerve after confirming the needle
placement. Lesion is made at 42°C for 120 sec. At least 2 to 3 lesions are done
to a good pulsed radiofrequency lesion.

Complication
Usually maxillary nerve block is a very straight forward procedure if
performed properly. Needle if pushed further could enter pterygomaxillary
fissure. If pushed further could also enter orbit and block optic nerve as well
leading to temporary or permanent blindness if neurolysis is done. Before
injecting needle placement should be confirmed under C-arm guidance so as
to prevent any accidental intravascular injection. There is also possibility of
cheek hematoma.

RECOMMENDED FOR FURTHER READING

1. P Prithvi Raj, et al. Radiographic imaging for regional anaesthesia and pain
management (1st Edn). Churchill Livingston 2003.
2. Steven Waldman. Atlas of interventional pain management (2nd Edn).
Saunders 2004.
3. Romanoff M. Somatic nerve blocks of the head and neck. Raj PP. Practical
management of pain (3rd Edn). St Louis, Mosby 2000;579-96.
82 Interventional Pain Management—A Practical Approach

Eleven

Mandibular Nerve Block

Jitendra Jain

INTRODUCTION
Mandibular nerve is third branch of trigeminal nerve, known as V3 division
of trigeminal nerve. Blocking of mandibular nerve is useful for post-operative
pain relief of the jaw and also in chronic pain conditions like cancer of
intraoral areas, e.g. lower jaw, tongue or oral mucosa, etc.

ANATOMY
Mandibular nerve emerges from the floor of middle cranial fossa.1,2 As the
V3 division of trigeminal nerve it comes out of the foramen ovale into the
infratemporal fossa (Fig. 11.1). Infratemporal fossa where mandibular nerve

Fig. 11.1: Showing the mandibular nerve coming out of trigeminal nerve just
posterior to the lateral pterygoid plate. Also shown in the diagram is the approach to the
needle through the coronoid notch
 Mandibular Nerve Block 83

enters after coming out of cranial cavity appears to be a rectangular structure.

Posteriorly it is bound by the carotid sheath and styloid apparatus. Anteriorly
is the posterior wall of the maxillary sinus, laterally is the ramus of mandible
and medially it is bound by the lateral pterygoid plate which is the posterior
extension of the sphenoid bone. It soon divides into small anterior and large
posterior trunk. The small anterior trunk gives off branch to masseter the
muscle of mastication and a sensory branch covering the sensory area
overlying the muscle namely buccinator intraorally and over the skin.
The large posterior trunk divides into auriculotemporal, lingual and
inferior alveolar nerve. It covers the anterior and external ear, temporo-
mandibular joint, parotid gland and temporal area. Intraorally it takes
sensory sensation from the anterior 2/3 of tongue, lower jaw and mucosa
of the cheek.

Indications
• Chronic pain conditions like Ca. tongue, lower jaw or floor of the mouth
• Acute pain conditions like fracture of mandible, preoperative, intrao-
perative or postoperative conditions.

Contraindication
• Local infection
• Coagulopathies
• Distorted anatomy.

Equipment and Drugs

• 25G ¾ inch needle, for local infiltration
• 22G 1½ inch needle or spinal needle, depending on the built of the patient
• 5 ml and 10 ml syringe
• 1 to 2% lignocaine
• 0.25 to 0.5% bupivacaine
• Depot steroids usually triamcinolone or alphamethyl prednisolone
40 mg
• 10 cm radiofrequency needle with 5 mm active tip
• Radiofrequency generator
• Alcohol 99%
• Phenol 6%.

Preparation
Preprocedure history and physical examination of the local area before
Mandibular nerve block is a must. Coagulation profile and requisite
preoperative blood investigation of the patient could be done depending
on the patient.
For this block usually no sedation is required unless Radiofrequency
Thermocoagulation ablation is planned. Patient is explained about the nature
84 Interventional Pain Management—A Practical Approach

of the procedure. Patient is also informed that during the procedure he or she
might feel numbness or current like sensation on the jaw when needle is
maneuver to target area or while stimulating the nerve. Patient should be
told that there might be slight numbness over jaw area after the procedure.
Also if neurolysis is planned then there might be weakeness in chewing
from that side of the jaw.

Position
• Supine position or sitting if patient is cooperative with head looking at
the ceiling
• Make sure height is comfortable for you to do the block.

Procedure
Preoperative antibiotic is supplemented before starting the procedure. Usual
external approach is from the center of the coronoid notch, i.e. mandibular
notch of the mandibular bone. Point of entry is just below the zygomatic arch
and anterior to temporomandibular joint. First antiseptic is applied. Local
anesthetic using 1% lignocaine is given along the skin. Needle is then pushed
medially perpendicular to the skin. After about a distance of 3 to 5 cm one
might encounter bone which would be lateral pterygoid plate of sphenoid
bone (Figs 11.2 and 11.3). One needs to slowly walk past the posterior edge of
the lateral pterygoid plate maintaining the same depth at the same level.
Patient might encounter paresthesia at this point. Use of peripheral nerve

Fig. 11.2: Showing needle hitting the lateral pterygoid plate

and redirected posteriorly to the mandibular nerve
 Mandibular Nerve Block 85

Fig. 11.3: Showing tranverse section of the face, showing needle

hitting the lateral pterygoid plate and redirected for mandibular nerve.
Also note that for blocking maxillary needle goes anteriorly

stimulator would be strongly recommended to place the needle as close to

the nerve as possible. C-arm could also be used to reassure the placement of
the needle by injecting contrast and using peripheral nerve stimulator. Once
confirmed the placement then 2 to 4 ml of local anesthetic is injected.
Continuous catheter could also be placed once the placement is confirmed
especially for post-operative pain relief patients.

Neurolysis
Neurolysis is done for inoperable oral cancer patients, although it is not
done very commonly. Volume of the neurolytic solution should be same
as the local anesthetic block, i.e. 2 to 4 ml. Neurolytic solution could be
alcohol 99% or phenol 6%. It should be used in incremental doses of 0.1 to 0.2
ml so as to prevent any form of accidental intravascular or intracranial
injection.

Radiofrequency Ablation
Radiofrequency ablation of the mandibular nerve can be done instead of
neurolysis. Standard parameters should be for radiofrequency ablation of
the Mandibular nerve. Sensory stimulation of 50 Hz at 0.4 to 0.6 V would
be the ideal response. Conventional radiofrequency is used at 80°C for 90 sec
after injecting local with 2 % lignocaine or 0.5% bupivacaine.
Pulsed radiofrequency or pulsed electromagnetic field should be applied
instead of conventional high temperature radiofrequency ablation after
confirming needle placement. Lesion is done at 42°C for 120 sec. At least
86 Interventional Pain Management—A Practical Approach

2 to 3 lesions are done to a good pulsed radiofrequency lesion. Pulsed

radiofrequency is strongly recommended instead of conventional high
temperature (80°C) radiofrequency ablation so as to preserve the motor
function. Immediate post-procedure there might be weakness of the jaw along
with numbness. Patients should be warned about these in advance.

Complication
Usually mandibular nerve is a very straight forward procedure if performed
properly. Needle if pushed further could enter pharynx. Needle could be
close to middle meningeal artery in the infratemporal fossa. So careful
aspiration is a must. Hematoma of the cheek is also a possibility.
Depth required to get the mandibular nerve should not be more than 5 to
6 cm. If one needs to go further kindly check the landmarks again used to do
the block.

RECOMMENDED READING
1. P Prithvi Raj, et al. Radiographic imaging for regional anaesthesia and pain
management (1st Edn). Churchill Livingston 2003.
2. Steven Waldman. Atlas of interventional pain management (2nd Edn). Saunders
2004.
3. Romanoff M. Somatic nerve blocks of the head and neck. Raj PP. Practical
management of pain (3rd Edn). St Louis, Mosby 2000, 579-96.
 Twelve

Sphenopalatine
Ganglion Block
Jitendra Jain

Sphenopalatine ganglion has generated interest of most of the medical

faculty for various reasons. It has been blamed for facial pain, headache,
dysmenorrhea, allergies and also sciatica.

ANATOMY (FIG. 12.1)

It is the largest group of neurons outside the cranial cavity. The SPG is one
of four parasympathetic ganglia in the head. It is located in the pterygo-
palatine fossa, posterior to the middle nasal turbinate under a 1 to 1.5 mm
layer of connective tissue and mucous membrane and anterior to the pterygoid
canal. This superficial location allows the block to be performed with topical
anesthetic or by injection.

Fig. 12.1: Showing SPG in pterygopalatine fossa with suspended from

maxillary nerve via sphenopalatine nerves
88 Interventional Pain Management—A Practical Approach

The pterygopalatine fossa is 1 cm wide and 2 cm high. It is bordered

anteriorly by the posterior wall of maxillary sinus, posteriorly by the medial
plate of the pterygoid sinus. Medially it has perpendicular plate of the
palatine bone while laterally there is infratemporal fossa. Superiorly it has
sphenoid sinus. Caudally the ganglion connects to the greater and lesser
palatine nerve.
The sensory afferent axons traveling through the SPG arise from the
maxillary division of the trigeminal nerve, which enters the pterygopalatine
fossa through the foramen rotundum to lie just superior to the SPG. The
sensory fibers connect the maxillary nerve to the SPG by way of five
branches that extend from the nasopharynx, nasal cavity, palate, and orbit.
The pharyngeal branch supplies the sphenoidal sinus and the mucosa of
the roof of the pharynx via the palatine canal, the greater palatine nerves
extend posteriorly, and the inferior nasal branches supply the palate via
the greater palatine foramen. The tonsil and soft palate are supplied via
the lesser palatine nerve as it arises from the lesser palatine foramen. The
nasopalatine nerve emerges through the sphenopalatine foramen, passes
along the nasal septum, and emerges through the median incisive foramen
to reach the hard palate. The posteriorly is ethmoidal and sphenoidal sinuses
below the periosteum of the orbit are supplied via the orbital branches.
The nasal cavity is supplied via the posterior superior nasal branches.
Sphenopalatine ganglion has a very complex ganglion in terms of its
neural connections. The nerve fibers leading into the SPG, i.e. sphenopalatine
ganglion has sensory nerve supply via the sphenopalatine nerve and the
maxillary nerve (establishing a strong “fine-fiber” connection between
trigeminal fibers and parasympathetic fibers inside the ganglion). It also has
the parasympathetic connection from the vagus nerve and the
3 vagal ganglia in the brain stem. Parasympathetic nerves travels on to the
nucleus petrosus major and fibers of the facial nerve originating at the ganglia
geniculi (establishing a connection to the 7th cranial nerve) which synapse
in the SPG with postganglionic fibers. These postganglionic fibers go to the
nasal mucosa and lacrimal glands.
The sympathetic connection is via the nucleus petrosus profundus
(establishing a connection with the superior cervical ganglion and the SNS).
The postganglionic fibers from upper cervical sympathetic ganglion join
the carotid plexus. Then from there via deep petrosal nerves and vidian
nerve they join the SPG.

Indications
• Sphenopalatine neuralgia
• Cluster headache
• Migraine
• Trigeminal neuralgia
• Atypical facial pain
• Post herpetic neuralgia of face
• Cancer pain of palate, base of tongue or pharynx.
 Sphenopalatine Ganglion Block 89

Contraindications
• Local infection
• Coagulopathy.

Equipment and Drugs

• 25G ¾ inch needle
• 22G 1½ inch needle or spinal needle
• 10 cm radiofrequency needle with 5 mm active tip
• 5 ml and 10 ml syringe
• 1 to 2% lignocaine
• 0.25 to 0.5% bupivacaine
• Lopamide/Iohexol
• Methylprednisolone or triamcinolone diacetate
• Radiofrequency generator.

Preparation
Patient preparation for a sphenopalatine ganglion blockade consists of
thorough patient education of the procedure, risks, benefits, expected
outcome, written informed consent, and large bore intravenous access.
Patient monitoring should include blood pressure and heart rate monitoring
and pulse oximetry is advised to observe any potential cardiac effects.
Ruling out local infection is a must. Radiofrequency ablation of SPG should
be performed under sedation.

Position
Position of the patient is supine. C-arm is place in lateral position so that TM
joint and external auditory meatus of both sides are overlap each other.
Pterygopalatine fossa should be visible as “inverted vas” posterior to
maxillary sinus and just anterior to anterior end of petrous part of temporal
bone (Figs 12.2 and 12.3).

Fig. 12.2: Showing needle in the “inverted vas” under C-arm which is pterygopalatine fossa
90 Interventional Pain Management—A Practical Approach

Fig. 12.3: Showing needle through the center of the coronoid notch, although in diagram it
looks as if it is over zygomatic arch but in reality it goes underneath the zygomatic arch

Procedure
Under strict aseptic precaution the local anesthetic is injected under zygoma
and above the coronoid notch. The radiofrequency insulated 10 cm needle is
then inserted with its direction towards the inverted vas means slightly
superior medial and anterior. Depth of the needle is checked on AP view. It
should not cross the lateral border of nose and should sort rest at the superior-
medial end of the maxillary sinus on C-arm (Fig. 12.4).

Fig. 12.4: Showing needle till the lateral border of nose and at the
superior-medial end of maxillary sinus on the C-arm
 Sphenopalatine Ganglion Block 91

Once the needle has reached the required area then stellate is removed
and local anesthetic either bupivacaine 0.5% is injected or lignocaine 2% is
injected with or without steroid. Volume usually should not be more than 2
ml, so if one is injecting contrast then be sure about the volume. Negative
aspiration is must to blood or clear fluid which could even be CSF. This
would mainly work as a diagnostic cum therapeutic block. If it is positive
then radiofrequency of the same could be planned at a later date.

Radiofrequency Ablation1,2
Once the needle is in place then SPG is stimulated to 50 Hz at 0.4 to 0.6 V.
Stimulatory response of the patient is important. If it stimulated upper
teeth then one might be close the maxillary nerve. If one is having numbness
or stimulation of hard or soft palate then needle might be inferior. The best
stimulation felt is in the nose or at the base of the nose. Also there might be
stimulation of the painful area. Once the stimulatory parameters are met
then conventional radiofrequency is used at 80°C for 90 sec after injecting
local with 2% lignocaine or 0.5% bupivacaine.
Pulsed radiofrequency or pulsed electromagnetic field could be applied
as well once confirming the needle placement at 42°C for 120 sec. At least 2 to
3 lesions are done so get a good effective lesion of SPG.

Complications
• Bleeding as nose is rich in vasculature, usually respond to pressure
• Infection if nasal mucosa is breached at the lateral border of nose
• Bradycardia while performing radiofrequency ablation. Atropine should
be kept ready.
After procedure patient might have hypoesthesia of palate, maxilla and
of posterior pharynx. It is again a day care procedure and patient can go
home after few hours of the procedure. In case of recurrence procedure
could be easily repeated.

REFERENCES
1. Salar G, Ori C, Iob I. Percutaneous thermocoagulation for sphenopalatine
ganglion neuralgia. Acta Neurochir (Wien) 1987;84:24-8.
2. Miles Day. Neurolysis of trigeminal and sphenopalatine ganglion: Pain practice
2001;1(2):171-82.

RECOMMENDED FOR FURTHER READING

1. Prithvi Raj, et al. Radiographic imaging for regional anaesthesia and pain
management (1st Edn). Churchill Livingston 2003.
2. Steven Waldman. Atlas of interventional pain management (2nd Edn). Saunders
2004.
92 Interventional Pain Management—A Practical Approach

Thirteen

Glossopharyngeal
Nerve Block
PN Jain

INTRODUCTION
Pain in the afferent distribution of the glossopharyngeal and vagus nerves
may be felt in the larynx, base of the tongue, tonsillar region, ear and
occasionally ipsilateral face, neck or scalp. Paroxysm of pain of unknown
etiology occurring in this distribution may be due to glossopharyngeal
neuralgia. The attacks are usually described as stabbing, sharp, ‘like a knife’,
‘like an electric shock’, and sometimes hot or burning. The intensity is
probably less intense than trigeminal neuralgia (TN). It may indeed be
confused with TN. Both neuralgias may be due to focal pressure along the
course of the nerve. It may be tortuous vertebral artery or posterior inferior
cerebellar artery impinging on the roots of ninth nerve. It may be trauma,
local infection, alongated styloid process or ossified styloid ligament.
However unlike TN, ninth nerve neuralgia is almost never associated with
multiple sclerosis. Patients are often more than 20 years old. Men and women
are equally affected. There is slight predominance of left sided cases in large
series. Individual attacks commonly last seconds or minutes and rarely occurs
at night. Pain is triggered by swallowing, yawning, coughing, and chewing.
A variety of cardiovascular and other symptoms may accompany the attacks.
Due to overlap of the sensory teritories of the seventh, ninth and tenth cranial
nerves a lesion of one does not always cause loss of sensation in the throat or
ear.

APPLIED ANATOMY (FIG. 13.1)

The glossopharyngeal nerve contains both motor and sensory fibers. The
motor fibers innervate the stylopharyngeus muscle. The sensory portion of
the nerve innervates the posterior third of the tongue, palatine tonsils, and
the mucous membranes of the mouth and pharynx. Special visceral afferent
sensory fibers transmit informations from the taste bud of the posterior third
of the tongue. Information from the carotid sinus and body that helps control
blood pressure, pulse and respiration is carried via the carotid sinus nerve
which is branch of the glossopharyngeal nerve. Parasympathetic fibers pass
 Glossopharyngeal Nerve Block 93

Fig. 13.1: Extraoral technique of IX nerve block

via the glossopharyngeal nerve to the otic ganglion. Postganglionic fibers

form the ganglion carry secretory information to the parotid gland.
The glossopharyngeal nerve exit from the jugular foramen in proximity
to the vagus, accessory nerves and the internal jugular vein. All three nerves
lie in the groove between the internal jugular vein and the internal carotid
during glossopharyngeal nerve block can result in intravascular injection or
hematoma formation. Even small amounts of local anesthetic injected into
the carotid artery at this location can produce profound local anesthetic
toxicity (Fig. 13.2).

Fig. 13.2: Surface anatomy: glossopharyngeal nerve block

The landmarks for glossopharyngeal nerve block include the styloid

process of the temporal bone. This osseous process represents the
calcification of the cephalad end of the stylohyoid ligament. Although the
process is usually easy to identify, if ossification is limited, it may be difficult
to locate with the exploring needle.
94 Interventional Pain Management—A Practical Approach

Glossopharyngeal nerve block with local anesthetic may be utilized for

palliation in acute pain emergencies, including glossopharyngeal neuralgia1
and cancer pain, during the wait for pharmacologic, surgical, or anti-
neoplastic methods to become effective. Additionally, this technique is of
value in patients with atypical facial pain2 in the distribution of the glosso-
pharyngeal nerve. Glossopharyngeal nerve block3 is also useful as an adjunct
to awake endotracheal intubation.
Destruction of the glossopharyngeal nerve4 is indicated in the palliation
for cancer pain, for example, from invasive tumors of the posterior tongue,
hypopharynx, and tonsils. The technique is also useful in the management
of the pain of glossopharyngeal neuralgia that has not responded to medical
management or in patients who are not candidates for surgical microvascular
decompression.

Indications for glossopharyngeal Nerve Block

Local anesthetic block Surgical anesthesia
Prognostic block before neurolytics
Adjunct to awake endotracheal intubation
Neurolytic block Palliation of cancer pain
Management of glossopharyngeal neuralgia

Contraindications to Glossopharyngeal Nerve Block

• Local infection
• Sepsis
• Coagulopathy
• Disulfiram therapy (if alcohol is used)
• Significant behavioral abnormalities
Local infection and sepsis represent absolute contraindications to all
procedures. Coagulopathy is a strong contraindication for glossopharyngeal
nerve block; however, owing to the desperation of many patients suffering
from aggressively invasive head and face malignancies, ethical and
humanitarian considerations dictate the use of this procedure despite the
risk of bleeding.
If there are strong clinical indications, blockade of the glossopharyngeal
nerve utilizing a 25-gauge needle may be carried out in the presence of
coagulopathy, albeit with an increased risk of ecchymosis and hematoma
formation.

TECHNIQUE OF GLOSSOPHARYNGEAL NERVE BLOCK

The Extraoral Approach
The patient is placed in the supine position. An imaginary line is visualized
running from the mastoid process to the angle of mandible. The styloid process
should lie just below the midpoint of this line. The skin is prepared with
antiseptic solution. A 22-gauge, 1.5 inch needle attached to a 10 ml syringe is
advanced through this midpoint location in a plane perpendicular to the
 Glossopharyngeal Nerve Block 95

skin. The styloid process should be encountered within 3 cm after contact is

made the needle is withdrawn and “walked off” the styloid process
posteriorly. As soon as bony contact is lost, and if careful aspiration reveals
no blood or cerebrospinal fluid, 7 mL of 0.5% preservative-free lidocaine
combined with 80 mg of methylprednisolone injected in incremental doses.
Subsequent daily nerve blocks are carried out in a similar manner, substituting
40 mg of methylprednisolone for the initial 80 mg dose. This approach may
also be utilized for breakthrough pain in patients who previously experienced
adequate pain control with oral medications.

The Intraoral Approach

The tongue is anesthetized with 2.0% viscous lidocaine. The patient is asked
to open the mouth widely, and the tongue is retracted inferiorly with a tongue
depressor or laryngoscope blade. A 22-gauge, 3.5 inch spinal needle that has
been bent about 25 degrees from horizontal is inserted through the mucosa
at the lower lateral portion of the posterior tonsillar pillar. The needle is
advanced approximately 0.5 cm after careful aspiration for blood and
cerebrospinal fluid, local anesthetic or steroid is injected as for the extraoral
approached glossopharyngeal nerve block.5

POTENTIAL COMPLICATIONS
The complications and unwanted side effects of blockade of the
glossopharyngeal nerve blocked are as follows:
• Dysphagia
• Ecchymosis and hematoma
• Post-procedure dysesthesias, including anesthesia dolorosa
• Weakness of trapezius muscle
• Weakness of tongue
• Hoarseness
• Infection
• Tachycardia
• Local anesthetic toxicity
• Trauma to nerves
• Sloughing of skin and subcutaneous tissue.
The major complications are related to trauma of the internal jugular
and carotid arteries. Hematoma formation and intravascular injection of
local anesthetic with subsequent toxicity represent significant problems for
the patient. Blocked of the motor portion of the glossopharyngeal nerve can
result in dysphagia secondary to weakness of the stylopharyngeus muscle.
If the vagus nerve is inadvertently blocked as often happens during
glossopharyngeal nerve block, dysphonia secondary to paralysis of the
ipsilateral vocal cord may occur. A reflex tachycardia secondary to vagal
nerve block is also observed in some patients. Inadvertent block of the
hypoglossal and spinal accessory nerves during glossopharyngeal nerve
block results in weakness of the tongue and trapezius muscle.
96 Interventional Pain Management—A Practical Approach

A small proportion of patients who undergo chemical neurolysis or

neurodestructive of the glossopharyngeal nerve experiences post-procedure
dysesthesias in the area of anesthesia. These symptoms range from mildly
uncomfortable burning or pulling sensation to severe pain. Severe post-
procedure pain, called anesthesia dolorosa, can be worse than the patient’s
original pain complaint and is often harder to treat. Sloughing of skin and
subcutaneous tissue had been associated with anesthesia dolorosa.
As mentioned previously, the glossopharyngeal nerve is susceptible to
trauma from needle, hematoma, and compression during injection proce-
dures. These complications, although usually transitory, can be quite up-
setting to the patient.

NEURODESTRUCTIVE PROCEDURES
The injection of small quantities of alcohol, phenol, and glycerol into the
area of the glossopharyngeal nerve has been shown to provide long-term
relief for patients with glossopharyngeal neuralgia or cancer-related pain
that has not responded to optimal trials of the previously mentioned therapies.
Destruction of the glossopharyngeal nerve can be also carried out by creating
a radiofrequency lesion6 under biplanar fluoroscopic guidance. This
procedure is reserved for cases that have failed all the previously described
treatments for intractable glossopharyngeal neuralgia and in patients whose
physical status precludes more invasive neurosurgical treatments.

REFERENCES
1. Dany JB. A study of four cases of glossopharyngeal neuralgia: Its diagnosis
and treatment. Arch Sug 1927;15:198-215.
2. Walman SD. The role of neural blockade in the management of headaches
and facial pain. Headache Digest 1991;4:286-92.
3. Brown DL. Glossopharyngeal nerve block. In Brown DL (Ed): Atlas of regional
anaesthesia. Philadelphia, Lea and Febiger 1990;1996-9.
4. Waldman SD, Waldman KA. The diagnosis and treatment of glossopharyngeal
Neuralgia. Am J Pain Management 1995;5:19-24.
5. Katz J. Glossopharyngeal nerve block. In Katz (Ed). Atlas of regional anaes-
thesia. Norwalk. CT. Appleton and Lange 1994:52.
6. Arbit E, Krol G. Percutaneous radiofrequency neurolysis guided by
computerized tomography for the treatment of glossopharyngeal neuralgia.
Neurosurgery.
 Fourteen

Stellate Ganglion Block

Preeti Doshi

Sympathetic block in the neck is the most commonly performed procedure

in the practice of chronic pain for problems involving head, face, neck and
upper arm. It is advocated for diagnostic, therapeutic and prognostic
purposes.
Selective sympathetic block was first described by Sellheim followed
shortly by Kappis1 who described use of sympathetic block in paravertebral
region for treatment of severe visceral pain syndromes. Shortly thereafter
Mandl2 in 1924 introduced percutaneous interruption of sympathetic chain
to treat pain of vascular insufficiency of lower extremities, which has been
the mainstay of treatment thereafter to treat the ischemic pain.
Current indications for the sympathetic blocks are diagnosis and treat-
ment of sympathetically maintained pain, treatment of neuropathic pain
states like post herpetic neuralgia or ischemic pain. They can also help
differentiate between somatic and sympathetic origin pain. Pain syndromes
responsive to initial block are then treated with repeated blocks or followed
by surgical, chemical or radio frequency sympathectomy.3
Stellate word is derived from its Latin equivalent, which implies star
shaped. Although stellate ganglion block is a commonly used term, stellate
ganglion [fusion of inferior cervical and first thoracic ganglia] is found in 70
to 80% individuals and hence perhaps either lower cervical sympathetic or
upper thoracic sympathetic block or cervicothoracic sympathetic block are
more appropriate terms.4

ANATOMICAL CONSIDERATIONS
The sympathetic chain extends from second cervical vertebra to the coccyx.
In the cervical and thoracic region it lies anterior to the bases of the transverse
processes or head of the ribs. They lie in close proximity to the somatic nerves.
However as it courses caudally towards the lumbar region it becomes more
anterolateral to the vertebral bodies and gets separated from somatic nerves
by the psoas muscle.3
Four cervical sympathetic ganglia are anatomically identified bilaterally
in most individuals. The upper three do not contribute much to the pain
98 Interventional Pain Management—A Practical Approach

practice and hence will not be discussed here. The cell bodies for the
preganglionic nerves are located in the anterolateral horn of the spinal cord;
fibers for the head and neck originate in the T1, T2 spinal cord segments,
whereas preganglionic nerves to the upper extremity originate at the T2-
T8 segments and at times T9. Preganglionic axons to the head and neck
exit with the ventral roots of T1 and T2, then travel as white rami before
joining the sympathetic chain and passing cephalad to synapse either at
the inferior [stellate], middle or superior cervical ganglion. Postganglionic
nerves either follow the carotid arteries to the head or integrate as the gray
communicating rami before joining the cervical plexus or upper cervical
nerves to innervate the structures of the neck.
To achieve successful sympathetic denervation of the head and neck,
the stellate ganglion should be blocked, because all the preganglionic nerves
either synapse here or pass on their way to more cephalad ganglia.
Sympathetic nerves to the upper extremity exit T2-T8 through ventral
spinal routes, travel as white communicating rami to the sympathetic chain,
then pass cephalad to synapse at the T2 ganglion, first thoracic or the inferior
cervical ganglion, and occasionally middle cervical ganglion. Most
postganglionic nerves leave the chain as gray communicating rami to join
the anterior divisions at C5-T1, nerves that form the brachial plexus. Some
postganglionic nerves pass directly from the chain to form the subclavian
perivascular plexus and innervate the subclavian, axillary and upper part
of the brachial arteries.
Inferior cervical ganglion in 70 to 80 % individuals is fused with the first
thoracic ganglion forming the stellate ganglion. It measures approximately
2.5 cm long, 1.0 cm wide and 0.5 cm thick. It usually lies in front of the neck
of first rib and extends to the interspace between C7 and T1.When elongated;
it may overlie the anterior tubercle of C7.
In persons with unfused ganglia, the inferior cervical ganglion rests
over C7 and the first thoracic ganglion over the neck of the first rib5
(Fig. 14.1).
Stellate ganglion is medially and posteriorly limited by the longus colli
muscle, the transverse process and prevertebral fascia, laterally by the
scalene muscles, anteriorly by the subclavian artery, and inferiorly by the
posterior aspect of pleura. Having originated from the subclavian artery
anteriorly, the vertebral artery enters the vertebral foramen and is located
posterior to the ganglion (Fig. 14.2).
Because the classic approach to the blockade of the stellate ganglion are
the anterior divisions of the C8 and T1 nerves. The Stellate ganglion supplies
sympathetic innervation to the upper extremity through the grey
communicating rami of C7, C8, T1 and occasionally C5 and C6. Other
inconstant contributions to the upper extremity are from the T2 and T3
gray rami which do not pass through stellate ganglion but join brachial
plexus to innervate the structures of the upper extremity. These fibers are
implicated when relief of the sympathetically mediated pain is inadequate
despite a satisfactory stellate ganglion block evidenced by a Horner’s
syndrome.
 Stellate Ganglion Block 99

Fig. 14.1: Anatomy of stellate ganglion

Fig. 14.2: Cross-section at C6 level

100 Interventional Pain Management—A Practical Approach

INDICATIONS
It is a widely practiced block for a variety of indications. They can broadly
be divided into three groups as follows:
1. Pain syndromes of head, face, neck and upper arm
a. Complex regional pain syndromes (CRPS) I and II [Post traumatic
syndromes]
b. Acute herpes zoster and post herpetic neuralgias
c. Phantom limb pain/post amputation stump pain
d. Pain secondary to neoplastic infiltration, Sudeck’s atrophy, Paget’s
disease
e. Post mastectomy neuropathic pain of the breast/pain due to Lym-
phoedema
f. Orofacial pain syndromes including neuropathic pain following
trigeminal ganglion ablation
2. Circulatory insufficiency of the upper extremity
a. Prevascular surgery for diagnostic/prognostic value
b. Post reimplantation surgery or post embolectomy vasospasm
c. Traumatic or embolic occlusion
d. Raynaud’s disease or phenomenon
e. Scleroderma
f. Vasculitis
g. Accidental injection of α-adrenergic drugs [e.g. thiopentone]
3. Miscellaneous:
• Hyperhidrosis
• Menier’s disease
• Certain types of cardiac arrhythmias.
Simultaneous bilateral stellate ganglion blocks are not advocated, except
for patients with pulmonary embolism where they may help if performed
immediately.

CONTRAINDICATIONS
Absolute contraindications are as follows:
• Local infection
• Patient refusal
• Patients with coagulopathy or on anticoagulants due to the possibility
of puncturing vital blood vessels in the neck
• Pneumonectomy or pneumothorax on the contralateral side
• Recent cardiac infarction, because stellate ganglion block cuts off the
cardiac accelerator nerves with deleterious effects.

Relative Contraindications
• Glaucoma due to possible rise in the intraocular pressure
• Atrioventricular block due to fear of aggravation of bradycardia.
 Stellate Ganglion Block 101

Preparation of the Patient

After ensuring suitability of the patient to undergo the procedure, one should
examine for the following before proceeding:
• Anatomical variation
• Neck mobility/extension
• Prior radical neck surgery/thyroid surgery scar
• Any infection at the site of injection
A pain physician should have a detailed discussion with the patient and
relatives about various aspects of the procedure like the immediate reversible
effects, possible complications and discharge instructions and so on. If the
cause of pain is unclear and block is diagnostic, a clear understanding may
allow the patient to record valuable information vital for diagnosis. The
goals of blockade and the number of blocks given vary with each individual
patient and each pain condition. A thorough explanation about realistic
expectation at a preprocedure visit will reduce the frustration and despair of
the patient. An informed consent is mandatory.
All standard resuscitation equipment, drugs, suction, oxygen delivery
systems, cardiac defibrillator, equipment for endotracheal intubation should
be readily accessible.
Placement of an intravenous line for sedation if necessary or adminis-
tration of emergency drugs is a sensible precaution, which I strongly
recommend. Monitored anesthesia care should also be offered.

EQUIPMENT AND DRUGS

Equipment
• 22G 1½” long needle
• 10 cm extension tube with a three-way
• 25 g hypodermic needle for local infiltration.

Optional
If RF lesion to be done:
• 5 or 10 cm pole needle with 2 to 5 mm exposed tip for radiofrequency
lesion
• Radiofrequency lesion generator.

Drugs
• Local anesthetic-0.25% bupivacaine or 0.5% ropivacaine
• 2% lignocaine for infiltration
• Steroids [optional]
• Non-ionic dye-omnipaque 240 or 300
• Neurolytic drug if indicated- 6% phenol or 100% alcohol.
102 Interventional Pain Management—A Practical Approach

TECHNIQUE
Literature has described various techniques based on the need for blocking
particular segments of sympathetic chain. By far the most popular one has
been the anterior paratracheal approach at C6 level, in view of the simplicity
and reliability with minimum complication rate. The Stellate ganglion block
has been conventionally performed blindly by surface landmarks. I
personally strongly recommend use of imaging for precision and safety. One
may use fluoroscopy, ultrasonography6 or CT scan as per the availability
and convenience. Use of imaging is mandatory for chemical or RF ablation
or for the posterior approach.

Blind Approach (Fig. 14.3)

The operator should identify the C6 tubercle or Chassaignac’s tubercle to
accurately place needle for the blind approach. The jaw may be kept slightly
open to relax the muscle. The patient should refrain from speaking as this
can move the muscle and dislodge the needle. She should be instructed to
raise her hand to indicate any difficulty. The carotid sheath should be
retracted laterally with non-dominant hand to prevent inadvertent puncture
of these vital structures.

Fig. 14.3: Point of entry at the cricoid level

Fluoroscopy Guided Approach

Patient is positioned supine with head straight without a pillow and a pad
beneath the shoulder on a radiolucent table (Fig. 14.4). This facilitates
extension of the neck and accentuates the landmarks. Hyperextension also
moves the oesophagus out of the way of point of entry. The operator should
identify the C6 tubercle (Chassaignac’s tubercle) to accurately place the needle
 Stellate Ganglion Block 103

Fig. 14.4: Position for doing [R] stellate ganglion block

for blind approach. The jaw may be kept slightly open to relax the muscle.
The patient should refrain from speaking as this can move the muscle and
dislodge the needle. She should be instructed to raise his hand to indicate
any difficulty.
The skin is aseptically prepared and draped. Index finger of the
nondominant hand should be used for palpation of the landmarks. After
making a skin wheal, 22 G short-bevel needle is introduced with the
dominant hand directly posterior perpendicular to the table in all directions.
The needle passes through underlying tissues till it contacts the bone at the
C6 tubercle on transverse process or its junction with the vertebral body.
Once the bone is encountered the needle is withdrawn 2 to 5 mm to avoid
injecting into the longus colli muscle. The needle should preferably be
attached to the extension tubing with the three-way to avoid chances of
displacement while attaching the syringe. One can also release the dominant
hand to aspirate and/or inject while grasping the hub with an artery forceps.
After negative aspiration, 2 to 3 ml of the dye can be injected to ascertain
proper position of the needle tip. Aim for a linear spread of the dye in
vertical direction on fluoroscopy (Fig. 14.5A). One can also verify the dye
spread on lateral view (Fig. 14.5B). An initial test dose should be injected in
all patients. An intravenous bolus of as less as 1.0 ml can produce seizure or
loss of consciousness. Careful and repeated aspiration for CSF and blood is
mandatory.
A modification of this technique includes needle placement at the C7
level.7 This is impossible without imaging as there is no tubercle and injury
to the pleura and vertebral artery is quite likely. The advantage is one can
use minimal amount of the drug like 1 to 2 ml for sympathetic block of the
head, face and neck.10 ml of local anesthetic is required to reach a level of
T2/T3 to block sympathetic outflow of the upper extremity.4
104 Interventional Pain Management—A Practical Approach

Fig. 14.5A: Vertical dye spread in AP view

Fig. 14.5B: Spread of dye in lateral view

A continuous technique has been described where a thin Teflon catheter

is inserted under image guidance onto C6 or C7 through a thicker cannula
which is later on removed.7 There is however a small risk of catheter migration
to the dural cuff or adjacent vessels. A continuous infusion can be given to
obviate the need for a series of blocks in patients with vascular insufficiency
or post herpetic neuralgia.8
 Stellate Ganglion Block 105

SUCCESSFUL SYMPATHETIC BLOCK

A successful sympathetic block to the head and neck can be recognized by
the Horner’s syndrome, which includes Ptosis, Meiosis, Enophthalmos, and
Anhidrosis. It may also cause conjunctival injection, nasal congestion.
However the presence of Horner’s syndrom does not always indicate
complete interruption of the sympathetic innervation of the upper extremity.
The following signs indicate effective sympathetic blockade of the upper
extremity:
• Dilatation of veins in the upper extremity.
• Elevation of the temperature of the skin by 1 to 3° measured by Thermo-
graphy or contact thermometry that is good except for the patients with
elevated temperature.
• Increase in the skin resistance [Sympathogalvanic response].
Malmqvist et al9 recommended that successful sympathetic block should
satisfy five criteria, which include:
a. Horner’s syndrome within 300 seconds.
b. Final skin temperature of 34°C or more, assuming an original
temperature of 32° C or lower, i.e. 1 to 3° temperature increase.
c. An increase in blood flow by 50% or more from preblock status.
d. An increase in skin resistance by 13° or more from preblock on the ulnar
and radial side of the blocked extremity.
e. Pulse amplitude changes, which are difficult to quantify.
Microneurography is a direct but invasive test requiring elaborate equip-
ment and experience. Temperature measurement is the most widely used
technique to assess complete sympathectomy of the affected side.

Selection of the Level of the Sympathetic Block

Matsumotos and Malmqvist et al reported that blockade at the level of C6
vertebra produced more successful sympathetic blockade to the head and
neck with less success of sympathetic block of the upper extremity. C7
level block produces more successful block of the upper extremity. More
appropriately, a sympathetic block by posterior approach to T2-T3 is more
reliable for the upper extremity.
Any local anesthetic can be used but a smaller volume (1-2 ml) will help
the operator to predict the response to radiofrequency ablation or chemical
ablation. Precise injection using fluoroscopy or MRI guidance is therefore
vital.

Post-procedure Care
The patient should be given a 15° head up position for about 10 to 15 minutes.
Patients often have a lumpy feeling in the throat and should be kept nil by
mouth for at least four hours. They also need to be reassured about the signs
of Horner’s syndrome which disappear by about 2 hours.
106 Interventional Pain Management—A Practical Approach

Complications
These can be classified into three categories as follows:

Technical Complications
• Vasovagal attacks
• Injury to the nerves and nearby viscera during insertion
• Injury to brachial plexus
• Trauma to the trachea or oesophagus [mediastinal or surgical emphy-
sema]
• Injury to the pleura or lung [pneumo/hemothorax]
• Injury of the thoracic duct on the left side
• Bleeding or local hematoma: Airway compression
• Post procedure neuritis in 10 to 15% patients lasting 3 to 6 weeks.

Infectious Complications
• Cellulitis
• Osteitis
• Local abscess.

Pharmacological Complications
These can be related to the dose, volume and site of deposition of local
anesthetic.

• Recurrent laryngeal nerve palsy: Hoarseness of voice, feeling of lump

in throat
• Respiratory difficulty due to phrenic nerve palsy
• Somatic blockade of brachial plexus roots due to spillage
• Intraarterial injection into vertebral or carotid artery-seizures
• Injection into the intrathecal or epidural space
• Bradyarrhythmias and hypotension
• Cerebral air embolism.
The most feared complications of the block are intraspinal injection or
seizures triggered by intravascular injection. If these occur one has to
institute resuscitative measures including intubation. Oxygen and mecha-
nical ventilation are required till the local anesthetic wears off and patient
resumes breathing. Mild sedation and reassurance may be needed to allay
anxiety. I.V. fluids and vasopressors may be given, as required. The effects
are generally self-limiting.

Chemical Neurolysis
The approach is similar to the stellate ganglion block performed at the level
of C7. A 22 G needle is introduced at the C7 level at the junction of the
transverse process with the vertebra. After confirming a good spread of
 Stellate Ganglion Block 107

the dye a total of 3 to 5 ml is injected. In AP view it should spread to inferior

cervical ganglion cephalad, first thoracic sympathetic ganglion caudal.6 In
lateral view it should spread to retropharyngeal space in front of the longus
colli muscle. A mixture of 2.5 ml of 6% phenol, 1 ml of 40 mg triamcinolone
and 1.5% of 0.5% ropivacaine has been suggested. Head is maintained in
elevated position for 30 minutes to prevent spread of phenol to the other
structures.

Radiofrequency Neurolysis
This technique in experienced hands can provide long-term attenuation
from pain in safer way, as it can be very precise having minimum effects
on the adjacent vital structures.10
A 20 or 22 G special insulated blunt needle with 5 mm active tip is
introduced through a special angiocatheter at the junction of the transverse
process with the vertebral body. The depth and direction should be
confirmed with AP and lateral views. Correct placement of the tip may be
confirmed also by injecting a small amount of the contrast medium. A
sensory (50 Hz, 0.9 V) and a motor (2Hz, 2V) stimulation trial must be
performed. This helps in ruling out placement close to the phrenic nerve
(lateral) and the recurrent laryngeal nerve (anterior and medial). While
motor stimulation is performed, the patient should say “ee” to ensure
preservation of the motor function. An 80° C lesion for 60 seconds is delivered.
The needle is then redirected to the most medial aspect of the transverse
process in the same plane. Motor and sensory stimulation is repeated to
ensure safety. A third and final lesion should be directed at the upper portion
of the junction of the transverse process and the body of C7.
Potential complications of radiofrequency lesioning are similar to those
caused by stellate injection. Some specific ones are persistent Horner’s
syndrome, injury to the phrenic nerve, recurrent laryngeal nerve, neuritis
(10-15% patients lasting 3-6 weeks) and vertebral artery injury.

Postsympathectomy Syndrome
Post sympathectomy neuralgia is a poorly understood painful condition,
which occurs in up to 50% of patients undergoing sympathectomy. This is
proposed to be a complex neuropathic and central deafferentation and
reafferentation syndrome.11 This can occur anywhere from few days to weeks
following chemical or surgical sympathectomy. This is characterized by deep,
aching pain with superficial burning and hyperesthesia, which may or may
not respond to narcotic analgesics. Tricyclic antidepressants may help reduce
the incidence of postsympathectomy neuralgia. Antiepileptic drugs like
Phenytoin, Carbamazepine or Gabapentin may be useful to reduce
spontaneous pain and allodynia. Mexiletine and I.V. lignocaine may help
some patients. Occasionally invasive therapies like sympathetic block or
more complete sympathectomy can also help.
108 Interventional Pain Management—A Practical Approach

CONCLUSION
Stellate ganglion block is one of the most frequently performed procedure in
the practice of chronic pain. It can provide good diagnostic, therapeutic and
prognostic value. It is strongly recommended to perform the block under
fluoroscopic guidance. It can produce complete sympathectomy to the head
and neck structures but only a partial sympathetic block of the upper
extremity in some patients with variation in anatomy. Here T2-T3 sym-
pathectomy may be desirable.

REFERENCES
1. Kappis M. Weitere erfahrungen mit der sympathectomie. Klin Wehr
1923;2:1441.
2. Brumm F. Die paravertebral injektion zur bekaempfung visceraler schmerzen.
Wien Klin Aschsch 1924;37:511.
3. Warfield CA, Bajwa ZH. Principles and Practice of Pain Medicine, TATA
McGraw Hill 2005;696-8.
4. Elias M. Review Article-Cervical Sympathetic and Stellate Ganglion Blocks.
Pain Physician 2000;3:294-304.
5. Ellis H. Feldman S. Anatomy for the anaesthetists, (3rd edn). Oxford blackwell
scientific publications 1979;256-62.
6. Hogan Q, Erickson S, Haddox D et al. The spread of solution during the
stellate ganglion block. Regional anaesthesia 1992;17:78-83.
7. Elias M. The anterior approach for thoracic sympathetic ganglion block using
a curved needle. Pain clinic 2000;12:17-24.
8. Elias M, Chakerian M. Repeated stellate ganglion block using a catheter for
paediatric herpes zoster ophthalmicus. Anaesthesiology 1994; 1994:950-52.
9. Malmqvist El, Bengtsson M, Sorenson J. Efficacy of stellate ganglion block: A
clinical study with bupivacaine. Reg Anaes 1992;17:340-47.
10. Geurts JW, Stolker RJ. Percutaneous radiofrequency lesion of the stellate
ganglion in the treatment of pain in the upper extremity reflex sympathetic
dystrophy. Pain clinic 1993;6:17-25.
11. Kramis RC, Roberts WJ, Gillette RG. Post-sympathectomy neuralgia:
Hypotheses on peripheral and central neural mechanisms. Pain 1996;64;1-9.
 Fifteen

Nerve Blocks for the

Scalp and Injections
Tilottama Mangeshikar

SENSORY SUPPLY OF THE SCALP

Six Sensory Nerve Branches of Either the Trigeminal Nerve or the
Cervical Nerve Supply to the Scalp
• The supratrochlear nerve is a branch of the ophthalmic division of the
trigeminal nerve. This nerve supplies the scalp in the medial plane at
the frontal region up to the vertex.
• The supraorbital nerve is also a branch of the ophthalmic division of
the trigeminal nerve. This nerve supplies the scalp at the front, lateral
to the supratrochlear nerve distribution, up to the vertex.
• The zygomaticotemporal nerve is a branch of the maxillary division of
the trigeminal nerve and supplies the scalp over the temple region.
• The auriculotemporal nerve is a branch of the mandibular division of
the trigeminal nerve and supplies the skin over the temporal region of
the scalp.
• The lesser occipital nerve is a branch of the cervical plexus (C2), which
supplies the scalp over the lateral occipital region.
• The greater occipital nerve is a branch of the posterior ramus of the
second cervical nerve. This nerve supplies the scalp in the median plane
at the occipital region up to the vertex.

Motor Supply
The frontal branch of the facial nerve supplies the frontal bellies of the
occipitofrontalis muscle, and the auricular branch of the facial nerve
supplies the occipital bellies of the muscle.
Blocks described:
• Deep cervical plexus block
• Superficial cervical plexus block
• Greater occipital nerve block
• Lesser occipital nerve block
• Great auricular nerve block
• Botulinum toxin A injections for migraine.
110 Interventional Pain Management—A Practical Approach

Deep Cervical Plexus Block (Figs 15.1 and 15.2)

The transverse processes of C2 to C4 are located 0.5 to 1 cm posterior to the
line joining the mastoid process with Chassaignac’s tubercle. The first needle
is placed at C4 as this is the easiest landmark to identify and serves to guide
placement of the C3 and C2 needles. The index finger of the free hand is used
to palpate the transverse process of C4 and compress the soft tissues. Firm
pressure may be required to feel the transverse processes. The palpating
index finger is then fixed in place on the transverse process while a 1 ½" to 2"
blunt 22-gauge regional needle is placed just off the tip of the index finger at
C4 in a caudal, medial, and slightly posterior direction. A distinct bony
endpoint is felt as the needle encounters the transverse process of C4. This
usually occurs at about 1" to 1¼” in a normal sized adult. The depth required
to reach the transverse processes of C3 and C2 increases, respectively.

Fig. 15.1: Deep cervical plexus: surface marking

Fig. 15.2: Deep cervical plexus: surface marking

needles entry position
 Nerve Blocks for the Scalp and Injections 111

Having placed the C4 needle, needles are now placed in a similar fashion
at C3 and C2. The C4 and C3 needles’ direction and depth are used to guide
placement of the C3 and C2 needles, respectively. If the patient has a large
neck, a 2" blunt 22 gauge needle will likely be required to reach the
transverse process of C2. An attempt is made to place all three needles
correctly before any local anesthetic agent is given. If blood appears in the
hub of a needle, the needle should be replaced prior to injection of local
anesthetic. If needle placement is difficult, a single needle at one level
(preferably located at C3), has been used successfully. The total volume of
local anesthetic (15 to 24 ml) that would be injected with three needles, is
now injected at the single needle location. Paresthesias may be elicited but
are not needed or sought to perform the block.
With the three needles successfully placed, the C2 needle is connected
(Fig. 15.3) to the control syringe containing the local anesthetic. With the
syringe attached, the needle is again confirmed to be resting upon the
transverse process. The syringe-needle unit is then carefully withdrawn by 1
to 2 mm. With needle stabilization, and following a negative aspiration test
for blood (vertebral artery) and CSF, 5 to 8 ml of the local anesthetic solution
is injected. The C2 needle is removed and the control syringe is reloaded
with the same amount of local anesthetic. The procedure is repeated for the
C3 and C4 needles, respectively. The C2 needle is injected first, as it’s
placement is the most difficult of the three needles, and repositioning the C2
needle would be difficult after the C3 and C4 needles have been injected and
their needles removed.
Alternatively, the clinician may opt to use block needles with attached
extension tubing. This eliminates the need to grasp and stabilize the needle
for attachment to the syringe, and minimizes the chance of dislodging a
neighboring needle by the operator’s finger.
Complications of a deep cervical plexus block include possible intraarte-
rial injection of local anesthetic into the vertebral artery resulting in an imme-
diate loss of consciousness, seizure, or temporary blindness.
A caudad needle direction is essential to minimize the risk of an
inadvertent epidural or intrathecal injection of local anesthetic.

Fig. 15.3: Performing the block

112 Interventional Pain Management—A Practical Approach

The phrenic nerve may also be anesthetized when performing the deep
cervical plexus block resulting in a temporary paralysis of the ipsilateral
diaphragm. Usually this is of no clinical significance.
The cervical fascia separates the cervical sympathetic chain and the
recurrent laryngeal nerve from the deep cervical plexus. If local anesthetic
is injected more superficially a temporary recurrent laryngeal nerve palsy
(hoarseness) and/or Horner’s syndrome (ptosis, miosis, anhydrosis) may
be observed on the same side.
If local anesthetic is injected into the brachial plexus sheath, a brachial
plexus block may be produced.

SUPERFICIAL CERVICAL PLEXUS BLOCK

The external jugular vein crosses the posterior border of the SCM muscle
belly at it’s midpoint (approximately at the C4 level). A 25 gauge spinal
needle is inserted perpendicular to the skin at the junction of the lateral
border of the SCM muscle and the external jugular vein. The tip of the spinal
needle is advanced to a depth equal to the thickness of the SCM muscle belly.
At this depth, the superficial cervical plexus is emerging from the neck. Four
ml of local anesthetic solution is injected at this point.
The spinal needle is then angulated to allow cephalad and caudad
subcutaneous tunnelling along the lateral border of the clavicular head of
the SCM muscle. Approximately 3 to 4 ml of local anesthetic is injected in
each direction. Care is taken to avoid puncture, and inadvertent injection of
local anesthetic into the external jugular vein.

GREATER AND LESSER OCCIPITAL NERVE BLOCKS

Anatomy (Fig. 15.4)
The greater occipital nerve arises from the dorsal primary ramus of the
second and third cervical nerve. It gives sensation to the medial portion of
the posterior scalp. The lesser occipital nerve arises from the ventral primary
rami of the second and third cervical roots and give supply to the cranial
surface of the pinna and adjacent scalp.
It arises from the second cervical nerve, sometimes also from the third; it
curves around and ascends along the posterior border of the
sternocleidomastoid.
Near the cranium it perforates the deep fascia, and is continues upward
along the side of the head behind the ear, supplying the skin and
communicating with the greater occipital, the great auricular, and the
posterior auricular branch of the facial.
The lesser occipital varies in size, and is sometimes duplicated.
It gives off an auricular branch, which supplies the skin of the upper and
back part of the auricula, communicating with the mastoid branch of the
great auricular.
This branch is occasionally derived from the greater occipital nerve. Disorder
in this nerve causes occipital neuralgia.
 Nerve Blocks for the Scalp and Injections 113

Fig. 15.4: Anatomy of occipital nerve and its branches

Technique (Fig. 15.5)

The greater occipital nerve runs with the occipital artery. The nerve is
identified at its point of entry to the scalp, along the superior nuchal line
midway between the mastoid process and the occipital protuberance. The
patient will report pain upon compression: the point at which maximal
tenderness is elicited can be used as the injection site. The scalp is cleansed
with an alcohol swab; 6 mg betamethasone (1 ml) is drawn into a syringe
containing 1 ml 2% lidocaine. A 25-gauge 5/8 inch needle is used for the
block. The needle is directed toward the occiput until bony resistance is
felt, thus ensuring that the subarachnoid space is not entered. About 0.6 ml

Fig. 15.5: Entry point for greater occipital nerve

114 Interventional Pain Management—A Practical Approach

is injected; the type of the needle is then withdrawn to just under the skin
and redirected about 5 degrees laterally and then again medially, to deposit
about 0.6 ml into each site to ensure a successful block. On completion of the
injection, the injected area is massaged and compressed to spread the steroid
suspension so that at least some of it bathes the nerve trunk. Hypesthesia
should appear within 1 to 2 minutes, extending forward on the scalp to the
interaural line. The lesser occipital nerve can be blocked by injecting 1 inch
inferior and medial to this area. The occipital artery can often be palpated
and used as a landmark for injection of both areas.

GREATER AURICULAR NERVE BLOCK

Anatomy
The greater auricular nerve arises from the ventral rami of C2 and C3. It
passes Erb’s point to supply the skin in the region of the ear, angle of the jaw,
and over the parotid gland.

Technique (Fig. 15.6)

The material for performing this block is standard neurostimulation needle,
with court bevel of 50 mm (24G) connected to a syringe of Luer Lock. A
cutaneous pen marker.
For the puncture the patient must be positioned with the head turned
towards the opposite side. The first reference mark is the mastoid (M in Fig.
15.6), to mark it with the pen; the second reference mark P – Fig. 15.6, the
lateral edge of SCM on the cricoid level. The block will be done on the line
joining these 2 points. The puncture point is done to 10 mm above the point
of SCM; the needle passes in and moves towards the mastoid, injecting
throughout. The injection is very slow with 7 ml of anesthetic solution, while
advancing towards the mastoid. A discrete massage supports the diffusion
of the product.

Fig. 15.6: Surface marking of technique

 Nerve Blocks for the Scalp and Injections 115

The territory supplied by the great auricular nerve is external ear, in its
inferior and posterior zone (half inferior external ear), as well as a small
cutaneous territory of the angle of the mandible. No complication is noted,
except, if the puncture is too deep, a diffusion on the facial nerve is possible,
with a transitory paresis.

BOTULINUM TOXIN A INJECTIONS FOR MIGRAINE

Botulinum toxin is a neurotoxin produced by clostridium botulinum, the
bacteria that thrive in poorly sterilized canned food and produce the severe
food poisoning called botulism. These are the toxin that paralyze nerves by
blocking the release of a substance called acetylcholine - which blocks the
muscles and prevents them from contracting thereby causing paralysis. The
substance which is ingested in spoiled food and causes the illness is known
as botulism.
However, in therapeutic uses, Botox is injected directly into the muscle
rather than absorbed into the bloodstream. The dose is a fraction of those
which cause botulism.
Botox is well known for its use in treatment of wrinkles. It has approval
for use in treating facial tics and spasms, dystonia and other forms of
spasticity in cerebral palsy for example, its tolerability and safety record for
these uses are excellent. The principle behind its use in this case is to relax
tense or spastic muscles by blocking acetylcholine release which stimulates
muscle contraction.
The discovery of Botox for treatment of migraine was quite by accident.
Several patients who were using Botox for injection of wrinkles also happened
to have migraine. They reported improvement in their headaches following
injection of Botox to their brow and forehead muscles.
The mechanism of action is not entirely clear. One possibility is that
Botox may decrease muscle contraction that may act as a trigger to migraine.
Another theory is that Botox may act on a brain related chemical like substance
P which is involved in pain and migraine mechanisms.
Careful trials studying migraine and chronic headache patients continue
to examine the efficacy of Botox. Several small trials have been completed
and results of a large placebo controlled trial are pending.
The average dose is 100-200 units. The onset of action is usually within
the first 2 to 3 weeks of injection however patients may require a set of 2 to 3
injections before maximum benefit is seen. Injections are spaced at 12 week
intervals.
Safety is always a concern. However, Botox’ record since 1989 is excellent.
There is no systemic absorption as there is with oral medication, therefore no
systemic side effects are seen. Drooping eyelids can occur with improper
injection technique but are transient.

Some Published Uses of Botulinum Toxin Type A

• Achalasia
• Blepharospasm
116 Interventional Pain Management—A Practical Approach

• Cervical dystonia
• Essential tremor.

Headache and Migraine

• Hemifacial spasm
• Hyperhydrosis
• Myofascial pain.

Occupational Dystonia
Pain (muscle spasm)
• Spasmodic dystonia
• Strabismus
• Spasticity
• Cerebral palsy
• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Wrinkles.

Technique and Sites (Figs 15.7 to 15.9)

• 2 CC saline for dilution
• 20 G 2" needle to draw up toxin
• Change needle
• 30 G ½ inch needle
• Skin prep with isopropyl alcohol
• Swab stick for minor bleeding
• Finger pressure on all injections sites.

Fig. 15.7: Procerus and frontalis

 Nerve Blocks for the Scalp and Injections 117

Fig. 15.8: Temporalis and orbicularis

Fig. 15.9: Occipitalis and neck muscles

 Sixteen

Suprascapular Nerve Block

Jitendra Jain

INTRODUCTION
Shoulder pain is common in the community, affecting 15 to 30% of adults at
any one time. Shoulder pain causes include degenerative disease affecting
the glenohumeral and acromioclavicular joints and supporting soft tissue
structures. Also in the list are inflammatory diseases such as rheumatoid
arthritis (RA), seronegative spondyloarthropathies, and crystal arthropathies.
Because of pain, a progressive loss of movement resulting in a loss of function.
These are the patients for which commonly suprascapular nerve block was
done. Also patient of shoulder reconstruction and replacement are also
benefiting from the suprascapular nerve block for early range of motion and
rehabilitation.

ANATOMY
Nerve fibers of suprascapular nerve originates from C5 , C6 and sometimes
also contributed by C4. Nerve leaves brachial plexus, passing inferiorly and
posterior under the coracoclavicular ligament through the suprascapular
notch.
Blood vessels accompany the suprascapular nerve in the suprascapular
notch. It provides muscular insertion to supraspinatus and infraspinatus of
the rotator cuff and sensory innervation of the shoulder joint and AC joint.
(Figs 16.1 and 16.2).

Indications
• Adhesive capsulitis
• Frozen shoulder1
• Acute shoulder pain
• Cancer pain and palliation
• Post shoulder reconstruction/replacement
• Rehabilitation of chronic arm or hand problem patients for shoulder
movement.
122 Interventional Pain Management—A Practical Approach

Fig. 16.1: Diagrammatic posterior view representing

suprascapular notch where the suprascapular nerve lies

Fig. 16.2: CT scan showing suprascapular notch with the white

round suprascapular nerve in it

Contraindication
• Coagulopathies
• Local infection.

Equipment and Drugs

• 2 ml, 5 ml and 10 ml syringes
• 18 G, 24 G needles for aspiration and skin infiltration respectively
• 10 cm radiofrequency (RF) needle with 10 mm active tip preferably blunt
 Suprascapular Nerve Block 123

• Local anesthetic lignocaine and bupivacaine2

• Triamcinolone or methylprednisolone, i.e. depot steroids3
• Phenol
• Pain management radiofrequency generator 4,5
• C-arm (Fluoroscopy).

Preparation
Diagnostic shoulder examination and needle entry points should be
examined before hand. Diagnostic blood investigation depending on the
patient could be asked for.
Usually this procedure is done under local anesthesia and if RF is planned
then conscious sedation could be used. For that ASA guidelines could be
followed.

Procedure
Patient is in the prone position. C-arm is used to locate the suprascapular
notch. Usually the trajectory is lateral to midline and cephalocaudal to have
a good view of the suprascapular notch (Fig. 16.3). Once after getting a good
vision of suprascapular notch 1½ inch needle or RF needle is used in gun
barrel vision just below the notch after infiltrating skin with lignocaine.
Once it hits the bone just below the notch needle is guided to walk of the
scapular body to enter the notch (Fig. 16.4). Usually within 4 to 5 cm one
should be able make contact with the body of the scapula. Paresthesia might
be encountered around shoulder region. If there is no paresthesia or if the
stimulator facility is available then stimulating suprascapular nerve is a
good idea. One should not go more than 1/2 inch after walking off the scapular
body into the notch. You might be puncturing the pleura. Iohexol is used to
confirm the position of the needle and also to check if there is no intravascular
spread if one is planning neurolysis. Using nerve stimulator for local block
injection or phenol is a good idea to reconfirm the position of the needle.

Fig. 16.3: Showing C-arm picture of suprascapular notch. Needle needs to be

directed to the notch in Gun barrel view
124 Interventional Pain Management—A Practical Approach

Fig. 16.4: Needle in the suprascapular notch, needs to be confirmed with contrast and
stimulatory parameters so as confirm the needle proximity to the suprascapular nerve

Local Anesthetic Block

10 ml of 0.25 to 0.5% bupivacaine with depot steroid 40 to 80 mg.

Neurolysis
4 to 5 ml of 6% phenol after confirming with local block.

Radiofrequency
Sensory stimulation at 0.3 to 0.6 V of 50Hz and motor stimulations double of
sensory parameters at 2Hz is done to confirm the placement. Once confirmed
pulsed radiofrequency at 42°C for 120 sec and 2 such cycles is used.
Post-procedure taking the benefit of pain relief cautious physiotherapy
and rehabilitation program is advisable for almost all patients unless
contraindicated.

Complication and Caution

• Intravascular injections and local anesthetic toxicity
• Pneumothorax
• Suprascapular nerve damage
• Caution to post block shoulder weakness and decreased sensation.
It is simple block and has a very good utility for shoulder pain due to
degenerative problems, trauma, cancer or surgery.

REFERENCES
1. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: A long-term follow-up. J
Bone Joint Surg 1992;74A:738-46.
2. Gado K, Emery P. Modified suprascapular nerve block with bupivacaine alone
effectively controls chronic shoulder pain in patients with rheumatoid arthritis.
Ann Rheum Dis 1993;52:215-8.
3. Van der Heijden GJ, van der Windt DA, Kleijnen J, et al. Steroid injections for
shoulder disorders: A systemic review of randomized clinical trials. Br J Gen
Pract 1996;46:309-16.
 Suprascapular Nerve Block 125

4. Rohof OJJM, Dongen VCPCV. Pulsed radiofrequency of the suprascapular

nerve in the treatment of chronic intractable shoulder pain in 2nd world
congress of pain. Istanbul: Blackwell Science: 2001.
5. Rinoo V Shah, Gabor B Racz. A Case Report. 2003;6;503-6. Pulsed mode
radiofrequency lesioning of the suprascapular nerve for the treatment of
chronic shoulder pain: Pain physician journal.
126 Interventional Pain Management—A Practical Approach

Seventeen

Intercostal Nerve Block

Jitendra Jain

INTRODUCTION
It is a very important tool to manage the patients with pain originating
from chest wall and upper abdomen. There are various medical conditions
for which this block could be considered.

ANATOMY
The intercostal nerves are composed of the anterior branch of the first till
the twelfth thoracic nerve.1 The typical ones are from 3rd till 11th thoracic
nerve. Slight variations in the typical course are seen with first, 2nd and
twelfth intercostal nerve.
The typical one (Fig. 17.1) gives four well defined branches in its way
starting from the thoracic root till the intercostal nerve. First is branches to
and fro from the thoracic sympathetic chain, i.e. Grey rami communicans.
Second branch is the posterior cutaneous branch which supplies the
paravertebral skin and muscles. Third is lateral cutaneous nerve arising
just anterior to the midaxillary line. This branch subcutaneous fiber might
overlap with the posterior and anterior cutaneous branches. Final branch
is the anterior cutaneous branch which actually gives cutaneous innervation
to the midline of the chest and abdomen.

Fig. 17.1: Showing a typical intercostal nerve giving various branches along
its course after exiting the dorsal foramen
 Intercostal Nerve Block 127

Twelfth intercostal nerve is called subcostal nerve which runs along

abdominal wall and joins L1 to finally continue as iliohypogastric and
ilioinguinal nerves.
T1 contributes to brachial plexus while T2 and T3 sends cutaneous
branches to medial aspect of arm as intercostobrachial nerve.

Indications
• Fractured ribs
• Sternotomy2
• Thoracotomy3
• Post herpetic neuralgia
• Post surgical thoracic or abdominal nerve entrapment
• Upper abdominal surgeries
• Appendectomy.

Contraindication
• Local infection
• Coagulopathy.

Equipment and Drugs

• 25G ¾ inch needle
• 22G 1½ inch needle
• 5 cm RF needle with 5 mm active tip
• 2 ml, 3 ml and 5 ml syringe
• 1 to 2% lignocaine
• 0.25%-0.5% bupivacaine
• Depot steroids
• 6% phenol
• Absolute alcohol
• Radiofrequency generator.

Preparation
Preprocedure history and physical examination of the local area before
intercostal block is a must. It mainly to understand to level at which block
is to be given and if at all there are any anatomical changes because of
pathology or surgery.
Coagulation profile and requisite preoperative blood investigation of
the patient could be done depending on the patient.
For this block usually sedation is not needed unless a patient is restless
or radiofrequency is planned.

Position
• Lateral
• Prone
• Sitting.
128 Interventional Pain Management—A Practical Approach

The rib to be blocked is identified and local anesthesia with lignocaine is

given along posterior axillary line or fluoroscopy is used after preparing the
skin with antiseptic. Inferior border of the rib is identified and if doing blind
rib is hit with the needle or fluoroscopy is used for guidance. After hitting the
bone needle is withdrawn till subcutaneous level and guided till the inferior
bony contact is lost. As soon as the bony contact is lost needle is advance for
about 1to 3 mm not more otherwise pleura might be punctured. Placement is
confirmed by stimulating and also by injecting dye at that level (Figs 17.2
and 17.3). Once confirmed then desired treatment modality is delivered.

Drugs Injected
• 0.5 to 1ml of 6% phenol or absolute alcohol.
• 1 to 2 ml of 0.25 to 0.5% bupivacaine with or without depot steroid 40 mg.
• Radiofrequency ablation, pulsed is preferred or lower temperature heating
with RF is preferred. Cryoablation4 can also be done if facility is available
(Fig. 17.3).
• Continuous block for post operative patients can be done by placing
catheter.

Fig. 17.2: Showing needle placement in the subcostal groove with

contrast spread in the area

Fig. 17.3: Fluoroscopic picture showing needle placement in the subcostal groove in
proximity to the intercostal nerve and undergoing radiofrequency ablation
 Intercostal Nerve Block 129

Complications
• Pneumothorax
• Local anesthetic allergy or toxicity due to proximity to blood vessels
• Infection.
Alcohol block if possible can be avoided as it might cause post procedure
neuritis.

REFERENCES
1. Moore DC. Anatomy of the intercostal nerve: Its importance during thoracic
surgery. Am J Surg 1982;144:371-3.
2. Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: A
follow-up study. Acta Anaesthesiol Scand 1999;43:563-7.
3. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery
predicts long-term post-thoracotomy pain. Clin J Pain 1996;12:50-55.
4. Pastor J, Morales P, Cases E, Cordero P, Piqueras A, Galan G, Paris F.
Evaluation of intercostal cryoanalgesia versus conventional analgesia in
postthoracotomy pain. Respiration 1996;63:241-5.
130 Interventional Pain Management—A Practical Approach

Eighteen

Intrapleural Block

DK Baheti

INTRODUCTION
The lung is covered with two layers of pleura. One is parietal and second is
pleural. The friction of both the layers while breathing causes pain. This
often leads to a peculiar situation for a patient, i.e. if he breathes heavily then
intensity of pain increases due to friction of both the pleura and if he hold the
breath due to fear of pain then chances of CO2 retention and even hypoxia
are there. Pleura are supplied by all the intercostals nerves. There is retrograde
diffusion of local anesthetic back towards intercostal nerves.

Indications
• Carcinoma of lung
• Carcinoma of gall bladder
• Secondary in the lung
• Post herpetic neuralgia
• Post surgical thoracic or abdominal nerve entrapment
• Upper abdominal surgeries
• Post thoracotomy pain.1

Contraindications
• Patient unable, unwilling to consent or uncooperative patient
• Known allergy to contrast
• Local or systemic infection
• Coagulopathy
• Pregnancy
• Concurrent use of anticoagulants
• Coexisting disease producing significant CVS or respiratory compromise
• Immunosuppression.
 Intrapleural Block 131

Equipment/Types and Sizes of Needle

• C-arm fluoroscopy or CT scan along with monitoring and resuscitation
facility.
• 26-gauge for skin infiltration and deep infiltration of local anesthetic.
• Epidural set (16-guage needle with epidural catheter and filter).

Drugs and Concentration

• Inj. lignocaine- 2% - (xylocard- preservative free)
• Inj. iohexol (omnipaque), a water soluble contrast
• Inj. bupivacaine 0.25%
• Inj. phenol in glycerine- 6 to 10% or Inj. tetracycline for pleurodesis.

Pre-operative Preparation
Informed consent.
Investigations complete blood count, bleeding time and clotting time.
Secure an intravenous line.
Monitoring of BP, SaO2, and ECG .
An antibiotic cover.

Procedure
Step 1 Patient in sitting position with arm rested on mayo’s trolley or lateral
decubitus position. After preparing the site, identify 7, 8, 9th
intercostal space and do the surfacing marking of 9th and 10th
intercostal spaces (Figs 18.1 and 18.2).

Fig. 18.1: Patient in sitting position with hand resting on Mayo’s trolly
132 Interventional Pain Management—A Practical Approach

Fig. 18.2: Surface marking of 9th and 10th intercostal space

In the 9th intercostal space at mid/post axillary line, under local

anesthesia advance 16-gauge Tuohy needle and contact the rib.
Then walk of superiorly about 3 to 5 mm with loss of resistance
technique using normal saline or put a drop of saline at hub of
needle (Hanging drop) to demonstrate the movement of saline drop
with respiration.
Step 2 Confirm the needle position under fluoroscopy anteriolateral view.
After repeated negative aspiration inject water soluble dye Inj.
omnipaque 3 to 5 cc. Confirm the spread of the dye under fluoroscopy.
Inject 3 to 4 cc of Inj. xyloacaine preservative free 3 to 5 cc.
Step 3 Now slowly introduce epidural catheter through epidural needle
about 3 to 5 cm into the pleura. Once again inject about 2 cc Inj.
omnipaque into the epidural catheter and confirm the spread of dye
under fluoroscopy in both anterior posterior and lateral view
(Figs 18.3 to 18.5).

Fig. 18.3: Catheter (as shown by the arrows) in pleural space

 Intrapleural Block 133

Fig. 18.4: AP view of pleurography Fig. 18.5: Lateral view of pleurography

Step 4 Tunnel the catheter into the adjacent skin. Fix it with adhesive tape
(Fig. 18.6).

Fig. 18.6: Tunneling of epidural catheter in intrapleural space

Step 5 Inject the Inj. tetracycline 8 to 10 cc through epidural catheter slowly.

Flush epidural catheter with Inj. bupivacaine 0.25% 4 to 5 cc.
Step 6 Shift to recovery area and monitor the vital parameters for 2 to 3
hours.

COMPLICATIONS
• Pneumothorax
• Local anesthetic allergy or toxicity due to proximity to blood vessels
• Infection.

REFERENCE
1. Bachman-Mennenga B, Biscoping J, Kuhn DEM, et al. Intercostal, interpleural
analgesia, thoracic epidural block or systemic opioid application for pain relief
after thoracotomy? Eur J Cardiothorac Surg 1993;7:12-8.
 Nineteen

Celiac Plexus Block

DK Baheti

INTRODUCTION
Kappis1 in 1914 first described the percutaneous posterior approach for the
block of splanchnic nerves and celiac plexus for surgical anesthesia. He in
1918 reported series of 200 cases with the same approach.
Jones2 in 1957 used alcohol neurolysis for long lasting relief of abdominal
pain. Bride Baugh, et al3 reported the role of neurolytic celiac plexus block for
abdominal malignancy.
The posterior approach is still widely used approach for the block of
celiac plexus and splanchnic nerves.
Abdominal pain is one of the most common symptoms by contrast to
other areas of the body, as abdominal organs have poorly developed sensory
systems and that is the problem for patient to describe the pain and for
physician to localize the pain. The purpose of the pain is to protect the organ
and patient form injury.
Abdominal viscera are relatively insensitive to many stimuli compared
with a more sensitive organ such as the epidermis. In addition to the relative
paucity of sensory nerve endings, as the same group of nerves may supply
several viscera. There are very few well known nociceptive triggers in the
abdominal cavity. These include abnormal distention or contraction of
hollow organ walls, ischemia of visceral musculature, direct action of
chemical substance on the mucosa, formation of allogenic mediators and
traction or compression of ligaments, vessels or mesentery.
The visceral pain is transmitted from nociceptors found on the walls of
the abdominal viscera via sympathetic and parasympathetic pathway. This
pain is nonspecific because of wide divergence and relatively small number
of afferent fibers innervating a large area with extensive ramification.
Patients usually have difficulty in localizing the source of pain and will
describe as aching, cramping or burning that fluctuates in the intensity.
Visceral pain is usually paroxysmal, colicky, deep, squeezing, and diffuse.
The pain originating from visceral structures and innervated by celiac plexus
can be effectively alleviated by blocking of celiac plexus. These structures are
138 Interventional Pain Management—A Practical Approach

pancreas, liver, gallbladder, omentum, mesentery, and alimentary tract from

stomach to the transverse portion of large colon.
An additional benefit to these patients may be effect of the celiac plexus
block is on the gastric motility.
Indications
1. Any pain originating from upper abdominal viscera such as stomach,
liver, gall bladder, kidney, spleen, pancreas, aortic lymphadenopathy,
omental mass, retroperitoneal tumors.
2. Pain due to chronic pancreatitis, alcoholic pancreatitis.
3. Any chronic upper abdominal pain of unknown origin.
Contraindications
1. Receiving anticoagulation therapy or suffering from congenital
abnormalities of coagulopathy.
2. Antiblastic cancer therapy.
3. Liver abnormalities associated with ethanol abuse.
4. The local skin infection at needle entry point or intra abdominal infection
and sepsis, intestinal obstruction.
5. The use of alcohol as neurolytic agent should be avoided in patient with
disulfiram therapy for alcohol abuse.
Equipment/Types and Sizes of Needle (Fig. 19.1)
• Procedure room with C-arm fluoroscopy or CT scan along with monito-
ring and resuscitation facility
• Radiofrequency lesion generator
• 26-gauge needle for skin infiltration and deep infiltration of local
anesthetic
• 18-guage needle or 11 no. surgical blade for skin puncture to facilitate the
insertion of blunt tip needle
• 20-guage 6” long blunt tip needle or 22-gauge 6” long needle.

Fig. 19.1: Blunt tip needle

DRUGS AND CONCENTRATION

• Inj. lignocaine- 2%- (xylocard- preservative free)
• Absolute alcohol
 Celiac Plexus Block 139

• Normal saline
• Inj. bupivacaine 0.25%.

Procedure
Pre Operative Preparation
Any interventional procedures should be done with informed consent. These
procedures are preferably done in procedure room or in operation theater.
The investigations such as complete blood count, bleeding time and clotting
time are necessary. An intravenous line is secured. The monitoring of BP,
SaO2, and ECG is mandatory. An antibiotic cover is necessary. The guidance
of fluoroscopy, ultrasound, CT scan is useful.
There are many approaches to perform the celiac plexus block such as
retrocrural, transcrural (uni or bilateral), transdiscal, transaortic, anterior
approach, splanchnic denervation. It is the choice of pain specialist which
approach he is comfortable with.
The author prefers posterior approach so it is given in detail step wise.

POSTERIOR APPROACH – COMMON AND PREFERRED APPROACH

Position and Landmarks (Fig. 19.2)
Step 1 In this approach the patient is in prone position with a pillow under
the abdomen to reverse to thoracolumbar lordosis also this position
increases the distance between costal margin and ileac crests and
transverse processes of adjacent vertebral bodies.
The preloading of the patient with Inj. ringer lactate 500 to 1000
ml at the start of the procedure how ever it depend on pre operative
hemodynamic status of the patient.
Step 2 The standard landmarks are ileac crests, 12th rib, and spinous
process of T12 and L1 vertebrae. Moore recommended that
intersection of 12th rib and lateral border of paraspinal muscles on
both sides and spine of L1 vertebra which forms an isosceles triangle.

Fig. 19.2: Landmarks and needle entry

140 Interventional Pain Management—A Practical Approach

Step 3 The point of needle entry is either four finger breadth or 6 to 8 cm

from midline. Inj. 2% lidocaine about 10 cc intradermally and deep
into the various layers in the direction of the needle. Then in case of
blunt needle make a skin niche with 18-gauge hypodermic needle or
with 11 no. surgical blade to facilitate the entry of blunt needle.
Step 4 A 15 cm 20-gauge styleted short bevel or blunt tip needle are directed
one side with 45 degree angle towards midline and cephalad to
contact body of L1 vertebra. Then second needle on other side also
inserted in the same manner as before. The position of the needle
should be confirmed antero-posterior (Fig. 19.3) and lateral view (Fig.
19.4) under fluoroscopy or under CT scan.

Fig. 19.3: Position of needles in AP view

Fig. 19.4: Position of needles in lateral view

Step 5 In lateral view after repeated negative aspiration, one needle at a

time should be redirected towards anterior border of L1 vertebra. The
tip of the both needle should be about 1 to 2 cm ahead of anterior
border of L1 vertebra. It is advised the tip of right side needle should
be little ahead of the left as more fibers of the celiac plexus are on the
right side.
 Celiac Plexus Block 141

Step 6 After repeated negative aspiration the 5 cc of 2% lidocaine injected to

have immediate pain relief. At this stage there can be sudden fall of
blood pressure, which can be treated either with Inj. mephenteramine
sulphate 3 to 6 mgm or inj. Ringer Lactate 500 to 1000 cc.
Step 7 After repeated negative aspiration 5 cc radiopaque dye iohexol
injected on each side and spread of the dye is confirmed under
fluoroscopy or CT scan. The spread of the dye should restrict to the
body of T12 and L1 vertebra (Figs 19.5 and 19.6). Both the pictures
should be saved for documentation.

Fig. 19.5: Spread of dye AP view

Fig. 19.6: Spread of dye lateral view

S Jain4 suggested that if CT guidance is used, the contrast material should

appear lateral to and behind the aorta. If contrast material is confined entirely
to the retrocrural space, the needles should be advanced to the retrocrural
space to minimize the risk of posterior spread of local anesthetic or neurolytic
agent to the somatic nerve roots.
142 Interventional Pain Management—A Practical Approach

Step 8 Once again after repeated negative aspiration, a mixture of Inj. alcohol
50% with the Inj. bupivacaine 0.25%, 20 to 25 cc should be injected
slowly on both sides. The needle should be withdrawn with stylet in
order to avoid spillage of neurolytic agent in the track of the needle.
Step 9 The vital signs of the patient should be observed in the recovery for
about 1 to 2 hours.

ANTERIOR APPROACH
This is done either under ultrasonographic or CT guidance. The needle entry
is 1.5 cm below and 1.5 cm left of the xiphoid process. A 22 gauge 15 cm
needle is directed perpendicular to the skin and advanced to the anterior to
the aorta under ultrasonographic or CT guidance. If CT is used 3 to 4 cc of Inj.
iohexol is used to confirm the spread of the dye and under ultrasonographic
guidance 10 to 15 cc of saline is used confirm needle position. Then repeated
negative 10 to 15 cc of 1% Inj. lidocaine is used to confirm the diagnostic
block. Then after repeated negative aspiration 1 to 15 cc of absolute alcohol is
injected. The needle is withdrawn with stylet.

INTRADISCAL APPROACH
The position of the patient is prone with a pillow under the abdomen and is
to be done under fluoroscopy. The T12 - L1 level is identified. A single 15 cm
20-gauge styleted needle at a time is passed through the midline on either
side.
The position of the needle anterior to the vertebral body is confirmed
under fluoroscopy. The dye iohexol 5 cc is injected and spread of the dye is
confirmed under fluoroscopy.
After repeated negative aspiration, a mixture of Inj. alcohol 50% with the
Inj. bupivacaine 0.25%, 20 to 25 cc should be injected slowly on both sides.
The needle should be withdrawn with stylet in order to avoid spillage of
neurolytic agent into the track of the needle.

COMPLICATIONS OF NEUROLYTIC CELIAC PLEXUS BLOCK

The iatrogenic complication reported during celiac plexus blocks are
pneumothorax (two cases) by Brown5; partial lower extremity paralysis (One
case) by Thomson et al.6; temporary paraplegia (One case) by Baheti.7
Iatrogenic complications such as chylothorax, pleural effusion, renal injury
and injury to veins also have been reported.
While performing lumbar sympathectomy Boas8 reported 6% incidence
of genitofemoral neuralgia, Cousins and associates9 reported 35 patients
with mild or severe neuralgia.
The neurological complications include disestesias, paresis in lower
extremities, paraplegia due to ischemia, spinal neurolytic injection, spasm
of anterior spinal artery.
 Celiac Plexus Block 143

The complications include abdominal pain, diarrhea, hypotension,

pneumothorax, injury to vessels.
Other complications such as backache, intravascular or subarachnoid
injection, neuralgia, muscle spasm are mentioned by P Raj et al.10
The role of sharp needle in above complications can not be ruled out.
The probable cause of above mentioned iatrogenic complications can
be the use of a 6 inches or a 15 cm long needles (sharp tip or short bevel),
which may results in a iatrogenic puncture of an internal organ like vein,
pleura, peritoneum and etc. and as mentioned above, these iatrogenic
complications have been reported in the literature from time to time.

EVOLUTION IN THE TECHNIQUE OF CPB

Since 1914 many advances have done in the performing of celiac plexus
block such as various routes like anterior, transaortic, thoracoscopic,
laparoscopic.
At the same time use of fluoroscopy, CT scan, ultrasound have made
difference and celiac plexus block can be performed with more accuracy
and long lasting pain relief can be produced. The use of non ionic dye has
become useful guideline to confirm the spread of dye and chances of dye
reactions are nil.

RECENT ADVANCES AND ITS IMPLICATIONS

The blunt tip needle recently introduced by Baheti DK11 for these blocks
(Celiac plexus block and lumbar sympathectomy) may further reduce the
rate of iatrogenic complications such as injury to vessels, peritoneum and
can be reduced.
The blunt tip needle used by author is a 20-gauge needle (locally made) is
of stainless steel and can be repeated autoclaved.

REFERENCES
1. Kappis M. Erfahrungen mit lokalanaesthesia bei Bauch operationen. Verh
Dtsch Ges Circ 1914;43:87.
2. Jones RR. A technique of injection of the splanchnic nerves with alcohol:
Anesth. Analg 1957; 36:75.
3. Bride Baugh LD, Moore DC, Campbell DD. Management of upper abdominal
cancer pain: Treatment with celiac plexus block with alcohol. JAMA
1964;190:877.
4. Jain S. The role of celiac plexus block in intractable upper abdominal pain. In
Racz GB (Ed): Technique of neurolysis. Boston, Kluwer Academic, 1989, 161.
5. Brown DL, Bully CK, Quiel EC- Neurolytic celiac plexus block for pancreatic
cancer pain. Anaesth. Analg 1987:66:869-73.
6. Thompson GE, Moore DC, Braidenbaugh LD. Abdominal pain and alcohol
celiac plexus block Anesth. Analg 1977:56:1-5.
7. Baheti DK. Neurolytic coeliac plexus block (NCPB): A ten year review of 212
cases. Bombay Hospital Journal 2001;43:1.
144 Interventional Pain Management—A Practical Approach

8. Boas RA. Sympathetic blocks in clinical practice. In Stanton-Hicks M (Ed).

International Anesthesia Clinics. Regional anesthesia: Advances in selected
topics. Boston. Little Brown 1978;16:4.
9. Cousins MJ, Reeve TS, Glynn CJ, et al. Neurolytic sympathetic blockade:
Duration of denervation and relief of rest pain. Anesth. Intensive care 1979;121-
35,
10. P Prithviraj, et al. Celiac plexus block and neurolysis. Radiographic imaging
for regional anesthesia and pain management. Churchill Livingston 2003;
164-74.
11. Baheti DK. Use of new modified needle with blunt tip for neurolytic sympathetic
block in abdominal malignancies. Abstracts, 11th World Congress on Pain:
I.A.S.P.Press 2005;489-90.
 Twenty

Lumbar Sympathetic Block

DK Baheti

INTRODUCTION
Brunn and Mandl in 19241 first described the Sellheim’s technique of Lumbar
Sympathetic Plexus block.

INDICATIONS
Diagnosis and Treatment
• Vascular insufficiency due to
– Peripheral vascular disease
– Diabetes
– Burger’s disease
– Raynaud’s disease
– Post vascular surgery
• Miscellaneous
– Complex regional pain syndromes I and II
– Herpes zoster
– Stump pain
– Phantom limb
– Frost bite
– Trench foot
– Renal colic
– Urogenital pain
– Hyperhidrosis.

Contraindications
• Patient unable or unwilling to consent
• Known allergy to contrast
• Local infection
• Coagulopathy
• Uncooperative patient
• Pregnancy
146 Interventional Pain Management—A Practical Approach

• Concurrent use of anticoagulants

• Known systemic infection
• Coexisting disease producing significant CVS or respiratory compromise
• Immunosuppression.

Equipment/Types and Sizes of Needle

• Procedure room with C-Arm fluoroscopy or CT scan along with moni-
toring and resuscitation facility
• 26-gauge for skin infiltration and deep infiltration of local anesthetic
• 18-guage or 11 no. surgical blade for skin puncture to facilitate the
insertion of blunt tip needle
• 20-guage 6" long blunt tip needle or 22-gauge 6" long needle
• Skin temperature monitor
• Emergency medications
• Needles: 3½ inch 25 G or 23 G needles
• Radiofrequency lesion generator.

Drugs and Concentration

• Inj. lignocaine- 2% (xylocard- preservative free)
• Inj. iohexol (omnipaque), a water soluble contrast
• Inj. bupivacaine 0.25%
• Inj. phenol in glycerine- 6 to10%.

Procedure
• Informed consent
• Patient preparation –I.V. and monitoring
• Antibiotics
• Prone position
• Square the endplates ipsilaterally under AP fluoroscopy.
• Identify the levels L2, L3 and L4.

POSITION AND LANDMARKS

Step 1 The patient is in prone position with a pillow under the pelvis to
reverse to lumbar lordosis. The L2 to L4 spinous processes are felt
and marking done. The point of needle entry is either four finger
breadth or 6 to 8 cm from midline. Inj. 2% lidocaine about 10 cc
intradermally and deep into the various layers in the direction of the
needle. Then in case of blunt needle make a skin niche with 18-gauge
hypodermic needle or with 11 no. surgical blade to facilitate the entry
of blunt needle.
Step 2 The blunt tip needle is then directed to pass below and slightly
medial to the inferior border of the transverse process at an angle
of about 10° to the sagittal plane. It is advanced about 2 cm deep to
the transverse process, where it should contact the side of the
 Lumbar Sympathetic Block 147

vertebral body. A slight decrease in the angle is made so as to allow

the needle to slip past at a tangent to the lateral aspect of the vertebral
body.
The position of the needle should be confirmed under fluoroscopy
in lateral view and the tip of needle distance to the anterolateral
surface of the vertebral body (Figs 20.1A and B).

Figs 20.1A and B: Ideal needle positions for lumbar sympathetic blocks (A) Position of
needle in lateral view; (B) Position of needle in AP view

Now confirm the loss of resistance. There should be no resistance to

injection.
If there is resistance the tip is in the psoas fascia. Inject 1ml of contrast.
In case the tip of needle is in psoas fascia then there will be a vacuolated
retroperitoneal pattern (Fig. 20.2).

Fig. 20.2: Psoas injection vacuolated retroperitoneal pattern

148 Interventional Pain Management—A Practical Approach

Step 3 After confirmation of repeated negative aspiration, inject 4 to 5 cc of

Inj. omnipaque 4 to 5 cc to confirm the spread of dye. Confirm the
spread of dye in posterioanterior view the dye will hug vertically the
spine. In lateral view the dye will spread along the anterior border of
spine, save the images. The same procedure is repeated on opposite
side (Figs 20.3A and B).

Fig. 20.3A: Spread of dye in AP view Fig. 20.3B: Spread of dye lateral view

Step 4 For diagnostic block Inj. bupivacaine 0.25% 6 to 8 ml injected on each

side. In case of neurolysis, Inj. phenol in oil 5 to 7cc on each side is
injected. Warming up of phenol and flushing the needle with 1 to 2cc
of normal saline will ease the injection of neurolytic agent (phenol).
Step 5 Before with drawing the needle put the stylet into it, to allow neurolytic
agent to spill the desired area. Inject Inj. xylocaine 2% into the needle
track while with drawing the needle. This will help to reduce the
needle pain following the procedure.
Step 6 Evidence of Sympatholysis
• Vasodilatation in lower limbs
• Raised temperature in lower limbs
• Decreased edema.
Records
Permanent AP and lateral images should be obtained to document
the final position of the needle and the extent of spread of the
contrast.
Post-procedural Care
Step 7 The vital signs of the patient should be observed in the recovery for
about 1 to 2 hours.

Problems
• Genitofemoral neuralgia up to 15%
• Intravascular injection
• Bleeding
• Hypotension.
 Lumbar Sympathetic Block 149

Discharge Instructions
No Driving for that Day
• Patient should monitor and record the extent and duration of any relief
that ensues
• Contact Doctor if headache, fever, chills, increased pain, paralysis or any
other unusual symptoms
• Resume previous activities over a period of several days.

REFERENCE
1. Brunn F, Mandl F. Die paravertebrale injection Zur Bekaempfung visceraler
Schmerzen. Wien Klin Aschsch 1924;37:511.
150 Interventional Pain Management—A Practical Approach

Twenty One

Hypogastric Plexus Block

DK Baheti, RP Gehdoo

INTRODUCTION
The superior hypogastric plexus lies in the retroperitoneal space anterior to
the fifth lumbar vertebra left of the midline, just inferior to the aortic
bifurcation. Its branches right and left and descends into the pelvis as the
inferior hypogastric plexus which gives rise to the pelvic, middle rectal,
vesicle, prostates, and uterovaginal plexus. Hypogastric plexus contains
postganglionic sympathetic fibers and afferent visceral pain fibers. Many
preganglionic parasympathetic fibers run independently and to the left of
the superior hypogastric plexus. The inferior hypogastric plexus receives
more parasympathetic fibers from the 2nd, 3rd, and 4th sacral levels.

Pelvic Innervations
The adnexal disorders pain is transmitted through the hypogastric plexus
and celiac plexus along the sympathetic afferent fibers and enters the CNS
at T10. Testicular pain transmitted through presacral ganglia along
sympathetic afferents with the spermatic plexus and blood vessels to the
CNS at the level of T10. Pain transmitted through presacral ganglion along
sympathetic afferents through the spermatic plexus and blood vessels to
the CNS at T10-11

Causes of Pelvic Pain

Endometriosis, carcinoma, of prostrate, uterus, cervix, rectum, sacrum,
trauma, post inguinal herniorrhaphy (ilioinguinal, genitofemoral nerve
trauma); chronic infection.

Indications
1. Chronic pain originating form pelvic viscera such as descending colon,
rectum.
2. Tumors from uterus, ovary; endometriosis.
3. Excruating pain due to irritable bladder syndrome, interstitial cystitis,
neurogenic bladder and bladder tumors.
 Hypogastric Plexus Block 151

4. Carcinoma of prostrate, testis, epididymisi

5. Bone tumors of sacrum.

Contraindications
• Patient unable or unwilling to consent
• Known allergy to contrast
• local infection
• Coagulopathy
• Uncooperative patient
• Pregnancy
• Concurrent use of anticoagulants
• Known systemic infection
• Coexisting disease producing significant CVS or respiratory compromise
• Immunosuppression.

Equipment/Types and Sizes of Needle

• Procedure room with C-arm fluoroscopy or CT scan along with monitoring
and resuscitation facility.
• 26-gauge for skin infiltration and deep infiltration of local anesthetic.
• 18-guage needle or 11 no. surgical blade for skin puncture to facilitate
the insertion of blunt tip needle.
• 20-guage 6” long blunt tip needle or 22-gauge 6” long needle.

Drugs and Concentration

• Inj. lignocaine- 2% (xylocard- preservative free)
• Inj. iohexol (omnipaque), a water soluble contrast
• Inj. bupivacaine 0.25%
• Inj. phenol in glycerine 6 to 10%.

PRE-OPERATIVE PREPARATION
Informed consent
Investigations such as complete blood count, bleeding time and clotting
An intravenous line
Monitoring of BP, SaO2, and ECG
Antibiotic cover is necessary
Imaging facilities- fluoroscopy, ultrasound, or CT scan.

PROCEDURE
Lateral approach.1
152 Interventional Pain Management—A Practical Approach

Position and Landmarks

Step 1 The patient is in prone position with a pillow under the pelvis to
reverse to lumbar lordosis (Fig. 21.1).
.

Fig. 2.1: Position of the patient on operation table

Step 2 The L4-L5 spinous processes are felt and marking done. Draw a line
lateral to L4-L5 intervertebral space. The point of needle entry is
either four finger breadth or 6 to 8 cm from midline. Inj. 2% lidocaine
about 10 cc intradermally and deep into the various layers in the
direction of the needle. If blunt needle is used then make a skin niche
with 18-gauge hypodermic needle or with 11 no. surgical blade to
facilitate the entry of blunt needle.
Step 3 The direction of needle should be approximately 45 degree medial
and caudad to avoid the transverse process of L5 and ala of sacrum.
In fluoroscopic lateral view confirm the tip of needle should be at
anterior junction of L5-S1 vertabrae. Confirm position posterio-
anterior view, the tip of needle must be no more than l cm from bony
outline of L5-S1.
Step 4 After confirmation of repeated negative aspiration, Inject 4 to 5 cc of
Inj. omnipaque 4 to 5 cc to confirm the spread of dye. Confirm the
spread of dye in posterioanterior view the dye will hug vertically the
 Hypogastric Plexus Block 153

spine. In lateral view the dye will spread along the anterior border of
spine, save the images. The same procedure is repeated on opposite
side (Figs 21.2 and 21.3).

Fig. 21.2: Position of needle with spread of dye in AP view

Fig. 21.3: Spread of dye in lateral view

Pictures courtesy: Dr Kailash Kothari and Dr C Das with permission

Step 5 For diagnostic block Inj. bupivacaine 0.25% 6 to 8 ml injected on

each side. In case of neurolysis, Inj. phenol in oil 5 to 7 cc on each
side is injected. Warming up of phenol and flushing the needle with
1 to 2 cc of normal saline will ease the injection of neurolytic agent
(phenol).
Step 6 Before with drawing the needle put the stylet into it, to allow
neurolytic agent to spill the desired area. Inject Inj. xylocaine 2%
154 Interventional Pain Management—A Practical Approach

into the needle track while with drawing the needle. This will help
to reduce the needle pain following the procedure.
Step 7 The vital signs of the patient should be observed in the recovery for
about 1-2 hours.

Other Approaches
Medial Approach
In this rotate the C-arm fluoroscope 15 degrees caudad so that x-ray beam
will look into pelvis. As this view enlarges the space between L-5 transverse
process, ala of sacrum and posterior anterior iliac spine.
Under local anesthesia under fluoroscopy mark the most inferior and
lateral part of this bone free space. The direction of needle should be medial
and slight caudad superior to the neural foramen. The tip of needle should
be at the anterior edge of body of L5 vertebra. Repeat the same steps on
opposite side.
After confirmation of negative aspiration inject 4 to 5 ml Inj. omnipaque
on each side.

Evidence of Sympatholysis
• Vasodilatation in lower limbs
• Raised temperature in lower limbs
• Decreased edema
• Decreased pain with sympathetic mediated pain.

Records
Permanent AP and lateral images should be obtained to document the final
position of the needle and the extent of spread of the contrast.

POST-PROCEDURAL CARE
The vital signs of the patient should be observed in the recovery for about 1 to
2 hours.

Problems
• Intravascular injection
• Bleeding
• Hypotension.

Discharge Instructions
No Driving for that Day
• Patient should monitor and record the extent and duration of any relief
that ensues
 Hypogastric Plexus Block 155

• Contact Doctor if headache, fever, chills, increased pain, paralysis or any

other unusual symptoms
• Resume previous activities over a period of several days.

REFERENCE
1. Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus
block for pelvic cancer pain. Anesthesiology 1990;73:23.
156 Interventional Pain Management—A Practical Approach

Twenty Two

Ganglion of Impar Block

DK Baheti

INTRODUCTION
The ganglion of Impar is also known as Ganglion of Walther1 and is the last
ganglion of the sympathetic trunk. It is single ganglion formed with fusion
of two ganglions of both sides and located retroperitoneally at level of
sacrococcygeal junction that marks termination of the paired paravertebral
chains. This receives fibers from the lumbar and sacral portions of
sympathetic and parasympathetic nervous system.

Indications
Pain originating either from pelvic viscera or sympathetically maintained
pain in the perineum is effective managed by ganglion of impar block. The
pain may be vague, burning or localized in perineum.

Equipment/Types and Sizes of Needle (Fig. 22.1)

• Procedure room with C-arm fluoroscopy or CT scan along with monitoring
and resuscitation facility.
• 26-gauge for skin infiltration and deep infiltration of local anesthetic.
• 18-gauge needle or 11 no. surgical blade for skin puncture to facilitate
the insertion of blunt tip needle.
• 22-gauge 3½” long spinal needle.

Drugs and Concentration

• Inj. lignocaine 2% (xylocard- preservative free).
• Iohexol (omnipaque) water soluble dye.
• Inj. bupivacaine 0.25%.
• Inj. phenol in glycerine 6 to 10%.
 Ganglion of Impar Block 157

Fig. 22.1: Patient position lateral decubitus

Procedure
Pre-operative Preparation
1. Informed consent.
2. Investigations such as complete blood count, bleeding time and clotting
time.
3. Procedure to be done in procedure room or in operation theater.
4. Monitoring of BP, SaO2, and ECG is mandatory.
5. I.V. access.
6. Antibiotic cover.
7. Imaging facility- C-arm fluoroscopy.

LATERAL POSITION APPROACH – ANOCOCCYGEAL OR TRANS-

SACROCOCCYGEAL APPROACH
Position and Landmarks
Step 1 Patient in lateral decubitus position with hip flexed. C-arm placed at
gluteal region focusing on sacrococcygeal bone.
Inj. xylocaine 1% 3 to 5 cc at the level of anococcygeal ligament, i.e.
midway between tip of coccyx and anus.
Step 2 Under fluoroscopy put an artery forceps just below sacrococcygeal
ligament.
158 Interventional Pain Management—A Practical Approach

Step 3 Infiltrate Inj. 2% lignocaine 4 to 5 cc deep upto sacrococcygeal ligament

(Fig. 22.2).

Fig. 22.2: Entry point for needle

Step 4 Push 22-gauge 3.5 inch needle directly into the retroperitoneal space.
Confirm the position of needle under fluoroscopy (Fig. 22.3).

Fig. 22.3: Needle in AP view

Step 5 After repeated negative aspiration inject 3 to 4 cc Inj. omnipaque to

confirm the spread of dye (Fig. 22.4).

Fig. 22.4: Spread of dye lateral view

 Ganglion of Impar Block 159

Step 6 For diagnostic block Inj. bupivacaine 0.25% 6 to 8 ml injected on each

side.
In case of neurolysis, Inj. phenol in oil 5 to 7 cc on each side is
injected. Warming up of phenol and flushing the needle with 1 to 2
cc of normal saline will ease the injection of neurolytic agent (phenol).
Step 7 Before with drawing of needle insert the stylet into it, to allow
neurolytic agent to spill the desired area. Inject Inj. xylocaine 2% into
the needle track while with drawing the needle. This will help to
reduce the needle pain following the procedure.
Step 8 The vital signs of the patient should be observed in the recovery for
about 1 to 2 hours.

Another Technique
Another technique is as follows:
Bent the spinal needle2 according to the curvature of coccyx, and introduce
the needle in midline and care to be taken not to puncture rectal wall. It is
advisable to introduce one finger into the rectum and guide the needle slowly.
Confirm the tip of the needle under fluoroscopy. After repeated negative
aspiration inject Inj. omnipaque 1 to 2 cc. Confirm the spread of the dye in
lateral and anterioposterior view. Save these pictures for documentation.

Contraindications
1. Anticoagulation therapy or suffer from congenital abnormalities of
coagulation.
2. Antiblastic cancer therapy.
3. The local skin infection at needle entry point or intra abdominal infection
and sepsis, intestinal obstruction.

REFERENCES
1. Warfield CA, Bajwa ZH. Principles and practice of pain medicine, New Delhi
Tata McGraw Publishing Company limited 2004;1:366.
2. Plancarte R, Amescua C, Patt R, Allende S. Pre sacral blockade of ganglion of
Walther (ganglion impar) [Abstract] Anesthesiology 1990;73;A 751.
Twenty Three

Cervical Epidural Block

H Bram

OVERVIEW
Cervical epidural injections, whether by translaminar or transforaminal
approach, are common techniques employed by interventional pain
specialists. These injections can be used for therapeutic or diagnostic
purposes. A physician who performs these injections should be well versed
and trained in lumbar epidural injections prior to attempting injections into
the cervical epidural space.

ANATOMY
The epidural space extends from the foramen magnum down to the
sacrococcygeal junction. The epidural space is bounded posteriorly by the
ligamentum flavum, laterally by the pedicles and intervertebral foramen,
and anteriorly by the posterior longitudinal ligament. The epidural space
contains fat, veins, arteries, connective and lymphatic tissue.1 Nerve roots
traverse the epidural space as they exit through their respective neural
foramina.
Flexion of the head increases the epidural space at the C7-T1. It is
important to note, for translaminar injections, that the epidural space narrows
above the C7-T1 segment increasing the potential for dural puncture or spinal
cord injury.

Indications
Cervical epidural injections are commonly employed to treat cervical
radiculopathy, cervical spondylosis, and neck pain. They can also be used
to treat pain emanating from cancer, such as a compressive lesion on a nerve
root. Less commonly they can be employed to treat symptoms related to acute
herpes zoster or a vaso-occlusive disorder such as Raynaud’s disease or
frostbite.2
Diagnostic transforaminal/selective root injections may be requested by
a surgeon, prior to surgery, in an attempt to isolate a potential pain-generating
segment.
164 Interventional Pain Management—A Practical Approach

Contraindications
The absolute contraindications for performing epidural injections are
coagulopathy, bleeding disorders, patient refusal, and an infection at the
intended needle insertion site.3 For transforaminal injections inability to
inject contrast, secondary to dye allergy, would also be an absolute
contraindication.
There are several relative contraindications: systemic infection, allergy to
injectate (if there is not a substitute for the intended injectate, i.e. local
anesthetic) and anatomic variations or postsurgical changes that alter the
anatomy in which the injection could result in an adverse outcome. A patient
with a physiologic disorder, such as a very brittle diabetic for epidural steroid
injection or cardiopulmonary compromise, e.g. patient with phrenic nerve
paralysis who is unable to lie supine or in a lateral decubitus position.

Equipment
Transforaminal epidural steroid injections can result in potential life-
threatening situations. Thus, certain equipment needs to be available for this
procedure, whether it is performed in a hospital setting, free-standing,
ambulatory suite, or in the office. The procedure room needs to have suction,
oxygen source, airway equipment, emergency drugs, and monitoring
equipment (Fig. 23.1). The Author always has intravenous access prior to
starting the procedure.
If one is performing a cervical epidural steroid injection, using the
translaminar approach and is planning on injecting local anesthetic into the
epidural space, the same equipment, including intravenous access, needs to
be available, as for a transforaminal injection, in case inadvertent
subarachnoid or subdural injection should occur.

Fig. 23.1: Emergency drugs, oxygen, AED

Equipment for Translaminar Epidural Steroids

For proper visualization, fluoroscopy is required. A C-arm, which has the
ability to provide a clear image and can be positioned into multiple angles.
 Cervical Epidural Block 165

• Antiseptic solution such as betadine with applicator sticks or Dura Prep®

and sterile drape
• 5 cc syringe – for the steroid/preservative free saline or local anesthetic
• 3 cc syringe - for contrast
• 5 cc syringe – for local anesthetic for skin anesthesia
• 5 cc loss of resistance syringe either glass or plastic
• 20 Gz Tuohy or Huber needle 10 cm in length
• 25 Gz or 27 Gz 5/8 inch to 1 inch spinal needle for skin anesthesia
• 5 cc to 10 cc of 1% lidocaine for skin anesthesia
• Nonionic contrast, such as omnipaque 240® or Isovue M200®
• Triamcinolone 40 mg/cc or betamethasone 6 mg/cc.
• Preservative free saline
• 1% preservative free lidocaine or 0.25% bupivacaine.
If the patient is allergic to the nonionic dye, for translaminar epidural
steroid injections, the Author has substituted 1 to 2 cc of gadolinium
(Magnevist®). Although acceptable for translaminar epidural steroid
injections, this dye is very faint and is not appropriate as a substitute for
transforaminal epidural injections.

Equipment for Transforaminal Injections

For proper visualization, fluoroscopy is required. A C-arm, which has the
ability to provide a clear image and can be positioned into multiple angles.
• Sterile prep solution either betadine or DuraPrep®
• Sterile drape (the Author prefers a clear fenestrated drape so that he is
able to visualize the patient’s face)
• 25 Gz or 27 Gz needle, 5/8 to 1 inch for skin anesthesia
• 1% lidocaine for skin anesthesia
• Three 3 cc syringes
• Three extension tubings
• 25-Gauge 2.5 inch short bevel needle
• Preservative free 1% or 2% preservative free lidocaine
• Nonionic contrast – Omnipaque 240® or Isovue-M 200®
• Triamcinolone 40 mg/cc, betamethasone 6 mg/cc or dexamethasone
10 mg/cc.

TECHNIQUE FOR TRANSLAMINAR EPIDURAL INJECTIONS

As with any interventional technique, the patient should be examined and
an appropriate history obtained prior to the procedure. The risk should be
discussed, which include, but are not limited to; allergic reaction, bleeding,
infection, nerve injury or damage, and postdural puncture headache. In
experienced hands, the highest risk is postdural puncture headache, which
is less than 1%. After the risks and benefits are discussed, consents should
be signed.
If the patient is having the translaminar epidural injection under strict
local anesthetic with no local anesthesic being injected into the epidural
166 Interventional Pain Management—A Practical Approach

space, intravenous access is not mandatory. If the patient is receiving local

anesthetic into the epidural space, then intravenous access needs to be
obtained.
The patient is brought into the procedure room and placed in a prone
position with a pillow under the chest with the neck flexed. The arms can be
placed at the patient’s sides or placed above the head (Fig. 23.2). If lateral X-
ray is being considered, during the procedure, the arms will need to be at the
sides. An antiseptic solution, such as betadine or DuraPrep® is applied and
strict aseptic technique should be employed. If sedation is being administered,
the patient should only receive light sedation and the physician should be
able to maintain verbal contact with the patient throughout the procedure. If
the patient, while receiving light sedation, becomes verbally unresponsive,
then the procedure should be stopped and the physician should wait until
the sedation dissipates to the point where he can resume verbal
communication. Failure to be able to speak with the patient during the
procedure increases the patient’s risk.

Fig. 23.2: Patient position for cervical

epidural injection

The C7-T1 interspace is identified under radiological guidance (Fig. 23.3).

The C-arm is placed in AP plane with a slight craniad or caudad tilt. The
skin is anesthetized with 1% or 2% lidocaine. A 5/8 to 1 inch needle can be
used for skin anesthesia.

Fig. 23.3: Pointer at C7-T1 interspace

 Cervical Epidural Block 167

After the skin is anesthetized with local, a 20-gauge Tuohy needle is

inserted until contact with the lamina of T1 with the needle in the midline or
just lateral the midline. This provides the physician with an idea of the
depth to the epidural space. The needle is then withdrawn slightly and the
loss-of-resistance syringe is attached. The needle is then advanced craniad
off the lamina and using loss-of-resistance technique, the epidural space is
located. After gentle aspiration for cerebrospinal fluid and blood, 1 to 2 cc of
nonionic contrast is injected, which should show epidural spread (Fig. 23.4).
Lateral X-rays can be used to confirm needle position, however, with the
patient in the prone position lateral radiographs are sometimes difficult to
obtain secondary to obstruction from the patient’s shoulders. The operator
should evaluate for rapid run off of dye, which would be indicative of vascular
uptake and if this occurs, the needle should be withdrawn and re-inserted

Fig. 23.4: Epidural spread of contrast

into the epidural space again using loss-of-resistance technique. The

practitioner may also notice contrast that appears as a band or streak and
does not diffuse across the midline like typical epidural spread (Fig. 23.5).
This signifies that the needle is superficial to the epidural space. Epidural
spread is normal or it can be extended several segments above the insertion
site at C7-T1. It is not recommended to go above the C7-T1 using intralaminar
approach because the risk of spinal cord trauma is higher above this segment
since the epidural space narrows above C7-T1.
After confirming needle position, steroid solution, i.e. 80 mg of
triamcinolone mixed with 3 cc of preservative-free normal saline can be
injected for treatment of cervical radiculopathy. If local anesthetic is desired,
0.5 to 1% lidocaine 3 cc can be injected or other low concentration local
anesthetic. If local anesthetic is used, this should be always with extreme
caution. If inadvertent spinal or subdural injection can occur, then the patient
can have profound hemodynamic shifts with marked hypotension. Any
physician administering local anesthetic into the epidural space needs to be
aware of the potential complications and be able to provide airway and
hemodynamic support.
The epidural needle should be cleared, if steroid is injected, by reinserting
the stylet, after the needle is withdrawn from the epidural space or by putting
168 Interventional Pain Management—A Practical Approach

1 mL to 2 cc of air through the needle so that you do not leave a potential

steroid tract. The patient is then observed as per office or surgical center
protocol and discharged to home if in stable condition.

Complications – Translaminar Epidural Injections

The potential complications from translaminar epidural steroid injections
are not very common. The most common side effect from epidural injections
is postdural puncture headache, which can be managed by conservative
means. Other potential complications include nerve injury and spinal cord
trauma. It cannot be over emphasized that these injections should never be
performed with heavy sedation in which the patient cannot respond verbally
to the pain interventionalist. The patient should be able to react to painful
stimuli and if intravenous analgesics are employed they should be used very
judiciously. If local anesthetic is employed, the physician needs to be able to
deal with the possibility of subarachnoid or subdural injection, which again
could result in marked hypotension. Vascular absorption of medication,
infection and allergic reaction to medication can also occur.

Transforaminal Injections Technique

The patient, like translaminar epidurals, is evaluated prior to the procedure.
Risks are again discussed with the patient, which include, but are not limited
to; bleeding, infection, nerve injury, postdural puncture headache, potential
for spinal anesthetic, and
paralysis. This procedure can
result in permanent
neurological damage and even
death, and only physicians
who are experienced in
interventional techniques
should perform this procedure.
The patient is brought into
the procedure room and
placed in a supine position
(Fig. 23.5). (This procedure can
also be performed in the oblique
or lateral decubitus position,
however the following
description will focus with the
patient in the supine position).
The patient’s neck is prepped
using strict aseptic technique.
If sedation is given, only light
sedation should be used and
the physician should always
be able to maintain verbal Fig. 23.5: Patient position for transforaminal
contact with the patient. epidural steroid injection on the left side
 Cervical Epidural Block 169

The fluoroscopy unit is placed into an oblique plane and a caudad tilt
may be applied in order to best visualize the desired foramen. The first
foramen visualized is C2-C3 with the C3 nerve exist this foramen (Fig. 23.6).
The lower half of the posterior wall of the foramen is formed by the superior
articular process. The desired target is the mid portion of the posterior wall,
which corresponds to the upper portion of the superior articular process
(Fig. 23.7). The needle will need to contact the anterior half of the superior
articular process. After skin anesthesia with 1 to 2% local anesthetic, a 25 Gz
2.5 inch short bevel spinal needle is directed under fluoroscopic guidance
down to the bony contact of the upper portion of the superior articular process.
This should be done either under continuous fluoroscopic guidance or with
small movements of the needle and then checking the needle position. The
needle should not stray into the foramen. The patient at times will experience
some pain into the neck and shoulder; however, if paresthesias occur in the
arm, the needle needs to be redirected. Once the superior articular process is

Fig. 23.6: Needle C3 foramen lat. view

Fig. 23.7: 25-gauge spinal needle contacting superior articular process

170 Interventional Pain Management—A Practical Approach

contacted, the needle should be slightly withdrawn and re-directed anteriorly

over the bone into the foramen (Fig. 23.8). The depth past the superior articular
process into the foramen is only a few millimeters and position should be
checked on AP fluoroscopy. The needle should not cross beyond the midline
of the facet pillars (Fig. 23.9). Once the needle has been placed and after
negative aspiration for cerebrospinal fluid and blood, 1 cc of nonionic

Fig. 23.8: Needle entering the foramen

Fig. 23.9: AP view of needle placement

contrast, i.e. omnipaque 240® or isovue-M 200® is injected, under live

fluoroscopy, and one should visualize spread down the nerve root and flow
into the epidural space (Figs 23.10 and 23.11). If there is quick absorption of
the contrast on live fluoroscopy with superior spread, the needle may be in
the vertebral artery. Rapid absorption with spread over the anterior surface
 Cervical Epidural Block 171

Fig. 23.10: Contrast in epidural space in AP view

Fig. 23.11: Oblique view of contrast in the epidual space

of vertebral body could signify flow into the anterior spinal artery (The Author
aborts the procedure if arterial flow is observed). Subarchnoid flow of contrast
may also be observed in which case the needle will need to be repositioned.
If adequate dye spread is noted, then 1% or 2% lidocaine can be injected into
the epidural space and 1 cc should suffice.
If steroids are used, the physician should wait to make sure that
intravascular or subarachnoid absorption of the local anesthetic does not
occur. If there are no adverse side effects from the local anesthetic injection,
epidural steroids can be injected, which can be 20 to 40 mg of triamcinolone,
6 to 12 mg of betamethasone, or 10 to 12 mg of dexamethasone.
The needle is withdrawn from the epidural space and cleared by inserting
the stylet back into the needle so as not to leave a steroid tract. The patient is
observed for an appropriate period of time and then discharged to home.
172 Interventional Pain Management—A Practical Approach

Complications – Transforaminal Epidural Injections

The potential complications from transforaminal cervical epidural steroid
injections include: postdural puncture headache, allergic reaction, infection,
injury to a nerve root or potential insertion of the needle into the spinal cord
and intravascular injection of medication. The most serious potential
complications are spinal cord injury and arterial injection of particulate
steroid resulting in neurological damage or even death.
The physician also has to be aware that local anesthetics injected, even in
small amounts, if inadvertently placed into the cerebral spinal fluid can
result in total spinal anesthesia.

REFERENCES
1. Bogduk, Nikolai. Practice guidelines for spinal diagnostic and treatment
procedures. San Francisco, CA: International Spine Intervention Society
2004;244.
2. McGraw, Kevin J. Interventional radiology of the spine. Totowa, New Jersey:
Humana Press, 2004;127-8.
3. Raj P Prithvi. Radiographic imaging for regional anesthesia and pain
management. Philadelphia, PA: Churchill Livingstone, 2003;101, table 16-1.
 Cervical Facet, Median Branch Blocks 173

Twenty Four

Cervical Facet,
Median Branch Blocks
H Bram

Cervical facet injections and cervical medial branch blocks are primarily
diagnostic injections. Cervical facet injections can be used for therapeutic
purposes, but in general are for diagnostic purposes. These injections are
used primarily to isolate the pain-causing generators. The physician, if he
is able to locate the painful segment can potentially offer the patient an
ablative procedure, such as radiofrequency rhizotomy, to provide more
profound and longer-lasting technique. There is not an advantage in
performing a cervical facet intra-articular injection over a cervical medial
branch block. Furthermore, there is a higher risk of potential complications
from an intra-articular injection.

ANATOMY
The cervical facet joints are composed of a superior facet articulating with an
inferior facet process. The cervical facet joint is innervated by the medial
branch of the dorsal ramus. Each facet joint has dual innervation: the medial
branch at the level of the joint and is also supplied by the medial branch
from the level above. Thus, at C4-5 this facet joint is innervated by the
medial branch from C4-5 and also from the medial branch at C3-4. This
has important clinical applications in that when performing a medial branch
block, for diagnostic information, 2 levels need to be anesthetized to evaluate
a specific facet joint as a potential pain generator.
The medial branches course along the posteriolateral and anteriolateral
articular pillars. The C4, C5 and C6 traverse the midportion of the articular
pillars. The C7 medial branch courses along the superior portion of the
articular pillar.1
At C3, there are again 2 medial branches: the larger, superior medial
branch, also known as the Third Occipital Nerve and the deep medial branch.
The Third Occipital Nerve runs, with some variation, across the C2-3 facet
line or just inferior to the facet joint line margin.
The deep medial branch runs inferior and parallel to the third occipital
nerve at the C3 articular pillar.2
174 Interventional Pain Management—A Practical Approach

INDICATIONS
Cervical facet and cervical medial branch blocks are predominately for
diagnostic evaluation of cervicogenic headaches, neck and shoulder pain.

CONTRAINDICATIONS
The absolute contraindication for this procedure is patient’s refusal, patient
with coagulation or bleeding abnormalities, and infection at the injection
site. The relative contraindications would be distorted anatomy, in which
the operator will not be able to deposit the medication into the target region
and systemic infection.

EQUIPMENT-CERVICAL FACET AND CERVICAL MEDIAL BRANCH

BLOCK
The equipment required is the same for both facet and medial branch blocks.
• An antiseptic solution such as betadine or DuraPrep
• Sterile drape
• 22 Gz or 25 Gz needles 3.5 inch for regular sized adults and 5 inch
needles for larger patients
• 1% or 2% lidocaine for skin anesthesia
• 5 mL or 10 cc syringes
• Sterile tubing
• 0.5 % bupivacaine, 0.75% ropivacaine or 0.5% ropivacaine
• Triamcinolone 40 mg/cc or celestone 6 mg/cc
• Nonionic contrast- Omnipaque 240® or Isovue M-200®
• C-arm for fluoroscopic guidance.

TECHNIQUE- CERVICAL MEDIAL

BRANCH BLOCK
Consent is obtained from the patient
after appropriate history and
physical examination is performed.
The patient is brought into the
procedure room and placed prone
on the table with arms at the side
and pillow under the chest. The
patient is prepped using antiseptic
solution and strict aseptic
technique. For the cervical medial
branch blocks, the head is turned
away from the target side (Fig. 24.1).
Fig. 24.1: Position of patient and C-arm
Thus if one is working on the left
side, the head is turned to the right to give better visualization of the articular
pillars as identified by the concavities (Fig. 24.2).
 Cervical Facet, Median Branch Blocks 175

Fig. 24.2: Needles lateral to articular pillar

The C-arm is in AP plane and rotated slightly caudad to give sharp

visualization of the concavities. Skin is anesthetized with local anesthetic
immediately lateral to the articular pillars. The needles are inserted aiming
at the lateral most aspect of the posterior surface of the bone.
After bony contact, the needle is withdrawn and moved slightly laterally
immediately adjacent to concavity (Fig. 24.3).

Fig. 24.3: Needles in AP view

176 Interventional Pain Management—A Practical Approach

Lateral X-rays are taken and the needles should be positioned within the
midportion of the articular pillar (Fig. 24.4).

Fig. 24.4: Needles in align to articular pillars

The C-arm needs to be adjusted to align the articular pillars or trapezoid

for a true lateral view (Fig. 24.5).

Fig. 24.5: Needle in AP view

Once the needles are in place, 0.3 mL to 1 cc of local anesthetic, i.e. 0.5%
bupivacaine is injected. For strictly diagnostic purposes only local anesthetic
should be injected and for diagnostic and therapeutic purposes, 1 mg /cc of
celestone or 10 mg/cc of triamcinolone can be added into the solution. The
needles are retracted and cleared by inserting the stylet back into the needle
so as not to leave a steroid track. The patient is discharged to home after an
appropriate period of time for postprocedural observation.
 Cervical Facet, Median Branch Blocks 177

For C3 or Third Occipital Nerve block, because of variable location, one

needle should be inserted to the midportion of the C2-3 facet line, with a
second and third needle being placed immediately superior and inferior to
the C2-3 facet line.1 For C3-6 medial branches the needles need to be inserted
in the midportion of the articular process. For C7 medial branch block, the
needle should be inserted along the superior portion of the articular pillar.

COMPLICATIONS
The risk from cervical medial branch block injections is in general, quite
low. The patient may experience temporary dizziness or ataxia from
relaxation of the posterior cervical musculature in the cervical spine and
this is a temporary affect, which resolves when the local anesthetic
dissipates. The patient may also potentially experience paresthesias in the
arms or weakness in the arms from anterior spread of the local anesthetic.
Vascular absorbtion, allergic reaction and infection are also potential
complications.

CERVICAL FACET - INTRAARTICULAR TECHNIQUE

The patient is brought into the procedure room and placed in prone position.
A pillow is placed under the chest and the neck is flexed and turned away
from the affected side.
The patient is prepped and draped using strict sterile technique.
The target facet joint is identified on fluoroscopic view with the C-arm.
Caudad tilt is placed on the C-arm in the anterior-posterior plane for sharp
visualization of the target joint.
The skin is anesthetized with local anesthetic, such as 1 % lidocaine. A
22 or 25-guage spinal needle is inserted towards the inferior aspect of the

Fig. 24.6: Needle position in oblique view

178 Interventional Pain Management—A Practical Approach

facet joint towards the mid position of the joint (Fig. 24.6). The needle, after it
strikes the bone is then withdrawn and re-directed superiorly to enter the
joint. Lateral X-ray is used to confirm that the needle is within the substance
of the joint. Care must be taken that the needle is within the substance of the
joint and does not extend through the joint for spinal cord trauma could
occur. After negative aspiration, the interventionist can inject a small amount
of nonionic contrast, 0.3 cc of omnipaque 240 or isovue-M 200 into the joint
to confirm that dye stays within the joint and does not spread into the epidural
or intrathecal region. If dye flow is suitable, then 0.5 cc of local anesthetic can
be injected, such as 0.5% ropivacaine or bupivicaine with 10 mg of
triamcinolone. The needle is withdrawn from the space and stylette is re-
inserted to clear the needle. The patient is observed for an appropriate amount
of time and discharged to home.

COMPLICATION
Intraarticular cervical facet injections can result in spinal cord injury, nerve
injury, vascular absorption, allergic reaction, infection and epidural or spinal
anesthesia.

REFERENCES
1. Bogduk, Nikolai. Practice guidelines for spinal diagnostic and treatment
procedures. San Francisco, CA: International Spine Intervention Society
2004;124-5.
2. Waldman, Steven D. Interventional pain management (2nd Edn). Philadelphia,
PA: WB. Saunders Company 2001;458.
 Lumbar and Caudal Epidural Blocks 179

Twenty Five

Lumbar and Caudal

Epidural Blocks
S Bakshi, GW Abrahamsen

INTRODUCTION
Epidural steroid injections are the placement of steroids into the epidural
space. They were first described in 1953 and epidural steroids have been
administered to millions of patients for the treatment of axial and radicular
back pain. Traditionally, these injections were performed with a “blind
approach” (without fluoroscopy) and lacked target specificity and contrast
spread to confirm needle placement into the epidural space. With the advent
and use of fluoroscopy the transforaminal approach became widespread,
with the thought that epidural steroids would be more effective if they
were delivered more accurately to the site of pathology.1-4
At the present time, the efficacy of epidural steroid injections remains
controversial. Only six prospective, blinded, randomized, controlled trials
reporting the efficacy of epidural steroids have been performed. Two
reported significant improvement of symptoms5,6 and four did not.7-10 A
meta-analysis of the epidural steroid injection literature from 1996 to 1993
revealed a 14% positive treatment effect over placebo.11 However, the earlier
studies were again performed with “blind” techniques.
The basis behind the use of epidural steroid injections is that chemical
mediators are released from a disc after injury to that disc. This results in
the release of phospholipase A2 (PLA2) from the nucleus pulposus into
the epidural space.12 PLA2 is an enzyme found in high concentrations in
disc material. PLA2 is highly inflammatogenic and propagates an
inflammatory cascade with the liberation of arachidonic acid with
inflammatory responses via leukotrienes and prostaglandins.13 Epidural
steroids act by blocking PLA2 activity and can exert an anesthetic like
activity by blocking nociceptive C-fiber conduction.14 This effect is reversed
when the corticosteroid is removed, suggesting a direct membrane effect.
Glucocorticoid receptor sites have also been located on norepinephrine and
5-hydroxytryptamine neurons within the dorsal horn substantia
gelatinosa.15,16
180 Interventional Pain Management—A Practical Approach

ANATOMY
The epidural space lies between the osseoligamentous structures lining the
vertebral canal and the dural membrane surrounding the spinal cord and
the nerve roots.17
The anterior epidural space is bordered anteriorly by the vertebral body,
intervertebral disc, and posterior longitudinal ligament and posteriorly by
the thecal sac. The posterior epidural space is bordered anteriorly by the
thecal sac and posteriorly by the ligamentum flavum and the laminae. Each
spinal nerve exists within an intervertebral foramen, bordered anteriorly
by the vertebral body and the disc, posteriorly by the facet joint, and
superiorly and inferiorly by the pedicles of the adjacent vertebrae.

Evaluation
Evaluation of a patient with back pain should begin with a detailed history
and physical examination. Patients will often complain of lower back pain
with radicular symptoms to the lower extremities, including pain,
numbness, paresthesiae, or weakness. Patients will often also describe
symptoms consistent with neurogenic claudication. Physical examination
may reveal paresthesiae in a dermatomal distribution; weakness in a
myotomal distribution; and a positive straight-leg raise.
Imaging studies should be performed including plain film radiographs
and MRI or CT scan to confirm a diagnosis that will benefit from epidural
steroid injections. Electrodiagnostic signs of radiculopathy may be helpful,
but are not an absolute prerequisite to epidural injections.

Indications
The main clinical indications for epidural steroid injections include: Disc
degeneration or herniation, spinal nerve root compression, spinal nerve
root inflammation, and spinal stenosis. Correlating the distribution of the
patients pain with the imaging study findings, the clinician can then decide
which epidural technique, level, and side of spine at which the injection
should be performed to achieve maximum benefit.
Epidural steroid injections should then be performed if the patient has
a diagnosed cause of radiculopathy, has not responded to non-surgical
conservative measures, and whose pain is likely to have an inflammatory
basis.

Contraindications
Absolute contraindications to epidural steroid injections include patients
who are unwilling to consent to the procedure, evidence of an untreated
infection at the site of the injection, pregnancy, and bleeding diathesis.
Relative contraindications are known allergy to the medications and dye
administered, concurrent use of anticoagulant medication, known systemic
infection, immunosuppression, severe respiratory or cardiovascular compro-
 Lumbar and Caudal Epidural Blocks 181

mise, and anatomic, congenital or surgical changes preventing safe

administration of medication into the epidural space. If the patient has a
known allergy to the medications used for the procedure, pre-medication
may then be required depending on the severity of the allergic reaction.

Equipment/Supplies
When performing epidural injections a C-arm fluoroscope is required for
precise needle placement and visualization of flow of contrast. The
equipment and supplies needed include: Tuohy epidural needles, 18 or 20-
gauge 3.5 inch (interlaminar), spinal needle, 22 or 25-gauge 5 inch short
bevel needle (transforaminal), 25-gauge 1.5 inch needle for administration of
local anesthetic, syringe 5 mL. 10 mL glass or plastic syringe (for interlaminar
approach using “loss of resistance technique”), 10 mL plastic syringe, 3 mL
syringe for injection of contrast, connection tubing, sterile gloves, drapes,
gowns, and povidone-iodine or chlorhexidine prep. Typically, the supplies
can be packaged in a custom epidural tray. Most patients also require
intravenous access. In some cases I.V. sedation is used. Physiological
monitoring should also be used throughout the procedure.

Medications
Medications used for epidural steroid injections vary but include: preservative
free sterile saline, water soluble, non-ionic radiographic contrast medium
(isovue or omnipaque), local anesthetic (lidocaine 1-2% or bupivicaine (0.125
- 0.5%), and a corticosteroid preparation (triamcinolone 20-80 mg,
betamethasone 6-18 mg, depomedrol 20-80 mg or dexamethasone).18,19
Common volumes used for the injectate include: Interlaminar approach:
total volume 6 to 8 mL, Transforaminal approach: total volume 2 mL, and
Caudal approach: total volume 10 to 15 mL. The clinician will then combine
1 to 2 mL of corticosteroid with local anesthetic or normal saline to achieve
the desired volume.

Techniques
The interlaminar approach, both midline and paramedian, involves insertion
of an epidural needle midway between the laminae of the adjacent vertebrae,
whereas the transforaminal approach involves insertion of a spinal needle
into the superior portion of an intervertebral foramen just inferior to the
pedicle.

Procedure
Interlaminar Approach
After informed consent is obtained, patient is placed prone on the fluoroscopy
table. It is advisable to place a small pillow under the lower abdomen to open
up the interlaminar space. At this point the skin is prepped and draped in a
sterile fashion.
182 Interventional Pain Management—A Practical Approach

After carefully identifying the appropriate interlaminar space that you

want to enter using fluoroscopy, make a skin mark over the lamina below the
target interspace. The skin and subcutaneous tissues are now anesthetized
using 1% lidocaine.
A 20-gauge Tuohy needle is now advanced to the lamina. It is preferable
to contact the superior border of the lower lamina so that you have
perception of the appropriate depth. The needle can now be walked off the
lamina till it is felt to enter the ligamentum flavum. At this point attach a
“loss of resistance” syringe to the needle. Depending on operator preference
you can either use saline or air for the loss of resistance technique. Carefully
advance the needle in small increments till you feel the loss of resistance
on entering the epidural space. Once the epidural space is entered 1 to 2 cc
of radio contrast dye is injected and the dye spread is visualized under
continuous fluoroscopy in the AP position. The C-arm is now rotated to
the lateral position and appropriate dye spread is reconfirmed in the lateral
position. The dye spread should be in the epidural space and there should
be no intravascular or intrathecal flow patterns. It is advisable to save
the hard copy of the dye spread patterns in both AP and lateral views
(Figs 25.1A to F).

Fig. 25.1A: Initial AP view Fig. 25.1B: Point of skin entry

Fig. 25.1C: Needle headed to lamina Fig. 25.1D: Needle walks off lamina
 Lumbar and Caudal Epidural Blocks 183

Fig. 25.1E: Reconfirm position on lat. Fig. 25.1F: AP view of dye spread

Transforaminal Approach
After informed consent is obtained, patient is placed prone on the fluoroscopy
table. Skin is prepped and draped in a sterile fashion.
After starting in the AP position, the C-arm is rotated slightly in an
oblique fashion, so that the typical Scotty dog picture can be visualized.
The initial target is the 6 o’ clock position of the pedicle. A skin mark is
placed directly over this point. Skin and subcutaneous tissues are then
anesthetized using 1% lidocaine. A 22 or 25-gauge 5 inch short bevel needle
is then advanced under fluoroscopic guidance towards the target point.
The needle position is then checked initially in the AP position and
subsequently in the lateral position to ensure that the tip of the needle is
finally in optimum position. At this point in the AP view the tip of the
needle should lie just below the mid-point of the pedicle and should not
cross the facet joint line. In the lateral view the needle tip should lie in the
posterior superior quadrant of the neural foramen. At this point once the
needle is felt to be in optimal position, 1 cc of radio contrast dye is injected
under continuous fluoroscopy. It is advisable to attach a low volume
extension tubing to the needle, and inject the dye and subsequent
medications via the extension tubing under continuous fluoroscopy. Care
is taken to see that there is appropriate dye flow pattern, and it is critical to
ensure that there is no intravascular dye spread. Continuous fluoroscopy
is used because intravascular injection can be missed if intermittent
fluoroscopy is used. In fact some people recommend routine use of digital
subtraction to rule out intravascular injection, however this has not become
a standard of care.
Once appropriate dye spread is confirmed, the steroid mixture can then
be injected. Use of non-particulate steroid preparation is preferable because
then there is less chance of vascular thrombosis.
184 Interventional Pain Management—A Practical Approach

When using this approach for the L5S1 interspace, it may require a caudal
cranial adjustment of the C-arm to get appropriate visualization of the target
by moving the superior articular process away.
The approach to the S1 foramen is different from the above. In this case
the needle is placed through the posterior S1 foramen onto the pedicle of
S1. The C-arm needs to be adjusted slightly cephalo-caudad and slightly
ipsilateral oblique to superimpose the anterior and posterior S1 foramen.
The needle enters at the lateral margin of the posterior S1 foramen. The
safe technique is to initially hit the bony surface of the sacrum first, and
then walk off into the foramen. At this point depth is checked in the lateral
position to make sure the needle does not pass anteriorly into the pelvic
cavity. Once needle is felt to be in appropriate position radiocontrast dye is
injected to ensure appropriate dye spread along the S1 nerve root sleeve.
At this point the mixture of cortisone is injected. Note that the dye and the
subsequent medications should be injected under continuous fluoroscopy
(Figs 25.2A to F and 25.3A to F).

Fig. 25.2A: Straight AP view Fig. 25.2B: Slight oblique angulation

with skin marker

Fig. 25.2C: Needle entry-oblique view Fig. 25.2D: Reconfirm in AP view

 Lumbar and Caudal Epidural Blocks 185

Fig. 25.2E: Lateral view of needle tip Fig. 25.2F: Final view of dye spread

Fig. 25.3A: AP view Fig. 25.3B: Needle entry point for S1

Fig. 25.3C: Needle headed towards Fig. 25.3D: Needle walks off bone
S1 foramen
186 Interventional Pain Management—A Practical Approach

Fig. 25.3E: Reconfirm in lateral view Fig. 25.3F: AP view of dye spread

Caudal Approach
After informed consent, patient is placed prone on the fluoroscopy table,
with a pillow under the lower abdomen. Skin is prepped and draped in a
sterile fashion. It is often helpful to have the patients rotate their feet inwards.
This procedure is ideally started with the C-arm in the lateral position.
It is helpful usually to manually feel for the indentation of the sacral cornua.
At this point skin and subcutaneous tissues are anesthetized.
Under lateral view of the fluoroscope, the needle is advanced cephalad
towards the sacral hiatus at a 45 degree angle. If you touch bone, readjust
the needle angle and try to walk the needle into the caudal canal. You will
initially feel the needle entering the sacrococcygeal ligament, followed by the
loss of resistance. At this point radiocontrast dye is injected and appropriate
dye spread is reconfirmed in both lateral and AP positions. Careful negative
aspiration is done before dye injection to ensure that no blood or CSF is
aspirated.
Since the caudal canal is spacious, usually 10 to 15 cc of steroid mixture
is injected (Figs 25.4A to E).

Fig. 25.4A: Initial lateral view Fig. 25.4B: Needle headed towards canal
 Lumbar and Caudal Epidural Blocks 187

Fig. 25.4C: Needle walked into Fig. 25.4D: Dye spread in lateral view
caudal canal

Fig. 25.4E: Dye spread in AP view

Post-procedural Care
Following the injection the patient should be monitored with physiological
monitoring for at least 30 minutes. If vital signs are stable and the patient is
doing well they may then be discharged. The patient should be advised of
home care instructions including possible bruising and increased pain at
the incision site for first few days following the procedure, in which ice
packs may be beneficial, rest and abstinence from driving for 24 hours post
procedure, increased activity as tolerated. The patient should notify the
office of any skin rashes, hives shortness of breath, wheezing, increase in
pain level, persistent nausea or vomiting, persistent headache which
worsens upon sitting, and fever greater than 100°F.

Complications
Potential risks are infrequent and divided into complications of needle
placement or medication side effects. Possible risks of needle placement
188 Interventional Pain Management—A Practical Approach

are pain at the injection site, nerve root injury, spinal cord injury, epidural
hematoma, epidural abcess, meningitis, osteomyelitis, and postdural
puncture headache. Local anesthetic side effects include weakness in lower
extremity secondary to motor block, cardiac arrhythmia, seizure, and
hypotension.20 Patients should also be advised of potential steroid effects
such as fluid retention, transient weight gain, hyperglycemia, hypertension,
cushing syndrome, facial flushing, and steroid myopathy.21 Allergic reactions
may also occur with any of the medication administered.
Added precaution should be used when performing transforaminal
epidural steroid injections. A case report22 warned of 3 cases of unexpected
paraplegia following lumbar transforaminal injections. The mechanism of
injury was not demonstrated, but was referred to be inadvertent, intra-
arterial injection of particulate steroids into a radicular artery that reinforced
blood supply of the lower end of the spinal cord. This reinforces the need
of careful attention when injecting the contrast medium to avoid possible
intra-arterial injection of steroids.

CONCLUSION
Lumbar epidural steroid injections performed under fluoroscopic guidance
are a safe and effective treatment modality for many conditions causing
back pain and radicular symptoms. It should therefore be considered in
the treatment plan in patients with a diagnosed, non-emergent cause of
back pain who have failed more conservative treatment options.

REFERENCES
1. Derby R, Kine G, Saal J, Reynolds J, Goldthwaite N, White A, Hsu K, and
Zucherman J. Response to steroid and duration of radicular pain as predictors
of surgical outcome. Spine 1992;17:S176-83.
2. Derby R, Bogduk N, Kine G. Precision percutaneous blocking procedures for
localizing spinal pain. Part 2. The lumbar neuraxial compartment. Pain Digest
1993; 3:175-88.
3. Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH (Ed),
Spine Care, Volume One: Diagnosis and Conservative.
4. Bogduk N. Spine update: Epidural steroids. Spine 1995;20:845-8.
5. Dilke TFW, Burry HC, Grahame R. Extradural corticosteroid injection in the
management of lumbar nerve root compression. BMJ 1973; 2:635-7.
6. Carrete S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for
sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336:1634-40.
7. Snoek W, Weber H, Jorgensen B. Double-blind evaluation of extradural
methylprednisolone for herniated lumbar disc. Acta Orthop Scand 1977;
48:635-41.
8. Ridley MG, Kingsley GH, Gibson T, et al. Outpatient lumbar epidural
corticosteroid injection in the management of sciatica. Br J Rheumatol 1988;
27:295-9.
9. Cuckler JM, Bernini PA, Wiesel SW, et al. The use of epidural steroids in the
treatment of lumbar radicular pain. A prospective, randomized, double-blind
study. J Bone Joint Surg Am 1985;67:63-6.
 Lumbar and Caudal Epidural Blocks 189

10. Bush K, Hillier S. A controlled study of caudal epidural steroid injections of

triamcinolone plus procaine for the management of intractable sciatica. Spine
1991; 16:572-5.
11. Rapp SE, Haselkorn JK, Elam K, et al. Epidural steroid injection in the treatment
of low back pain: A meta-analysis. Anesthesiology 1994; 81:A923.
12. Rydevik B, Brown MD, Lundborg G. Pathoanatomy and pathophysiology of
nerve root compression. Spine 1984; 9:7-15.
13. Saal JS, Franson RC, Dobrow R, et al. High levels of inflammatory phos-
pholipase A2 activity in lumbar disc herniations. Spine 1990;15:674-8.
15. Johansson A, Hao J, Sjolund B. Local corticosteroid blocks transmission in
normal nocioceptive C-fibers. Acta Anesthesiol Scand 1990; 34:335-8.
16. Fuxe K, Harfstrand A, Agnati LF, et al. Immunocytochemical studies on the
localization of glucocorticoid receptor immunoreactive nerve cells in the lower
brain stem and spinal cord of the male rat using monoclonal antibody against
rat liver glucocorticoid receptor. Neuroscience Lett 1985; 60:1-6.
17. Fenton DS, Czervionke LF. Image-Guided Spine Intervention. Saunders
Philadelphia 2003; 100.
18. Bogduk N, Aprill C, Derby R. Selective nerve root blocks. In: Wilson DJ (Ed),
Interventional radiology of the musculoskeletal system. Edward Arnold,
London 1995;10:121-32.
19. Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH (Ed),
Spine Care, Volume One: Diagnosis and conservative treatment. Mosby, St
Louis 1995; 22:322-43.
21. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten
WK. Complications of fluoroscopically guided transforaminal lumbar epidural
steroid injections. Arch Phys Med Rehabil 2000; 81:1045-50.
22. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: Report
of three cases. The Spine Journal 2002; 2:70-75.
190 Interventional Pain Management—A Practical Approach

Twenty Six

Lumbar Facet and Median

Branch Block
S Bakshi, GW Abrahamsen

INTRODUCTION
The facet joint is a true synovium-lined joint located in the posterior
compartment of the spine that allows the spine to flex, extend, and rotate.
The major causes of facet mediated back pain are osteoarthritis, erosions of
the adjacent bone margins of the facets, bony overgrowth of the facets and
articular processes, degenerative conditions resulting in reduction or loss
of facet joint cartilage, or acute causes such as instability of the joint itself
after trauma such as a motor vehicle accident. Facet pain is often an under
diagnosed cause of back pain. However, the prevalence of facet joint
mediated pain in patients with chronic spinal pain has been established as
15 to 40% of lower back pain.1-3 Facet mediated pain is more common in the
elderly than the younger population.
Facet mediated back pain has been studied for many years. Many studies
have also been performed demonstrating facet mediated pain with the
resolution of symptoms following injection of local anesthetic. In 1997 and
1998. Dreyfuss and colleagues, as well as, Kaplan et al performed studies
demonstrating that lumbar medial branch blocks are target-specific and a
valid test of zygapophysal joint pain.4,5 Once the diagnosis has been
established through lumbar medial branch blocks numerous studies have
shown dramatic and long lasting relief of pain following lumbar medial
branch neurotomy.6,7

Evaluation
Diagnosing facet mediated back pain should first begin with a detailed history
and focused physical examination. One should suspect facet disease if the
patient is complaining of poorly localized lower back pain that may be referred
to the hip or thigh. These patients may also be employed in occupations that
require repeated or excessive hyperflexion, hyperextension, or twisting
movements of the spine. The physical examination may reveal facet
tenderness and pain upon extension or lateral bending of the spine. Otherwise,
the patient is neurologically intact. Referred pain to the lower extremities is
 Lumbar Facet and Median Branch Block 191

not a contraindication for lumbar medial branch blocks. Pain referred as far
as the leg and foot has been relieved by anesthetizing lumbar zygapophysial
joints.8,9
Imaging studies are helpful but may be unreliable indicators of
facetogenic pain.10 Multiple studies have shown a lack of correlation between
the results of conventional clinical examination and the response to
controlled blocks.11-14 This is the reason why a detailed history and
examination in conjunction with facet joint injections and medial branch
blocks play a vital role in the diagnosis and management of facetogenic
pain.

ANATOMY
In order to accurately and completely diagnose and manage facet mediated
pain, one must understand the anatomy of the spine. The spine can be
broken up into three compartments: anterior, middle, and posterior. The
anterior compartment consists of the vertebral bodies and disc spaces, the
middle compartment consists of the epidural space and the neural foramina,
and the posterior compartment consists of facet and sacroiliac joints. The
zygapophysial joints (facet joints) are synovial joints between the superior
and inferior articular processes of adjacent vertebrae. Each joint is
surrounded by a thin, loose articular capsule. The capsule is attached to
the margins of the articular processes of adjacent vertebrae. Accessory
ligaments unite the laminae, transverse processes, and spinal processes
and help stabilize the joint.15
The zygapophysial joints are innervated by articular branches that arise
from the medial branches of the dorsal primary rami of the spinal nerves.
As these nerves pass posteroinferiorly, they lie in groves on the posterior
surfaces of the medial parts of the transverse processes. Each articular
branch supplies two adjacent joints; therefore, each joint is supplied by
two nerves. Thus, for example, the L3-4 joint is innervated by L2 and L3
medial branches. (Table 26.1)

Table 26.1: Innervation of various zygapophysial joints

Joint Innervation

L2-3 L1, L2 MBB

L3-4 L2, L3 MBB
L4-5 L3, L4 MBB
L5-S1 L4, L5 MBB

Also keep in mind that the numbering of the medial branches differs
from their location. Thus the L4 medial branch courses over the L5
transverse process and the L3 medial branch courses over the L4 transverse
process.
192 Interventional Pain Management—A Practical Approach

Procedures
Once there is suspicion of facet mediated pain, the clinician then must decide
to proceed with purely diagnostic medial branch blocks with local anesthetic
or diagnostic and therapeutic intraarticular facet blocks with steroids. The
clinician must also keep in mind that typically facet disease is not often
limited to only one joint.
The purpose of performing medial branch blocks is to conclude if the
patient’s typical back pain is relieved by an injection of local anesthetic to
the nerve. If the patient responds to the medial branch block, then a more
permanent procedure, such as medial branch radiofrequency denervation
can be considered. With this in mind, it is crucial to rule-out false-positive
responses with the injection. Typically, 80% reduction of the patient’s typical
pre-procedure pain is considered a positive response. The clinician
interpreting the results of the block must also consider placebo effect and
the medial branch blocks are often repeated with a short-acting local
anesthetic. A patient with 2 positive medial branch blocks concordant with
the duration of action of the local anesthetic used should then be considered
for medial branch rhizotomy.
Intra-articular facet blocks can also be considered for suspected
facetogenic pain. This injection involves injecting a combination of a short
or long-acting local anesthetic with a steroidal agent. This technique is
thought to have a two-fold effect of diagnosing suspected facetogenic pain
with the added benefit of reduction of inflammation from within the joint
providing long lasting resolution of symptoms. However, it is felt that the
longer lasting benefit of radiofrequency neurotomy after diagnosis with
medial branch blocks is more beneficial then intra-articular injections with
steroidal agents.
At this time the current guidelines of the International Spine Intervention
Society state that lumbar medial branch blocks have replaced, or should
replace, intra-articular injections in the diagnosis of lumbar zygapophysial
joint pain, stating: Medial branch blocks are relatively easier to perform,
medial branch blocks are safer and more expedient, medial branch blocks
are more easily subjected to controls, intra-articular blocks lack therapeutic
utility, i.e. if positive, they lack a valid subsequent treatment, medial branch
blocks do have therapeutic utility for, if positive, the pain can be treated by
radiofrequency neurotomy.16

CONTRAINDICATIONS
Absolute contraindications to medial branch and intra-articular injections
include infection, anti-coagulation therapy, and pregnancy. If a patient is
on anticoagulants medical clearance should be obtained from the treating
physician to discontinue anticoagulants and a PT/PTT, INR should be
obtained prior to the procedure. The clinician initiating these treatment
modalities should also use caution if patient has known allergies to contrast
dye and/or local anesthetics. Concurrent treatment with anti-inflammatory
 Lumbar Facet and Median Branch Block 193

medication and aspirin should be stopped prior to the injections to prevent

uncontrolled bleeding.

Equipment
These blocks are typically performed in a fluoroscopy suite under sterile
technique using a C-arm fluoroscope. Equipment needed usually consists
of sterile gloves and drapes, iodine based solution or alcohol-based
antiseptic for skin preparation, 2 to 5 mm syringes, 25-gauge needle to
anesthetize the skin, spinal needles 22 to 25-gauge 3.5 inch (1 per level), and
a 18-gauge needle to draw up medication.

Medication
The typical local anesthetics used are bupivacaine 0.5% and lidocaine 2%.
Omnipaque is used as the contrast medium. In addition, triamcinolone or
depo medrol is used when performing intra-articular blocks. When performing
medial blocks, no more than 0.5 ml is required to block the nerve adequately.

Techniques
Lumbar Facet Joint Injection
After informed consent is obtained, patient is placed on the fluoroscopy
table with a pillow under the lower abdomen. Skin is prepped and draped
in a sterile fashion.
Initial AP view of the spine is visualized. Once you reconfirm the exact
level at which you want to perform the injection, the C-arm is rotated obli-
quely until the posterior part of the facet joint just begins to open. The angle
will vary with the level of the joint being injected, since the upper lumbar
facet joints have a different orientation than the lower lumbar facet joints.
The ideal point of skin entry is just lateral to the inferior edge of the inferior
articular process. Usually this is the widest part of the joint and is easiest to
enter. This point is marked on the skin, and 1% lidocaine is used to anesthetize
the skin and subcutaneous tissues.
At this point a 22 or 25-gauge spinal needle is used to enter the joint
space using a “tunnel” approach. Often a pop is felt as you enter the joint
space. This may or may not reproduce the patient’s typical concordant pain.
Injecting about 0.25 cc of radio contrast dye into the joint reconfirms appro-
priate position of the needle in the joint. Once appropriate placement of the
needle in the joint has been confirmed, a mixture of local anesthetic and
cortisone is injected into the joint (Figs 26.1A to E).
194 Interventional Pain Management—A Practical Approach

Fig. 26.1A: Initial AP view Fig. 26.1B: Oblique view with joint
space opened up and marker on skin

Fig. 26.1C: Needle headed into Fig. 26.1D: Dye spread within
joint space joint space AP view

Fig. 26.1E: Lateral view of dye spread

 Lumbar Facet and Median Branch Block 195

Medial Branch Block

After informed consent is obtained, patient is placed on the fluoroscopy
table in the prone position with a pillow placed under the lower abdomen.
Skin is prepped and draped in a sterile fashion.
The procedure is started with a straight AP position of the C-arm. The
C-arm is then rotated in an oblique fashion till the “Scotty dog”
configuration is visualized. For the medial branches L1 to L4 the target
position for the needle lies at the junction of the base of the transverse
process and the superior articular process.
Under fluoroscopic guidance a 22 or 25-gauge spinal needle is advanced
to this target position. Once the needle hits bone at this point, it is walked
off the bone. Needle position is then checked in lateral position to make
sure that it is not too far into the neural foramen.
At this point some people recommend injecting a small volume of
radiocontrast dye to confirm that there is no vascular uptake. Once you
have confirmed that needle is in the correct position, 0.3 to 0.5 cc of local
anesthetic solution is injected to anesthetize the appropriate medial branch.
It should be noted that the procedure for blocking the medial branch at L5
differs from the above procedure since the target point here is the
superomedial aspect of the sacral ala. Once again, after the needle hits bone
at this point, it should be walked off the bone slightly to ensure that the
needle lies in contact with the nerve.
It is critical to ensure that the appropriate nerves are selected depending
on which joint is being investigated. For example, if one wants to block the
L4 -5 joint, the medial branches to be blocked will be the L3 and L4 nerves,
which run at the level of the L4 and L5 transverse process respectively
(Figs 26.2A to F).

Fig. 26.2A: Initial AP view Fig. 26.2B: Oblique view with marker
on skin for L4 MBB block
196 Interventional Pain Management—A Practical Approach

Fig. 26.2C: AP view with marker Fig. 26.2D: Needle at L4 MBB

for L5 MBB Block

Fig. 26.2E: Needle at L5 MBB Fig. 26.2F: Lateral view of needle position

Post-procedural Care
The patient is discharged with postprocedural instructions to contact the
office immediately in cases of increased temperature, onset of rash, new
onset weakness in the extremities, severe unrelieved pain, etc. The patient
should also be given a detailed explanation on how to accurately record
their response to the injection and should follow-up in the office in 3 to 4
days. The patient can resume normal activities the following day and should
refrain from driving or operating heavy machinery the day of the procedure.
In cases where steroids are used, it may take 3 to 5 days for the full effect of
the medication to take place.

Potential Complications
Medial branch blocks and intra-articular injections are relatively safe
procedures. However, potential complications include, bleeding, infection,
post-procedural radicular or back pain, thecal sac puncture and subsequent
spinal headache, allergic reaction to medication, and possible vasovagal
reaction.
 Lumbar Facet and Median Branch Block 197

CONCLUSION
Medial branch and intra-articular blocks are extremely useful procedures
in the diagnosis and management of facet mediated back pain. With proper
training they are relatively easy procedures and are excellent predictors to
long-term outcome of treatment with radiofrequency denervation to the medial
branches.

REFERENCES
1. Manchikanti L. Facet pain and the role of neural blockade in its management.
Curr Rev Pain 1999;3:348-8.
2. Bogduk N. International spinal injection society guidelines for the performance
of spinal injection procedures. Part 1: Zygapophyseal joint blocks. Din J Pain
1997;13:285-302.
3. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain
stemming from the zygapophysial joints. Is lumbar facet syndrome a clinical
entity? Spine 1994; 19: 1132-7
4. Dreyfuss P, Schwarzer AC, Lau P, Bogduk N. Specificity of lumbar medial
branch and L5 dorsal ramus blocks: A computed tomography study. Spine
1997; 22:895-902.
5. Kaplan M, Dreyfuss P, Halbrook B, Bogduk N. The ability of lumbar medial
branch blocks to anesthetize the zygopophysial joint. Spine 1998; 23:1847-52.
6. Van Kleef M, Barendse GAM, Kessels A, Voets HM, Weber WEJ, de Lange S.
Randomized trial of radiofrequency lumbar facet denervation for chronic low
back pain. Spine 1999;24:1937-42.
7. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and
validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint
pain. Spine 2000; 25:1270-77.
8. McCall IW, Park WM, O’Brien JP. Induced pain referral from posterior elements
in normal subjects. Spine 1979; 4:221-2.
9. Mooney V, Robertson J. The facet syndrome. Clin Orthop 1976; 115:149-56.
10. Schwarzer AC, Wang SC, O’Driscoll D, et al. The ability of computed
tomography to identify a painful zygapophysial joint in patients with chronic
low back pain. Spine 1995; 20:907-12.
11. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain
stemming from the zygapophysial joints. Is lumbar facet syndrome a clinical
entity? Spine 1994; 19: 1132-7
12. Schwarzer AC, Wang S, Bogduk N, McNaught PJ, Laurent R. Prevalence and
clinical features of lumbar zygapophysial joint pain: A study in an Australian
population with chronic lower back pain. Ann Rheum Dis 1995; 54:100-106
13. Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N. Pain from the
lumbar zygapophysial joints: A test of two models. J Spinal Disord 1994;
7:331-6.
14. Revel M, Poiraudeau S, Auleley GR, Payan C, Denke A, Nguyen M, Chevrot
A, Fermanian J. Capacity of the clinical picture to characterize low back pain
relieved by facet joint anesthesia. Proposed criteria to identify patients with
painful facet joints. Spine 1998; 23:1972-7.
15. Moore KL, Dalley AF, et al. Clinically oriented anatomy. 4th edition. Lippencott
Williams and Wilkins 1999.
16. Bogduk N. Practice guidelines for spinal diagnostic and treatment procedures.
International spine intervention society 2004; 47-8.
198 Interventional Pain Management—A Practical Approach

Twenty Seven

Sacroiliac Joint Block

S Gupta, J Richardson

INTRODUCTION
Intra-articular injection of local anesthetic into the sacroiliac joint (SIJ) is a
diagnostic test that is used to confirm or refute that the pain is arising from
the sacroiliac joint. If the pain is relieved it suggests that the targeted joint is
the source of pain. However, injection of steroids into the SIJ can often provide
satisfactory pain relief for several weeks or months allowing the patient to
decrease oral medication.

Anatomy
The sacroiliac joint (SIJ) has a diffuse innervation, and the contributing nerves
do not have a sufficiently fixed course such that they can all be selectively
anesthetised and hence SIJ pain cannot be diagnosed using nerve blocks. A
Japanese study of 18 cadavers, using macroscopic and histologic techniques,
showed that the joint is innervated anteriorly from the ventral rami of L5 to
S2 and via branches from the sacral plexus, and posteriorly from the lateral
branches of the S1-4 dorsal rami.1 The SIJ can be anesthetized only by intra-
articular injections of local anesthetic.
Injections of corticosteroids into the sacroiliac joint have been shown to
be efficacious in the treatment of sacroiliitis in some2,3 but not all 4 controlled
and observational, outcome studies. In clinical practice we see some patients
respond with clinically significant pain relief for a significant duration which
allows the patients to reduce the analgesic requirement with increased levels
of activities.

Indications
The most important indication for SIJ blocks is to know if a patient’s pain is
arising from a SIJ or not. The risk of false-positive responses applies to all
diagnostic blocks. One simple way of decreasing the incidence of false
positive response is to repeat the block twice and if the patient gets good
pain relief on two different occasions, the chances of a false positive response
decreases. Establishing the diagnosis of SIJ pain may be worthwhile in order
 Sacroiliac Joint Block 199

to prevent the patient pursuing futile investigations for other possible sources
of pain.
History or physical examination may give us some idea if the pain may
be arising for the SIJ but cannot accurately identify a painful SIJ. An area,
about 3 x 10 cm in size, just inferior to the ipsilateral posterior superior iliac
spine, is the characteristic site to which pain from the SIJ is referred in normal
volunteers, referral to this area is common from other sources such as lumbar
intervertebral disc and the lower lumbar facet joints. In patients with SIJ
pain, the pain may be referred distally into the lower limb, but patterns of
referral in the buttock, thigh, calf or foot do not distinguish SIJ pain from
other sources of pain. Radiological studies including CT and MRI do not
give any conclusive evidence if the pain is arising from the SIJ.
It has been established by several investigators that, in patients with SIJ
pain, pain is always maximal below L5 5-8. Therefore, pain that is maximal
above L5 is highly unlikely to be from the sacroiliac joint.

Contraindications
Absolute contraindications: Systemic or localized bacterial infection in the region
of the block to be performed, bleeding diathesis, possible pregnancy.
Relative contraindications: Allergy to contrast medium or local anesthetic.

Equipment
Fluoroscopy is mandatory. The procedure is performed under aseptic
conditions. 25G and 21G hypodermic needles, 2ml and 5 ml syringes are
used.
A 22 or 25-gauge 100 mm spinal needle is commonly used. A slight curve
at the distal 5 mm of the needle can be helpful to navigate the needle into the
joint.
Intravenous solutions, sedation or antibiotics are not required.
Bupivacaine 0.5% or lignocaine 25% can be used with or without steroids
(Methylprednosolone 40 mg or Triamcinolone 40 mg). Given the limited
capacity of the sacroiliac joint about 2 to 3 ml is required to block the joint
adequately.
Contrast medium is required to verify intra-articular placement of the
needle.

Procedure
Baseline data concerning the location and extent of pain, including a pain
score, and the movements and activities of daily living that are prevented by
the pain are recorded so that these can be tested after the SIJ injection to
establish if the pain is arising from the SIJ.
Informed consent must be obtained. Risk of infection, bleeding, and
allergic reaction should be discussed.
200 Interventional Pain Management—A Practical Approach

The patient should lie prone on an operating table and the procedure is
performed under aseptic conditions. Under AP view, the SI joint presents
multiple sinuous lines running caudo-cranially, in a semi-parallel fashion
(Fig. 27.1). As a rule, the more medial of these lines are formed by the posterior
margins of the joint. In order to overlap the anterior and the posterior margins
of the SIJ the C-arm should be rotated, usually to the contralateral side (as
opposed to rotating the C-arm to ipsilateral side for facet joint block), so as to
have all the margins superimposed along the caudal one-third of the joint
line (Fig. 27.2). A target point is selected 1 to 2 cm cephalad of the inferior end
of the joint line. After identifying the target point, local anesthetic is injected
into the skin and subcutaneous tissue directly over the target point. A 22 or
25 g 100 mm curved tip needle is targeted to hit the sacrum (adding a slight
bend to the distal 5 mm of the needle helps navigate the needle). Once the
needle has struck the sacrum, it should be withdrawn slightly and redirected
towards the joint space (Fig. 27.3). Entry into the joint can be recognized by
loss of bony resistance as the tip slips between the sacrum and the ilium. On

Fig. 27.1: AP view of the sacroiliac Fig. 27.2: The anterior and the poste-
joint. The medial joint line is the rior joint line have been superimposed
posterior joint line (arrow) by contralateral oblique rotation of the
C-arm

Fig. 27.3: A 22 g needle with a curved tip is

seen entering the inferior part of the SI Joint
 Sacroiliac Joint Block 201

fluoroscopy, the tip will be seen to lie between the two bones. Sometimes, if
not often, the tip of needle will be seen to bend slightly, as it wedges between
the bones.
The tip of the needle should be inserted less than a few millimeters into
the joint. If necessary, depth of insertion should be checked and evaluated
on lateral imaging. Too great an insertion risks having the needle emerge
from the anterior aspect of the joint into the presacral tissues. Arterial
penetration can occur in this location.4
Once the needle has entered the joint space, intra-articular placement
must be confirmed with an injection of contrast medium. If the needle has
been correctly placed injection of 0.3 to 0.5 ml of contrast medium will out-
line the joint space. In postero-anterior views, the contrast medium should
be seen to travel cephalad along the joint line (Fig. 27.4). In lateral views the
contrast medium most densely outlines the perimeter of the joint (Fig. 27.5).
Once correct intra-articular placement of the needle has been achieved 2.5 to
3.0 ml local anesthetic with or without steroid can be injected.
A different approach may be necessary if the above explained approach
is unsuccessful or if the joint lines cannot be superimposed (Fig. 27.6). In
order to isolate the posterior margin, the C-arm should be rotated, usually
to the contralateral side, so as first to have all margins superimposed along
the caudal one-third of the joint. Next, by rotating the C-arm in either
direction, the anterior and posterior joint margins should be separated until
they appear as separate entities. Rotation is then continued or adjusted
until the cortical lines of the posterior joint is maximally crisp (Fig. 27.7).
This orientation coincides with the beam being directed into the posterior
opening of the inferior joint space. Usually, 5 to 20 degrees of contralateral
rotation is necessary to properly image the inferior joint planes. A target
point is selected 1 to 2 cm cephalad of the inferior end of the joint. This

Fig. 27.4: Contrast medium spread Fig. 27.5: Contrast medium spread can
along the SI joint (contralateral oblique be seen along the perimeter of the joint
view) line in lateral view as marked by the
arrows
202 Interventional Pain Management—A Practical Approach

Fig. 27.6: The medial joint lines are the Fig. 27.7: With slight contralateral
margins of the posterior SI joint line oblique rotation the posterior joint lines
(arrow) have become crisp and a curved tip
needle is seen entering the joint

should be a zone of maximum radiolucency in the target region. A puncture

point on the skin is selected directly overlying the target and the joint is
entered as described above and contrast medium injected (Figs 27.8 and
27.9).

Fig. 27.8: Contrast medium spread Fig. 27.9: Lateral view showing the
along the SI joint line tip of the needle and the perimeter of
the joint line as shown by the arrows

Post-procedural Care and Evaluation

After the injection, the patient should be monitored for 30 minutes to ensure
that there is no lower extremity weakness or numbness resulting from
leakage of local anesthetic onto the lumbosacral plexus via a ventral capsular
tear or over penetration of the needle.
Appropriate discharge instructions should be given.
In clinical practice we observe that low back pain could be arising from
more than one structure. One way of interpreting the block would be to
assume that the degree of pain relief obtained is that which is arising from
 Sacroiliac Joint Block 203

the SIJ in question. The International Spinal Intervention Society (ISIS)

suggests that “it is prudent to consider a response negative if there is < 50%
pain relief, equivocal if there is 51 to 74% relief, and positive of there is at
least 75% improvement, with the confidence that the response is truly positive
as the percentage relief increases towards 100%. Moreover, any apparently
positive response should be tested with a subsequent block to decrease the
false positive response”.9

Conclusion
SIJ pain is more common than we think. Studies have quoted the incidence of
SIJ pain to be up to 15% among patients complaining of low back pain. If a
patient has most of the pain below L5 level it is more likely to be arising from
the SIJ. In our experience a mixture of local anesthetic and steroid can be
useful in carefully selected patients who derive satisfactory pain relief for
several weeks or months allowing them to reduce analgesic consumption
with increased activities.

REFERENCES
1. Ikeda R. Innervation of the sacroiliac joint. Macroscopic and histologic studies.
J Nippon Med School 1991;58:587-96.
2. Maugars Y, Mathis C, Berthelot J. Assessment of the efficacy of sacroiliac
corticosteroid injection in spondylarthropathies. A double-blind study. Br J
Rheum 1996;35:767-70.
3. Braun J, Bollow M, Seyrekbasan F, et al. CT Guided corticosteroid injection of
the sacroiliac joint in patients with spondyloarthropathy with sacroiliitis.
Clinical outcome and follow up by dynamic magnetic resonance imaging. J
Rheumatol 1996;23:659-64.
4. Hanly JG, Mitchell M, MacMillan L, et al. Efficacy of sacroiliac corticosteroid
injection in patients with inflammatory spondyloarthropathy: Result of a 6
month controlled study. J Rheumatol 2000;27:719-22.
5. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back
pain. Spine 1995;20:31-7.
6. 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;21:1889-92.
7. Dreyfuss P, Michaelsen M, Pauza K, et al. The value of history and physical
examination in diagnosing sacroiliac joint pain. Spine 1996; 21: 2594-2602.
8. Slipman C, Jackson H, Lipetz J, et al. Sacroiliac joint pain referral zones. Arch
Phys Med Rehabil, 2000;81:334-8.
9. Sacroiliac Joint Block. In: Practice guidelines for spinal diagnosis and treatment
procedures. N Bogduk (Ed). International Spine Intervention Society 2004:
66-85.
 Twenty Eight

Percutaneous Adhesiolysis for

Failed Back Surgery Syndrome
and Other Applications
Laxmaiah Manchikanti, Mark V Boswell,
Rinoo V Shah, James E Heavner

INTRODUCTION
The first reported epidural injection for chronic low back pain was performed
in 1901.1 The initial reports of epidurography were in 1921.2 In ongoing
efforts to manage chronic pain, cold hypertonic saline was administered
intrathecally in 1967.3 Subsequently, the use of intrathecal cold saline to
relieve pain in cancer patients was reported.4 The determining factor in the
therapeutic effect of cold hypertonic solution was reported as its hypertonicity
rather than the temperature.5
Racz et al6,7 reported the first use of epidural hypertonic saline to faci-
litate lysis of adhesions and evaluated permeability of the dura in dogs in
vitro, demonstrating slow transdural equilibration of hypertonic saline.
Hyaluronidase was used in an attempt to alter the rapidity of onset and
extent, intensity, and duration of caudal anesthesia.8,9
Over the years, multiple investigators6,7,10-20 have studied the effective-
ness of adhesiolysis and hypertonic saline neurolysis with or without
hyaluronidase.

APPLIED ANATOMY
• The spine is divided anatomically into three compartments. These
compartments have been defined as the anterior, neuroaxial, and
posterior.21
— The anterior compartment is comprised of the vertebral body and the
intervertebral disc (Fig. 28.1).
— The structures within the epidural space and neural pathways form
the neuroaxial compartment, and the posterior compartment is
composed of the posterior lamina and zygapophysial joints, along
with the bony vertebral arch structures (Fig. 28.1).
• The anatomical orientation of the vertebral spinous processes are varied
throughout the spinal axis.
— In the lumbar spine, the spinous processes are directly above the
widest portion of the interlaminar space, allowing both a midline
and a paramedian approach to be relatively easy (Fig. 28.1).
208 Interventional Pain Management—A Practical Approach

• The neuraxial compartment consists of all structures within the osseous

and ligamentous boundaries of the spinal canal (Fig. 28.1).
— Within this compartment is the epidural space.
— The epidural space contains fat, epidural veins, epidural arteries,
and lymphatics.
— The most common constituent of the epidural space is epidural fat.22,23
— Epidural fat acts as a shock absorber to protect the contents of the
epidural space and can also act as a depot for drugs and anesthetics
injected into the epidural space.
• The spinal canal extends from the foramen magnum to the sacrum, which
is bounded posteriorly by the ligamentum flavum and periosteum,
anteriorly by the posterior longitudinal ligament that lies over the dorsal
aspects of the vertebral bodies and discs and laterally by pedicles and
intervertebral foramen.24
— The spinal cord ends at L1 or L2 in adults and the dural sac continues
to the spinal cord and conus, running down to the level of S2 (Fig.
28.1).24
• The dural sac rests on the floor of the vertebral canal.
• The anterior relations of the dural sac are the backs of the vertebral bodies
and the intervertebral discs. Covering these structures is the posterior
longitudinal ligament.
— The anterior spinal arteries and sinuvertebral nerves run across the
floor of the vertebral canal and are located anterior to the dural sac.
— The dural sac posteriorly is related to the roof of the vertebral canal,
the laminae, and ligamentum flava.
• The epidural space is a potential space intervening between the dural
sac and the osseo-ligamentous boundaries of the vertebral canal (Fig.
28.1).
— The epidural membrane is a thin layer of areolar connective tissue,
which varies from diaphanous to pseudomembranous in structure.24
— The epidural membrane surrounds the dural sac and lines the deep
surface of the laminae and pedicles.
— The epidural membrane lines the back of the vertebral body and then
passes medially deep to the posterior longitudinal ligament, where it
detaches to the anterior surface of the deep portion of the ligament,
ventrally, opposite the vertebral bodies.
— The posterior longitudinal ligament covers laterally the back of the
disc, preventing the epidural membrane from covering the back of the
annulus fibrosus.
— The epidural space extends from the foramen magnum to the end of
the dural sac at S2. The actual size of the posterior epidural space
varies greatly. It expands to 4 to 6 mm at its greatest width in the mid-
lumbar spine and gradually decreases to about 3 mm at the S1 level.
• The epidural space surrounds the dural sac.
— It is bordered posteriorly by the ligamentum flavum and periosteum,
and anteriorly by the posterior longitudinal ligament and vertebral
bodies.
— Laterally it is bordered by the pedicles and intervertebral foramina.
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 209

A. Median sagittal section of the B. The ligamentum flavum

lumbosacral part of the vertebral column (1) Intervertebral foramen (2) Ligamentum
flavum (3) Vertebral body (4) Intervertebral disc

C. Sacral canal, sacral nerves, D. Identification of the sacral hiatus

and sacral venous plexus anatomical landmarks
(1) Dura Mater (2) Venous plexus (3) S1
anterior primary ramus (4) S2 nerve root (5)
S3 nerve root (6) Posterior primary ramus (7)
S4 nerve root (8) S5 nerve root (9) Coccygeal
nerve (10) Filum Terminale (11) Coccyx (12)
Posterior primary ramus (13) Termination of
Dura Mater (14) 2nd posterior sacral foramen
(15) L5 (16) Cauda equina

Fig. 28.1: Anatomy of lumbosacral epidural space

210 Interventional Pain Management—A Practical Approach

— The epidural space is widest in the midline underneath the junction

of the lamina and narrows laterally beneath the zygapophysial joint.
— Laterally the ligamentum flavum joins the joint capsule of the adjacent
zygapophysial joint.
— The actual size and shape of the epidural space is determined by the
manner of attachment of the dural sac to the walls of the spinal canal,
as well as the shape of the spinal canal at different levels.
— Studies have demonstrated a dorsomedian connective tissue band in
the lumbar epidural space. The posterior epidural space is divided by
this dorsomedian connective tissue band (plica median dorsalis) and
additional transverse connective tissue bands.
— However, controversy exists about whether the dorsomedian
connective tissue is continuous, fenestrated or interrupted.
— The epidural space may be compartmentalized, which can account
for the limitation of the injected substances.
• The ligamentum flavum has been proposed to be joined in the midline.
There appears to be a paired nature to the ligament having both a right
and left portion.
— Cryomicrotome sectioning performed on the epidural space has shown
that there is a variable degree of fusion of the ligamentum flavum in
the midline.
— The ligamentum flavum in the lumbar spine is thicker than in the
cervical and thoracic spine.
• The sacrum is a triangular bone, dorsally convex, that consists of the five
fused sacral vertebrae (Fig. 28.1). It articulates cephalad with the fifth
lumbar vertebra and caudad with the coccyx.21
— The concave anterior surface features four parts of large anterior sacral
foramina that provide passage from the midline sacral canal for the
anterior rami of the upper four sacral nerves.
— The anterior foramina are unsealed and provide a ready escape
passage for solutions injected into the sacral canal.
— The dorsal surface of the sacrum is variably convex and irregular,
with important prominences representing the fused elements of the
sacral vertebrae.
— In the midline, there is a median crest with three or more, but commonly
four, prominent tubercles which are variable, representing the sacral
spinous processes.25 Lateral to the crest and medial to the four posterior
sacral foramina is the intermediate sacral crest, with a row of four
tubercles, which represent the upper four sacral articular processes
(Fig. 28.1).
— The remnants of the S5 inferior articular processes are prominent and
palpable through the skin and constitute the sacral cornua and,
together with adjacent coccygeal cornua which they abut, are key
landmarks for identification of the sacral hiatus and successful caudal
blockade.
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 211

• The coccyx is a small triangular bone consisting of three to five fused

rudimentary vertebrae (Fig. 28.1).
— The coccyx attaches to the lower part of the sacrum. The tip of the
coccyx is an important landmark.
• The sacral hiatus is a defect in the lower part of the posterior wall of the
sacrum, formed by the failure of laminae of S5, and usually part of S4, to
meet and fuse in the median plane.
— A variable space is left which is described as an inverted U or V,
covered by the thick fibrous posterior sacral coccygeal ligament.25
— Direct access to the caudal canal is obtained by penetration of the
sacrococcygeal ligament.
— There is significant variation in the normal anatomy in this area, with
a widely and highly variable (in sizes and shapes) the sacral hiatus.
The hiatus lies higher than the lower one-third of the S4 in about 50%
of specimens.25
— The distance between the tip of the dural sac and the apex of the
hiatus is highly variable from 20 to 45 mm.
— Absent hiatus has been described in approximately 7% of specimens,
and very small (less than 2 mm) AP diameter of the canal at the apex
of the hiatus in 5% of specimens. However, in practice, absent hiatus
is probably seen in less than 1% of patients.

INDICATIONS AND CONTRAINDICATIONS

The purpose of percutaneous adhesiolysis is to eliminate the deleterious
effects of scar formation, which can physically prevent direct application of
drugs to nerves or other tissues to treat chronic back pain with or without
radiculopathy, and to assure target delivery of drugs.
Indications are listed in Table 28.1.
Contraindications are listed in Table 28.2.
Adhesiolysis of epidural scar tissue, followed by the injection of

Table 28.1: Indications for lysis of epidural adhesions

• Duration of pain of at least 6 months

• Average pain levels of 5 on a scale of 0 to 10
• Intermittent or continuous pain causing functional disability
• Chronic low back and/or lower extremity pain which has failed to respond or
poorly responded to non-interventional and non-surgical conservative management
and fluoroscopically-directed epidural injections
• Chronic low back and/or lower extremity pain resulting from:
— Failed back surgery syndrome
— Epidural fibrosis
— Spinal stenosis
— Radiculopathy
— Small herniated discs
— Fractures of the vertebral bodies
— Vertebral metastases
— Degenerative diseases
212 Interventional Pain Management—A Practical Approach

Table 28.2: Contraindications for lysis of epidural adhesions

• Large contained or sequestered herniation

• Cauda equina syndrome
• Compressive radiculopathy
• Uncontrolled major depression or psychiatric disorders
• Uncontrolled or acute medical illnesses
• Chronic severe conditions that could interfere with the interpretations of the
outcome assessments for pain and bodily function
• Pregnancy and lactation
• History of adverse reaction to local anesthetic, steroids, hypertonic saline or
contrast
• Patients unable to understand the informed consent and protocol
• Patients unable to be positioned in prone position to perform the procedure
• Infection
• Anti-coagulant therapy
• Non-aspirin anti-platelet therapy

hypertonic saline, as described by Racz, Viesca, and others6,7,19 involved on

Day 1: epidurography, adhesiolysis, and injection of hyaluronidase,
bupivacaine, triamcinolone diacetate, and 10% sodium chloride solution;
injections of bupivacaine and hypertonic sodium chloride solution followed
on days 2 and 3. Manchikanti et al12-17 described and studied a modification
of the Racz protocol modifying a 3 day procedure to a 1 day procedure.
Clinical effectiveness of percutaneous adhesiolysis was evaluated in three
randomized, controlled trials, 11,16,17 and five retrospective evalua-
tions,6,12,14,15,18 with encouraging results.
Chopra et al20, in a systematic review of the role of adhesiolysis in the
management of chronic spinal pain, sought to answer multiple questions
which included the following:
In managing chronic low back and lower extremity pain –
1. Is percutaneous adhesiolysis an effective treatment?
2. Is percutaneous adhesiolysis superior to epidural steroid injections?
3. Does the addition of hypertonic sodium chloride solution improve
outcome?
4. Does the addition of hyaluronidase improve outcome?
5. Is percutaneous adhesiolysis a safe procedure?
The systematic review concluded that there was strong evidence to indi-
cate effectiveness of percutaneous epidural adhesiolysis with administration
of epidural steroids short-term and long-term in chronic, refractory low back
pain and radicular pain. They also concluded that there was moderate
evidence of effectiveness with the addition of hypertonic saline. They reported
that the evidence of effectiveness of hyaluronidase was negative. They also
concluded that adhesiolysis provided relief in patients who failed to respond
with relief with epidural steroid injections. In addition, they also concluded
that adhesiolysis with hypertonic saline neurolysis was a safe procedure
with minimal complications when performed appropriately by trained hands.
Results of published trials of percutaneous adhesiolysis and hypertonic
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 213

saline neurolysis as utilized by Chopra et al20 are listed in Table 28.3. In

addition, evidence of adhesiolysis and hypertonic saline neurolysis analysis
results are listed in Table 28.4.

TECHNICAL CONSIDERATIONS
The technique of lumbar adhesiolysis involves accessing the lumbar epidural
space either by utilizing a caudal, interlaminar, or transforaminal approach.
Entry is performed with a 16-gauge RK needle, followed by advancement of
a Racz catheter into the epidural space, with appropriate lysis of adhesions
under radiographic control utilizing nonionic contrast medium.
Subsequently, a combination of local anesthetic and steroid is injected into
the epidural space through the catheter; followed by hypertonic saline
neurolysis which is carried out by a slow and intermittent injection of
hypertonic saline, either by infusion or in incremental doses. In classic Racz
technique, the procedure is repeated without steroids on Day 2 and Day 3;
whereas, with other modifications, the catheter is removed after performing
the initial procedure.

RACZ TECHNIQUE
The technique employed by Racz and colleagues,6-11,19 is described as
percutaneous epidural neuroplasty and is outlined in Table 28.5.

General Principles
• The consent form should include all possible complications related to
the procedure.
• Intravenous access is strongly recommended.
— It may be necessary to sedate the patient with midazolam and fentanyl.
Although sedation is given, it is important that the patient be awake
and responsive during the procedure to ensure that the spinal cord is
not compressed during the injection.
• Fluoroscopy is mandatory.
• A water-soluble, nonionic contrast medium is used because of the
possibility of unintended subarachnoid injection.

The Caudal Approach

• The patient is placed prone with a pillow under the abdomen to straighten
the lumbar spine, with toes pointing inward.
• Monitors are applied, including electrocardiography sensors, a pulse
oximeter, and a blood pressure cuff.
• The sacral area is prepared with sterile technique and draped from the
top of the iliac crest to the bottom of the buttocks.
— The sacral cornua and the sacral hiatus are palpated with the index
finger of the operator’s nondominant hand.
 Table 28.3: Results of published trials of percutaneous adhesiolysis and hypertonic saline neurolysis
Study/Methods Participants Intervention(s) Outcome(s) Result(s) Conclusion(s)
17 Experimental groups: Timing: 3 months, Positive short-term
Manchikanti et al 25 patients in Group I 72% of patients in
A randomized, served as controls and Adhesiolysis, hypertonic 6 months, and Group III and long-term
double blind trial were treated with saline neurolysis, 12 months (adhesiolysis and relief
catheterization but no steroid and local Outcome measures: hypertonic
adhesiolysis anesthetic and VAS pain scale, neurolysis), 60%
25 patients in Group II were adhesiolysis, normal Oswestry of patients in
treated with saline, steroid. Disability Index 2.0, Group II
catheterization, Control group: Work status, opioid (adhesiolysis
adhesiolysis, followed by Catheterization and no intake, range of only), compared
injection of local adhesiolysis motion to 0% in Group I
anesthetic, normal saline, measurements and (control) showed
and steroid psychological significant
25 patients in Group III evaluation by P-3 improvement at
consisted of adhesiolysis 12-month follow-
followed by injection of up
local anesthetic,
hypertonic saline, and
steroid

Heavner et al11 59 patients with chronic Group I: hypertonic saline Timing: 4 weeks, Initially 83% of the Positive short-term
A randomized, double intractable low back pain. plus hyaluronidase 3 months, patients showed and long-term
blind trial All the patients failed Group II: hypertonic saline 6 months. and significant relief
conservative Group III: isotonic saline 12 months improvement
214 Interventional Pain Management—A Practical Approach

management, along with (0.9% NaCl) Outcome measures: compared to 49%

fluoroscopically directed Group IV: isotonic saline Pain relief of the patients at 3
epidural steroid plus hyaluronidase months, 43% of
injections. the patients at 6
months, and 49%
of the patients at
12 months
Contd...
Contd...
Study/Methods Participants Intervention(s) Outcome(s) Result(s) Conclusion(s)

Manchikanti et al16 45 patients were evaluated Experimental group: Timing: 1 month, Experimental group Positive short-term
A randomized, 15 patients in group I were Adhesiolysis, 3 months, showed improve- and long-term
controlled trial treated conservatively hypertonic saline 6 months, ment with pain relief
30 patients in group II were neurolysis and epidural 1 year relief in 97% at
treated with steroid injection, one or Outcome measures: 3 months, 93% at
percutaneous epidural more occasions. Pain relief, 6 months, and
adhesiolysis and Control group: Physical functional status, 47% of the
hypertonic saline therapy exercise psychological patients at
neurolysis program and status, employment 1 year Generalized
medication status anxiety disorder,
somatization
disorder, average
pain, and
functional status
improved
significantly in
Group II

Manchikanti et al14 A retrospective randomized Adhesiolysis, hypertonic Timing: Initial relief was Positive short-term
A retrospective evaluation of the saline neurolysis and 4 weeks, reported in 79% of and negative
randomized effectiveness of 1-day injection of steroid 3 months, the patients with long-term relief
evaluation adhesiolysis and 6 months, 68% of the
hypertonic saline 12 months patients reporting
neurolysis in 129 Outcome measures: relief at 3 months,
patients Pain relief 36% at 6 months
Percutaneous Adhesiolysis for Failed Back Surgery Syndrome

and 13% at 12
months with 1
215

injection
Contd...
Contd...
Study/Methods Participants Intervention(s) Outcome(s) Result(s) Conclusion(s)

Manchikanti et al15 60 post lumbar Adhesiolysis, hypertonic Timing: With multiple Positive short-term
A retrospective laminectomy patients saline neurolysis and 3 months, injections, initial relief and long-
evaluation of 60 post were included after injection of steroid 6 months, relief was seen in term relief
lumbar laminectomy failure of conservative 12 months 100% of the
patients with chronic management Outcome measures: patients, however
low back pain Pain relief it declined to 90%
at 3 months, 72%
at 6 months, and
52% at 1 year

Reproduced from Chopra et al. 20 Role of adhesiolysis in the management of chronic spinal pain: A systematic review of effectiveness and complications.
Pain Physician 2005; 8:87-100 with permission from authors and American Society of Interventional Pain Physicians.
216 Interventional Pain Management—A Practical Approach
 Table 28.4: Results of published reports of percutaneous lysis of
lumbar epidural adhesions and hypertonic saline neurolysis

Methodological Initial Relief Long-term Relief Results

Quality Score(s)

Study Study AHRQ Cochrane No. of < 3 months 3 months 6 months 12 months Short-term Long-term
Characteristics Score(s) Score(s) Patients < 3 months > 3 months
Manchikanti et al17 RA, DB 10/10 10/10 G1=25 33% 0% 0% 0% P P
G2=25 64% 64% 60% 60%
G3=25 72% 72% 72% 72%
Heavner et al11 RA, DB 7/10 7/10 59 83% 49% 43% 49% P P
Manchikanti et al16 RA 5/10 6/10 C=15 NSI NSI NSI NSI P P
Tx=30 97% 97% 93% 47%
Manchikanti et al14 R 4/8 —- 129 79% 68% 36% 13% P N
Manchikanti et al15 R 4/8 —- 60 100% 90% 72% 52% P P

RA = randomized; DB = double blind; R = retrospective; NA = not available; NSI - no significant improvement; P = positive; N = negative

Reproduced from Boswell et al10 Interventional techniques in the management of chronic spinal pain: Evidence-based practice guidelines. Pain Physician
2005; 8:1-47 with permission from authors and American Society of Interventional Pain Physicians.
Percutaneous Adhesiolysis for Failed Back Surgery Syndrome
217
218 Interventional Pain Management—A Practical Approach

Table 28.5: Percutaneous epidural neuroplasty technique

as per Racz and colleagues

In the operating room:

1. Place epidural needle.
2. Inject iohexol (omnipaque-240) and visualize spread of contrast medium
(epidurogram).
3. If filling defect corresponding to area of pain is present, thread Racz Tun-L-
Kath® (Epimed) catheter into filling defect (scar), while injected normal saline
through the catheter; observe fluoroscopically to visualize washout of contrast
and opening of scar.
4. Inject additional iohexol to ascertain opening of scar and spread of injectate
within the epidural space.
5. Inject preservative-free saline with or without hyaluronidase (Wydase).
6. Inject 0.25% bupivacaine or 0.2% ropivacaine plus corticosteroid (4 mg
dexamethasone or 40 mg methylprednisolone or triamcinolone).
7. Tape catheter in place.
In the postoperative care unit:
• Inject 0.9% or 10% saline 30 minutes after steroid/local anesthetic injection.

In clinic area:
1. Once on each of the following 2 days, inject 0.25% bupivacaine or 0.2%
ropivacaine; 30 minutes later, inject 0.9% or 10% saline.
2. After the last treatment, remove the epidural catheter.

Adapted and updated from Heavner JE, et al.11 Percutaneous epidural neuroplasty.
Prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase.
Reg Anesth Pain Med 1999; 24:202-207 with permission from authors and American
Society of Interventional Pain Physicians.

— The entry point through the skin, approximately 1 to 2 cm lateral and

2 cm inferior to the sacral hiatus, is in the gluteal fold opposite the
affected side.
— The entry point is infiltrated with a local anesthetic such as lidocaine.
— A 16-gauge RK needle® is passed through the described entry point.
— The needle is advanced to a point below the S3 foramen to prevent S3
nerve root damage.
• Placement is confirmed by lateral and anteroposterior fluoroscopic views.
— After aspiration is negative for blood and cerebrospinal fluid (CSF),
10 mL of iohexol (Omnipaque®-240) or metrizamide (Amipaque®) is
injected under fluoroscopy.
• Next, insert a catheter into the scarred area.
— The ideal epidural catheter is a stainless steel, fluoropolymer-coated,
spiral-tipped Racz Tun-L-Kath-XL®(Epimed International Inc.) as
illustrated in Fig. 28.2.
— The bevel of the needle should face the ventrolateral aspect of the
caudal canal on the affected side.
— Multiple passes may be necessary to place the catheter into the scarred
area.
— To facilitate steering of the catheter into the desired location, a 15
degree bend is placed at its distal end.
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 219

A. RK epidural needle B. Tun-L-Kath and Tun-L-XL/24

epidural catheters

Fig. 28.2: Special needle and catheter for adhesiolysis

(Courtesy: Epimed International, Gloversville, NY, with permission)

• After final placement of the catheter and negative aspiration, another

5 to 10 mL of contrast medium is injected through the catheter.
— This additional contrast should spread into the area of previous filling
defect and outline the targeted nerve root (Figs 28.3A to E). Fifteen
hundred units of hyaluronidase (Wydase®) in 10 mL of preservative-
free saline is injected rapidly.
— Afterward, 10 mL of 0.2% ropivacaine or 0.25% bupivacaine and 40
mg of triamcinolone or methylprednisolone are injected through the
catheter in divided doses. Other corticosteroids may also be used.
220 Interventional Pain Management—A Practical Approach

A. AP view of RK needle in place B. Lateral view with RK needle in

through the sacral hiatus place at sacral epidural space

C. AP view of epidural filling defect D. Catheter guided to lumbar

epidural space (AP view)

E. Lateral view of epidural filling

Fig. 28.3A to E: Caudal epidural adhesiolysis

 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 221

• When the procedure is completed, the catheter should be secured to the

skin with 2-0 nylon on a cutting needle, with application of antibiotic
ointment and gauze.
— The catheter is connected to an adapter and to a bacteriostatic filter
that is not removed until three daily injections have been completed.
The filter is capped, and the catheter is taped to the flank of the patient.
• During the procedure, the patient is given I.V. antibiotics in the form of
cephalosporins (Rocephin®), 1g/day, to prevent bacterial colonization
that is especially hazardous because of the epidurally-administered
steroid.
• Once the patient is taken to the recovery room (placed with the affected
side down) and vital signs are checked, 9 mL of 10% hypertonic saline is
infused over 20 to 30 minutes.
— Occasionally, the patient may complain of severe, burning pain during
the infusion. The cause is usually the introduction of hypertonic saline
into non-anesthetized epidural tissue.
— Should the patient complain of pain, the infusion must be stopped
and another 3 to 5 mL bolus of local anesthetic is given. After 5 minutes,
the hypertonic saline infusion can be restarted without incident.
— After completion of the hypertonic saline infusion, 1.5 mL of
preservative-free normal saline is used to flush the catheter. Once this
task is completed, the cap is replaced on the filter.
• The catheter is left in place for 3 days.
— On the second and third days, it is injected once a day with 10 mL of
0.2% ropivacaine after negative aspiration from the catheter. Fifteen
minutes later, 10 mL of 10% saline is infused over 20 minutes for
patient comfort.
— As in any hypertonic saline infusion series, the catheter must be
flushed with 1.5 mL of preservative-free normal saline.
— On the third day, the catheter is removed 10 minutes after the last
injection.
— A triple antibiotic ointment is placed on the wound, which is covered
with a bandage or other appropriate dressing.

Interlaminar Lumbar Approach

The technique for lysis of epidural adhesions in these areas of the spinal
cord must be modified to ensure that initially the needle is positioned in the
epidural space and that spinal cord compression by subsequent injections is
avoided.
• The patient is placed in the lateral or prone position on the fluoroscopy
table.
222 Interventional Pain Management—A Practical Approach

— Sterile preparation and draping is carried out.

— Skin entry should be 1.5 to 2 levels below the desired epidural entry to
facilitate catheter placement.
• After local anesthetic is used on the skin, an 18-gauge needle is inserted
through the same puncture site to form an entry wound.
— Through the puncture site, a 16-gauge RK needle is first advanced
under fluoroscopic guidance (AP view) to determine the direction of
the needle.
— Next, in the lateral view, the needle is advanced to the point just
before the “straight line” formed by the fluoroscopic image of the
anterior border of the spinous process in the lateral view (the insertion
site of the ligamentum flavum).
— The lateral view under fluoroscopy demonstrates the depth of needle
placement.
— Lastly, an AP view is checked again to confirm the direction of the
needle.
— When the direction is satisfactory, the loss-of-resistance technique is
used to advance the needle into the epidural space.
• Inject contrast to outline the filling defect.
• A Racz Tun-L-Kath or Racz Tun-L-Kath-XL epidural catheter is passed
in an anterocephalad direction toward the filling defect outlined by the
contrast, until the catheter tip enters the scarred area.
— After negative aspiration, 1 to 3 mL of nonionic contrast is injected
while observing the fluoroscope screen for spread within the
adhesions and runoff of contrast is observed.
— Once an outflow or runoff tract is seen (i.e. either opening of the
neuroforamina or caudal spread), 3 to 5 mL of 0.9% preservative-free
saline with 1500 units hyaluronidase is injected.
— Lastly, 0.2% ropivacaine (4 mL) and 40 mg (1 mL) triamcinolone
diacetate are injected after negative aspiration, while attention is
directed to watch for displacement of the contrast.
— For safety purposes, the local anesthetic is given in divided doses to
first rule out intrathecal subdural (1-2 mL), or intravascular injection.
Five minutes later the rest of the volume of the local anesthetic and
steroid is injected.

MODIFIED MANCHIKANTI TECHNIQUE

The technique utilized by Manchikanti et al16 is outlined in Table 28.6 and
illustrated in Figs 28.4 to 28.6.

Facilities
The procedure is performed in a sterile operating room under appropriate
sterile precautions utilizing fluoroscopy, RK needle, and a spring-wire
catheter.
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 223

Table 28.6: Percutaneous epidural adhesiolysis technique

In the operating room:

1. Place epidural needle.
2. Inject omnipaque 240 and visualize spread of contrast medium with caudal or
lumbar epidurogram.
3. After identification of the filling defect corresponding to the area of the pain,
thread a Racz catheter into filling defect.
4. Inject additional omnipaque 240 to ascertain opening of the scar and spread of
injectate within the epidural space and nerve roots.
5. Inject preservative-free saline 10-20 mL.
6. Inject 2% xylocaine 5 mL.
7. Tape the catheter in place in a sterile fashion.
In the recovery room:
1. After ascertaining for motor blockade, inject 6 mL of 10% saline in two divided
doses of 3 mL each,
15-30 minutes after injection of local anesthetic.
2. Inject 6-12 mg of celestone soluspan, or 40-80 mg of alcohol-free depo medrol,
or 40-80 mg of triamcinolone.
3. Inject 0.5-1 mL of normal saline and remove the catheter.

Adapted and modified from Manchikanti et al.16 Role of one day epidural adhesiolysis in
management of chronic low back pain: A randomized clinical trial. Pain Physician 2001;
4:153-166 with permission from authors and American Society of Interventional Pain
Physicians.

Preparation
After the initial evaluation, the patient is transferred to the holding area,
where appropriate preparation is carried out, including preoperative
evaluation, with I.V. access, and administration of antibiotic, based on
protocol and patient condition.

Consent
An appropriate detailed consent is obtained from all patients.

Operating Room
• Procedural steps are illustrated in Figures 28.4A to D and 28.5A to F.
— Patient is positioned in prone position.
— Sterile preparation is carried out with povidone-iodine (Betadine®)
prep.
— Draping is carried out to cover the patient, extending into the
midthoracic or cervical region.
— Appropriate monitoring, of BP, pulse, and pulse oximetry is carried
out.
— Sedation is slowly administered.
— The fluoroscope is adjusted over the lumbosacral region for AP and
lateral views.
224 Interventional Pain Management—A Practical Approach

A. C-arm positioning in AP B. Fluoroscopic view in AP

position position

C. C-arm positioning in lateral position D. Fluoroscopic view in lateral position

Fig. 28.4A to D: Percutaneous adhesiolysis with caudal approach–positioning,

preparation and fluoroscopy

— A physician, scrubbed and in sterile gown and gloves, infiltrates the

area for needle insertion with local anesthetic.
— An RK needle is introduced into the epidural space under fluoros-
copic utilization.
— Once the needle placement is confirmed to be in the epidural space, a
lumbar epidurogram is carried out utilizing approximately 2 to 5 mL
of contrast. Finding the filling defects by examining the contrast flow
into the nerve roots is the purpose of the epidurogram.
• After appropriate determination of epidurography, a Racz catheter, which
is a spring-guided, reinforced catheter, is slowly passed through the RK
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 225

A. Catheter placement and adhesiolysis B. Fluoroscopic view of catheter

placement

C. Contrast injection after adhesiolysis D. AP fluoroscopic view with filling

of L5 and S1 nerve roots

E. Lateral fluoroscopic view after completion F. Appropriate dressing applied

Fig. 28.5A to F: Percutaneous adhesiolysis with caudal approach –
catheter placement, adhesiolysis and epidurography
226 Interventional Pain Management—A Practical Approach

needle to the area of the filling defect or the site of pathology determined
by MRI, CT, or patient symptoms.
— Following the positioning of the catheter into the appropriate area by
mechanical means, adhesiolysis is carried out.
— After completion of the adhesiolysis, a repeat epidurogram is carried
out by additional injection of contrast.
— If appropriate adhesiolysis is completed, nerve root filling as well as
epidural filling will be noted. Figures 28.6A to F illustrates an example
of the procedure.
— Figures 28.7A to C illustrates subarachnoid injection of contrast.
• At this time, variable doses of local anesthetic are injected. Commonly
injected are 5 to 10 mL of 2% lidocaine hydrochloride or 5 to 10 mL of
0.25% bupivacaine.
• Following completion of the injection, the catheter is taped utilizing bio-
occlusive dressing; and the patient is turned to the supine position and
transferred to the recovery room.

Recovery Room
• The patient is very closely monitored for any potential complications or
side effects. If no complications are observed and the patient reports good
pain relief without any motor weakness, hypertonic saline neurolysis is
carried out at this time by injection of variable doses of 10% sodium
chloride solution.
— Hypertonic neurolysis may be carried out by an infusion pump or
repeat injections in doses of 2 to 3 mL, ranging from 6 to 10 mL total,
followed by injection of steroid (Celestone® 6 to 12 mg or Depo Medrol®
40 to 80 mg).40
• The catheter is flushed with normal saline, removed, and checked for
intactness.
— The wound is also checked at this time.
• The patient is ambulated if all parameters are satisfactory. I.V. access is
removed, and the patient is discharged home with appropriate
instructions.

SIDE EFFECTS AND COMPLICATIONS

The most common and worrisome complications of adhesiolysis in the
lumbar spine are related to dural puncture, spinal cord compression, catheter
shearing, infection, steroids, hypertonic saline, and hyaluronidase.19,20,26-38
Complications are listed in Table 28.7. Unintended subarachnoid or subdural
puncture with injection of local anesthetic or hypertonic saline is one of the
major complications of the procedure. Hypertonic saline injected into the
subarachnoid space has been reported to cause cardiac arrhythmias,
myelopathy, paralysis, and loss of sphincter control.30 In fact, Aldrete et al31
attributed incidences of arachnoiditis following epidural adhesiolysis with
hypertonic saline to subarachnoid leakage of hypertonic saline. However, a
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 227

A. AP view of lumbar epidurogram B. AP view contrast injection with

right S1 nerve root filling

C. Lateral view of “C” with filling D. AP view showing defect on right

defect on right side with Racz catheter in place

E. AP view following F. Lateral view of ‘B’

appropriate adhesiolysis

Fig. 28.6A to F: Examples of caudal epidural adhesiolysis with right S1 radiculitis

228 Interventional Pain Management—A Practical Approach

A. Lumbar interlaminar epidural with subarachnoid filling patterns – AP and lateral views

B. Lumbar interlaminar epidural with subarachnoid filling patterns – AP and lateral views

C. Caudal epidural adhesiolysis–subarachnoid distribution of contrast–AP and lateral views

Fig. 28.7A to C: Subarachnoid pattern of contrast injection
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 229

Table 28.7: Potential complications of percutaneous adhesiolysis

Pain
• Pain at the site of the needle insertion
• Exacerbation of existing pain
• Pain in the low back
Infection
• Soft tissue abscess
• Epidural abscess
• Meningitis
• Encephalitis
Bleeding
• Soft tissue hematoma
• Epidural hematoma
• Spinal cord hematoma
• Neve root sheath hematoma
Trauma
• Soft tissue
• Nerve root
• Spinal cord
Inadvertent injection
• Dural puncture
• Subdural injection
• Intrathecal injection
• Intravascular injection
Miscellaneous
• Spinal cord compression
• Cauda equina syndrome
• Arachnoiditis
• Paraplegia
• Increased intrathecal pressure
• Increased intraocular pressure
• Retinal hemorrhage
• Torn catheter
• Retained catheter
Local anesthetic effects
Steroid side effects

study of 108 patients suffering from intractable pain treated by intrathecal

hypertonic saline, reported that sphincter disorders were present in 8% of
the patients, with 2.7% experiencing cauda equina syndromes with
paraplegia.33 The study also reported rapid recovery in one patient, but quite
slow and incomplete recovery in the others, attributing the cauda equina
syndromes to pre-existing arachnoiditis in one patient and two
arteriovascular diseases in the others. In a survey of 648 neurosurgeons and
1,943 patients treated for pain, it was reported that 31.2% had used intrathecal
hypertonic saline with adverse reactions in 11.2% of the patients as compared
to adverse reactions in only 7.6% of those treated with normal or diluted
saline injections.34 Twenty-two patients, or 1%, suffered significant morbidity
with paraplegia or tetraplegia in 16, or 0.76% of the patients, and monoparesis
in one patient (0.05%).
The second specific complication of percutaneous epidural adhesiolysis
is related to catheter shearing and its retention in the epidural space. Even
230 Interventional Pain Management—A Practical Approach

though the RK needle (Epimed International Inc.) and Racz Catheter (Epimed
International Inc.) have been specifically designed for this procedure, catheter
shearing has been reported. Racz et al19 reported this problem as occurring
in five such cases. Manchikanti and Bakhit32 also reported a torn Racz
catheter in the lumbar epidural space, which was successfully removed.
Spinal cord compression following rapid injections into the epidural space,
epidural infection, direct trauma to the spinal cord, neural trauma, and
occasional sensitivity (3%) to hyaluronidase are potential complica-
tions.36-38 Other side effects are related to the administration of steroids and
are generally attributed to the chemistry or pharmacology of the steroids.26
However, therapeutic doses of epidural steroids in appropriate dosing was
without complications.39

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2. Sicard JA, Forestier J. Methode radiographique d’exploration de la cavite
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3. Hitchcock E. Hypothermic subarachnoid irrigation for intractable pain. Lancet
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4. Ventrafridda V, Spreafico R. Subarachnoid saline perfusion. In Bonica JJ (Ed.),
Advances in Neurology, Vol. 4. Raven Press, New York, 1974, 477-84.
5. Hitchcock E. Osmolytic neurolysis for intractable facial pain. Lancet 1969;1:
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6. Racz GB, Holubec JT. Lysis of adhesions in the epidural space. In Racz GB
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7. Racz GB, Heavner JE, Singleton W, Caroline M. Hypertonic saline and
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8. Payne JN, Rupp NH. The use of hyaluronidase in caudal block anesthesia.
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9. Moore DC. The use of hyaluronidase in local and nerve block analgesia other
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11. Heavner JE, Racz GB, Raj PP. Percutaneous epidural neuroplasty. Prospective
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hyaluronidase. Reg Anesth Pain Med 1999;24:202-7.
12. Manchikanti L, Pampati VS, Rivera JJ, Fellows B, Beyer CD, Damron KS, Cash
KA. Effectiveness of percutaneous adhesiolysis and hypertonic saline neurolysis
in refractory spinal stenosis. Pain Physician 2001;4:366-73.
13. Manchikanti L, Bakhit CE. Percutaneous lysis of epidural adhesions. Pain
Physician 2000;3:46-64.
 Percutaneous Adhesiolysis for Failed Back Surgery Syndrome 231

14. Manchikanti L, Pakanati RR, Bakhit CE, Pampati VS. Role of adhesiolysis and
hypertonic saline neurolysis in management of low back pain. Evaluation of
modification of Racz protocol. Pain Digest 1999;9:91-6.
15. Manchikanti L, Pampati VS, Bakhit CE, Pakanati RR. Non-endoscopic and
endoscopic adhesiolysis in post lumbar laminectomy syndrome. A one-year
outcome study and cost effectiveness analysis. Pain Physician 1999;
2:52-8.
16. Manchikanti L, Pampati VS, Fellows B, Rivera JJ, Beyer CD, Damron KS. Role
of one day epidural adhesiolysis in management of chronic low back pain: A
randomized clinical trial. Pain Physician 2001;4:153-66.
17. Manchikanti L, Rivera JJ, Pampati VS, Damron KS, McManus CD, Brandon
DE, Wilson SR. One day lumbar epidural adhesiolysis and hypertonic saline
neurolysis in treatment of chronic low back pain: A randomized, double-blind
trial. Pain Physician 2004;7:177-86.
18. Hammer M, Doleys D, Chung O. Transforaminal ventral epidural adhesiolysis.
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19. Viesca CO, Racz GB, Day MR. Special techniques in pain management: Lysis
of adhesions. Anesthesiol Clin North Am 2003;21:745-66.
20. Chopra P, Smith HS, Deer TR, Bowman RC. Role of adhesiolysis in the
management of chronic spinal pain: A systematic review of effectiveness and
complications. Pain Physician 2005;8:87-100.
21. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and
sciatica: A report of pain response to tissue stimulation during operation on
the lumbar spine using local anesthesia. Orthop Clin North Am 1991;22:
181-7.
21. Bogduk N. The innervation of the lumbar spine. Spine 1983;8:286-93.
22. Standring S. Macroscopic anatomy of the spinal cord and spinal nerves. In
Standrin S (Ed). Gray’s Anatomy: The anatomical basis of clinical practice.
Churchill Livingstone, London, 2005;775-88.
23. Bowsher D. A comparative study of the azygous venous system in man,
monkey, dog, cat, rat and rabbit. J Anat 1954;88:400-406.
24. Woollam DHM, Millen JW. The arterial supply of the spinal cord and its
significance. J Neurochem 1955;18:97-102.
25. Willis RJ. Caudal epidural blockade. In Cousins MJ, Bridenbaugh PO (Eds.),
Neural blockade in clinical anesthesia and management of pain. Lippincott-
Raven Press, New York, 1998;323-42.
26. Manchikanti L. Role of neuraxial steroids in interventional pain management.
Pain Physician 2002;5:182-99.
27. Raj PP, Shah RV, Kay AD, Denaro S, Hoover JM. Bleeding risk in interventional
pain practice: Assessment, management, and review of the literature. Pain
Physician 2004;6:3-52.
28. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, Mulroy
MF, Rosenquist RW, Rowlingson J, Tryba M, Yuan CS. Regional anesthesia in
the anticoagulated patient: Defining the risks (the second ASRA Consensus
Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain
Med 2003;28:172-97.
29. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: Report
of three cases. Spine J 2002;2:70-75.
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31. Aldrete JA, Zapata JC, Ghaly R. Arachnoiditis following epidural adhesiolysis
with hypertonic saline report of two cases. Pain Digest 1996; 6:368-70.
32. Manchikanti L, Bakhit CE. Removal of a torn Racz® catheter from lumbar
epidural space. Reg Anesth 1997;22:579-81.
33. Kim RC, Porter RW, Choi BH, Kim SW. Myelopathy after intrathecal
administration of hypertonic saline. Neurosurgery 1988;22:942-5.
34. Lucas JS, Ducker TB, Perot PL. Adverse reactions to intrathecal saline injections
for control of pain. J Neurosurg 1975;42:557-61.
35. Nelson DA. Intraspinal therapy using methylprednisolone acetate. Spine
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steroid injection. Arch Ophthalmol 1995;113:309-13.
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attempted epidural anesthesia under general anesthesia. Reg Anesth Pain
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38. Rathmell JP, Garahan MB, Alsofrom GF. Epidural abscess following epidural
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 Epiduroscopy for Chronic Low-Back Pain and Radiculopathy 233

Twenty Nine

Epiduroscopy for Chronic Low-

Back Pain and Radiculopathy
S Gupta, J Richardson

INTRODUCTION
Endoscopic surgical procedures are one of the most significant advances in
modern medicine. The development of miniature endoscopic instruments
has given us a better insight into the contents of the epidural space and has
helped in targeted therapy in the spinal canal. It also allows us to diagnose
and treat patients while awake and without the need for an open surgical
incision. This results in reduced risk, less trauma, shorter recovery time
and reduced cost.

Technical Requirements
Outpatient based endoscopy procedures require miniaturized instruments
because the patient is awake and under light sedation during the procedure.
For epiduroscopy we need high quality optics, a cold light source, flexibility,
steerability and a system for constant administration of a distending
medium of saline. All this has to be made with as small an outside diameter
as possible and it is really in the last decade that these requirements have
been met.
How does epiduroscopy differ from gadolinium enhanced MRI which
is the best available method of imaging to identify fibrous tissue in the
spinal canal?
Epiduroscopy is better than MRI scan in identifying nerve root
vascularity, nerve root inflammation, nerve root sensitivity, identification
of fibrous tissue, diagnostic localization of pain and therapeutic aspect of
pain management.1,2
MRI scan is better than epiduroscopy in delineating nerve root anatomy,
identifying disc prolapse, assessment of spinal canal size and exclusion of
serious pathology.

Pathophysiology of Radicular Pain

For generation of radicular pain, ischemia and/or inflammation are
necessary. The nucleus pulposus which contains Phospholipase A2 and
234 Interventional Pain Management—A Practical Approach

other irritant chemicals can leak from damaged intervertebral discs and can
initiate an inflammatory reaction in the nerve root/dorsal root ganglion and
can also subsequently promote fibrosis. Studies have shown that application
of nucleus pulposus material to the nerve roots slows down nerve conduction
and impairs nerve function.3-5 Cytokines present in the synovial fluid of the
facet joints can leak due to rupture of the joint capsule and cause nerve root
irritation. Trauma, ischemia, inflammation of the nerve root and surgery can
promote fibrosis, which can alter blood and CSF flow and compromise
nutrition of the nerve root.

Proposed Treatment Algorithm for Low-Back Pain with Radiculopathy

History of Back pain and Radiculopathy

↓
Conservative Treatment (CT) (Pharmacotherapy, Physiotherapy, Psychology)
↓ ↓
Pain Relief with Conservative Therapy (CT) No Pain Relief with Conservative
Therapy (CT)
↓ ↓
Continue Conservative Therapy Epidural Steroid Injection (ESI)
(Interlaminar/Transforamenal)
↓
If ESI not successful Pain relief with ESI - continue CT
↓
Rule out Facet joint or Disc pathology
↓
Consider Epiduroscopy
↓
If Epiduroscopy successful - continue Conservative Therapy as necessary
↓
If Epiduroscopy unsuccessful - Consider Stimulation Therapy

Indications (Patient Selection)

Patients who have low-back pain with radiculopathy with no surgically
correctable pathology on imaging and who have failed to respond to con-
servative management and epidural steroid injections are suitable for
epiduroscopy. Before embarking on to epiduroscopy one should be con-
vinced that the pain is not arising from the facet joints or the intervertebral
discs.
Failed Back Surgery Syndrome (FBSS) is a term for patients who continue
to have persistent back and/or leg pain even after surgery. It is a combi-
nation of severe nociceptive and neuropathic pains with superadded psycho-
logical component as treatment fails and time goes on. Between 5 and 50% of
surgical interventions on the lumbar spine result in chronic pain.
Approximately 37,500 patients with this syndrome are generated annually
 Epiduroscopy for Chronic Low-Back Pain and Radiculopathy 235

each year in the USA. As epiduroscopy can mobilize adhesions by mechanical

and hydrostatic neuroplasty it may have a specific role to play for these
patients without causing any further major trauma.

Contraindications
Contraindication for epiduroscopy include lack of consent, local infection at
the sacral entry site, use of anticoagulants or a bleeding diathesis,
hypersensitivity to amide local anesthetics or contrast media, pregnancy,
marked obesity and uncontrolled hypertension. The patient needs to be
able to lie prone for at least an hour.

How does SE Relieve Back pain?

The proposed mechanisms are that the saline flush helps in diluting and
“washing out” of Phospholipase A2 and other irritant materials leaked from
the intervertebral discs and the facet joints. Nerve roots with its inherent
structural weakness, its poor blood supply and its nutritional reliance on
CSF are easily engulfed by adhesions, compromising its nutrition.
Epiduroscopy may improve nerve root nutrition and vascularity by breaking
down adhesions. This is done by the saline flush used which helps in hydro-
static adhesiolysis (neuroplasty) and by mechanical adhesiolysis by the tip
of the epiduroscope. Steriotactic placement of medications such as local
anesthetic, steroid, clonidine and hyaluronidase provides targeted therapy.
Studies have shown that upto 50% of epidural drug delivery may not be in
the right place. Adhesions in the epidural space can prevent solutions
reaching their target.

Epiduroscopy: Instrumentation and Procedure

Epiduroscopy is used for visualization and treatment of spinal canal. It is
commonly performed via the caudal approach but the epidural space can
also be visualized by carefully passing the spinal endoscope through a Tuohy
needle at any level of the spine.
For epiduroscopy, patients are awake and in prone position with their
feet inverted, as this improves access to the caudal epidural space. Soft
pillows are placed under the patient as the procedure takes approximately
one hour. The lumbar, sacral and caudal area is cleaned with betadine and
draped as in any other surgical procedure.
In patients who are not allergic to penicillin cefuroxime 1.5 g is given I.V.
as antibiotic prophylaxis.

Epidural Access Kit

Needles and syringes to inject local anesthetic into the skin, 18G Touhy
needle, guide wire, dilator and epidural sheath (similar to pulmonary artery
catheter sheath).
236 Interventional Pain Management—A Practical Approach

The procedure is carried out under midazolam sedation but a sensible

verbal contact must be maintained with the patient during the entire
procedure. Lignocaine 1% is injected into the skin over the sacrococcygeal
area and the caudal epidural space is entered with an 18G Tuohy needle
under lateral fluoroscopic guidance. Once the caudal epidural space is
identified, radio-contrast dye is injected to obtain a baseline epidurogram.
This may identify areas of filling defect that may correspond to the patient’s
symptom. A guide wire is then advanced into the epidural space through the
Tuohy needle under fluoroscopy. The Tuohy needle is removed and a bold
incision made at the entry point of the guide wire to facilitate smooth entry of
the dilator along with the epidural sheath into the caudal epidural space.
Adequate care is taken to prevent the guide wire becoming kinked. This is
exactly as done when inserting a pulmonary artery catheter sheath in the
intensive care unit (Figs 29.1 to 29.3).

Fig. 29.1: Epidural access kit

Fig. 29.2: Pre-procedure epidudrogram showing filling defect in the symptomatic right S1
nerve root area. There is also a filling defect around the right L4 and L5 area but this patient
did not have any symptoms in the area supplied by right L4 and L5 and the filling defect was
ignored.
 Epiduroscopy for Chronic Low-Back Pain and Radiculopathy 237

Fig. 29.3: Epidural needle with guide wire in place. The epidural sheath and the dilator are
being assembled to pass over the guide wire into the caudal epidural space

Video Guided Catheter (VGC) or Steering Device

VGC is radiopaque and guides the flexible fiberoptic endoscope in the
epidural space. The VGC we use is 2.7 mm in external diameter. It has two
1.3 mm working channels with a two-way steering mechanism and a
radiopaque tip. The two working channels can be used; one for the fiberscope,
the other for saline flush/instrumentation.
Side Port: There are two side ports that terminate with standard female luer
locks. One side port is used for saline infusion and to monitor the epidural
space pressure and the other port is left open to air to act as a vent for excess
saline thus preventing excessive rise in epidural pressure.
Accessory Port: This port contains a Tuohy Borst adapter, duck bill valve, and
side port channel. These ports are used to pass accessories through the
working lumen of the catheter, i.e. fiberoptic scope, instruments.
Handle assembly: Houses the steering mechanism and is used to hold and
direct the VGC.
Steering dial: Controls the steering mechanism that manipulates the tip of the
VGC and thus the fiberscope can be directed in two different directions. This
is exactly like using a fiberoptic bronchoscope.
VGC Shaft: Flexible shaft with steerable tip.
VGC distal tip: Radiopaque tip of VGC can be viewed under fluoroscopy (Fig.
29.4).

Flexible Fiberoptic Endoscope

The flexible fiberoptic endoscope works in conjunction with the VGC to
provide direct visualization of the targeted pathology. The fiberoptic scope
we use is 0.9 mm in external diameter and 125 cm long. Magnification is 40x
and has a resolution of 10,000 pixels. It has a standard 32 mm eyepiece that
couples to the video coupler. The distal tip incorporates the micro lens
assembly.
238 Interventional Pain Management—A Practical Approach

Fig. 29.4: The video guided catheter or the steering device with the
handle which contains the steering device

The scope is connected to a cold light source and further connected to a

video staking system to obtain images on the screen.
The flexible fiberoptic scope is passed through one of the lumena of the
video guided catheter and threaded to project about 1 mm beyond the tip of
the VGC. The side port of the VGC is connected to saline flush, which is hung
about one meter above the level of the patient. A pressure-monitoring device
may also be connected via a three-way tap to monitor epidural space pressure.
It is important to keep the epidural pressure as low as possible and at least
below the mean arterial pressure. Side effects such as headache, paresthesiae
and back pain are directly proportional to the epidural space pressure.
The VGC along with the microendoscope is introduced into the epidural
space through the epidural sheath. Saline is necessary for visibility and
helps in hydrostatic adhesiolysis (neuroplasty). The tip of the VGC is guided
towards the suspected sites of nerve root pathology under fluoroscopy.
Hydrostatic pressure and movement of the tip of the VGC helps in releasing
epidural adhesions and improves visibility and further spread of saline.
With time, the epidural space clears and it will be possible to identify struc-
tures such as nerve roots. When the nerve root(s) responsible for the patients’
symptom is touched, it produces exactly the same type and pattern of the
patient’s pain. After achieving satisfactory adhesiolysis and identifying the
pathological nerve root, an epidurogram is performed and can be compared
with the pre-procedure image. Generally a better spread of dye is noted. A
steroid containing solution is injected at this site through one of the side
ports of the VGC.
The VGC along with the fiberoptic endoscope and the epidural sheath is
removed. The wound is covered with steri strips. The patient is kept supine
for the next one hour and then discharged home (Figs 29.5 to 29.12).
Epiduroscopy for Chronic Low-Back Pain and Radiculopathy 239

Fig. 29.5: The fiberoptic scope

Fig. 29.6: The fiberoptic scope is being passed through the accessory
port of the video guided catheter

Fig. 29.7: The fiberoptic scope projects about 1 mm beyond the tip of the
video guided catheter and is being focused
240 Interventional Pain Management—A Practical Approach

Fig. 29.8: The video guided catheter which houses the fiberoptic scope is guided to the
suspected site of pathology under fluoroscopic and video guidance

Fig. 29.9: Post procedure epidurogram showing good dye spread along the
right S1 nerve root which was the pathological site in this patient
 Epiduroscopy for Chronic Low-Back Pain and Radiculopathy 241

Fig. 29.10: Epiduroscopic picture showing adhesion which appear white, epidural fat
which appear glistening, blood vessel, epidural space and dura

Fig. 29.11: Epiduroscopic picture showing inflamed tissue,

adhesions epidural fat and nerve root

Fig. 29.12: Epiduroscopic picture showing adhesions

Sterilization Procedure for Fiberoptic Scope

NU-CIDEX: Contains 3500ppm peracetic acid. If the equipment is immersed
in NU-CIDEX for five minutes it acts as a disinfectant and if immersed for
ten minutes it sterilizes the equipment. Ethylene oxide gas sterilization can
also be used.
242 Interventional Pain Management—A Practical Approach

Safety Considerations
Patient must be awake as they serve as their own monitor. Epidural space
pressure due to saline infusion should not exceed mean arterial pressure.
The procedure should be stopped if patient reports pressure, paresthesia
or complains of headache, ear-pressure, neck or shoulder pain as these
symptoms indicate a rise in epidural space pressure. If these symptoms do
not decrease the procedure may have to be abandoned.

Side Effects
Pain at the insertion site. Headache during or after the procedure. Small
amounts of drainage from the epidural sheath insertion site. Paresthesiae
during the procedure

Complications
Macular hemorrhage due to the transmission of epidural space pressure due
to the hydraulics of CSF, dural puncture headache, epidural infection and/
or abscess, numbness, tingling, paresthesia, nerve root avulsion, meningitis,
and arachnoiditis. To our knowledge there is no reported incidence of
paralysis although this can be a potential complication.

Outcome Studies Following Spinal Endoscopy

As a general conclusion it may be said that about one third of patients derive
significant pain relief and improved function after spinal endoscopy and
another third derive no benefit from the procedure.6-11 Geurts et al7 concluded
that 45% of their patients has >50% pain relief at12 months following the
procedure. There are several case reports suggesting favorable outcome
following spinal endoscopy. However, Raffaeli et al12 had 3 potentially lethal
complications out of 10 patient examinations. These involved serious
medullar irritation resulting in seizures, bradycardia and respiratory
depression requiring emergency drug treatment and assisted ventilation.
These events probably resulted from the large volume of epidural fluid that
was used during the procedure (up to 1200 ml), as well as heavy sedation.
Excess epidural space pressure is transmitted throughout the neuroaxis via
the hydraulics of the CSF. The resulting intracranial pressures would have
been very high. With our own examinations, lasting approximately one hour,
we use approximately 100 ml of saline.

Conclusion
Back pain is a major problem in the society. No satisfactory treatment if yet
available in all cases. The number of patients with Failed Back Surgery
Syndrome is rising. If conservative measures or epidural steroid injections
fail, epiduroscopy is a safe and effective day case treatment option in
carefully selected patients who have low-back pain and radiculopathy.
 Epiduroscopy for Chronic Low-Back Pain and Radiculopathy 243

Outcome results are encouraging although further studies are urgently

needed. The use of laser13 or radiofrequency co-ablation technique14 to
facilitate adhesiolysis in the epidural space appears promising.

REFERENCES
1. Igarashi T, et al. Thoracic and lumbar extradural structure examined by
extraduroscope. Br J Anaesth 1998;81:121-5.
2. Igarashi T, et al. Inflammatory changes after extradural anaesthesia may effect
the spread of local anaesthetic within the extradural space. Br J Anaesth
1996;77:347-51.
3. Otani K, Arai I, et al. Nucleus pulposus induced nerve root injury: Relationship
between blood flow and motor nerve conduction velocity. Neurosurgery
1999;45 (3):614-9.
4. Olmarker K, et al. Pathogenesis of sciatic pain: Role of herniated nucleus
pulopsus and deformation of spinal nerve root and dorsal root ganglion. Pain
1998;78:99-105.
5. Byrod G, Rydvik B, Nordborg C, Olmarker K. Early effects of nucleus pulposus
application on spinal root morphology and function. European Journal of
Spine 1998;7:445-9.
6. Richardson J, McGurgan P, Cheema S, Prasad R, Gupta S, et al. Spinal endoscopy
in chronic low back pain with radiculopathy – A prospective case series. (MERIT
Centre, Bradford Royal Infirmary. Anaesthesia 2001;56:454-60.
7. Geurts JW, Kallewaard JW, Richardson J, Groen GJ. (Rijnstate Hospital,
Arnhem, The Netherlands and The MERIT Centre Bradford Royal Infirmary,
Bradford, UK.) Targeted methylprednisolone acetate/hyaluronidase/
clonidine injection after diagnostic epiduroscopy for chronic sciatica: A
prospective, one-year follow-up study. Reg Anesth Pain Med 2002; 27(4):
343-52.
8. Igarashi T, Hirabayashi Y, Seo N, Saitoh K, Fukuda H, Suzuki H. Lysis of
adhesions and epidural injection of steroid/local anaesthetic during
epiduroscopy potentially alleviate low back and leg pain in elderly patients
with lumbar spinal stenosis. Br J Anaesth 2004;93:181-7.
9. Manchikanti L, Pampati V, Bakhit CE, et al. Non-endoscopic and endoscopic
adhesiolysis in post lumbar laminectomy syndrome. A one-year outcome
study and cost effective analysis. Pain Physician 1999;2:52–8.
10. Manchikanti L, Rivera JJ, Pampati V, et al. Spinal endoscopic adhesiolysis in
the management of chronic low back pain: a preliminary report of a
randomized, double-blind trail. Pain Physician 2003;6:259–67.
11. Dashfield AK, Taylor MB, Cleaver JS, Farrow D. Comparison of caudal steroid
epidural with targeted steroid placement during spinal endoscopy for chronic
sciatica. A prospective, randomized, double-blind trial. Br J Anaesth
2005;94:514-9.
12. Raffaeli W, Pari G, Visani L, Balestri M. Periduroscopy. Preliminary reports –
technical notes. The Pain Clinic 1999;11(3):209-12.
13. Ruetten S, Meyer O, Godolias G. Application of holmium YAG laser in
epiduroscopy. Extended practicabilities in the treatment of chronic back pain
syndrome. Journal of Clinical Laser Medicine and Surgery 2002;20(4)
203–6.
14. Raffaeli W, Righetti D. Surgical radiofrequency epiduroscopy technique
(R-ResAblator) and FBBS treatment: Preliminary evaluations. Acta Neurochir
2005;92:121-5.
244 Interventional Pain Management—A Practical Approach

Thirty

Spinal Cord Stimulation

Sanjay Bakshi, GW Abrahamsen

INTRODUCTION
Chronic pain is often a difficult and costly condition to treat. In many cases,
patients’ symptomatology will fail to improve with traditional treatment
modalities such as pharmacotherapy (NSAIDS, and neuropathic pain
medications), physical therapy, chiropractic treatment, interventional spinal
injections (epidural steroid injections, facet joint injections, sacroiliac joint
blocks, stellate ganglion blocks, sympathetic blocks, etc.), and surgery. In
these cases, treatment can be very frustrating for the clinician and patient
and will often result in escalating doses of opioid pain medications.
At this point in a patient’s treatment plan a clinician may consider moda-
lities such as spinal cord stimulation (SCS). SCS has shown to be very effective
and has been used worldwide for the treatment of angina, peripheral vascular
disease, and chronic pain syndromes such as failed back syndrome, chronic,
regional pain syndrome (CRPS), phantom limb, and arachnoiditis.1-3 It is
estimated that more than 250,000 neurostimulators have been surgically
implanted since 1967.4
Spinal cord stimulation therapy blocks neuropathic pain by applying
electrical stimulation over the spinal cord. This modality is most successful
at alleviating neuropathic appendicular pain, but studies have also shown
resolution of neuropathic axial pain.5 SCS was first introduced in 1967 by
Norman Shealy and colleagues.6

Mechanism of Action
The mechanism of action of spinal cord stimulation still remains contro-
versial. The most commonly accepted mechanism is based on the gate control
theory of pain published by Melzack and Wall in 1965.7 This theory first
proposed that painful “electrochemical” nociceptive information in the
periphery is transmitted to the spinal cord in small-diameter, unmyelinated
C-fibers and lightly myelinated A-Delta fibers. These fibers terminate at the
substantia gelatinosa of the dorsal horn, the gate, of the spinal cord. Sensation
such as touch and vibration is carried in large myelinated A-beta fibers and
 Spinal Cord Stimulation 245

also terminate at this gate in the spinal cord. Therefore, the basis of this
theory is that reception of large fiber information such as touch or vibration
would turn off or close the gate to reception of small fiber information, resulting
in analgesia.8
It has also been proposed that electrical stimulation may release putative
neurotransmitters or neuromodulators, which effect prolonged pain relief.9,10

Indications
As mentioned earlier, SCS can be successfully used for many intractable
pain conditions including angina, peripheral vascular disease, and chronic
pain syndromes such as failed back syndrome, chronic regional pain
syndrome (CRPS), phantom limb, and arachnoiditis. However, in the
United States, the primary indications for SCS are failed back syndrome,11
and complex region pain syndrome.12-16 In contrast, in Europe SCS is com-
monly used as treatment for chronic intractable angina,17-19 and peripheral
vascular disease. SCS is also being used for pelvic pain, urologic disorders,
occipital neuralgia and various other neuropathic pain conditions.
When considering SCS therapy the patient should have exhausted all
conservative treatment modalities. The patient should also not be a candi-
date for corrective surgery which may alleviate the patients’ symptoms. At
this point a SCS trial may be considered using a multidisciplinary approach
including neuropsychological screening to ensure appropriate patient
selection.20 Possible candidates for SCS therapy should also be reasonably
intelligent to use the device, interpret their reduction of symptoms, and have
good home support.

Contraindications
Neuropsychological clearance should rule out any underlying personality
disorders, substance abuse, secondary gain issues, or unrealistic expectations
from treatment that may alter the results from the trial. Other contraindications
to SCS treatment include systemic infection, women who are pregnant or
lactating, patients with a demand type cardiac pacemaker, coagulopathy,
patients who experience discomfort from the sensation of TENS, and
individuals who fail to achieve less than 50% reduction of pain during trial
stimulation. After SCS has been implanted MRI and diathermy are also
contraindicated.

Trial Stimulation
Prior to permanent implantation of SCS, all patients should undergo a trial.
The most common trial method is a percutaneous trial, where leads are
inserted into the epidural space percutaneously, and left in for a period of
a few days to a week. At the end of the trial period, the leads are removed
in the office by pulling them out of the skin. Some people prefer to do the
trial by securing the leads in place surgically, and connecting it to a
temporary extension that is externalized.
246 Interventional Pain Management—A Practical Approach

Some people also do an “on the table” trial. This trial only addresses the
distribution of the stimulation pattern. It does not address the reduction of
the patient’s symptoms prior to permanent implantation of the device. For
this reason, this method is infrequently used and may result in a higher rate
of explantation of the stimulator device.
The patient should be assessed for a 50 to 70% reduction of the patients’
typical pain, increase in the ability to perform activities of daily living, and
possible reduction in patient’s narcotic medication usage. Although spinal
cord stimulation may reduce pain, it does not completely eliminate pain.21-24
The benefit of a SCS trial is that the patient can experience the sensation
of stimulation and assess the percentage of pain relief prior to surgical
implantation.

Surgical Implantation
Following a successful trial, planning for surgical implantation of the leads
and generator should begin. As with any surgical procedure pre-operative
clearance and informed consent should be obtained. Prior to the procedure
the clinician should discuss with the patient a suitable implantation site
for the pulse generator. It should be in a location that the patient would be
able to reach with a remote to activate the device. Depending on operator
and patient preference, the pulse generator or battery can be implanted in
the flank, lower abdominal wall, or buttocks. Poorly placed pulse generators
can lead to discomfort at the IPG site which may require surgical revision.
The clinician will also need to decide whether to use a laminotomy or
percutaneous lead. The other decision to be made is whether to have a
standard or rechargeable battery.

Equipment
Currently, the three major manufacturers of spinal cord stimulation devices
in the United States are Medtronics Inc., Advanced Neuromodulation
Systems (ANS), and Advanced Bionics. The actual device should be decided
on a case by case basis to suit individual patient’s needs.
The basic components of the system are the lead, and the battery. The
leads are percutaneous and laminotomy leads. The batteries are
radiofrequency or externally powered, pulse generator or internally
powered, and the new rechargeable batteries (Figs 30.1A to C).

Procedure
Step 1 – Trial Stimulation
Most often the trial is done percutaneously and this technique will be
discussed here. The procedure described here is for placement of leads in
the thoracic epidural space for treatment of back and leg pain. The patient
lies on the table in the prone position with a pillow placed under the
 Spinal Cord Stimulation 247

Fig. 30.1A: Different types of batteries

(Courtesy of Medtronic, USA)

Fig. 30.1B: Different types of percutaneous leads

(Courtesy of Medtronic, USA)

Fig. 30.1C: Different types of surgical leads

(Courtesy of Medtronic, USA)
248 Interventional Pain Management—A Practical Approach

abdomen. Mild sedation is used for the procedure. The procedure may be
performed in a fluoroscopy suite or an operating room setting. Strict aseptic
techniques are used. Antibiotics are given prophylactically before the
procedure.
Initially fluoroscopy is used to count the levels. The author usually places
a spinal needle across T10 so it serves as a landmark and you do not need
to recount which level you are at. You can also make markings on the skin
with a marking pen.
The entire procedure is done using fluoroscopy. Needle entry is usually
at the T12-L1 level or L1-L2 level. Note that the angle of entry is much
more shallow than a regular epidural. This makes it easier to thread the
lead in the epidural space. It is preferable to first hit the lamina below to
get an idea of depth. The needle is then walked off the lamina into the
interlaminar space. Epidural space is identified using loss of resistance
technique.
Once the epidural space is identified, the lead is inserted and threaded
up to the T8 level. At this point you should check a lateral view to make
sure the lead is in the posterior epidural space.
Sequential trialing is then done to check at which level patient gets
appropriate coverage of the painful area. Depending on the patients pain
distribution either 1 lead or 2 leads may be used. It is critical that the patient
not be too sedated otherwise they will not be able to give you adequate
feedback about their stimulation pattern if it is appropriately covering their
area of pain.
Once you are satisfied that there is good overlap between the patients
painful area and stimulation pattern, the needle is removed, with the lead
left in place. After removal of the needle, make sure that the lead has not
moved. This is done by comparing with the previous fluoroscopy picture.
The lead is then fixed to the skin and sterile dressing is applied. Hard copies
of the fluoroscopy films are saved for later reference during the permanent
implantation.
At this stage the patient can be discharged home for an extended trial,
or admitted for an inpatient trial depending on operator preference, and
the patient’s medical condition. If the patient is being discharged home it
is advisable to observe the patient for a few hours after the procedure to
make sure they do not develop any neurological deficits. Antibiotics are
prescribed for the entire period that the leads remain in the patient during
the trial. After the trial, the leads can be removed right in the doctors office.
If the patient reports more than 50% relief of pain, and has improved activities
of daily living during the trial period, they are considered appropriate
candidates for a permanent implantation. Ideally they should use less pain
medications during the trial period but that is not an absolute requirement
for the trial to be considered successful (Figs 30.2A to F).
 Spinal Cord Stimulation 249

Fig. 30.2A: Initial position of patient

(Courtesy of Medtronic, USA)

Fig. 30.2B: Needle entry percutaneous approach

(Courtesy of Medtronic, USA)

Fig. 30.2C: Loss of resistance technique

(Courtesy of Medtronic, USA)
250 Interventional Pain Management—A Practical Approach

Fig. 30.2D: Fluoroscopic view of lead position

(Courtesy of Medtronic, USA)

Fig. 30.2E: Sterile dressing applied at end of procedure

(Courtesy of Medtronic, USA)

Fig. 30.2F: Programmer to check stimulation pattern

(Courtesy of Medtronic, USA)

Step 2 – Permanent Implantation

Once the patient is felt to be a successful candidate depending on the trial,
the permanent implantation is performed. Prior to the procedure the
implanting physician needs to have a detailed discussion with the patient
about which type of battery would be appropriate, and the preferred site
of implantation of the battery. The battery can be inserted in the flank,
upper abdominal wall or the buttocks.
 Spinal Cord Stimulation 251

On the day of the procedure the battery site should be marked out in the
holding area prior to the procedure.
On the operating table the patient is positioned in the prone position.
Initial steps are exactly as for the trial.
Once the leads are in place, and the patient has appropriate coverage
similar to or better than the trial, an incision is made around the lead, and
dissected down to the supraspinous ligament. The lead is now anchored to
the supraspinous ligament. This is probably the most important part of the
procedure since the most common complication is movement of the leads.
Therefore the leads need to be carefully secured to the supraspinous
ligament.
The next step is the preparation of the pocket for the battery. The pocket
is created so that there is adequate space for the battery as well as any
excess lead or extension which needs to be tucked behind the battery. A
radiofrequency generator should be generated no deeper than 1 cm below
the skin, whereas a pulse generator is placed deeper, but no deeper than 1
inch below skin.
Once the pocket is created, tunneling is done between the pocket and
the lead site, and the system is connected between the lead and the battery,
either via an extension, or directly to the battery itself.
The entire system is checked at this point. If appropriate coverage is
still present, the incisions are both closed in layers. Patient is usually
discharged home the same day or the next day (Figs 30.3A to I).

Post-procedure Care following Surgical Implantation

Following surgical implantation, routine incision management and suture
removal should be followed. Typically, the SCS is activated following
removal of sutures. The patient should also refrain from any strenuous
activity or reaching above the head until approximately 6 weeks. At this
time the system is said to have matured, forming a fibrous capsule around
the implant.

Fig. 30.3A: Incision around needle Fig. 30.3B: Needle removed – lead left in place
(Courtesy of Medtronic, USA) (Courtesy of Medtronic, USA)
252 Interventional Pain Management—A Practical Approach

Fig. 30.3C: Anchor being threaded in

(Courtesy of Medtronic, USA)

Fig. 30.3D: Pocket created for battery

(Courtesy of Medtronic, USA)

Fig. 30.3E: Pocket being prepared for battery

(Courtesy of Medtronic, USA)
 Spinal Cord Stimulation 253

Fig. 30.3F: Tunneling between lead and battery site

(Courtesy of Medtronic, USA)

Fig. 30.3G: Battery being connected

(Courtesy of Medtronic, USA)

Fig. 30.3H: Battery being placed into

pocket (Courtesy of Medtronic, USA)

Fig. 30.3I: Incision closed in layers

(Courtesy of Medtronic, USA)
254 Interventional Pain Management—A Practical Approach

The patient should also have a thorough explanation on how to use the
device. In some cases, the patient will have multiple programs and will
require different degrees of stimulation throughout the day to achieve pain
reduction.

Complications
Potential complications following SCS implantation include epidural
hematoma, dural puncture headache, infection (including meningitis,
epidural abcess), lead migration, pocket seroma, stitch abcess, and
equipment failure.
The most serious complications are epidural hematoma and epidural
abcess. Clinically, they are very rare, and can be minimized by meticulous
surgical technique, and ensuring that the patients are not on any
anticoagulation medication.
Dural puncture headache will typically resolve on its own, however,
some patients may require an epidural blood patch for symptomatic relief.
If a dural puncture headache occurs during a SCS trial it is recommended
to abort the trial until resolution of the symptoms because the results of the
trial may not be as accurate. Pocket seroma is an unlikely complication.
This may require drainage if the seroma is severe or infected.
Lead migration is the most common complication following SCS
implantation. When a lead migrates a patient will experience a change or
complete loss of stimulation. Patients should be informed of the compli-
cation and the possibility of further surgical exploration to correct lead
positioning.
Any part of the SCS system can fail at any point. Battery life is the most
frequent issue. Numerous variables will affect the duration of battery life.
These variables include the hours of use per day, the number of active
electrodes, and program settings including amplitude, pulse width, and
frequency. Newer pulse generators now have a rechargeable battery option,
which may be considered in patients whose settings require more demand
on the battery. However, patients should be informed that the rechargeable
battery will also require replacement at some point.

Conclusion
Spinal cord stimulation can be a very valuable tool in the management of a
wide variety of intractable chronic pain syndromes. It should be considered
only when conservative measures have been exhausted and surgery is not
a viable option. The success rate from this treatment modality can be high
if performed with a multidisciplinary approach, in an appropriate candi-
date, using meticulous surgical technique, and with long-term follow-up.
 Spinal Cord Stimulation 255

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stimulation on the quality of life in patients with therapeutically chronic
refractory angina pectoris. Neuromodulation 1999;2:33-40.
2. Claeys LG. Spinal cord stimulation and critical leg ischemia. Neuromodulation
1999;2:1-3.
3. Kumar K, Toth C, Nath RK, Laing P. Epidural spinal cord stimulation for
treatment of chronic pain – some predictors of success. A 15-year experience.
Surg Neurol 1998;50:110-21.
4. Industry estimates (Advanced neuromodulation systems and medtronic
neurological), October 1999.
5. Law JD. Spinal stimulation: Statistical superiority of monophasic stimulation
of narrowly separated, longitudinal bipoles having rostral cathodes.
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of the dorsal column. Preliminary clinical reports. Anesth Analg 1967;46:
489-91.
7. Melzack R, Wall P. Pain mechanisms: A new theory, Science 1965;150:971-8.
8. Krames ES. Neuroaugmentation. Mechanisms of action of spinal cord
stimulation. Intervention Pain Management (2nd Ed) 2001; 53;561-5.
9. Levin BE, Hubschmann OR. Dorsal column stimulation: Effect of human
cerebrospinal fluid and plasma catecholamines. Neurology 1980;30:65-71.
10. Meyerson BA, Brodin E, Linderoth B. Possible neurohumeral mechanisms in
CNS stimulation for pain suppression. Appl Neurophysiol 1985; 48:175-80.
11. North RB, Ewend MG, Lawton MT, Piantadosi S. Spinal cord stimulation for
chronic, intractable pain: Superiority of “multi-channel” devices. 1991; 44:119-
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12. Oakley JC, Weiner RL. Spinal cord stimulation for complex regional pain
syndrome: A prospective study of 19 patients at 2 centers. Neuromodulation
1999;2:47-51.
13. Bennett DS, Alo KM, Oakley J, Feler CA. Spinal cord stimulation for complex
regional pain syndrome (RSD): A retrospective multicenter experience from
1995-1998 of 101 patients. Neuromodulation 1999;3:202-10.
14. Broseta J, et al. Chronic epidural dorsal column stimulation in the treatment of
causalgic pain. Appl Neurophysiol 1982;45:190-94.
15. Barolat G, Schwartzman R, Woo R. Epidural spinal cord stimulation in the
management of reflex sympathetic dystrophy. Stereotact Funct Neurosurg
1989;53:29-39.
16. Stanton-Hicks M. Spinal cord stimulation for the management of complex
regional pain syndromes. Neuromodulation 1999;2:193-202.
17. Mannheimer C, Augustinsson LE, Carlsson CA, et al. Epidural spinal electrical
stimulation in severe angina pectoris. Br Heart J 1998; 59:56-61.
18. Augustinsson LE. Spinal cord stimulation in severe angina pectoris: Surgical
technique, intraoperative physiology, complications, and side effects. PACE
1989;12:693-4.
19. Murphy DF, Giles KE. Dorsal column stimulation for pain relief from intractable
angina pectoris. 1987;3:365-8.
256 Interventional Pain Management—A Practical Approach

20. Olson KO, Bedder MD, Anderson VC, et al. Psychological variables associated
with outcomes of spinal cord stimulation trails. Neuromodulation 1998;1:6-
13.
21. North R, et al. Failed back syndrome: 5-year follow-up after spinal cord
stimulator implantation. J Neurosurg 1991;28(5):692-9.
22. Kumar K, et al. Treatment of chronic pain by epidural spinal cord stimulation:
A 10-year experience. J Neurosurg 1991;75:402-7.
23. Racz G, et al. Percutaneous dorsal column stimulator for chronic pain control.
Spine 1989;14(1):1-4.
24. North R, et al. Spinal cord stimulation for chronic, intractable pain: Experience
over two decades. J Neurosurg 1993; 32(3):384-95.
 Thirty One

Neuromodulation for
Chronic Pain
Sarvendra Rai, Paresh K Doshi

Pain is an “unpleasant sensory and emotional experience associated with

actual or potential tissue damage.”1
As multiple drugs (viz. opoids and non-opoids), peripheral pain
procedures (e.g. rhizotomies, epidural injections etc.) are available for the
pain relief, neurosurgical interventions viz. peripheral nerve stimulation,
spinal cord stimulation or deep brain stimulation for pain relief is required
in a very small select group of patients. The neurosurgical interventions for
chronic pain can be broadly classified into lesional surgeries (involving
some form of destruction of nerves or group of cells) or stimulation proce-
dures. Usually lesional procedures are reserved for patients with shorter life
expectancy (e.g. cancer pain) or patients who cannot afford stimulation
procedures. Nociceptive pain is more responsive to lesional procedures
whereas neuropathic pain responds well to stimulation procedures. In this
chapter we shall focus on various stimulation procedures for treatment of
chronic pain. We shall discuss three common Neurostimulation procedures,
i.e. peripheral nerve stimulation (PNS), spinal cord stimulation (SCS) and
motor cortex stimulation (MCS). Though the indications may vary, the
selection criteria for offering these treatments are common.

Selection Criteria For Neuro Stimulation Procedures2

1. A defined, non malignant organic cause of pain.
2. Failure of medical management for at least 6 months.
3. Remedial surgical procedure not feasible or advisable.
4. Absence of major psychiatric disorder as determined by psychiatric
screening.
5. Elimination of inappropriate drug use before implantation.
6. Absence of unresolved issues of secondary gain or litigation that could
potentially be central to the propagation of the pain complaint.
7. Ability to give informed consent for the procedure.
If the patient is found to fulfill the selection criteria a detailed pain and
psychological assessment is done using one or more of the following
batteries of examination:
258 Interventional Pain Management—A Practical Approach

a. Oswestry Disability Index (ODI)3

b. The McGill Pain Questionnaire (MPQ)4
c. Beck Depression Inventory (BDI)5,6
d. Ronald Morris Questionnarie (RMQ)7
e. Pain score by modified visual analog scale.8,9

Peripheral Nerve Stimulation (PNS)

Electrical stimulation of large-diameter, afferent fibers of the peripheral
nervous system has been used to relieve localized neuropathic pain
syndromes. The stimulating electrode is implanted on a nerve between the
CNS and the site of the painful pathology. The common indications for
PNS include post traumatic neuropathic pain, occipital neuralgia, and
intractable facial pain.

Hardware
This again comprises of electrodes and pacemaker. There are two types of
stimulating electrodes:
a. Cuff type which encircles the nerve because of encircling nerve there
are high chances of post operative nerve edema and consisting injury.
b. Flat array type (Fig. 31.1) as used in the spinal cord stimulation. The
mobility of peripheral nerve is less as compared to spinal cord hence
less chances of displacement.
The IPG is the same that is used for the SCS.

Mechanism of Peripheral Nerve Stimulation

Electric current applied during stimulation directly blocks cell membrane
depolarization and axonal conduction in afferent state, so that the patient
experiences light tingling sensation instead of pain in areas innervated by
stimulated nerves.10-12

Fig. 31.1: Peripheral nerve stimulation meshed lead

 Neuromodulation for Chronic Pain 259

Operative Technique
The first stage trial procedure is performed under mild sedation and local
anesthesia to monitor patient’s feedback and ensure maximum coverage
of painful areas by the stimulator. The electrode can be either implanted
percutaneously or through a small incision at the site of the nerve depending
on the choice of electrode. The electrode is placed in close proximity of the
nerve, in case of cuff electrodes it is used to encircle the nerve. Following
this a trial stimulation is performed to confirm the distribution of paresthesia.
Trial screening is continued for a period of 3 to 4 days. After successful trial,
i.e. >50% pain relief, the second surgery of pacemaker implantation is
performed under general anesthesia.

Results
Peripheral nerve stimulation offers pain relief in >60% of patients.13 There is
a high incidence of reoperation due to development of tolerance, dislodgement
of the lead or only because of suboptimal response. However, this can be
carried out under local anesthesia without additional morbidity. Patients
responding favorably can also be taken off the analgesic medications.

Spinal Cord Stimulation (SCS)

SCS was first introduced by Shealy.14 They first placed the electrodes over
the dorsal columns (DCs) in the subarachnoid space through a laminectomy.
As this did not prove to be a practical way of conducting SCS it was
subsequently abandoned. In 1975, Dooley described percutaneous
implantation of electrodes in the dorsal epidural space.15 Since than SCS
has been widely used in the treatment of chronic pain.

Mechanism of Action of SCS

The basic scientific background of the initial spinal cord stimulation trials
was the gate control theory by Melzack and Wall.10 Their theory proposed
that stimulation of Aβ fibers modulates the dorsal horn “gate” and therefore
reduces the nociceptive input from the periphery. Indeed, several studies
demonstrated that dorsal horn neuronal activity caused by peripheral
noxious stimuli could be inhibited by concomitant stimulation of the dorsal
column. However, it seems that other mechanisms may play a more
significant role in mechanisms of action of spinal cord stimulation. This
involves release of neurotransmitters like gamma amino-butyric acid
(GABA), Substance P (SP), adenosine etc. This has been well documented in
animal studies.16-18 These neurotransmitters are released at the level of dorsal
horn by direct stimulation and also through the activation of inhibitory
pathways from the brain stem. DC stimulation also leads to stimulation of
ascending pathways, in turn activating cells in the brain stem, which in turn
activate descending inhibition.19
260 Interventional Pain Management—A Practical Approach

In peripheral vascular disease, spinal cord stimulation may also abolish

peripheral ischemic pain by restoring the balance ratio of oxygen supply
and demand and thus preventing ischemia.20 Patients with chest pain due
to refractory angina pectoris respond well to spinal cord stimulation. Many
possible explanations exist for spinal cord stimulation’s mechanism of action
in myocardial ischemia. The most likely mechanism for pain relief consists
of redistribution of the coronary blood flow from regions with normal
perfusion in favor of regions with impaired myocardial perfusion.21,22 This
anti-ischemic effect of spinal cord stimulation was shown by coronary blood
flow measurements and positron emission tomography. Other lines of
evidence show that modulation of the intrinsic cardiac nervous system
might contribute to the therapeutic effects of spinal cord stimulation in
patients with angina pectoris.23 In this proposed mechanism, spinal cord
stimulation may suppress the excitatory effects of myocardial ischemia on
intrinsic cardiac neurons.

Indications for SCS1,2

1. Failed back syndrome
2. Ischemic pain with peripheral vascular disease in lower extremities
in recent years
3. Complex regional pain syndromes – characterized by presence of partial
injury to peripheral nerve
4. Peripheral neuropathy
5. Peripheral nerve injury or neuralgia and so called sympathetic
dystrophy
6. Post amputation pain syndromes including phantom limb and stump
pain
7. Pain associated with lower limb spasticity
8. Multiple sclerosis
9. Spinal cord injury/lesion/cauda equina syndrome
10. Post-herpetic/intercostal neuralgia
11. Upper limb pain secondary to disc surgery and miscellaneous pain
syndromes
12. Intractible angina pectoris
13. Peri-rectal pain.

Hardware
SCS component consists of trial leads, permanent leads and implantable
pulse generator (IPG) or external pulse generator. The electrodes are of
two types, one is percutaneous and other is a plate-type. Some of the
common electrode configurations available in India, are:
a. Pisces – Quadripolar: Electrodes consists of 4 cylindrincal contact points,
each 3 mm in length and spaced 6 mm.
b. Resume I/II: Electrodes have 4 circular contact points, each with
stimulating area 12 mm2.
 Neuromodulation for Chronic Pain 261

c. Specify lead : It has two, four electrode arrays spaced 2 mm apart, contact
points are 2 × 3 mm and are spaced 6 mm apart vertically.
The pulse generator can be implantable (Itrel 3, Medtronic) or radio
receiver based pulse generator with external stimulator (Xtrel, Medtronic).
The battery life of implantable pulse generators depend on the use of the
pacemaker, but usually last for an average of 4 to 5 years.

Surgical Technique
As with all implantable therapies,
this consist of trial phase, followed
by permanent implantation. There
are two methods of placing the
leads in epidural space. One is
percutaneous method and the
other is by open laminotomy. The
percutaneous lead implantation is
done under local anesthesia with
sedation. Confirmation of the
distribution and pattern of
paresthesia is critical to a good
outcome of SCS (Fig. 31.2). It has
been observed that this is more
important especially for patients
requiring SCS for low back and
radicular pain. However, if there
has been a previous spinal
surgery or the condition requires
the use of plate electrodes (e.g. C1- Fig. 31.2: Percutaneous lead electrodes
for DCS in a patient with
C2 region) a laminotomy will need failed back surgery
to be performed at the level of
implantation and general
anesthesia may be required.

Position of Electrode Insertion

for Various Conditions
a. Occipital, jaw and neck pain: Electrode insertion at C1 and C2 level
b. Upper limb pain: Electrode insertion between C5 and T1
c. Lower limb pain: Electrode insertion between T9 and T11
d. For Angina pain: Electrode insertion between C7 and T1.
Following a successful screening period, the lead can be internalized
and connected to the pacemaker. The implantable pulse generators come in
mainly two different configurations. One is single channel (Itrel 3) and the
other is dual channel (Synergy). It is possible to perform horizontal
stimulation between two leads using synergy pacemaker. This is useful in
axial pain syndromes and also to limit side effects.
262 Interventional Pain Management—A Practical Approach

Tolerance
Tolerance leading to decrease or ineffective stimulation remains a problem.
It is caused by plasticity of pain pathways either in the spinal cord thalamus
or cortex. Some times fibrosis around the stimulation tip can cause increase
current thresholds. Minor lead displacements can be another reason for
increased current requirements. Other factors like physiological,
pathological and psychological factors may also be contributory to tolerance.
One of the ways to overcome tolerance is by having stimulation “holiday”
upto 6 weeks. In case of lead displacement or fibrosis, repositioning of the
lead can be attempted.24-26

Complications/Adverse Effects of SCS

Descending Order of Frequency
1. Hardware failure: Displaced electrodes, fractured electrodes, IPG
malfunction
2. Infection
3. Subcutaneous hematoma
4. CSF Leak
5. 90 degree rotation of pulse generator
6. Discomfort over pulse generator
7. Insulation damage
8. Spinal cord or nerve injury
9. Damage due to electromagnetic fields, e.g. diathermy, security system.

Results
The pain relief following SCS ranges from 50 to 60% in most reported series
with failure or poor results in 30 to 36% patients. It has been documented
that patients with failed back surgery syndrome respond better to spinal
cord stimulation than the re-operation.27 Reported success rates in treating
failed back surgery syndrome vary from 12 to 88%, with higher efficacy
reported in recent studies28-30 systematic review of the literature related to
spinal cord stimulation and failed back surgery syndrome by Turner et al 31
revealed that on average, 59% of patients had > 50% pain relief. The average
complication rate in the same study was 42% but related to mainly minor
complications. Besides pain relief, spinal cord stimulation improves
functional status in a significant number of patients, with a 25% return-to-
work rate28 and up to 61% improvement in activities of daily living.31 The
reduced consumption of analgesics with spinal cord stimulation treatment
varies from 40 to 84% in published reports.32,33 Radicular pain responds
more consistently than lumbar pain in patients with failed back syndrome.
The initial response obtained in phantom limb pain patients can wear off
over time. In patients with reflex sympathetic dystrophy the response rate in
one of the large series.34
 Neuromodulation for Chronic Pain 263

Conclusion
In the long run SCS is very cost effective compared to medical management.
SCS provides significant long-term pain relief and improves the quality of
life. Multipolar and Multichannel stimulation programs in SCS have
improved the long-term success rate. In the present era complication rate is
low which makes SCS relatively safe and effective approach for intractable
pain management. Tolerance remains major problem in long-term course.

Motor Cortex Stimulation

The term “deafferentation pain” has been used to refer to pain in which the
flow of afferent nervous impulses has been partially or completely
interrupted.35 Patients with deafferentation pain usually display sensory
loss. The symptom common to all patients is a disturbance of temperature
and pain sensibilities, whereas vibration and touch sensibilities may not be
impaired.36-38 There is increasing physiological evidence that nociceptive
neuronal signal can be modulated by the input of non-noxious somatosensory
information, such as light tactile sense, at multiple levels of central nervous
system (CNS).39,40 However, this modulation has to be done at a site above
the level of deafferentation, e.g. deafferentation pain of peripheral nerve
system can be effectively controlled by thalamic stimulation.41-43

Indications for MCS

1. Central neuropathic pain which has failed to respond adequately to
medical therapy
2. Anesthesia dolorosa
3. Trigeminal deafferentiation pain
4. Central pain secondary to stroke. Severe motor deficit is a contraindication
for MCS
5. Post herpetic neuralgia
6. Peripheral deafferentiation pain syndromes like brachial plexus or sciatic
nerve injury
7. Spinal cord injury
8. Phantom limb and stump pain.

Mechanism of Pain Relief

Deafferentation pain secondary to CNS lesions, such as thalamic pain, has
proved to be the most difficult pain syndrome to control even with
stimulation therapy.44-46 Pain control in such cases can be attempted by
stimulating at a level more rostral to the thalamic relay nuclei. This is the
basis for offering motor cortex stimulation (MCS). Tsubokawa and Katayama
demonstrated that stimulation applied to precentral gyrus rather than the
postcentral gyrus sometimes produced stronger pain inhibition. Stimulation
of the postcentral gyrus even exacerbated pain in many patients. The area
264 Interventional Pain Management—A Practical Approach

providing strong pain inhibition appeared to correspond to the motor cortex,

since that area caused muscle contractions at higher intensity.46,47
Intact somatosensory cortex is not a prerequisite for the MCS but intact
corticospinal tract neuronal system originating from the motor cortex is
required for the pain relief to be effective. According to one study MCS
attenuates brainstem spinal pain reflexes. Recent studies in such patient
with functional MRI have shown that the cortical stimulation increases
CBF in the ipsilateral thalamus, cingulate gyrus, orbitofrontal cortex and
brainstem.

Surgical Technique
As with other stimulation therapies this also is a two staged procedure
comprising of trial stimulation and permanent stimulation. Based on the
MRI projections of the central sulcus a localized craniotomy is performed
centered over it. The exact location of precentral sulcus is mapped using
median nerve somatosensory evoked potentials. This is marked across the
dura and the motor cortex is stimulate to elicit motor response (recorded
by EMG and observing muscle contractions) in the areas of pain. Once the
target site is confirmed the stimulating array of electrodes is replaced by a
Medtronic Resume lead (Fig. 31.3). Trial stimulation is performed for 2 to 5

Fig. 31.3: Epidural electrodes for motor cortex stimulation

 Neuromodulation for Chronic Pain 265

days. Stimulation parameters are frequency 40 Hz, pulse width 90 ms and

amplitude 1 to 3 V. If there is more than 50% pain relief electrode is internalized
and connected to an Itrel 3 pulse generator for permanent stimulation.

Results
The pain control rates in MCS ranges from 44 to 100%, depending on
indications and technique.48 The average pain control of more than 50% is
achievable in >50% cases. Thalamic pain syndrome, post stroke pain,
phantom limb pain and posttraumatic neuralgic pain (brachial plexus injury)
have a better response. Patients may develop tolerance over long period of
stimulation. This may be secondary to fibrosis in the epidural region around
the electrodes or due to displacement of the electrodes.

Complications
1. Hemorrhage, infection as in any other surgery.
2. Risk of focal seizures due to motor cortex stimulation.

Conclusion
With the development in imaging technology and combination of functional
MRI guided neuronavigation and intraoperative mapping has improved
the targeting of motor cortex. Now studies have shown that patient’s
suffering with neuropathic facial pain of central and peripheral origins are
greatly benefited. Emerging technology and innovation will bring better
results in future.

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10. Melzack R, Wall PD. Pain mechanism: A new theory. Science 1965;150:951-79.
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the dorsal columns: Preliminary report. Anesth Analg 1967;46:489-91.
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Pain 1992;50:51-7.
18. Alo KM, Yland MJ, Redko V, et al. Lumbar and sacral nerve root stimulation
(NRS) in the treatment of chronic pain, a novel anatomic approach and
neurostimulation technique. Neurostimulation 1999;2:19-27.
19. Linderoth B, Foreman R. Physiology of spinal cord stimulation: Review and
update. Neuromodulation 1999;2:150-64.
20. Kumar K, Toth C, Nath KR, Verma AK, Burgess JJ: Improvement of limb
circulation in peripheral vascular disease using epidural spinal cord
stimulation. A prospective study. J Neurosurgery 1997;86:662-9.
21. DeJongste MJ. Spinal cord stimulation for Ischemic heart disease. Neurol Res
2000;22:293-8.
22. Erdek MA, Staats PS. Spinal cord stimulation for angina pectoris and vascular
disease. Anesthesiol Clin North America 2003;21:797-804.
23. Foreman RD, Linderoth B, Ardell JL, et al. Modulation of intrinsic cardiac
neurons by spinal cord stimulation: Implications for its therapeutic use in
angina pectoris. Cardiovascular Research 2000;47:367-75.
24. North RB, Kidd DH, Zahurak M, et al. Spinal cord stimulation for chronic
intractable pain: Two decade’s experience. Neurosurg 1993;32:384-95.
25. Pineda A. Dorsal column stimulation and its prospects. Surg Neurol 1975;4:157-
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26. Pineda A. Complications of dorsal column stimulation, J Neurosurge
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27. Kolin MT, Winkelmuller W. Chronic pain after multiple lumbar discectomies
– Significance of intermittent spinal cord stimulation. Pain 1990;5:S241.
28. North RB, Kidd DH, Lee MS, et al. Spinal cord stimulation versus reoperation
for the failed back surgery syndrome: A prospective randomized study design.
Stereotact Funct Neurosurg 1994;62:267-72.
29. North RB, Ewend MG, Lawton MT. Failed back surgery syndrome: Five year
follow up after spinal cord stimulator implantation. A prospective, randomized
study design. Neurosurg 1991;28:692-9.
30. Burchiel KJ, Anderson VC, Brown FD, et al. Prospective multicenter study of
spinal cord stimulation for relief of chronic back and extremity pain.
Spine1996;21:2786-94.
31. Turner JA, Loeser JD, Bell KG. Spinal cord stimulation for chronic low back
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32. Burchiel KJ, Anderson VC, Brown FD, et al. Prospective multicenter study of
spinal cord stimulation for relief of chronic back and extremity pain. Spine
1996;21:2786-94.
33. Kolin MT, Winkelmuller W. Chronic pain after multiple lumbar discectomies
– Significance of intermittent spinal cord stimulation. Pain 1990;5:S241.
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Textbook of stereotactic and functional neurosurgery, Gildenberg PL, Tasker
RR (Eds), Mcgraw Hill 1998.
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Edinburgh. Churchill Livingstone, 1984;119-32.
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39. Fields HL, Adams JE. Pain after cortical injury relieved by electrical stimulation
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40. Hillman P, Wall PD. Inhibitory and excitatory factors influencing the receptive
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41. Gybles JM. Indications for the use of neurosurgical techniques in pain control,
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43. Hosobuchi Y, Adams JE, Rutkin B. Chronic thalamic stimulation for the control
of facial anesthesia dolorosa. Arch Neurol 1973;29:158-61.
44. Tasker RR. Deafferntation, in Wall PD, Melzack R (Eds). Text book of Pain.
Edinburgh, Churchill Livingstone, 1984;119-32.
45. Tsubokawas T, Katayama Y, Yamamoto T, et al. Chronic motor cortex
stimulation for the treatment of central pain. Acta Neurochir Suppl 1991;52:
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46. Tsubokawas T, Katayama Y, Yamamoto T, et al. Deafferentation pain and
stimulation of thalamic sensory relay nucleus: Clinical and experimental study.
Appl Neurophysiol 1985;48:166-71.
47. Takashi Tsubokawa, Yoichi Katayama, Yamamoto T, et al. Chronic motor
cortex stimulation in patients with thalamic pain. J Neurosurg 1993;78:393-
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268 Interventional Pain Management—A Practical Approach

Thirty Two

Discography

Sudhir Diwan, P Annello

Introduction
Lindblom, in the 1940s, was first to describe a diagnostic disc puncture
procedure, which he modified into what we call modern day discography.
This procedure was previously used as an adjunct to myelography.
Discography involves the injection of contrast into intervertebral discs to
visualize any disruptions in the disc structure. Discography was further
expanded to evaluate the patient’s response to the injection in an attempt to
reproduce the patient’s pain. Modern discography has predominantely
become a purely diagnostic modality, which can be utilized to obtain
information in order to evaluate discogenic pain, and to determine the level
of intervention or fusion.
Provocative discography is the term applied for the procedure to reproduce
discogenic pain by injecting contrast in the disc. The pain is reproduced by
two ways; first, by chemical irritation of sensitive tissue and secondly, by
increasing the intradiscal pressure due to volume and stretching the annular
fibers of the disc. Discography helps to evaluate disc morphology and confirm
the diagnosis for consideration of surgical intervention. It also helps to
confirm normal discs.

Why do Intervertebral Discs Cause Pain?

After extensive literature review it is believed that only the outer third of the
annulus fibrosus has sensory nerve supply. But in case of internal disc
disruption, there is ingrowth of sensory fibers into the inner third with
neovascularization and neural expression of substance P. These ingrowths
of nerve fibers play an important role in the pathogenesis of discogenic low
back pain.1
At least one-third of patients with chronic low back pain have internal
disc derangement (IDD). Disc degeneration is a progressive condition that
gradually involves the entire nucleus and spreads radially to the annulus.
IDD can happen with an intact annulus, and discography is gold standard
to determine IDD.
 Discography 269

Indications for Discography

• To confirm the source of pain in patients with a documented disc bulge.
• As a preoperative procedure to confirm the vertebral level for spinal fusion.
• Discography may help to distinguish source of pain either from the disc
or scar tissue in postsurgical patients.
• In patients who are status post a fusion and continue to have persistent
pain, discography can be used to see whether or not the discs adjacent to
the fusion are the source of the patient’s symptoms.
• To determine if other treatment modalities, e.g. IDET, nucleoplasty,
chemonucleolysis would be of benefit for the patient’s pain.2,3

Contraindications
• Patients unable to understand the procedure and unwilling to provide
written consent.
• Systemic infection or localized infection at the site of procedure to be
performed.
• Coagulopathic patient.
• Allergy to contrast medium.
• Significant myelopathic changes due to risk of aggravation of myelopathy.

Cervical Discography
Anatomy of Cervical Spine
• Cervical discs have certain characteristics distinct from other parts of the
spine.
• Radicular pain originating exclusively from cervical disc herniation is
much less common than in the lumbar region.
• The posterior longitudinal ligament in the cervical region is thicker, with
a double layer, enclosing the posterior and lateral parts of the disc, while
it is a much thinner, single layer, with weaker lateral protection in the
lumbar area.
• The facet joints protect the cervical nerve roots from impingement by
interposing a bony wall between the disc and the nerve root.
• The nuclear material of the cervical disc lies more anterior than it does in
the lumbar spine, therefore posterior displacement is difficult to occur
unless great forces are applied on the disc.
• The outer annulus is substantially thicker in the posterior portion of the
cervical disc, making it more difficult for the disc to bulge posteriorly.
• Treatment of cervical discogenic pain is difficult because the disc receives
sensory input from potentially different sources, and it is unclear which
among them are responsible for pain.
• The anterior aspect of the disc receives sensory innervation from the
sympathetic chain and the posterior aspect receives innervation from the
sinovertebral nerves. It is thought that these nerves provide innervation
to the facet joints as well.
270 Interventional Pain Management—A Practical Approach

Indications of Cervical Discography

There are several indications for performing cervical discography. These
indications can be divided into those patients who have had a neurosurgical
intervention or not.
• In surgical naïve patients, cervical discography is used to determine the
source of pain in patients with documented evidence of a disc bulge on
modern imaging studies like MRI or CT scan.4
• Discography may be used to reproduce pain in patients with persistent
radicular pain but imaging studies may not show any anatomical
abnormalities.
• Cervical discography can also be used as part of the preoperative workup
for patients who are candidates for cervical fusion. It helps to determine
the level of fusion by finding the disc that is most symptomatic and needs
to be fused.
• Cervical discography can also be used to distinguish whether the etiology
of a patient’s pain is from a disc herniation or scar tissue.

Technique for Cervical Discography (Figs 32.1 to 32.5)

Fluoroscopic suite or operating room with C-arm fluoroscope is mandatory
to perform the discogram at any level5 (Fig. 32.3). The C-arm is rotated to 20
to 25 degree obliquely and angled cephalad or caudad to align the endplates
of the intervertebral disc space.
• Prophylactic antibiotic should be considered.
• The patient is placed in the supine position with the neck in the neutral
position.
• The right side of the neck is preferred due to the leftward orientation of
the esophagus at this level. The neck is prepped and draped in the normal
sterile fashion.
• Important structures must be noted at this level including the trachea,
carotid artery, jugular vein and esophagus.
• The medial border of the sternocleidomastoid muscle is palpated and
local anesthetic is injected subcutaneously at the chosen level of cervical
disc.
• A 25-gauge, 3.5 inch styletted needle is placed through the skin and
advanced to the middle of the disc in question.
• The needle is advanced incrementally with imaging. If a paresthesia is
elicited, the needle should be withdrawn and then readvanced cephalad
toward the middle of the disc.
• Once the disc is contacted, the needle is advanced incrementally under
lateral view of the C-arm until the middle of the disc is penetrated.
• Imaging is performed in order to avoid going though the back of the disc
either into the spinal canal or the pleura.
• 0.3 ml of contrast is injected with careful attention being paid to resistance
to injection, patient’s response and whether or not pressure is maintained
or dissipated in the disc via manometery.6
 Discography 271

• Make precise notes of amount of contrast injected, volume at which patient

experienced pain, pressure at which patient experienced pressure/pain,
and pain response (location, character, distribution, intensity and
concordance with chronic pain).
• The discogram should be evaluated for the integrity of the disc and a
decision should be made whether the adjacent disc needs to be studied or
whether local anesthetic should be injected in the disc of question.
• The decision to inject local anesthetic into the disc space can give
erroneous information if adjacent discs are to be evaluated. The local
anesthetic can possibly track epidurally or it can anesthetize some of the
nerves that provide sensory input to the adjacent discs.

Fig. 32.1: Drawing demonstrating the technique for the anterior approach to the cervical
disc. Abbreviations: SCM-sternocleidomastoid muscle, CA-carotid artery, JV-jugular vein,
VA-vertebral artery
Imaging Details with X-ray
• The images of the injected disc should be evaluated to see whether or not
the disc and its components are intact.
• The condition of the disc will determine where the contrast will collect.
• A normal disc will appear as a lobulated mass with some posterolateral
clefts due to the normal aging process of the disc.
• If the inner annulus is torn, a transverse pattern of contrast will show on
the nucleogram or if the tears of the annulus extend to the outer layer, a
radial pattern will be noted.
• It is also possible for the contrast to flow into the epidural space or the
endplate of the vertebra if the annulus is completely disrupted.
272 Interventional Pain Management—A Practical Approach

Fig. 32.2: X-ray imaging of cervical spine demonstrating entry of

needles into C4-C5 and C5-C6 disc spaces

Fig. 32.3: Fluoroscopic suite with C-arm fluoroscope and

fluoroscopic procedure table

Fig. 32.4: Fluoroscope positioned for oblique view

 Discography 273

Fig. 32.5: Fluoroscope positioned for lateral view

• In certain situations, the injected contrast may flow between the layers of
the annulus.

Anatomy of Thoracic Spine (Fig. 32.6)

• Thoracic discs are located between the cartilaginous endplates of the
vertebrae above and below it.
• The disc of the thoracic spine is characterized by a thick fibroelastic
annulus that surrounds a gelatinous nucleus pulposus.
• These annular fibers run in an oblique direction from adjacent vertebrae.
• These annular fibers receive sensory input from various sources including
sinovertebral nerves (posteriorly) and the sympathetic chain (anteriorly).
• Nerve roots leave laterally through the intervertebral foramina.
• The disc can impinge the nerve roots if herniated laterally.
• The disc can impinge the spinal cord if herniated posterolaterally.

Fig. 32.6: Cross-section through thoracic area demonstrating

entry point of styletted needle
274 Interventional Pain Management—A Practical Approach

Indications for Thoracic Discography

• Often most useful in determining source of pain but performed the least
due to least likelihood of a thoracic disc to herniate.
• Patients with pain in whom testing have been normal or unrevealing.
• In postsurgical patients with persistent pain, one may want to differentiate
scar tissue from disc tissue or evaluate the discs adjacent to a fusion.
• In presurgical candidates, discography may be used to further evaluate
the levels to be fused.

Technique for Thoracic Discography

• Prophylactic antibiotics should be considered.
• Patient is placed in prone position with a pillow under the lower chest in
order to flex the spine.
• If CT is being used, make careful note of pleura, lung, ribs, nerve roots
and spinal cord.
• The spinous process above the disc of question is located and the skin 1.5
inches laterally on either side is prepped, draped and anesthetized.
• A 22-gauge, 3.5 inch styletted needle is placed through the skin and
advanced to the middle of the disc of question.
• The needle is advanced incrementally with imaging. If a paresthesia is
elicited, the needle should be withdrawn and then readvanced cephalad
toward the middle of the disc.
• Once the disc is contacted, the needle is advanced incrementally until the
middle of the disc is penetrated. Imaging is performed in order to avoid
penetration of the back of the disc either into the spinal canal or the
pleura.
• Similar to the cervical discogram, 0.3 ml of contrast suitable for intrathecal
use is injected with careful attention being paid to resistance to injection,
patient’s response and whether or not a pressure is maintained or
dissipated in the disc via manometry.
• Take note also of amount of contrast injected, volume at which patient
experienced pain, pressure at which patient experienced pressure/pain,
and pain response (location, character, distribution, intensity and
concordance with chronic pain).
• The discogram needs to be evaluated to check the integrity of the disc and
a decision needs to be made if there is need to evaluate the adjacent disc
spaces or to inject local anesthetic in the disc of question.
• The decision to inject local anesthetic into this disk space can give
erroneous information if the adjacent discs are to be evaluated. The local
anesthetic can possibly track epidurally or it can anesthetize some of the
nerves that provide sensory input to the adjacent discs.
 Discography 275

Imaging Details with X-ray

• The images of the injected disc need to be evaluated to see whether or not
the disc and its components are intact.
• The spread of the contrast will determine the condition of the disc.
• A normal disc will appear as a lobulated mass with some posterolateral
clefts due to the normal aging process of the disc.
• If the inner annulus is torn, a transverse pattern of contrast will show on
the nucleogram or if the tears of the annulus extend to the outer layer, a
radial pattern will be noted.
• It is also possible for the contrast to flow into the epidural space or the
endplate of the vertebra if the annulus is completely disrupted.
• In certain situations, the injected contrast may flow between the layers of
the annulus.

Lumbar Discography (Figs 32.7 to 32.12)

Anatomy of Lumbar Spine
• Radicular pain of discogenic origin is much more common in the lumbar
region than any other region.
• Unlike the cervical region, the bony facets do not protect the nerve roots.
• The posterior longitudinal ligament of the lumbar spine is thinner and
less protective. This is especially true in the lateral aspects of the spine.
• The nuclear material in the lumbar spine is located more posterior than
that of the cervical or thoracic spine.
• The nerve roots leave the spinal cord laterally and the laterally herniated
disc can easily cause classic radicular symptoms.
• The innervation of the lumbar discs is very similar to that of the discs of
the cervical and thoracic spine. The outer third of the annulus fibrosus of
the disc is supplied by multiple sensory nerves.

Indications for Lumbar Discography7

• To determine source of pain in patients with documented disc bulge from
previous studies.
• Patients with pain in whom testing have been normal or unrevealing.
• To differentiate scar tissue from disc tissue or evaluate the discs adjacent
to a fusion in post-surgical patient with persistent pain.
• In presurgical candidates, discography may be used to further evaluate
the levels needed to be fused.

Technique for Lumbar Discography

• Patient is placed in the prone position with a pillow under the abdomen
to slightly flex the lumbar spine.
• Imaging can be obtained to locate vital organs like lungs, ribs, aorta, vena
cava, kidneys, nerve roots, and spinal cord.
276 Interventional Pain Management—A Practical Approach

• The spinous process below the disc of question is palpated and the skin
1.5 inches laterally is sterilely prepped, draped and anesthetized with
1% lidocaine.
• A 22-gauge, 5 inch styletted needle is placed through the skin and
advanced to the middle of the disc of question.
• The needle is advanced incrementally with imaging. If a paresthesia is
elicited, the needle should be withdrawn and then redirected cephalad
toward the middle of the disc.
• Once the disc is contacted, the needle is advanced incrementally until the
middle of the disc is penetrated. Imaging is performed in order to avoid
penetration though the back of the disc or too laterally either into the
spinal canal or the pleura (in L1 discography).
• Similar to cervical discogram, contrast suitable for intrathecal use is
injected with careful attention being paid to resistance to injection,
patient’s response and whether or not pressure is maintained or
dissipated in the disc via manometery.
• Take note also of amount of contrast injected, volume at which patient
experienced pain, pressure at which patient experienced pressure/pain,
and pain response (location, character, distribution, intensity and
concordance with chronic pain).
• The discogram needs to be evaluated to check the integrity of the disc and
a decision needs to be made if there is need to evaluate the adjacent disc
spaces or to inject local anesthetic in the disc of question.
• The decision to inject local anesthetic into this disk space can give
erroneous information if the adjacent discs are to be evaluated. The local
anesthetic can possibly track epidurally or it can anesthetize some of the
nerves that provide sensory input to the adjacent discs.

Fig. 32.7: Cross-section demonstrating the technique for lumbar discography. The needle is
advanced toward the disc 8-10 cm from midline. The needle is angled 45 degrees from the
surface of the skin
 Discography 277

Fig. 32.8: X-ray demonstrating the oblique view of the lumbar spine.
Refer to next figure for needle entry

Fig. 32.9: Drawing depicting the “Scotty Dog” view of the lumbar spine. This figure
can be used with the prior figure to determine exact point of needle entry

Imaging Details With X-ray

• The images of the injected disc need to be evaluated to see whether or not
the disc and its components are intact.
• The condition of the disc will determine where the contrast will collect.
• A normal disc will appear as a lobulated mass with some posterolateral
clefts due to the normal aging process of the disc.
• If the inner annulus is torn, a transverse pattern of contrast will show on
the nucleogram or if the tears of the annulus extend to the outer layer, a
radial pattern will be noted.
278 Interventional Pain Management—A Practical Approach

Figs 32.10A and B: Drawings depicting possible contrast flow after

injection within the discs of the lumbar spine

Fig. 32.11: X-ray demonstrating contrast in the L2-3 and L3-4 disc space
 Discography 279

Fig. 32.12: X-ray demonstrating contrast in the L4-5 and L5-S1 disc space

• It is also possible for the contrast to flow into the epidural space or the
endplate of the vertebra if the annulus is completely disrupted.
• In certain situations, the injected contrast may flow between the layers of
the annulus.

Side Effects and Complications of Discography

• Increased pain
• Headache
• Seizures
• Nausea
• Discitis (2-3% with single needle, 0.7% with double needle)
• Sympathetic block
• Diarrhea
• Urticaria
• Spinal headache
• Meningitis
• Intrathecal hemorrhage
• Arachnoiditis
• Epidural abscess/hematoma
• Trauma to nerve roots or spinal cord or cauda equina
• Allergic reaction to contrast
• Severe reaction to accidental intradural injection
• Damage to the disc
• Discography does not result in herniation of nucleus material or annular
deterioration. Long-term follow-up studies have not demonstrated damage
to normal disks after discography
280 Interventional Pain Management—A Practical Approach

• The incidence of discitis is 2-3% when a single-needle technique is used

and 0.7% when a double-needle technique is used
• The incidence of discitis might decrease to less than 1% when
prophylactic antibiotics are used
• The patient is instructed to ice the injection sites, and to call if they have
any fever or any systemic signs of infection such as rigors, chills or shaking
• Pneumothorax (Upper lumbar, thoracic and lower cervical)
• Hemothorax (Upper lumbar, thoracic and lower cervical)
• Retroperitoneal hematoma (lumbar).

REFERENCES
1. Freemont AJ, Peacock TE, et al. Nerve ingrowth into diseased intervertebral
disc in chronic back pain. Lancet 1997;350:178-81.
2. Derby R, Howard MW, et al. The ability of pressure controlled discography to
predict surgical and non-surgical outcomes. Spine 1999;24-372.
3. Derby R and Lee SH. Discography? Intradiscal electrothermal annuloplasty.
Pain medicine and management. Wallace MS and Staats PS (Eds.), Mc Graw
Hill, New York 2005:350-53.
4. Sachs BL, Vanharanta H, et al. Dallas discogram description: A new classification
of CT discography in low back pain disorders. 1987;12:287-94.
5. Schellhas KP, Garvey TA, et al. Cervical discography: Analysis of provoked
responses at C2-3, C3-4 and C4-5. Am J Neuroradiol 2000;21:269-75.
6. Jarvik J, Deyo R. Diagnostic evaluation of low back pain with emphasis on
imaging. Ann Intern Med 2002;137:586.
7. Guyer RD, Ohnmeiss DD. Contemporary concepts in spine care. Lumbar
discography. Spine 1995;20:2048-59.
 Intradiscal Electrothermal Therapy (IDET) 281

Thirty Three

Intradiscal Electrothermal
Therapy (IDET)
A Sharma

INTRADISCAL ELECTROTHERMAL THERAPY

Intradiscal electrotherapy was developed by Saal and Saal in 2000 as a
treatment for chronic low back pain. Chronic low back pain can be caused by
intervertebral disc derangement (IDD). It has also been postulated that annular
disruption can be the source of back pain. In a normal disc, nociceptive nerve
fibers innervate only the outer third of the disc, but as a result of degenerative
changes and internal disc disruption, the nerves and the blood vessels can
grow into the deeper layers of the annulus and can cause clinically severe
discogenic low back pain.1,2
30 to 50% of cases of low-back pain are due to internal disc disruption
(IDD). 3 Internal disc disruption is a biochemical, biophysical, and
morphological disruption of the nucleus pulposus and annulus fibrosis of
the disc, which is categorized by radial or circumferential fissures extending
from the nucleus pulposus to the outer third of the annulus. The presence of
fissures or tears within the annulus can cause chronic inflammatory and
mechanical stress on the intervertebral disc, which can result in nerve growth
and new vascularization causing sensitization and pain.
Discogenic back pain can be treated with conservative treatment including
activity modification, pain medications, anti-inflammatory, physical therapy,
steroid injections, chiropractic care, acupuncture, and other modalities.
Surgical fusion is also an accepted treatment for discogenic low back pain
which has not responded to conservative treatment. There has been
significant variation in the outcome following surgical fusion, which is also
associated with surgical risks including infection, adjacent segmental
instability, as well as pseudoarthrosis.
IDET is a minimal invasive technique used to treat highly selective patients
with chronic low back pain as a result of internal disc disruption or annular
tear. It is currently approved only for use in the lumbar spine.
Internal disc disruption is diagnosed based on discography where there
is reproduction of back pain, which is concordant at low pressures less than
50 PSI. The pain intensity should be greater than 6/10 on a visual analog
scale and the CT scan after discography shows grade 3 or greater annular
282 Interventional Pain Management—A Practical Approach

tear, which extends to the outer third of the annulus and controlled disc
stimulation at adjacent level, is normal without any pain.
The possible mechanism of action of intradiscal IDET is still debatable,
and the most likely causes are alteration in spinal segment mechanics via
collagen modification, thermal nociceptive fiber destruction in the annulus,
biochemical mediation of inflammation, and decrease in vascular ingrowth
as well as possible healing of the annular tear.4
IDET uses radiofrequency energy, which is converted to thermal energy.
Initially, the technique was used by Sluijter for radiofrequency lesioning of
the nociceptive fibers on the disc annulus where the radiofrequency heat
was delivered to the annulus through a needle.5 The technique produced
relatively small lesion because of the needle. Subsequent to that, Hayashi
showed contraction of collagen fibers when exposed to temperature greater
than 65 degrees Centigrade during surgery of the shoulder joint capsules
using radiofrequency heat energy.
IDET uses a thermal resistive catheter placed intradiscally at the side of
the radial or circumferential annular tear where radiofrequency energy is
delivered to the posterior or posterolateral annulus, which gets converted
into heat and causes thermal lesioning of the disc annulus. Temperatures
above 55 degrees Centigrade result in shrinkage of collagen fibers. Heat
labile hydrogen bonds can form triple helix of the collagen molecules to
unwind and transition into a less organized, random, and contracted state.
Subsequent to thermal treatment, fibroblast activity increases and new, more
stable stiffer collagen is formed and the nerve endings are destroyed.6- 8

INDICATIONS
This procedure is indicated for patient’s suffering with chronic low-back
pain for more than three months, who have had adequate conservative and
non-operative treatment with no improvement. They have no neurological
deficits and have normal neurological exams with normal straight leg raising
test, MRI reveals intact disc height or at least 80% of disc height maintenance
with no significant herniation, might show annular tears or degenerative
changes. There is no evidence of spondylolisthesis or segmental instability.
Also, psychological factors and serious medical conditions are evaluated.
Subsequent to that, the patient undergoes diagnostic provocative discography
and satisfies the criteria for internal disc disruption.

TECHNIQUE (FIGS 33.1 TO 33.9 )

IDET procedure is performed similar to a standard discography approach to
the disc, which is posterolateral. Informed consent is obtained from the
patient. The procedure is explained in detail including the physical limi-
tations as well as explanation that pain relief might not be obtained for three
to six months. Subsequent to that, prophylactic antibiotics are given.
Cephazolin 1g is given intravenously. If allergic to penicillin, clindamycin
600 mg I.V. is given. Antibiotics are given 30 minutes prior to the procedure.
 Intradiscal Electrothermal Therapy (IDET) 283

The procedure is performed in a sterile environment with very mild

sedation. Most of the patients require only 1 to 2 mg of midazolam and 100
mcg of fentanyl. Occasionally, the patient might also need propofol. It is
important to keep the patient awake during the insertion of the introducer
needle as well as during the heating procedure to look for any radicular
pain. The procedure is performed under fluoroscopy guidance on a
radiolucent table.
The patient is placed in a prone position with one to two pillows under
the stomach to obliterate the lumbar lordosis and it also makes it easier to
access the L5-S1 disc. A lap sheet with Ioban is used for draping. Subsequent
to that, under fluoroscopy guidance, an appropriate level is identified. Under
AP fluoroscopy guidance, the endplates are lined up and then an oblique
fluoroscopy view is obtained to place the superior articular process roughly
into the center of the disc space. Entering from the opposite side of the patient’s
pain or from the opposite side of the annular tear is suggested. For example,
if the annular tear is on the left side, enter the disc from the right side. A skin
mark is placed just lateral to the superior articular process and is infiltrated
with 1% lidocaine. A spinal needle is used to infiltrate the local anesthetic
up to the superior articular process. It is very important not to use too much
local anesthetic in the deep tissue plane so as to avoid infiltrating the nerve
root. A 17 Gz 6 inch long introducer needle is then introduced through the
skin. A small incision is made with a #11 blade to make the entry of the
needle easier. The needle is entered under fluoroscopy guidance. The tip of
the needle is kept in the medial direction towards the superior articular
process. The needle should be curved slightly for access to the L5-S1 disc if
there is a high iliac crest. Once the SAP process is passed, advance the needle
very slowly making sure the nerve root is not irritated. It is important to keep
the patient awake at this point. Once the nerve root is passed, the annulus is
entered and the canula is placed into the posterior central aspect of the
corresponding disc. AP and lateral views are obtained. The trocar is removed
and the IDET catheter is introduced. The catheter is then slowly advanced
under lateral fluoroscopy view as it starts to come around the posterior
annulus. The catheter should not enter the spinal canal through an annulus
tear. Once the catheter has successfully navigated the posterolateral aspect
of the annulus, the view is changed to AP view and then the catheter is
advanced from one pedicle to the other pedicle. Sometimes resistance is
encountered because of the catheter tip lodging into the annular tear. At this
point, watch for kinking of the catheter even with slight resistance. If kinking
is noted, the catheter is withdrawn, redirected, and again attempt to navigate
through the posterior annulus. If after a few attempts you are still unable to
do so, then move the introducer needle in a more central or more posterior
location and then re-introduce the catheter. On occasion it is possible not to
be able to cover the whole posterior annulus. In that case, the technique can
be performed from both sides with another needle introduced from the
284 Interventional Pain Management—A Practical Approach

opposite side and catheter navigated to the opposite posterior annulus. Again,
it is important not to use too much pressure while navigating the catheter as
kinking can occur. If there is a kink in the catheter, then a new catheter has to
be used.
After appropriate position of the catheter, final AP and lateral fluoroscopy
views are obtained to confirm the placement of the catheter. Following that,
a P90 protocol developed by Saal and Saal is used, which involves heating
the catheter up to a total of 16.5 minutes with a maximum temperature of 90
degrees centigrade. There are also other protocols available. Sometimes the
patients are not able to tolerate this maximum temperature because of
significant back pain, which starts as the catheter starts to heat up to 85
degrees Centigrade. During the process of heating, the patient is asked to let
us know if they start to notice any pain going down their legs. Back pain is
common during the heating part as the pain radiates into the buttocks and
thighs.
Once the heating is done, the catheter is removed slowly making sure
there is no resistance. If there is resistance, than the catheter and needle are
removed together. The catheter is removed and verified that the tip of the
catheter is intact. Subsequent to that, 0.75% marcaine mixed with 3 mg of
clindamycin 1.5 mL is used for the disc as a prophylactic intradiscal antibiotic
to prevent discitis. The needle is subsequently removed. A bandage is usually
applied and then the patient is taken to the recovery room.

Fig. 33.1: This is an oblique fluoroscopy view of the patient undergoing an L5-S1 IDET
procedure. The patient is placed in prone position with two pillows under the stomach in
order to move the iliac crest away. Approach to L5-S1 disc is identified in this patient, which
is a triangle, formed by the superior articular process of S1, the iliac crest, and the L5
vertebral body on the top. L5-S1 disc is usually the most difficult disc to approach through
the posterolateral approach for any percutaneous procedures especially in males because
of high iliac crest
 Intradiscal Electrothermal Therapy (IDET) 285

Fig. 33.2: This is an oblique fluoroscopy view. A needle is introduced and bony contact is
made with the lateral aspect of the superior articular process to note the depth of insertion
as well as to keep the needle as close to the superior articular process so as to avoid
injuring the nerve root. Note that this procedure is being performed under end-on view

Fig. 33.3: The needle is slightly withdrawn and re-directed just lateral to the superior
articular process. At this point, it is important to ask the patient if they notice any pain down
the leg as the needle is advanced further. The resistance of the annulus is usually felt as the
tip goes through the annulus and then the resistance goes away
286 Interventional Pain Management—A Practical Approach

Fig. 33.4: AP fluoroscopy view. The needle tip is beyond the annulus into the nucleus, end-
plates are lined up so as to make sure the needle is placed in the center of the disc space

Fig. 33.5: Lateral fluoroscopy view, again noting

the needle to be in the center of the disc space
 Intradiscal Electrothermal Therapy (IDET) 287

Fig. 33.6: IDET catheter is advanced under lateral fluoroscopy view. The two proximal and
distal markers can be seen. The catheter is advanced and has started to curve back after
contacting the inner annulus

Fig. 33.7: AP fluoroscopy of IDET catheter is advanced further and can be seen wrapping
around the posterior annulus. Both proximal and distal markers are out of the needle. At this
point, the distal marker needs to be advanced slightly more so as to cover most of the
posterior annulus
288 Interventional Pain Management—A Practical Approach

Fig. 33.8: The catheter is advanced further and both proximal and distal markers are lying
along the posterior annulus from pedicle to pedicle. The distal marker is being shadowed
by the introducer needle

Fig. 33.9: Lateral view to confirm the catheter is not in the spinal canal
 Intradiscal Electrothermal Therapy (IDET) 289

POST-OPERATIVE INSTRUCTIONS
The patient is to wear a brace for six weeks after the IDET procedure. An LSO
lumbar brace is usually prescribed. The patient is instructed to limit their
sitting from 30 to 40 minutes at a time for the first four weeks. They can
perform sedentary activity one to three weeks after the procedure, but are to
avoid excessive sitting. The patient can drive after the first few days, but the
patient should limit driving time to 30 minutes. The patient is instructed not
to lift more than 10 pounds for the first four weeks. They can walk 20 minutes
daily and advance to 20 minutes twice daily after two weeks.
The patient is usually seen in our office two weeks after the procedure.
Subsequent to that, their activity is increased slightly. At 6 to 8 weeks, they
are sent for physical therapy, and resume daily activity with attention to
back care and subsequent strengthening program.

COMPLICATIONS
Complications from this procedure can be related to the needle - injury of the
nerve root, possibility of infection or discitis, and catheter tip breakage or
dislodgement. Postoperatively, the patient can develop herniation if physical
activity is not limited because of weakness of collagen fibers.11
There have also been cases reported of spinal cord injury and nerve root
injury secondary to catheter misplacement, which was not diagnosed prior
to the heating process.9,10

STUDIES RELATED TO IDET

In 1998, Saal and Saal presented 25 IDET patients. These patients underwent
six months of conservative treatment followed by discography. The patients
reported functional improvement and reduction of pain medicine. The initial
study was not successful as it lacked control. Also, the researchers were the
inventors of the IDET.
Saal and Saal published two-year follow-up data of 62 IDET patients.12
Out of 62, 4 patients did not follow up in one year. The patients had the same
inclusion and exclusion criteria. They were also excluded if they had any
prior back surgery. At 24 months, the reported mean visual analog scale was
3.4 as compared to 6.5 pre-procedurally, 50% of the patients experienced a 4-
point reduction in the visual analog scale and 71% patients experienced a 2-
point reduction in the visual analog scale. They also showed improvement
in quality of life. They did not report any complication in their study. This
study was criticized for lack of randomization and lacks of control group as
well as the investigators were the developers of this technology.
Bogduk and Karasek published a two-year follow-up study on IDET
patients with chronic low-back pain.13 Visual analog scale for pain, work
status, and opioid use were used as outcome measures at three months. At
three months, the pre-treatment median visual analog scale dropped from
8.0 to 3.4. At 24 months, 50% of IDET patient group had at least 50% relief of
290 Interventional Pain Management—A Practical Approach

pain and 20% were completely pain free. The authors also concluded that
the results are related to the catheter placement as close as possible to the
annular tear and the fissures.
Lee et al. conducted a prospective non-randomized study in 62 patients
with chronic low-back pain.14 They also included patients who had prior
discectomy. There was a statistical significant improvement in low-back
pain. The study also was non-randomized and had no placebo control.
Pauza performed a randomized placebo control IDET study.15 Un-
compensated volunteers were selected. A total of 264 people were eligible.
Patients were excluded from the study if they had any prior spine surgery,
radicular pain, herniated disc, spinal stenosis, scoliosis, or narcotic usage
greater than 100 mg of morphine. Also, the patients were excluded if they
had workman compensation issues or personal injuries. A total of 64 patients
were candidate for randomization. These patients underwent psychological
testing, discography, and clinical examination.
The patients were randomized for IDET procedure or sham procedure.
All the patients had the introducer needle introduced into the annulus.
Randomized decision took place at the time of insertion of the introducer
needle. The IDET group underwent standard heating of the IDET probe to
90 degree Centigrade. The sham group experienced the same visual and
auditory environment as the treatment group. Following that, both groups
were subjected to graded physical rehabilitation and follow-up was
maintained for 12 months. Results showed 40% of patients treated with
IDET experienced 50% or more pain relief, but 50% of patients experienced
no notable improvement, 6% of patients showed worsening of pain, and
21% of patients showed greater than 80% reduction of pain.

SUMMARY
In general, IDET is a minimal invasive technique that shows significant
promise for treatment of low-back pain coming from internal disc disruption
or discogenic etiology, after receiving failed conservative treatments. It is a
procedure which carries minimal risk if performed appropriately and
suggests that half of the patients will notice significant improvement of back
pain. The results are not as encouraging as they were with the initial studies,
but this procedure is suggested to be performed on carefully selected patients
who have primarily back pain and have undergone testing including
discography and have not lost more than 80% of the disc height.

REFERENCES
1. Freemont A, Peacock T, Goupille P, et al. Nerve in-growth into diseased
intervertebral disc in chronic low back pain. Lancer 1997;350:178-181.
2. Coppes M, Marani E, Thomeer R, Groen G. Innervation of painful discs. Spine
1997;22:2342-9.
3. Karasek M, Bogduk N. Intradiscal electrothermal annuloplasty: Percutaneous
treatment of chronic discogenic low back pain. Tech Reg Anesth Pain Manage
2001;5:130-35.
 Intradiscal Electrothermal Therapy (IDET) 291

4. Saal JA, Saal JS. Intradiscal electrothermal therapy for the treatment of chronic
discogenic low back pain. Clin Sports Med 2002;21:167-87.
5. Sluijter ME. The use of radiofrequency lesions for pain relief in failed back
patients. Int Disability Studies 1988;10:37-43.
6. Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic
low back pain: Prospective outcome study with a minimum 2-year follow-up.
Spine 2000;27:966-74.
7. Heary R. Intradiscal electrothermal annuloplasty: The IDET procedure. J Spinal
Disord 2001;14:353-60.
8. Narvani A, Tsiridis E, Wilson L. High intensity zone, intradiscal electrothermal
therapy, and magnetic resonance imaging. J Spinal Disord Techniques 2003;16:
130-36.
9. Hsia A, Isaac K, Katz J. Cauda equina syndrome from intradiscal electrothermal
therapy. Neurology 2002;55:320-28.
10. Djurasovic M, Glassman S, Dimar J, Johnson J. Vertebral osteonecrosis
associated with the use of intradiscal electrothermal therapy: A case report.
Spine 2002;27:325-8.
11. Cohen S, Larkin T, Polly D. A giant herniated disc following intradiscal
electrothermal therapy. J Spinal Disord Techniques 2002;15:537-41.
12. Saal JA, Saal JS. Thermal characteristics of lumbar discs: Evaluation of a novel
approach to targeted intradiscal thermal therapy. Presented at the 13th Annual
Meeting of the North American Spine Society, San Francisco, CA 1998;23-8.
13. Bogduk N, Karasek M. Two year follow up of a controlled trial of intradiscal
electrothermal anuloplasty for chronic low back pain resulting from internal
disc disruption. Spine 2002;2:343-50.
14. Lee M, Cooper G, Lutz C, Hong H. Intradiscal electrothermal therapy (IDET)
for treatment of chronic lumbar discogenic pain: A minimum 2-year clinical
outcome study. Pain Physician 2003;6:443-8.
15. Pauza K, Howell S, Dreyfuss P, et al. A randomized placebo-controlled trial of
intradiscal electrothermal therapy (IDET) for the treatment of discogenic low
back pain. Spine 2004;4:27-35.
292 Interventional Pain Management—A Practical Approach

Thirty Four

Percutaneous Lumbar
Discectomy
Sudhir Diwan, Dana Tarcatu

INTRODUCTION
It is estimated that 70 to 90% of all persons will experience low-back pain at
some time in their lives. 80 to 90% will recover within about three months
with physical therapy, medications, exercise and rest. However, some of
these patients will go on to have chronic low-back pain.
Recently, a number of techniques have been developed that are
applicable to the treatment of lumbar disc herniation and discogenic pain
due to degenerative disc disease.
Pain generated by internal disc derangement is a relatively new concept.
Several studies have demonstrated the presence of sensory nerve fibers in
the annulus fibrosus of the disc and ingrowth of new nerves into degene-
rated discs in patients with chronic back pain.
These techniques have been designed either to shrink or remove disc
material believed to be causing lumbar pain and/or radiculopathy. Studies
have shown that by reducing the volume of disc, there is significant
reduction in the intradiscal pressure that subsequently relieves the pressure
over nerve roots. The most commonly examined and applied percutaneous
techniques include arthroscopic microdiscectomy,1 automated percutaneous
lumbar discectomy, 2 percutaneous laser disc decompression3-13 and
chymopapain,14,15 as well as other procedures.

General Criteria for Patient Selection

Persistent low-back pain for at least 6 months.
Patients have failed at least 3 months of aggressive non-operative therapy
such as:
• Medications (NSAIDs, non-narcotic analgesics, narcotic analgesics,
neural stabilizing medications)
• Injection therapy such as epidural steroid and facet injections
• Physical therapy.
 Percutaneous Lumbar Discectomy 293

Imaging in the Past Six Months Demonstrating

• At least 40 to 50% of the disc height preserved
• Annular tears
• No significant compressive lesion
• No significant central canal, neural foraminal, or lateral recess stenosis
at the involved level
• Contained disc herniations.

Other Selection Criteria

• Concordant pain during provocative discography involving 1 or more
discs
• Motivated patient with realistic expectations.

Contraindications
• Coagulopathy
• Severe radicular symptoms requiring surgery
• Previous disc surgery at the suspected level (relative contraindication)
• Imaging studies suggestive of nondiscogenic pathology
• Physiologic impairment that might interfere with post-procedure
rehabilitation instructions
• Inflammatory arthritis
• Pregnancy
• Infection (systemic or local)
• Medical comorbidity that may affect appropriate follow up.

General Guidelines
Most procedures are performed in an operating room suite with the patient
placed in a prone position on a standard operating table with bolster support
(Fig. 34.1). This allows the use of fluoroscopy in which there is little
radiographic obstruction. Local anesthesia is used in most of the cases. The
C-arm fluoroscop is used to obtain anteroposterior, oblique (“needle eye
view”), and lateral images (Fig. 34.2). Under strict sterile condition and
fluoroscopic guidance, the appropriate disc level is localized. The so-called
“Scotty dog” view is achieved by oblique fluoroscopic view.

Fig. 34.1: Diagram illustrating patient positioning for percutaneous discectomy

294 Interventional Pain Management—A Practical Approach

Fig. 34.2: Photograph demonstrating C-arm fluoroscopic use and operating room setup

Nucleoplasty
One of the commonly performed percutaneous procedure in the treatment of
both discogenic low-back pain and radiculopathy secondary to contained
disc herniation or disc bulge is nucleoplasty. It is a newer minimally invasive
procedure that involves the percutaneous removal of disc material by using
a co-ablation technique.

Specific Indications for Nucleoplasty Include

The indications for nucleoplasty include:
• MRI documented contained disc herniation or bulge
• Failed conservative treatment for more than 6 weeks
• Positive provocative discogram.

Contraindications
Complete disc space collapse leading to inaccessibility of the intervertebral
space.
• Active disc space infection
• Medical conditions that would preclude its safe performance.
• Coagulopathy
• Spinal stenosis.

Equipments
• Perc-D wand (ArthroCare)
• ArthroCare power generator
• 17-gauge Crawford needle
• C-arm fluoroscope
• Fully equipped procedure room (operating room).

Procedure
Nucleoplasty involves the percutaneous insertion of a cannula positioned
in the disc space. It is critical to have the best and safest approach to that
 Percutaneous Lumbar Discectomy 295

area. Therefore, we usually use the anatomical triangular working zone

described by Kambin, Parke, and O’Neill, et al. as landmark (Fig. 34.3).
This “working triangle” avoids the exiting nerve root. The cannula is
inserted on the same side as the patient’s pain, i.e. the side ipsilateral to the
disc herniation. The 17-gauge Crawford needle is used to access the disc and
the Perc-D wand passes through the needle and appropriately placed in the
center of the disc and midway between superior and inferior endplates. The
wand is connected to ArthroCare power generator. Through the wand, the
power and voltage are alternated to 125 V for ablation and 65 V for coagulation
(Fig. 34.4 upper and lower). Approximately series of 6 channels are created
within the disc to remove about 1 cc volume of nucleus pulposus. The
procedure is performed under monitored anesthesia care in about 25 to 30
minutes.
The catheter has a low-temperature resister at its tip. The resister generates
a plasma field that disintegrates disc material into its hydrogen and oxygen
constituents. The gases escape through the needle (Fig. 34.5). A localized
area of increased temperature may result in the ablation of adjacent residual
disc material. The tissue ablation and thermal treatment create a series of
channels within the disc, reducing the pressure from the contained disc
herniation or the nerve root and other pain generating structures.

Fig. 34.3: Diagrams demonstrating the working triangles and safety zone
for catheter placement
296 Interventional Pain Management—A Practical Approach

Fig. 34.4: Upper: Nucleoplasty cannula in the disc space. Lower: Anteroposterior fluoroscopic
image demonstrating placement of the nucleoplasty cannula in the disc space

Fig. 34.5: Channeling during the nucleoplasty treatment

 Percutaneous Lumbar Discectomy 297

Dekompressor Discectomy
The Dekompressor probe (Fig. 34.6) manufacture by Stryker is disposable
equipment intended for percutaneous discectomy. It is used to aspirate the
disc material. Other than the probe, the placement of the introducer cannula,
indications, contraindications are exactly the same as in nucleoplasty. The
added advantage in this procedure is to visually appreciate aspirated disc
material in the probe that can be sent for histological examination and for
patient satisfaction.

Fig. 34.6: Schematic presentation of dekompressor probe by stryker

Post-procedure Care
This is an ambulatory procedure that does not require any specialized care.
Patient should rest for 2 to 3 days with limited ambulation, no strenuous
work or bending. Lifting of 10 to 15 lbs only for 2 weeks. Physical therapy is
indicated for at least 5 weeks. There is no need to wear a brace.

Outcome Results
Updated literature review supports that with increasing technical skills and
improved equipment, nucleoplasty yields very positive results for relief of
low-back pain and radiculopathy. Best results have been demonstrated in
patients with diffuse disc protrusion and radicular pain, in whom good
relief of radicular pain occurs almost immediately after the procedure.

Percutaneous Hydrodiscectomy
This is a newer technique in advancement of minimally invasive discectomy
that involves fluid jet technology. The spinejet hydrodiscectomy system
includes a microresector and access cannula set that uses power of water to
cut the tissues and aspirate part of nucleus pulposus simultaneously. The
fluid jet technology uses a high velocity stream of water to cleanly remove
tissue. Anecdotal reports suggest that this technique may have a role in
treating discogenic pain in selected group of patients. However, the benefits
298 Interventional Pain Management—A Practical Approach

and risks of the procedure need to be evaluated by randomized trials to

validate the effectiveness of the procedure.

Percutaneous Laser Disc Decompression (PLDD)

Choy and Diwan have done initial clinical research targeting YAG laser to
reduce disc volume by vaporizing the disc. The laser was delivered in the
center of the disc by an optical fiber through a 17-gauge introducer cannula.
In vitro and in vivo studies have demonstrated sharp decrease in intradiscal
pressure by decreasing the volume of the disc and subsequently taking
pressure off of the compressed nerve root. However, this procedure did
not achieve popularity due to expensive equipment and postoperative back
spasms due to heat dispersion in the entire disc. Due to high potential for
severe endplate and nerve root injury secondary to inability to control the
heat dispersion, quest for least expensive, safer and minimal invasive
technique continued.

Chemonucleolysis
Chemonucleolysis was the first technique used to percutaneously decom-
press the disc. In this approach, chymopapain, a proteolytic enzyme derived
from latex of the papaya plant, is used to degrade a portion of the nucleus
pulposus at the center of the disc. The use of chymopapain has virtually
ceased in the United States due to several early instances of fatal anaphylactic
reaction and acute transverse myelitis associated with its use. Though the
chymopapain product is no longer marketed in the United States,
chemonucleolysis continues to be popular, especially in Europe, due to its
proven success rate and much improved management of allergic reaction
when allergic pretesting is performed.

Nucleotome
Nucleotome was introduced in 1985. This automated shaver device mecha-
nically withdraws nucleus pulposus from the disc in a procedure called
“automated percutaneous lumbar discectomy” or APLD. The single use
disposable APLD device is comprised of a reciprocating blade action, which
draws disc tissue through a side-mounted port where it is subsequently
aspirated from the disc. The device uses a 2.8 mm diameter cannula for disc
access and does not require the use of an external controller. Again, this
procedure did not become popular due to high cost and cumbersome nature
of the equipment.

Summary
Internal disc disruption and contained disc herniations are common causes
of low-back and/or lower extremity pain, which may become chronic if not
diagnosed in a timely manner. Percutaneous disc decompression has been
shown to be effective in relieving pain due to symptomatic contained disc
 Percutaneous Lumbar Discectomy 299

herniation. Consideration of various complications and proper patient

selection improve the chances of procedure success. Reherniation, insta-
bility, and potential for accelerated degeneration may be associated with
percutaneous disc decompression procedures.
Despite the fact that percutaneuos lumbar discectomy has been around
for almost 20 years, scientific proof of its efficacy still remains relatively poor.
Well-designed research of sufficient scientific strength, comparing these
techniques to both conventional surgery and conservative management of
lumbar disk herniation is needed to determine whether percutaneous
discectomy deserves a prominent place in the treatment arsenal for lumbar
disk herniation.

REFERENCES
1. Yeung A. The evolution of percutaneous spinal endoscopy and discectomy:
State of the art. The Mount Sinai Journal of Medicine 2000;67:327-32.
2. Onik G, et al. Automated percutaneous discectomy. Neurosurgery 1990;26:
228-32.
3. Choy DS, Diwan S. In vitro and in vivo fall of intradiscal pressure with laser
disc decompression. J Clin Laser Med Surg 1992;10(6):435-7.
4. Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Physician
2006;9:139-46.
5. Benz R, Garfin Steven. Current techniques of decompression of the lumbar
spine. Clinical orthopaedics and related research 2001;384:75-81.
6. Singh K, Ledet E, et al. Intradiscal therapy: A review of current treatment
modalities. Spine 2005; 30: s20-s26.
7. Sharps L, Isaac Z. Percutaneous disc decompression using nucleoplasty. Pain
Physician 2002; 5:121-6.
8. Singh V, Pyrani C, at al. Percutaneous disc decompression using ablation
(Nucleoplasty™) in the treatment of chronic discogenic pain. Pain Physician
2002; 5:250-59.
9. Pomerantz S, Hirsch J. Intradiscal therapies for discogenic pain. Semin
Musculoskeletal Radiol 2006;10:2;125-36.
10. Fenton D, Czervionke L. Image-guided spine intervention 2003;10:257-83.
11. Welch W, Gerszten P Neurosurg Focus 2002;13(2).
12. McGraw K, Silber J. Intradiscal electrothermal therapy for the treatment of
discogenic back pain. Applied Radiology 2001;30(7):11-6.
13. Choy DS, Diwan S, et al. Percutaneous laser disc decompression: A new
therapeutic modality. Spine 1992; 17(8) 949-56.
14. Nordby EJ, Javid MJ. Continuing experience with chemonucleolysis. Mt Sinai
J Med 2000; 67(4): 311-3.
15. Brown MD. Update on chemonucleolysis. Spine 1996; 21(24 Suppl): 62S-8S.
300 Interventional Pain Management—A Practical Approach

Thirty Five

Vertebroplasty

Samir Dalvie

INTRODUCTION
Percutaneous vertebroplasty was introduced in France in 1987 by Deramond1
and Gailibert2 for treating vertebral hemangioma. It is a simple, minimally
invasive procedure for treating painful collapsed vertebrae. This procedure
took some time to be established in mainstream medical practice, and was
primarily used for tumor therapy in Europe for lesions such as multiple
myeloma, lymphoma, metastatic disease and symptomatic benign tumors of
the spine.3 In North America, the first training course was held in 1998, and
the primary use was for osteoporotic compressions fractures.4,5
Kyphoplasty6,7 is a variation in the technique, where an inflatable balloon
tamps is used to achieve partial fracture reduction and correction of kyphosis
before cement injection.

Indications
In principle it is used for the treatment of painful vertebrae due to ostolysis.
Indications in the clinical setting are as follows:
1. Osteoporotic vertebral compression fractures (VCF) (Fig. 35.1).
More than 60% of post-menopausal women have abnormal bone mineral
density, and 40% of these will sustain a vertebral fracture in their lifetime.
There may be no history of definite trauma in 50%.
Persistently painful fractures are associated with an increase in
morbidity and mortality, with significant limitation of activities of daily
living. Thoracic kyphosis is associated with a decrease in respiratory
function.
Non-operative management consists of bracing, analgesics and
medical management of osteoporosis.
Persistent pain may be associated with significant disability in
activities of daily living, respiratory compromise and inactivity leading
to venous thrombosis, etc. For many patients, a vertebral compression
fracture represents the end of their independent life.
 Vertebroplasty 301

Fig. 35.1: MRI picture of compression fracture

Most vertebral fractures can be treated effectively by percutaneous

vertebroplasty, with pain relief in 80 to 90% patients within 72 hours.
2. Malignant vertebral collapse
Pathological fractures due to malignant infiltration of vertebral bodies
can be a cause of severe pain and disability. This includes metastasis
from spindle cell tumors as well as hematological malignancies such as
myeloma or lymphoma. Conventional treatment for palliation of pain
consists of radiation along with analgesics, braces etc. More resistant
cases may be subjected to major surgical procedures such as spinal
stabilization or corpectomy and reconstruction.
Percutaneous vertebroplasty is an excellent, minimally invasive
alternative with excellent results for pain relief. A filling of the lytic
cavity caused by tumor infiltration is usually associated with excellent
pain relief. Radiation therapy and vertebroplasty are complementary,
and radiation should be performed after vertebroplasty.
3. Vertebral Hemangioma
Symptomatic vertebral hemangiomas can be treated with vertebroplasty,
with or without prior instillation of ethanol. This amounts to cement
embolization of the hemangioma, and produces good result. A trans-
arterial angiogram and embolization is no longer considered necessary.
In cases requiring surgical decompression due to progressive neurological
symptoms, performing a vertebroplasty prior to surgical laminectomy is
associated with reduced bleeding and complications.
302 Interventional Pain Management—A Practical Approach

Contraindications
1. Absence of proper indication.
2. Bleeding disorder.
3. Incompetence of posterior wall.
4. Vertebra plana. (complete collapse of the vertebra).
5. Sensitivity to local anesthetic, ingredients of bone cement.
Relative contraindications include improper set-up, inability to visualize
radiologic anatomy adequately and severe medical disease with too many
levels of involvement.

Mechanism of Action
The effects of vertebroplasty are primarily attributed to mechanical
stabilization. The cement enters into the fracture planes, any cavities and
into the interstices of the osteoporotic bones, and fuses these when the
cement hardens. This would also abolish macro and micro motion on
loading of the vertebrae.
Secondary mechanism could include ablation of the painful nerve en-
dings by chemical and thermal effects of the setting cements.
Hemangiomas are addressed by filling of the venous channels with
cement, thus permanently embolising them.

Procedure
The procedure is performed in an operating room or a fully equipped
radiology suite. Essential equipment includes image intensification, if
possible bi-plane, radiolucent adjustable table and equipment for
monitoring vital parameters. A well trained and co-ordinated team
consisting of technicians, nurses and an anesthetist makes the procedure
simpler.
The procedure may be performed under local anesthesia with sedation
or general anesthesia. Local anesthesia is preferred to restrict the morbidity
of the procedure; however general anesthesia may be required in very
apprehensive and un-cooperative patients or for multilevel procedures. I.V.
access is mandatory, and I.V. antibiotics should be used prophylactically.
The patient is placed prone on the table on pillows or a radio-lucent
mattress. The anatomy is defined with the C-arm. If the anatomic landmarks
are not properly identifies, the procedure should be abandoned. The skin
is prepared and draped in a sterile fashion.

Step 1 The entry point of the pedicle is marked on the skin by using crossed
Kirshner wires, targeting the pedicle (35.2). For convergence of the
needles, the skin entry-point should be slightly laterally placed. The
skin is infiltrated with local anesthesia. Under lateral projection, the
depth is infiltrated up to the periosteum.
 Vertebroplasty 303

Fig. 35.2: Entry point on skin using Krishner wire

A stab knife is used to make a 4 mm incision in the skin. The

procedure is performed with a bone biopsy (Jamshidi) needle, 11-
gauges in the lumbar spine, and 13-gauge for the thoracic pedicles.
Step 2 Under fluoroscopic control, the needle is advanced into the pedicle,
alternating the AP and lateral projections. Gentle hammering may be
required if the bone is hard, else the needle is advanced by gentle
rotation (Fig. 35.3). If the patient feels pain, I.V. sedation may be used
at this point. I.V. midazolam and fentanyl are administered on an ‘as
needed’ basis.
When the tip of the needle reaches the posterior cortex of the
vertebra, the position is checked in the AP projection to make sure
that the tip lies lateral to the medial wall of the pedicle.

Fig. 35.3: Jamshidi needle into pedicle- AP view

304 Interventional Pain Management—A Practical Approach

Step 3 It is then advanced to lie in the anterior third of the body (Fig. 35.4).

Fig. 35.4: Needle advanced deep into the body of vertebra

If bi-pedicular procedure is required, the same is repeated on the
opposite side.
If required, and not contraindicated, non-ionic contrast may be
injected at this point. This has however not been found to add value
to the procedure and is now rarely performed.
Step 4 The cement is now prepared. Low or medium viscosity cement with
added barium is used. The author uses Simplex or CMW3 bone cement.
Barium powder which is previously sterilized is added to the powder.
One teaspoon is added and mixed well. A teaspoon of the mixture is
then removed to keep the amount of powder same. The liquid in then
mixed well. When liquid, it is filled in a 20 cc syringe, which is then
used to fill 1 cc syringes. The air is removed from these syringes. The
consistency is then periodically checked. Ideal consistency must be
similar to toothpaste, if it is too liquid there is a higher risk of leakage.
The stylet is removed, and cement injected slowly, with 0.2 cc
increments under continuous fluoroscopic control (Fig. 35.5).

Fig. 35.5: Injecting the cement in body

 Vertebroplasty 305

It is mandatory to watch closely that the cement is not leaking into the
surrounding tissue or vascular system. The stylet itself is used to gently
push the cement as well as clean the needle. Alternate injections are made
into each pedicle. The end point of injection is when the anterior third is
filled, or if leakage starts.

Fig. 35.6A: Cement in body of vertebrae- AP view

Fig. 35.6B: Cement in body of vertebrae- lateral view

306 Interventional Pain Management—A Practical Approach

Fluoroscopy must be confirmed in both planes (Figs 35.6A and B).

Typically 2 to 6 cc of cement are required for each vertebra. Neurological
monitoring can be carried out in the awake patients, and the patients should
be asked about leg pain, which may be the result of intra-canal leakage.
The needles are left inside till the cement begins hardening, to prevent
back flow of the cement through the needle tracks. After removal of the
needle, the stab incisions may be secured with a suture, and dressed. The
patient should be turned after the cement is fully hardened.

Post-operative Protocol
The patient may turn in bed, and can be made to sit 4 to 6 hours after the
procedure. Analgesics may be required for the soft tissue pain. The patient
can then be mobilized. Medical measures for control of osteoporosis are
continued. The patient is encouraged to remain ambulatory and participate
in activities of daily living.

COMPLICATIONS
Complication rates tend to vary with the underlying bone pathology as
well as the experience of the operator. Published complication rates 1.3%
in osteoporosis, 2.5% in hemangiomas and 10% in metastatic disease.
Cement embolism is the most dreaded complication, and can lead to
morbidity and mortality. The cause is leakage of the liquid cement into the
venous system para-vertebrally or epidurally.
Leakage of cement into the epidural space may cause neurological deficit
related to spinal cord or root compression or radiculopathy. This may be
due to a cortical breach in the posterior wall or filling of epidural veins.
Such a complication may necessitate emergency decompressive surgery.
Delayed cord compression may result from retropulsion of the cement mass,
if there is collapse around the vertebroplasty.
Common complications include complications of positioning, notably
a rib fracture. Uncommonly reported are deep infection, anaphylaxis and
increased pain due to thermal necrosis
Long-term effects of the cement are as yet unknown; however there may
be an increased incidence of adjacent level fractures related to increased
stiffness of the cemented vertebra. Newer substances including hydroxy-
apatite cement are under development to improve the biological acceptance
of the construct.

RESULTS
Relief of back pain is the sole objective of percutaneous vertebroplasty.
Various reports state the success rates as 80 to 90% for significant or complete
reduction of pain from a vertebral fracture.
 Vertebroplasty 307

KYPHOPLASTY
Kyphoplasty is a variation in the technique of vertebroplasty. This involves
introducing a balloon tamp into the vertebral body by a similar
percutaneous route. This is inflated using normal saline under pressure.
Expansion of the balloon causes the fractured endplates to be partially
reduced, thus achieving a partial correction of kyphosis. It also creates a
cavity, with a wall of compacted cancellous bone. The device is then deflated
and removed. Bone cement is then injected into the cavity as with the
vertebroplasty techniques.
Proponents of the kyphoplasty claim that its advantages include a
fracture reduction as well as correction of the kyphosis. The creation of a
cavity allows the cement to be injected at much lower pressures, and at a
higher viscosity, and hence the chances of cement leakages are much lower.
The disadvantages include a high cost of the disposable equipment, and
longer treatment time, which may need a general anesthetic.
The available evidence does not suggest that the kyphoplasty has a clear
advantage, as the pain relief is similar, and correction of kyphosis is not
statistically significant. Cement leakage rates are lower than vertebroplasy,
but the clinical complication rate is similar.

REFERENCES
1. Deramond H, Depriester C, Gailibert P. Percutaneous vertebroplasty with
polymethylmethacrylate. Technique, indications and results. Radiol Clin North
Am 1998; 533-46.
2. Gailibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment
of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie
1987; 33: 166-8.
3. Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for
pain relief and spinal stabilization. Spine 2000;25: 923-8.
4. Voormolen MH, Mali WP, Lohle PN. Percutaneous vertebroplasty compared
with optimal pain medication treatment: Short-term clinical outcome of patients
with sub acute or chronic painful osteoporotic vertebral compression fractures.
The VERTOS study. Am J Neuroradiol 2007;28(3):555-60.
5. Shen M, Kim Y. Osteoporotic vertebral fractures. A review of current surgical
management techniques. Am J Orthop 2007;36(5):241-8.
6. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for
vertebral compression fractures: A comparative systematic review of efficacy
and safety. Spine 2006;31(23):2747-55.
7. De Negri P, Tirri T, Paternoster G, Modano P. Treatment of painful osteoporotic
or traumatic vertebral compression fractures by percutaneous vertebral aug-
mentation procedures: A nonrandomized comparison between vertebroplasty
and kyphoplasty. Clin J Pain 2007; 23(5):425-30.
308 Interventional Pain Management—A Practical Approach

Thirty Six

Ozone and its Applications in

Pain Management
Gautam Das

Since disc prolapse was first diagnosed by Dandy and subsequently by

Mixter and Barr it has been implicated as one of the important cause of low-
back pain radiating to limbs. Apart from conservative therapy all other forms
of treatment aim at decompressing the nerve roots. These can be done by
taking the disc out by surgery or by decompressing the foramen and disc by
different interventions. The various treatment options have confused
clinicians due to significant failure rate associated with different kinds of
surgeries as well as with different interventions.
Outcome studies of lumbar disc surgeries document a success rate between
49 to 95% and re-operation after lumbar disc surgeries ranging from 4 to
15%. Reasons for this failure are: (1) dural fibrosis, (2) arachnoidal adhesions,
(3) muscle and fascial fibrosis (4) mechanical instability resulting from the
partial removal of bony and ligamentous structures required for surgical
exposure and decompression (5) presence of neuropathy. There has been
surge of interest in search of safer alternative method of decompressing the
nerve roots maintaining the structural stability. Epidural steroid injection,
transformational epidural procedures has a high success rate (up to 85%)
but chances of recurrences are there specially if these interventions are done
at later stage. Chemonucleolysis using chymopapain has also high success
rate (approximately 80%) with low recurrences but not popular owing to the
chances of anaphylaxis following intradiscal chymopapain injection.
Injection of ozone for discogenic radiculopathy (low-back pain with radiation
to legs) has developed as an alternative to chemonucleolysis and disc surgery
owing to its high success rate, less invasiveness, fewer chances of recurrences
and remarkably fewer side effects.
Muto2-7 suggested intradiscal injection of ozone for disc hernia in 1998
under CT guidance. Leonardi popularized fluoroscopy guided ozone
injection into the intervertebral disc. After that, successful outcome has
been reported from various European centers. It is very important to note
from those reports that complications are remarkably few. Not a single
serious life-threatening complication was found even after 30,000 cases of
ozone nucleolysis, which stresses the safety of these procedures.
 Ozone and its Applications in Pain Management 309

How ozone acts? The action of ozone is due to the active oxygen atom
liberated from breaking down of ozone molecule. When ozone is injected
into the disc the active oxygen atom called the singlet oxygen or the free
radical attaches with the proteo-glycan bridges in the jelly-like material or
nucleus pulposus. They are broken down and they no longer capable of
holding water. As a result disc shrinks and mummified and there is
decompression of nerve roots. It is almost equivalent to surgical discectomy
and so the procedure is called ozone discectomy or ozone ucleolysis. Besides,
it has an anti-inflammatory action due to inhibitions of formation of
inflammation producing substances; tissue oxygenation is increased due
to increased 2, 3 diphosphoglycerate level in the red blood cells. All these
leads to decompression of nerve roots, decreased inflammation of nerve
roots, and increased oxygenation to the diseased tissue for repair work.

Indications
Ozone nucleolysis may be done in most kinds of disc related pain.
1. It can be done in degenerated disc without any prolapse and nerve root
irritation. This category is called discogenic back pain. Dull ache in the
low-back increasing with flexion of spine is the main clinical feature.
Provocative discogram should be performed for this group.
2. It can be done in contained disc prolapse or disc bulge with root
irritation.
3. It may be done in non-contained disc (extruded or sequestrated disc) as
well.

Procedure
The patient is taken to the operation theater lying on prone position with a
pillow under lower abdomen. The area is prepared and draped in sterile
manner. It is done usually under local anesthesia with intravenous sedation
(midazolam and fentanyl). Intravenous antibiotic like ceftriaxone 1G should
be given prior to procedure. The procedure should be done under C-arm
guidance. Though may be done under CT guidance.

Step 1 C-arm first should be focused to a pure anterior-posterior view to

view the diseased disc. Then C-arm is cranially/caudally to abolish
any double endplates and thereby getting widest possible view of
disc space. Then C-arm is rotated obliquely away from vertebral
column such that facet joint come at the center of the endplates (Fig.
36.1).
Now the needle entry point is just lateral to the superior pars/
articular pillar exactly at the center of the disc (Fig. 36.1).

Step 2 20 or 22 G needle is introduced into the diseased disc using tunnel

vision (end on view, so that needle is seen almost as a single point)
under fluoroscopic guidance (Fig. 36.2).
310 Interventional Pain Management—A Practical Approach

Fig. 36.1: Needle entry point just lateral to superior articular process

Fig. 36.2: Tunnel vision in lateral view

Step 3 The position of needle tip may be confirmed by complete AP and

lateral view (Figs 36.3 and 36.4).

Fig. 36.3: Needle position in lateral view–Tip of needle at center of disc

 Ozone and its Applications in Pain Management 311

Fig. 36.4: Needle tip in AP view- Tip of needle in center of disc

Step 4 Some small amount of radiopaque dye (omnipaque) may be injected

for discogram which is optional (Figs 36.5A, B and 36.6).

Fig. 36.5A: Discogram in AP view

Fig. 36.5B: Discogram in AP view

312 Interventional Pain Management—A Practical Approach

Fig. 36.6: Discogram in lateral view

Step 5 Then some 3 to 10 cc of oxygen-ozone mixture (at a concentration of

29-40 microgram/ml) is injected into the disc. Ozone at this
concentration is not all harmful for the surrounded tissue. So if ozone
spreads to the surrounded tissues including spinal cord, there is no
harm. Ozone molecule is not stable. It has a half-life of 20 minutes
only. So, within 20 minutes only half of the original ozone remains,
the rest becomes oxygen. Increase in temperature decreases its half-
life. For injection it is always freshly prepared on site (from an ozone
generator) for immediate administration. Only ozone resistant syringes
can be used for injecting it. While needle with the syringe is taken out
some amount of oxygen-ozone mixture is also injected into the para-
spinal muscle and para-radicular soft tissue to reduce nerve root
inflammation and increased oxygenation of the para-spinal muscles.

Contraindications
There are few conditions when this procedure should not be performed.
These are: active bleeding from any site, pregnancy, G6PD deficiency, active
hyperthyroidism, loss of control of urination and defecation, and progressive
sensory and motor loss.

Complications
Complications are very rare. They include post-procedural muscle spasm
and burning pain (these are transient) and discitis (very rare due to the
bactericidal effect of ozone). Other complications are similar to discographic
procedure.
Ozone nucleolysis or ozone discectomy has a success rate of about 80%.
On the other hand surgical discectomy has much higher side effects compared
to remarkably few side effects of ozone discectomy. Ozone discectomy is
usually a day care procedure and general anesthesia is not usually required.
It is gaining popularity in different countries including India due to low
 Ozone and its Applications in Pain Management 313

cost, less hospital stay, fewer post-procedural discomforts and morbidity

and very few side effects.

REFERENCES
1. D’Erme M, Scarchilli, Artale AM, et al. Ozone therapy in lumbar sciatic pain.
Radiol Med 1998;95(1-2):21-4.
2. Muto M, Adreula C, Leonardi M. Treatment of herniated disc by oxygen-
ozone injection. J Neuroradiol 2004;31:183-9.
3. Muto M, Avella. Percutaneous treatment of herniated lumbar disc by intradiscal
oxygen-ozone injection. Interventional Neuroradiology 1998;4:273-86.
4. Vijay S Kumar. Total clinical and radiological resolution of acute, massive
lumber disc prolapse by ozone nucleolysis. Rivista Italiana di Ossigeno-
ozonoterapia 2005;4.
5. Nordby EJ, Fraser RD, David MJ. Chemonucleolysis. Spine 1996;21:1102-5.
6. Andreula CF, Simonetti L, De Santis, F et al. Minimally invasive oxygen ozone
therapy for lumber disc herniation. Am J Neuroradio 2003;24:996-1000.
7. Torri G, Della GA, Casadei C. Clinical experience in the treatment of lumbar
disc disease, with a cycle of lumbar muscle injection of an oxygen + ozone
mixture. Int J Med Biol Env 1999;27:177-83.
314 Interventional Pain Management—A Practical Approach

Thirty Seven

Radiofrequency Coagulation

Anil Sharma

HISTORY OF LESIONING OF NEVOUS SYSTEMS

Cryogenic Lesioning: Cryogenic lesioning has been used for cooling the tip
of the probe to an extremely low temperature to freeze a region of tissue
around the tip. This has been used for several years. The diameter of the
probe is usually larger and duration of pain relief is shorter than other
modalities.
Ultrasound: Ultrasound energy has also been used in the 1950s for lesions in
the brain. It is difficult to control the size of the lesion, and also difficult to
monitor the temperature.
Chemical Destruction: Injection of alcohol, phenol, or a glycerol has been used
for peripheral nerve destruction. The disadvantage is not being able to control
the flow of the injected material as a result the lesions are irregular, variable
in size, and a significant chance of development of neuroma afterwards.
Lasers: Lasers have also been used to make lesions in the nervous system. It is
difficult to quantify the extent and rapidity of tissue destruction using the
laser and is not amendable to adequate temperature monitoring.

Radiofrequency Lesioning
Radiofrequency lesioning has been used since the 1950s, initially using
continuous radiofrequency in the 1 megahertz range.1,2
Radiofrequency lesioning is generated by a radiofrequency generator,
which is connected to the electrode placed in the body. The current flows
between the tissues. The active electrode is positioned where the heat lesion
has to be made and the other electrode is the large grounding pad, which is
not intended to produce heat lesioning. The mechanism of the tissue heating
is primarily ionic.3 The radiofrequency voltage on the tip of the needle sets
up electric fields in the space around the needle and the heat is generated. It
is important to understand the tip of the needle does not actually heat up.
The tip of the needle has a sensor, which gives a temperature reading. The
equilibrium is usually reached in about 60 seconds. The size of the lesion
depends on the electrode tip length as well as diameter and the temperature
at the tip.
 Radiofrequency Coagulation 315

Radiofrequency denervation is a therapeutic procedure in which a Teflon-

coated electrode with an exposed tip is inserted close to a nerve in such a
manner that when a high frequency electric current is applied, it concentrates
on the exposed tip and heats the immediate surrounding tissues and
coagulates them.

LUMBAR RADIOFREQUENCY DENERVATION

This procedure is for the treatment of low-back pain originating from lumbar
facet joint etiology. The rationale is based on performing diagnostic controlled
blocks of medial branches that innervate the symptomatic joint, and the
patient obtaining significant relief of back pain, up to 80%. Usually two sets
of diagnostic injections are done. They can be done with a different duration
of local anesthetic. After each diagnostic injection, the patient should report
significant relief of back pain, which should be appropriate to the duration
of local anesthetic used.

Anatomy of Medial Branches4,5

Medial branches of L1 to L4 dorsal rami all assume a similar course. Each
medial branch crosses the base of the transverse process of the vertebra below,
that is, a L3 medial branch crosses over the L4 transverse process and the L4
medial branches crosses over the L5 transverse process. Each nerve runs in
a groove, which is formed by the junction of the transverse process and the
superior articular process at each level. Each medial branch runs under the
mamilla-accessory ligament6 and it curves medially to enter the multifidus
muscle. The ligament holds the nerve in place and there is little variation in
the location of the nerve. Within the multifidus muscle, the medial branches
divide into superior and inferior articular branches, which supply the relative
facet joints above and below. As a result, each medial branch supplies two
joints, that is, one joint is supplied by two medial branches. The segmental
number of the joints innervated is not the same as segmental number of
nerves that innervate them, so the L2 and L3 medial branch will innervate
the L3-4 facet joint. The L5 dorsal ramus differs in its anatomy. It crosses over
the most medial aspect of the ala of sacrum, and it is the dorsal ramus itself,
which crosses the ala rather than its medial branch. It is located in the groove
just lateral to the SAP of S1.

Principle of Radiofrequency Denervation

Radiofrequency denervation is performed by alternating a higher frequency
electrical current between the larger surface area, which is the grounding
pad, and a small surface area, which is the uninsulated tip of the needle. As
the current approaches the electric tip, the electrical field becomes more dense
and stronger and the current alternates causing the charged molecules to
oscillate. Oscillation heats the tissue sufficiently to coagulate them. The
volume of the coagulated tissue assumes the shape of a long spheroid whose
long axis is formed by the uninsulated tip of the needle.
316 Interventional Pain Management—A Practical Approach

Coagulation occurs principally around the long axis of the needle that is
sideways.7,8 A very small amount of coagulation occurs distal to the tip of
the needle. The size of the lesion and the dimension is proportional to the
size of the electrode that is the length of electrode and the diameter of the
electrode.
This concept about the lesion is important as placing the electrode
perpendicular to the nerve will create a very small lesion and may quite miss
it. Consequently, for optimal coagulation, electrode should be placed parallel
to the nerve. Also, if smaller sized electrodes are used then multiple lesions
have to be made.
The length of the sideway lesions is up to 1.6 to 2 electrodes distance. As
a result of this, if multiple lesions are made, then the electrodes should be
placed not more than one electrode distance between the consecutive
placements.
Size of the lesion also depends on the duration of coagulation. As the
temperature of the electrode reaches 65 degrees, coagulation starts on the
surface. The volume of the coagulation tissue expands as the temperature
increases to 80 degree Centigrade. At 30 seconds, the lesion increases to 85%
of its maximum size. At 60 seconds, it reaches 94% of the size, which is
attained at 90 seconds; thereafter increasing the time further does not increase
the size of the lesion, so the optimal duration of coagulation is between 60
and 90 seconds.
The electrode of choice for lumbar radiofrequency is 150 mm, 20-gauge,
long straight probe, with 10 mm active tip. Most common parameters are 80
degrees Centigrade for 90 seconds.

Patient Selection
The optimal patient for lumbar radiofrequency denervation is a patient with
pain for at least three months with no indication of resolving by natural
history. The pain has not responded to conservative treatment.
The pain is focal axial in nature, appears to be coming from facet joint
etiology and has undergone controlled diagnostic blocks of the target medial
branches with a different local anesthetic, done twice with each time the
patient getting significant pain relief, greater than 80%.
Previous surgery does not preclude a successful response to percutaneous
radiofrequency denervation and also can be done after recurrence of pain
following previous radiofrequency denervation, as long as the duration of
relief was more than one year.
The procedure is limited to minimal possible levels depending on the
diagnostic test. The most common is three levels to denervate two facet joints.
Coagulating more levels than that can cause greater portion of the lumbar
musculature to be denervated.
 Radiofrequency Coagulation 317

Contraindications
Absolute contraindications to lumbar radiofrequency denervation are
evidence of untreated infection, either systemic or at the proposed site,
bleeding diathesis, patient is medically or psychologically unstable, as well
as pregnancy.
Relative contraindications are patients with pacemaker and anatomical
derangements that would compromise the safe placement of electrode,
coexisting medical illness, immunosuppression, or unrealistic patient or
family expectation.

Radiofrequency Denervation of Lumbar Medial Branches9

(Figs 37.1 to 37.14)
Once the target points are identified under fluoroscopic guidance, the skin is
anesthetized with local anesthetic and the probe is inserted. The electrode is
placed parallel to the medial branches, so the C-Arm is tilted caudally and
oblique to and the junction of SAP and transverse process is identified. It is
always wise to make bony contact first, either at the inferior aspect of superior
articular process or near the junction of the transverse process and the
superior articular process. Once the depth is known, the needle is withdrawn
slightly and readjusted to pass along the neck of the superior articular process
by no more than a few millimeters. At this point, AP view of the placement is
done which should show that the needle tip is against the lateral surface of
the superior articular process. Subsequent to that, the lateral fluoroscopy
view is obtained, which should show that the uninsulated tip lies along the
middle of the neck of the superior articular process and the tip of the needle
is appropriately away from the neural foramen.

Fig. 37.1: This is an AP fluoroscopy view of the lumbar spine. The landmarks to be noted are
the transverse process, the superior articular process, and the junction between those
two. Also to be noted, this patient has spondylolysis at L5
318 Interventional Pain Management—A Practical Approach

Fig. 37.2: Lumbar spine with caudal tilt of the C-arm, again noting the junction of superior
articular process and transverse process. A needle is placed at an angulation so that they
are parallel to the facet nerves

Fig. 37.3: After caudal angulation, an oblique view is performed, 15 to 20 degrees. Again,
the landmark to be noted is the junction of superior articular process, transverse process,
and the pedicle
 Radiofrequency Coagulation 319

Fig. 37.4: Skin mark is placed at the junction of the superior articular process and transverse
process, and a radiofrequency probe, 150 mm long with 10 mm active tip, is being introduced
with the tip being directed towards the junction of superior articular process and transverse
process

Fig. 37.5: This is in AP fluoroscopy view showing the radiofrequency probe lying in the
gutter between the superior articular process and transverse process
320 Interventional Pain Management—A Practical Approach

Fig. 37.6: The second radiofrequency probe of similar length is now placed at L4 facet
nerve, again noting the junction of the superior articular process and transverse process. A
bony contact is encountered and then subsequent to that, the needle slipped a few millimeters
anteriorly

Fig. 37.7: This is in AP fluoroscopy view note that the radiofrequency probes are at the
junction of the superior articular process and transverse process in the gutter. The active tip
is lying parallel to the course of the medial branches
 Radiofrequency Coagulation 321

Fig. 37.8: Lateral fluoroscopy view showing the appropriate placement of the needles with
the active tip lying along the lateral aspect of the superior articular process. Needle tip is
posterior to the neural foramen

Fig. 37.9: Radiofrequency probe is being placed for L5 medial branch. This is performed
under AP fluoroscopy guidance with slight cranial tilt to the C-arm. Usually the caudal tilt
needed for lumbar facet nerves from L2 to L4 is not needed. The bony landmark is the
superior articular process of S1, concavity or at the most medial aspect of the ala sacrum.
A bony contact is made to determine the depth
322 Interventional Pain Management—A Practical Approach

Fig. 37.10: The radiofrequency probe is now slipped anteriorly about

2 mm after bony contact is made

Fig. 37.11: Lateral fluoroscopy view is showing placement of

radiofrequency probe for L5 medial branch
 Radiofrequency Coagulation 323

Fig. 37.12: Same patient with slight oblique view towards the left
side to confirm the placement of the probes

Fig. 37.13: This is in AP fluoroscopy view of patient undergoing

L4 and L5 medial branch radiofrequency denervation
324 Interventional Pain Management—A Practical Approach

Fig. 37.14: Lateral view of the same patient

Once the fluoroscopy views are confirmed, then sensory testing for the
medial branch is performed at 50 Hz. The current is slowly advanced in 0.1
increments and the patient is asked for reproduction of his back pain, pressure,
or buzzing sensation in the back. Also, the patient is instructed to inform us
if the pain starts to radiate in a radicular pattern down the legs. Usually with
good placement, sensory stimulation is noted at less than 0.5 volts. Once the
sensory testing is over, motor stimulation is carried out at 2 Hz, which should
be done up to three times of sensory threshold. At this time, stimulation of
paravertebral or multifidus muscles is usually noted, but there should be no
motor stimulation of the lower extremities.
Once these parameters are noted and done at each level, 0.5 mL of 2%
lidocaine is given through each needle to anesthetize the medial branch and
radiofrequency coagulation is carried out. Usual setting is 80 degrees
Centigrade for 90 seconds at each level.
Location of L5 dorsal ramus is different than the ones at L1 to L4 and the
electrode is placed in not as much oblique or caudal direction. The target
area is the most superior medial aspect of the ala area of sacrum, which is
usually seen as a groove just lateral to the superior articular process of S1.
Again, appropriate AP and lateral views should be obtained to check for the
electrode placement relative to the neural foramen.
Once the procedure is done, 5 mg of kenalog mixed with 0.75% marcaine
total 0.75 ml volume is injected at each level to decrease the incidence of post
procedure pain and neuritis. The electrodes are removed. The area is cleaned
and small bandages are applied. The patient is taken back to the recovery
room. It is emphasized to the patient that they can experience numbness in
the legs and that they must be careful when standing or walking immediately
after the procedure because local anesthetic can track down to the segmental
nerve root.
 Radiofrequency Coagulation 325

Post-operative Care
The patient is given detailed postoperative instructions including phone
numbers in case of any problems. The patient is asked to apply cold packs
for one to two days and to report any unusual symptoms including wound
infection. Pain medications may be requested for a few days after the
procedure. The patient is scheduled for a follow up visit two weeks after the
procedure. Sometimes it could take up to three weeks for the patient to
experience pain relief from this procedure. Initially they can develop neuritis
or a hyperesthesia over the skin in the lower back where the medial branches
provide some cutaneous supply. Rarely the symptoms can be quite
bothersome, in those cases; trial of medications like gabapentin, topical
lidocaine patch or cream can be beneficial for three to four weeks.

Complications of Lumbar Radiofrequency

Lumbar radiofrequency treatment is quite a safe procedure, but there are
certain generic and theoretical risks, which are for any minimally invasive
procedure. These include hematoma, infection, and allergic reactions. The
placement of electrodes is done in such a way that it avoids any significant
structure during insertion. Electrodes penetrate only the skin and posterior
back muscles, and the spinal nerves lie anterior to where the electrodes are
placed, so if the electrode is placed correctly there is no risk of nerve root
injury. Also performing the procedure with less sedation will avoid any
potential complications. The grounding plate has to be applied correctly
otherwise there is a risk of skin burn. There is potential for increased pain as
well as increased sensitivity of the skin, which a lot of patients complain as
sunburn for up to 2 to 3 weeks after the procedure. If the symptoms are
bothersome, then local lidocaine cream or patch can be applied and also
occasionally gabapentin like medications can be prescribed to decrease the
sensation.

RADIOFREQUENCY DENERVATION OF CERVICAL MEDIAL BRANCHES

Anatomy of Cervical Medial Branches10
The medial branches of the cervical dorsal rami course along the anterolateral
and posterolateral aspect of the articular pillars. There is slight variation in
the course of the medial branches depending on the level. At C5 level, the
medial branch is along the middle fifth of the height of the articular pillar.
The variation becomes greater at levels further away from the C5. For example,
the C4 medial branch run relatively slightly higher along across the C4
articular pillar and the C6 medial branch will run slightly lower on the C6
articular pillar. The C7 medial branch is most often located crossing the
superior articular process of C7. In an AP fluoroscopy view, the nerve is most
often located on the corner formed by the junction at the C7 superior articular
process and the root of the C7 transverse process.
326 Interventional Pain Management—A Practical Approach

At C3 level there are two medial branches, the C3 deep medial branch,
which is involved in the nerve supply to the C3-4 facet joint and the C3
superficial medial branch, which is much larger and is also called the third
occipital nerve and provides nerve supply to the C2-3 facet joints. In the
lateral view, the C3 deep medial branch is usually running across the upper
half of the C3 articular pillar. The third occipital nerve (the superficial C3
medial branch) crosses the C2-3 facet joint. In AP fluoroscopy view, the C3
deep medial branch is located slightly caudally into the upper half of the
convexity of the C3-4 facet joint. The third occipital nerve is usually present
into the lower half of the convexity of the C2-3 facet joints.
These variations in the location of the cervical medial branches need to
be recognized for the proper application of radiofrequency denervation. The
cervical medial branches are small targets and one needs to be more precise
in the location of the needle to achieve an optimum result. The articular
pillars are directed caudally and posteriorly so the electrode directed in that
direction will place the exposed tip of the probe parallel to the medial branch.
If a direct anterior-posterior approach of the needle is used, then the
lateral aspect of the superior articular process and any osteophyte coming
from that will prevent the electrode from being placed directly on the nerve.
The third occipital nerve runs transversally across the anterolateral and
lateral aspect of C2-3 facet joints. The electrode in that position can be placed
without the caudal tilt.

Indication and Patient Selection

This is similar to radiofrequency denervation of lumbar facet nerves. The
patient should have two diagnostic cervical medial branch blocks with
different duration of local anesthetic with each providing around 80% relief
of the pain.

Complications
Complications are similar to those of lumbar medial branch blocks. In
addition, radiofrequency denervation of the third occipital nerve causes a
numbness and neuritis in the occipital area and will also cause ataxia. Ataxia
is not disabling. It amounts to the sense of potential unsteadiness. It is readily
overcome if the patient uses vision to locate horizontal objects in the near or
far distance.

Procedure for Radiofrequency Denervation of

Cervical Medial Branches (Figs 37.15 to 37.23)
The patient is placed in the prone position with two pillows under the chest.
My choice for cervical radiofrequency is from the posterior approach. While
performing an AP fluoroscopy view, the mandible can obscure the good
view of the concavities and articular pillars. The neck is rotated slightly to
one side so as to remove the mandible shadow from the cervical spine. In
 Radiofrequency Coagulation 327

Fig. 37.15: This is an AP fluoroscopy view of the cervical spine. Please note the neck has
been tilted slightly to the left side so as to avoid the mandible shadow from the cervical spine
and because of this a very clear picture of concavities of the articular pillars are identified
on the right side. The C-arm is also rotated caudally to obtain sharp view of concavities

Fig. 37.16: A radiopaque marker is placed just lateral to the

concavity of the C5 medial branch location
328 Interventional Pain Management—A Practical Approach

Fig. 37.17: A 100 mm long radiofrequency probe with a 5 mm active tip is introduced. A bony
contact is made and then the needle is slightly withdrawn and slipped anteriorly for about 2
to 3 mm as can be seen on this fluoroscopy

Fig. 37.18: This is a picture for placement for C7 medial branch. Again, a skin mark
is placed at the junction of the transverse process and superior articular process of C7
 Radiofrequency Coagulation 329

Fig. 37.19: A radiofrequency probe is placed along

the previously marked site and bony contact is made

Fig. 37.20: Radiofrequency probes are placed with similar technique along C4, C5, C6,
and C7 cervical medial branches. This is an AP fluoroscopy view
330 Interventional Pain Management—A Practical Approach

doing so, one must obtain a true AP fluoroscopy view by tilting the C-arm so
that the spinous processes are placed into the center of the spine. After this
the C-arm is tilted caudally to outline the articular pillars as identified by the
concavities.
A skin mark is placed just lateral to the target concavity and the skin is
infiltrated with 1% lidocaine. Following that, the radiofrequency probe is

Fig. 37.21: Slight oblique view of the similar patient with the
probes seen along the concavities

Fig. 37.22: Slightly more oblique view to look for the placement of the probe. It is noted that
the tip of the needles are away from the neuroforamen. The needle at C4 was slightly
withdrawn back after this view
 Radiofrequency Coagulation 331

Fig. 37.23: Lateral view of the same patient, the probes are seen appropriately at C4 and C5.
The needle tip should not be anymore anterior than as visualized on these views. Because
of the shoulders, it is usually difficult to visualize the lower levels, but it usually can be done
by coning the C-arm and using a slightly high output, but unfortunately with scanning the
flouroscopic picture that view could not be reproduced

introduced. My choice is 20 Gz 100 to 150 mm long radiofrequency probe

with a 5 mm active tip. The electrode is passed through the skin, subcutaneous
tissues, and the muscles. A bony contact is made at the most lateral aspect of
the concavity and, then the needle is slightly withdrawn and slipped
anteriorly.
The patient is sedated very mildly during this procedure and is asked to
report if they notice any pain going down the upper extremities.
The C7 medial branch occupies the lateral aspect of the superior articular
process and can be found on the superior aspect of the medial end of the C7
transverse process. A probe is placed at the junction of the transverse process
with superior articular process. Again, the C7 medial branch does not pass
along the articular pillar so the angulation of the needle can be less caudally
oriented as opposed to the medial branches at the higher levels.
The third occipital nerve has two branches, a deep branch and a
superficial branch. To denervate the deep branch, the probe is placed along
the concavity of the C3 articular pillar and sometimes the electrode has to be
moved down to the upper half of the convexity of the C3-4 facet joints.
For the third occipital nerve, which is the superficial branch of the third
medial branch, the radiofrequency probe is placed across the C2-3 facet joint.
This is quite a large nerve with variable location. The first probe is placed
along the middle of the C2-3 facet joints and then another denervation can be
performed slightly superior and inferior to that. In the AP fluoroscopy view,
the electrode is placed directly across the convexity of the joint.
Once the probes are appropriately placed; AP, oblique, and lateral
fluoroscopy view is obtained. After confirming these three views, sensory
stimulation is carried out at 50 Hertz. The patient usually notices a buzzing
332 Interventional Pain Management—A Practical Approach

sensation in the back of the neck, between 0.1 to 0.5 volts at 50 Hertz; also
sustained contraction of deep cervical muscles can be noted. Following this,
motor stimulation is carried out at 2 Hertz. The motor testing is done three
times the sensory threshold. The patient is carefully evaluated for any motor
movement of the upper extremities suggesting nerve root stimulation. Once
appropriate testing is done, 0.5 mL of 2% lidocaine is given through each
needle and radiofrequency denervation is performed at 80 degrees Centigrade
for 60 seconds.

Post-operative Recovery
The patient is given detailed instructions regarding the procedure and follow-
up visit. The patient is monitored for any neurological deficits for 30 to 50
minutes in the recovery room and discharged home. The patients may have
ataxia after this procedure which is usually self-limited if they focus in the
distance to achieve balance.

Repetition
Radiofrequency of the medial branch can be repeated again. It does not
permanently destroy the nerves. The cell bodies of the nerves remain intact
and the nerve regenerates and the pain can reoccur. On an average, the
patient can expect up to 350 to 400 days of complete pain relief and when the
pain reoccurs, it is usually not as severe. Repeated radiofrequencies can be
performed, but repeating within one year is not recommended.

REFERENCES
1. Shealy CN. The role of the spinal facets in back and sciatic pain. Headache
1974;14:101-4.
2. Shealy CN. Percutaneous radiofrequency denervation of spinal facets.
J Neurosurg 1975;43:448-51.
3. Organ LW. Electrophysiologic principles of radiofrequency making. Appl
Neurophysiol 1976;39:69-76.
4. Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. J Anat
1982;134:383-97.
5. Bogduk N. The innervation of lumbar spine. Spine 1983; 8:286-93.
6. Bogduk N. The lumbar mamillo-accessory ligament. Its anatomical and
neurosurgical significance. Spine 1981;6:162-7.
7. Bogduk N. Macintosh J, Marsland A. Technical limitations to efficacy of
radiofrequency neurotomy for spinal pain.
8. Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy
of the cervical medial branches. A validated treatment for cervical
zygapophyseal joint pain. Neurosurgery Quarterly 1998;8:288-308.
10. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and
validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint
pain. Spine 2000;25:1270-77.
 Thirty Eight

Intrathecal Implantable Devices

DK Baheti

INTRODUCTION
Intrathecal drug delivery system provides targeted delivery of medications
and minimizes the side effects of morphine. Yaksh1 documented the
physiological basis of the pain relief due to intrathecal opoids as the
modulation of inhibitory mechanism occurring at the spinal cord. The
analgesic effect of intrathecal opioids are dose dependent and stereo specific.
However opioid toxicity can be easily reversed with naloxone.

INDICATIONS
• Chronic pain due to malignancy
• Life expectancy is short
• Chronic pain due to spasticity
• Long lasting pain not relieved by conventional technique
• Failed back surgery syndrome
• Complex regional pain syndrome
• Post herpetic neuralgia.

CONTRAINDICATIONS
• Patient unable or unwilling to consent
• Known allergy to contrast
• Local infection
• Coagulopathy
• Pregnancy
• Concurrent use of anticoagulants
• Known systemic infection
• Coexisting disease producing significant CVS or respiratory
compromise
• Immunosuppression.
334 Interventional Pain Management—A Practical Approach

DRUGS USED
Following drugs can be used alone or in combination:
• Local anesthetics
• Clonidine
• Opioid- morphine
• Baclofen.

Screening of Patient
Screening of the patient is mandatory before considering for intrathecal or
epidural implantation of port or pump. Any interventional procedures should
be done with informed consent. These procedures are preferably done in
procedure room or in operation theater. The investigations such as complete
blood count, bleeding time and clotting time are necessary. An intravenous
line is secured. The monitoring of BP, SaO2, and ECG is mandatory. An
antibiotic cover is necessary. The guidance of fluoroscopy is useful.
The opioid or other drug used for intrathecal or epidural screening should
be preservative free.
The patient is hospitalized for few days during which time the infusion
rate is gradually increased. The longer the trail time, the greater the likelihood
of decreased placebo response. During trail period the monitoring of pain
intensity, functional status, vital functions mainly respiration and other
parameters, use of breakthrough medications is of prime importance.
Intrathecal Trial–It is done by doing either by lumbar puncture or implanting
a temporary catheter. If intrathecal catheter is not available of to make the
procedure cost effective one can use pediatric epidural catheter. The tunneling
of catheter is done. The intrathecal dose of opioid is 1/300th of usual oral
dose.
Epidural trial–It is done by putting epidural catheter. It performed similarly.
The epidural daily dose of opioid is 1/30th of oral dose.
One time bolus–It is the method of choice for screening of these patients. The
intrathecal dose is given and the monitoring of pain intensity, functional
status, vital functions mainly respiration and other parameters, use of
breakthrough medications is of prime importance for twenty four hours is
adequate.
Side port Catheter-It is surgically implanted for trial. The advantage is adding
an implantable infusion pump after successful trial. However the added risk
of infection may be there.
The opioid (morphine) conversation dosage from other routes of
administration to intrathecal is as follows:
• Intrathecal to epidural = 1:10
• Intrathecal to intravenous = 1:100
• Intrathecal to oral = 1:300
 Intrathecal Implantable Devices 335

EQUIPMENT FOR INTRATHECAL IMPLANTATION

• Implantable intrathecal infusion pump
• Accessories- connecting tubes
• Implantable port with accessories
• Surgical trolly with appropriate instruments.

PROCEDURE
Before starting go through the details of the literature and video of the
intrathecal implantation port or pump. Follow the instructions meticulously.
This procedure can be done either in local or general anesthesia. Follow
the same procedure protocol done during screening trial of the drug. The
pump, catheter tubings, connectors should be dipped in antibiotic solution
for at least thirty minutes.

Step-1
Patient in lateral decubitus position identify the L3-4 space under fluoroscopy
and do the lumbar puncture. Document the good flow of cerebrospinal fluid
(Fig. 38.1). Clamp the catheter to avoid the unnecessary loss of CSF.
Withdrawing of spinal needle will help to minimize the leakage.

Fig. 38.1: Free flow of CSF

336 Interventional Pain Management—A Practical Approach

Step-2
Under local anesthesia make a paramedian incision for fixing and tunneling
of the catheter.

Step-3
Under aseptic precautions and local anesthesia make 10 to 12 cm incision in
lower quadrant of abdomen (Fig. 38.2). Fashion a subcutaneous pocket large
enough to admit the implantable pump. The pocket should allow the
placement of pump comfortably without struggle and prevent the rotation.
As a guideline all four fingers should be easily admitted to metacarpo-
phalengeal joints into the pocket.

Fig. 38.2: Abdominal marking for implantable port

Undermine the upper side of incision about 2.5 cm or width of pump so

wound can be closed without tension. A depth of 2.5 cm is ideal for telemetery.
All bleeding points should be meticulously cauterized.

Step-4
Now, infiltrate, the track of tunneling with local anesthetic solution. Next,
tunnel the catheter connecting intrathecal catheter to pump (Fig. 38.3). Pass
the malleable tunneler device into the track of previously injected local
anesthetic solution. Pass the catheter though tunneling device towards the
pocket of lower quadrant of abdomen (Fig. 38.4). Confirm the free flow of
CSF.
 Intrathecal Implantable Devices 337

Fig. 38.3: Tunneling of the catheter

Fig. 38.4: Inserting the intrathecal catheter

338 Interventional Pain Management—A Practical Approach

Step-5
Fix the connection between the intrathecal catheter using, male to male tubing
connector (Fig. 38.5). Tie this, joints with non 2-0 absorbable suture. Now
take an anchoring suture with muscle fascia in figure of 8 fashion. This is to
avoid migration of intrathecal catheter.

Fig. 38.5: Fixation of catheter in the lumbar area

Step-6
Aspirate any air in the programmable pump and fill the pump with the
prescribed drug (Fig. 38.6).
Again check the free flow of CSF. Connect the extension catheter to the
programmable implantable pump. Secure with 2-0 nonabsorbable suture tie.
Place the programmable pump along with the catheter into the pocket at
lower quadrant of abdomen. Confirm that there is no kinking of the extension
catheter.
This is the diagrammatic representation of the pump in situ (Fig. 38.7).
 Intrathecal Implantable Devices 339

Fig. 38.6: Filling of the drug into the port

Fig. 38.7: Diagrammatic representation of intrathecal drug delivery system (pump) in situ
340 Interventional Pain Management—A Practical Approach

POST-PROCEDURE CHECK LIST

X-ray- Lumbo thoracic spine- Position of catheter.

COMPLICATIONS
• Surgical
– Bleeding and hematoma
– Epidural or intrathecal hemorrhage
– Wound infection- site of implant or catheter
– Meningitis.
• Implantable device related problems
– Kinking of catheter: When residual volume of drug vary more than
20%
– Solution- Fluroscopy or inject dye into the system (Before injecting
dye remove the same volume of drug from system to avoid over dosage)
– Volume discrepancy
– Failure of self sealing septum
– Battery failure
– Pump motor failure
– Failure of telemetery.

HELPFUL HINTS
A thorough conversation with patient and relatives regarding the procedure,
side effects of opioid, possible complications is vital.
The length of screening trial is important.

REFFERENCE
1. Yaksh TL. Spinal opiate anaesthesia. Characteristics and principles of action.
Pain 1981;11:293-346.
 Thirty Nine

Blunt Tip Needle

DK Baheti

INTRODUCTION
The iatrogenic complication during any interventional procedure are
reported in literature such as in celiac plexus blocks are pneumothorax
(two cases) by Brown1; partial lower extremity paralysis (One case) by
Thomson et al2; temporary paraplegia (One case) by Baheti.3 While performing
lumbar sympathectomy Boas4 reported 6% incidence of genitofemoral
neuralgia, Cousins and associates5 reported 35 patients with mild or severe
neuralgia.
The other iatrogenic complications such as chylothorax, pleural effusion,
renal injury and injury to veins also have been reported. The neurological
complications include disestesias, paresis in lower extremities, paraplegia
due to ischemia, spinal neurolytic injection, spasm of anterior spinal artery.
P Raj et al6 mentioned the complications such as backache, intravascular or
subarachnoid injection, neuralgia, muscle spasm.
The role of tip of needle in above mentioned complications can not be
ruled out.
The probable cause of above mentioned iatrogenic complications can
be the use of sharp tip or short bevel needle, which may results in a puncture
of an internal organ like vein, pleura, peritoneum and etc., and as mentioned
above, these iatrogenic complications have been reported in the literature
from time to time.

RECENT ADVANCES AND ITS IMPLICATIONS

The blunt tip needle (Fig. 39.1) recently introduced by Baheti DK7 for these
blocks (celiac plexus block and lumbar sympathectomy) may further reduce
the incidence of iatrogenic complications such as injury to vessels, internal
organ, peritoneum and pleura.
The new blunt tip needle is a 20-gauge 15 cm or 6”needle made up of
stainless steel (locally made), which can be repeatedly autoclaved.
This needle is successfully used by author in more than 300
interventional pain management procedures which includes celiac plexus
344 Interventional Pain Management—A Practical Approach

Fig. 39.1: Blunt tip needle

block, lumbar sympathectomy, and hypogastric plexus block and there is no

incidence of injury to any vessel or viscera.
The author has also used 31/2” needle for single shot epidural and
transformational lumbar epidural successfully.
However it is found that blunt tip needle is not suitable for caudal epidural
block as there is difficulty in puncturing of sacrococcygeal membrane.
The patent for the above needle is applied for.

REFERENCES
1. Brown DL, Bully CK. Quiel EC. Neurolytic celiac plexus block for pancreatic
cancer pain. Anaesth Analg 1987:66: 869-73.
2. Thompson GE, Moore DC, Braidenbaugh LD. Abdominal pain and alcohol
celiac plexus block. Anesth Analg 1977:56:1-5.
3. Baheti DK. Neurolytic coeliac plexus block (NCPB): A ten year review of 212
cases. Bombay Hospital Journal 2001;43(1).
4. Boas RA- Sympathetic blocks in clinical practice. In Stanton-Hicks M (Ed).
International Anesthesia Clinics. Regional anesthesia: Advances in selected
topics. Boston, Little Brown 1978;16(4).
5. Cousins MJ, Reeve TS, Glynn CJ, et al. Neurolytic sympathetic blockade:
Duration of denervation and relief of rest pain. Anesth Intensive Care
1979;7:121-35.
6. P Prithviraj, et al. Celiac plexus block and neurolysis. Radiographic imaging
for regional anesthesia and pain management. Churchill Livingston 2003;164-
74.
7. Baheti DK. Use of new modified needle with blunt tip for neurolytic sympathetic
block in abdominal malignancies- Abstracts, 11th World Congress on Pain:
IASP, Press 2005;489-90.
 Forty

Intramuscular Stimulation

K Kothari

INTRODUCTION
Pain is the 2nd most common cause of physician visit after common cold.
Musculoskeletal pain affects every individual at some or other point of
his/her lifetime. Chronic myofascial pain or chronic pain that occurs in
the musculoskeletal system without any cause is one of the most difficult
conditions to diagnose and treat. Most of the available therapies usually
give only temporary relief.
This technique is based on peripheral neuropathy mode.2 This hypothesis
believes that pain is the result of abnormal peripheral nerve function rather
than a direct tissue injury.

History
In 1970 Dr Gunn noticed during examination of patients who had back pain
for long period without signs of injury, had tenderness over muscle motor
points in affected myotomes. He postulated that tender motor points are
sensitive indicators of radicular involvement or irritation at the nerve root.
Tender points differentiate a simple mechanical low-back strain, which
usually heals quickly, from one that is slow to improve.3 His study of patients
with tennis elbow and shoulder pain showed that tender points at these
points were secondary to cervical spondolysis and radiculopathy (i.e.
neuropathy originating at the nerve root). Treating the neck, but not the
elbow and shoulder was able to provide relief.4,5

Pathophysiology of Neuropathic Pain

Pain is a signal of tissue injury conveyed to the central nervous system via
a healthy nervous system.
The definition of pain as given by the International Association for the
Study of Pain, underscores this: “an unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or described
by the patient in terms of such damage”.1
348 Interventional Pain Management—A Practical Approach

The traditional model fails to explain many pain syndromes associated

with damage to the peripheral nerve, or to the pathways coursing through
the dorsal horn and spinal cord.
Why persistent pain occurs?
1. Inflammation do not subside despite of variety of treatment causing
ongoing release of inflammatory mediators.
2. Psychological factors, e.g. somatosensory disorders, depression etc.
3. Nervous system malfunction–Myofacial pain is a neuropathic pain of
the musculoskeletal system. These conditions are labelled according to
their local sites like low-back pain, neck muscle spasm, facet joint pain,
tennis elbow, lateral epicondylitis etc. The underlying mechanism is
supposed to be supersensitivity of muscles16 and muscle shortening.

Peripheral Mechanism in Neuropathic Pain

Sensitization can occur following tissue inflammation or damage to a
peripheral nerve. Damage to the peripheral nerve is most commonly caused
by spondolysis at root level (i.e. radiculopathic pain) when all fibers of the
peripheral nerve can be damaged and can lead to any or all of the following
effects: Muscle shortening, Autonomic (complex regional pain syndrome),
trophic changes like dermatomal hair loss or weakening of tendons of
muscle. These changes may be absent in early disease.
Initially term “pain following neuropathy”6 was used but subsequently
as it was realized that anterior and posterior rami are almost always involved,
denoting radiculopathy (neuropathy at the nerve root), radiculopathic pain
is more correct denomination.

Cannon and Rosenblueth’s Law of Denervation

The normal physiology and integrity of all innervated structures are
dependent on the arrival of nerve impulses via the intact nerve to provide
a regulatory or trophic effect. When this flow (probably a combination of
axoplasmic flow and electrical input) is blocked, innervated structures are
deprived of the trophic factor, which is vital for the control and maintenance
of cellular function. “Atrophic” structures become highly irritable and develop
abnormal sensitivity or supersensitivity according to Cannon and
Rosenblueth’s Law of Denervation:6
When a unit is destroyed in a series of efferent neurons, an increased
irritability to chemical agents develops in the isolated structure or structures,
the effect being maximal in the part directly denervated.
All denervated structures develop super-sensitivity (including skeletal
muscle, smooth muscle, spinal neurons, sympathetic ganglia, adrenal
glands, sweat glands, and brain cells). Cannon and Rosenblueth’s original
work was based on total denervation and decentralization for super-
sensitivity to develop, accordingly, they named the phenomenon denervation
supersensitivity. But it is now known that physical interruption and total
denervation are not necessary.
 Intramuscular Stimulation 349

The supersensitive muscle cells can generate spontaneous electrical

impulses that trigger false pain signals or provoke involuntary muscle
activity8 and supersensitive nerve fibers can become receptive to chemical
transmitters at every point along their length instead of at their terminals
only. Interconnecting pathways are possible between sensory and
autonomic (vasomotor) nerves and may contribute to “reflex sympathetic
dystrophy” or the “complex regional pain syndrome”.

Spondolysis and Radiculopathy1

Of the innumerable causes of nerve damage, such as trauma, metabolic,
degenerative, toxic, and other conditions, chronic attrition from spondylosis
(the structural disintegration and morphologic alterations that occur in the
intervertebral disc, with patho-anatomic changes in surrounding structures)
is by far the most common.6 The spinal nerve root is notably prone to injury
from pressure, stretch, angulation, and friction. interestingly, neuropathy
itself contributes to degenerative conditions.7 Neuropathy degrades the
quality of collagen, causing it to have fewer cross-links; it is therefore markedly
frailer than normal collagen9. Radiculopathic pain syndromes should
therefore be treated with some urgency to delay degeneration. Any degree of
spondylosis, early or late can irritate and disturb function in the segmental
nerve.
Muscle shortening is an early and common feature of radiculopathy.
Painless, reversible, tight muscle knots can be felt in most patients even in
young ones. Pain is not therefore a feature of radiculopathy unless
nociceptive pathways are involved. Many neuropathies are pain free, such
as sudomotor hyperactivity in hyperhidrosis, and muscle weakness in
ventral root disease.

CENTRAL MECHANISMS IN NEUROPATHIC PAIN1

Interactions between peripheral and central mechanisms occur to produce
post injury hypersensitivity and neuropathic pain. The spinal cord can
modify or amplify incoming signals. Central sensitization, a state of
hyperexcitability of the dorsal horn neuron, can occur after damage to a
peripheral nerve or after low-frequency repetitive C fiber nociceptor input.10
Central sensitization results from:
• increased spontaneous activity of dorsal horn neurons11,12
• increased response to afferent input
• expansion of receptive field size– pain can spread to one or many segments
up and down (by dispersion of the primary afferent input through
propiospinal connections in adjacent layers 5 and 6 of the dorsal horn)
• reduction in threshold
• prolonged after discharges.
350 Interventional Pain Management—A Practical Approach

CLINICAL FEATURES
The history hardly guides pain physician towards diagnosis. Experience
of examiner and his knowledge in segmental nerve supply myotomes are
key to diagnosis.The physical signs of neuropathy are distinctive and one
should always look for these as it is must for early diagnosis and treatment.
1. Allodynia: Muscles can be tender, especially over motor points.
Autonomic vasoconstriction differentiates neuropathic pain from
inflammatory pain, in neuropathic pain, affected parts are perceptibly
colder.
2. Sudomotor activity: Excessive sweating may follow painful movements.
The pilomotor reflex is often hyperactive and visible as “goosebumps”
in affected dermatomes augmented by pressing upon a tender motor
point, especially the upper trapezius.1 There can be interaction between
pain and autonomic phenomena. A stimulus such as chilling, which
excites the pilomotor response can precipitate pain; vice versa, pressure
upon a tender motor point can provoke the pilomotor and sudomotor
reflexes.

Trophedema: Increased permeability in blood vessels can lead to local

subcutaneous tissue edema (“neurogenic” edema or “trophedema”).
This can be confirmed by the peau d’orange effect (orange-peel skin),
found over affected regions by “skin rolling”, that is, by squeezing an
area of skin and subcutaneous tissue. In trophedema, the skin is tight
and wrinkles absent; subcutaneous tissue consistency is firmer; and the
Matchstick test may be positive.12 Trophedema is non-pitting to digital
pressure, but when a blunt instrument such as the end of a matchstick
is used, the clear-cut indentation is produced and persists for many
minutes matchstick test). This simple test for neuropathy is more sensitive
than electromyography.
Trophic changes such as dermatomal hair loss may also accompany
neuropathy.1
3. Trophic: Skin and nails can be affected, and there may be hair loss.

Enthesopathy:1 Tendinous attachments to bone are often thickened.

Common sites are insertion of semispinalis capitis at the occiput,
longissimus capitis at the mastoid process, deltoid insertion, common
extensor origin at lateral epicondyle of elbow, origin of erector spinae.
4. Motor: Muscle shortening is a fundamental feature of musculoskeletal
pain syndromes and of all the structures that develop supersensitivity,
the most widespread and significant is striated muscle. Signs in muscle
are therefore most relevant and consistent.
Muscle shortening may be palpated as ropey bands in muscle. Focal
areas of tenderness and pain in contractures are often referred to as “trigger
points”. Tender points can be found throughout the involved myotome.
Muscle shortening causes a large variety of pain syndromes by its pulling
effect on various structures.
 Intramuscular Stimulation 351

Because the significant changes are primarily in muscle, Knowledge of the

segmental nerve supply to muscles is a clue to diagnosis.
Even when symptoms appear to be in joints or tendons, it is changes in
muscle that are most consistent increased muscle tone, tenderness over
motor points, taut and tender, palpable contracture bands, and resultant
restricted joint range.
During examination, each and every constituent muscle must be
palpated and its condition noted. Palpation requires detailed knowledge
of anatomy, and the skill to palpate comes only with practice.
Moreover, because many paraspinal muscles are compound (e.g. the
longissimus) and extend throughout most of the length of the vertebral
column, the entire spine must be examined even when symptoms are
localized to one region

DIAGNOSIS
As already discussed history and lab tests give little assistant to the
diagnosis, apart from above mentioned clinical features, some features that
indicate neuropathic pain are:
• Pain when there is no ongoing tissue-damaging process
• Delay in onset after precipitating injury. (It generally takes 5 days for
supersensitivity to develop)
• Dysesthesias - unpleasant “burning or searing” sensations, or “deep,
aching” pain: which is more common than dysesthetic pain in musculo-
skeletal pain syndromes
• Pain felt in a region of sensory deficit
• Neuralgic pain; paroxysmal brief “shooting or stabbing” pain
• Loss of joint range or pain caused by the mechanical effects of muscle
shortening
• Abnormal bowel function (e.g. “irritable bowel syndrome”)
• Increased vasoconstriction and hyperhidrosis
• “Causalgic pain”; “reflex sympathetic dystrophy” or “complex regional
pain syndrome”.13
Laboratory and radiologic findings are generally not helpful.
Thermography reveals decreased skin temperature in affected
dermatomes and this can be an indication of neuropathy, but does not
necessarily signify pain.

TREATMENT
To treat myofacial radiculopathic pain is challenge. There are various
options available to the interventional pain physician.
1. Pharmacologic Management: Is difficult.
1. Adequate sleep: It is proposed that sleep disturbance occurs from a
variety of reasons. TCAs help promote restorative sleep and heighten
the effects of the body’s natural pain-killing substances (endorphins),
and increases non-rapid eye movement (non-REM) stage 4 sleep.
352 Interventional Pain Management—A Practical Approach

Low levels of serotonin and norepinephrine are related to depression,

muscle pain, and fatigue.
Administering TCAs such as amitriptyline helps correct these
deficiencies. Recommended dosing (Amitryptyline) - 25 to 50 mg 2 to
3 hours before bedtime, allowing peak sedative effect with minimal
carry-over effect. May increase dosing to 50 to 75 mg over the next
weeks if needed for added control.
Benzodiazepines are a second alternative, but should be used
cautiously at bedtime due to their tendency to stabilize the erratic
brain waves that interfere with restorative sleep in patients with
fibromyalgia.
2. Treat fatigue and depression: If no response with TCAs, consider adding
selective serotonin reuptake inhibitor (fluoxetine) in the morning.
Recommended dosing 20 mg every morning (QAM). This class of
drugs works to block the re-uptake of serotonin, which in turn allows
the body to utilize greater amounts of serotonin. Treat muscle
spasms. Cyclobenzaprine or low dose benzodiazepines (clonazepam)
are used to treat muscle spasms. See explanation above for
pathophysiological effect of these medications. Cyclobenzaprine also
modulates muscle tension at a supraspinal level. Dosing is 10 to 30
mg every day (QD) or, if greater dosing is needed, divide the doses,
with the smaller dose in the morning and the larger dose in the evening
3. Adequate pain control
• Non-steroidal anti-inflammatory agents – Aceclofenac, parace-
tamol, diclofenac sodium, ibuprofen are all used. Most of the time
they do not work well for these chronic conditions.
• Tramadol may work for few patients. Dosage – 25 to 50 mg tds.
Can be used in combination of paracetamol.
• Muscle relaxants like tizanidine, Thiocolchicoside (Myoril) etc.
are useful in relieving the muscle spasm in acute injury but their
effect in chronic myofacial pain is not clear.
• Local application of various gel/ointments like diclofenac/cap-
saicin etc. can be used. They acts as counterirritants .
• Alternative therapies like hot and cold fomentation, massage can
be useful along with physical therapy.

PHYSICAL THERAPY TREATMENT PRINCIPLES

The goal in treatment is to desensitize supersensitivity15 by restoring the
flow of impulses in a peripheral nerve. When the flow of impulses is briefly
blocked, any supersensitivity that develops will also be transient. But when
contractures and shortened muscles are present, their release is usually
necessary to restore joint range and relieve pain: typically, when the several
most painful contracture bands in a muscle are released, relaxation of the
entire muscle follows.
 Intramuscular Stimulation 353

Acupuncture
• Needle entry in the tissue stimulates it and releases contracture.
• Intramuscular stimulation is based on neurophysiologic concepts.
Traditional acupuncture which is based on ancient philosophy.
• Acupuncture is a word of Western origin, coined in the 16th century to
describe the Chinese use of a needle to promote healing in certain
diseases.

Varieties of Acupuncture
Classical or Traditional Acupuncture, which forms part of the total entity
of Traditional Chinese Medicine (TCM) is widely employed in China. There
are various alteration to the acupuncture across the world but I will not go
into details and we will discuss about this novel technique known as Intra
Muscular Stimulation (IMS).

Intra Muscular Stimulation (IMS)

• This technique is an innovation of Dr C Chan Gunn, MD from at The
Institute for the Study and Treatment of Pain (iSTOP), Vancouver.
• IMS is a system of dry needling that is based on a radiculopathy model
for chronic pain.
• IMS requires a medical examination and diagnosis. It treats specific
anatomic entities selected according to physical signs.
• Anatomy and neurophysiology knowledge is the basis for this therapy.

Equipments
• Cleaning solutions
• The fine, flexible, acupuncture needle. They comes in various sizes – 25
mm, 40 mm, 50 mm, 75 mm
For superficial muscles 25 mm needles is used, for deep placed muscles
longer needles are used.

Indications
• Chronic neck pain - spondylosis
• Frozen shoulder
• Achilles tendonitis
• Bicipital tendonitis
• Bursitis, pre-patellar capsulitis
• Carpal tunnel syndrome
• Cervical fibrositis
• De Quervain’s
• Facet joint pain syndrome
• Hallux valgus
• Juvenile kyphosis and scoliosis
354 Interventional Pain Management—A Practical Approach

• Low-back sprain
• Plantar fascitis
• Piriformis syndrome
• Rotator cuff syndrome
• Shin splints
• Tennis elbow
• Torticollis (acute).

Procedure
The skin is prepared using betadine and alcohol. Under strict aseptic
precautions the needle entered in the affected muscles. Needle is inserted
at regular distance throughout the tender muscle band (Fig. 40.1). To assist
the insertion of needle plunger can be used.

How much Deep to Penetrate

It is the experience of the pain physician to decide how deep one must go.
Care is taken to avoid injury to any major vessels or important organs like
pleura.
The activated and sensitized nociceptors of muscles are so exquisitely
tender that firm pressure applied to it gives rise to a flexion withdrawal
reflex (jump sign) and in some cases the utterance of an expletive (shout
sign). The optimum strength of dry needling at a myofacial trigger point
site is the minimum necessary to abolish these two reactions.14
When the needle penetrates normal muscle, it meets with little
resistance. When it penetrates a contracture, there is firm resistance, and
the needle is grasped by the muscle. The patient feels a peculiar, cramping
or grabbing sensation - the “Deqi response”.

Fig. 40.1: Needle in position

 Intramuscular Stimulation 355

When the needle enters fibrotic tissue, there is a grating sensation.

Sometimes, the resistance of a fibrotic muscle is so intense that its hardness
is mistaken for bone, and increased pressure on the needle may be required
to force it in.

The Needle Grasp (Fig. 40.2)

When the needle penetrates a shortened muscle, it often provokes the
muscle to fasciculate and release quickly – in seconds or minutes. A
shortened muscle that is not quickly released, however, will invariably
grasp the needle. The needle-grasp can be detected by the therapist when
an attempt is made to withdraw the needle the grasp resists withdrawal.
Leaving the grasped needle in situ (Fig. 40.3) for a further period (typically
10-30 minutes) can lead to the release of a persistent contracture.

Fig. 40.2: Needle grasp

Fig. 40.3: Needle in situ

356 Interventional Pain Management—A Practical Approach

Failure of a correctly placed needle to induce needle-grasp signifies that

spasm is not present and therefore not the cause of pain - in which case,
the condition will not respond to this type of treatment.
When there are many muscles, each with many muscle bands or fasciculi
requiring treatment, it may be convenient to hasten contracture-release by
augmenting the intensity of stimulation. The traditional method is to twirl
(rotate) the grasped needle - a motion that specifically stimulates
proprioceptors. As an alternative to twirling the needle, heat (moxibustion)
or electrical stimulation is sometimes used.
Needling can give magic response in many patients. Following needling,
physical signs of peripheral neuropathy, such as muscle contracture
(“spasm”), vasoconstriction and tenderness can disappear within seconds
or minutes. (It is extremely satisfying to see these signs disappear before
one’s eyes). Other signs, like trophedema may diminish more gradually,
sometimes even taking days to disappear, but ultimately, all signs vanish
following successful treatment.
The needle as a powerful diagnostic and treatment tool: The fine, flexible,
solid needle is more than a therapeutic tool, it is also a unique and powerful
diagnostic instrument.

How does Twirling the Needle Work?

When a muscle is in spasm, muscle fibers cling to the needle, and twisting
causes these fibers to wind around its shaft. This coiling of muscle fibers
shortens their length, converting the twisting force into a linear force.
Unlike traction or manipulation, this stimulation is very precise and
intense because the needle is precisely placed in a taut muscle band. The
needle-twirling maneuver vigorously stimulates muscle proprioceptors and
gives rise to a peculiar, subjective sensation known in TCM as the Deqi
(formerly written as Teh Chi) phenomenon. This distinctive sensation is an
extreme version of the muscle-ache felt in myofascial pain.
Twirling the grasped needle elicits the stretch or myotatic reflex. The
reflex is activated by the muscle stretch and causes a contraction in that
same muscle.
By stipulating the needle-grasp and the Deqi phenomenon as
requirements for diagnosis and treatment, TCM has recognized the central
role of muscle proprioceptors in chronic musculoskeletal (radiculopathic)
pain.
In recurrent or chronic pain, fibrosis eventually becomes a major feature
of the contracture; response to dry needle treatment is then much less
dramatic and less effective. The extent of fibrosis present is not necessarily
correlated with chronologic age: scarring can occur after injury or surgery,
and many older individuals have sustained less wear and tear than younger
ones who have subjected their musculature to repeated physical stress.
The treatment of extensive fibrotic contractures necessitates more
frequent and extensive needling because release of the contracture is usually
 Intramuscular Stimulation 357

limited to the individual muscle bands needled. To relieve pain in such a

muscle, it is necessary to needle all tender bands. It is rare to encounter a
muscle that is totally fibrotic and cannot be released by accurate, vigorous
needling.

Mechanism of Pain Relief in IMS

Ideally, stimulation should use the body’s own bio-energy, which can be
recruited in the form of the “current of injury”.1 First described by Galvani in
1797, this current is generated when tissue is injured, for example, following
injection or dry needling techniques including acupuncture.
When the needle pierces muscle, it disrupts the cell membrane of
individual muscle fibers, mechanically discharging a brief outburst of injury
potentials referred to as ‘insertional activity’.1 Injury potentials delivered on
needle insertion are able to relax a shortened muscle instantly or within
minutes.
Needling also induces a sympatholytic effect that spreads throughout
the body segment, releasing vasoconstriction.1 Pain in muscles, tendons and
joints caused by excessive muscle tension is eased when the shortened
muscles are relaxed. Subjective improvement (which can sometimes occur
within minutes) can be confirmed objectively; for example, as increase in
joint range, or reduction of joint effusion. Endogenous opiates, now used
to explain needling techniques, such as acupuncture, cannot account for
all the observed effects.1
Unlike external forms of stimulation, stimulation from a needle lasts
for several days until the miniature wounds heal.
Needling has another unique benefit unavailable to other forms of local
therapy: It delivers to the injured area the platelet-derived growth factor
(PDGF) which induces deoxyribonucleic acid (DNA) synthesis and
stimulates collagen formation.16 Body cells are normally exposed to a filtrate
of plasmas (interstitial fluid) and would only see the platelet factor in the
presence of injury, hemorrhage and blood coagulation.1
IMS differs from Traditional Acupuncture in that it:
• Requires a medical examination searching for early signs of radiculopathy
• Requires a knowledge of anatomy
• Requires a medical diagnosis that usually implicates spondylosis, uses
neuroanatomic points that are found in a segmental pattern, instead of
using traditional acupuncture points, determines the points to be treated
according to physical signs. The effects of IMS appear very quickly and
they can be used to monitor progress.

Post-procedure Care: This is day care procedure and patient is discharged

from the hospital same day.

Injection of “Trigger-points”: In recent years, the injection of “trigger

points” has become widely used.
358 Interventional Pain Management—A Practical Approach

They differ considerably-

TRIGGER POINT IMS

Localized phenomena - foci of hyper-irritable Super-sensitivity manifestations

tissue
Hollow traumatic needle with a bevel – may Needle is pointed and solid almost
be harmful atraumatic
Noxious source is not eliminated Releases contractures – results in long-
term relief
Injection of saline or local anesthetic, with or No medication is injected
without steroids
Serious side-effects due to steroid use may No side effects due to injection
occur

CONCLUSION
Musculoskeletal pain is radiculopathic pain involving segmental peripheral
nerve supplying affected muscle. Diagnosis is mainly clinical. Diagnosis is
by signs of neuropathy which are subtle but can be found if the clinician
knows where to look, and what to look for.
Unfortunately, all external forms of physical stimulation are passive,
and when application is halted, stimulation ceases.
Intramuscular stimulation is a great scientific technique which is based
on anatomy (myotomes). The knowledge of myotomes is essential.
It requires minimal instruments (only thin solid flexible needles). Simple
OPD technique and excellent results makes this technique very popular. It
can be used in variety of conditions.
I will end this chapter with one massage – For many conditions IMS act
as magic for the patients suffering from chronic musculoskeletal pain. Every
pain physician must learn this technique to give patient a quality, cost
effective and long lasting pain relief treatment.

REFERENCES
1. Loeser JD, et al. Gunn’s intramuscular stimulation – The technique. Bonica’s
Management of Pain ( 3rd Edn).
2. Gunn CC, Neuropathic pain: A new theory for chronic pain of intrinsic origin.
Annals of the Royal College of Physicians and Surgeons of Canada 1989;22(5):
327-30.
3. Gunn CC, Milbrandt WE. Tenderness at motor points—A diagnostic and
prognostic aid for low back injury. Bone Joint Surg 1976;58A:815-25.
4. Gunn CC, Milbrandt WE. Tennis elbow and the cervical spine. On Mod Assoc
1978; 14:803-25.
5. Gunn CC, Milbrandt, WE. Tenderness at motor points: An aid in the diagnosis
of pain in the shoulder referred from the cervical spine. JAOA 1977,77:196-
212.
6. Gunn CC. “Prespondylosis” and some pain syndromes following denervation
supersensitivity. Spine 1980;(5):185-92.
7. Cannon WB, Rosenblueth A. The supersensitivity of Denervated structures, a
law of denervation. New York, MacMillan 1949.
 Intramuscular Stimulation 359

8. Culp WJ, Ochoa J. Abnormal nerves and muscles as impulse generators. New
York, Oxford University Press,1982.
9. Klein L, Dawson MM, Heiple KG. Turnover of collagen in the adult rat after
denervation. Bone joint Surg 1977;59A: 1065-7.
10. Woolf CJ, Doubell TP. The pathophysiology of chronic pain increased
sensitivity to low threshold AB-fiber inputs. Curr Opin Neurobiol 1994 ;4:525-
34.
11. Woolf CJ, Thompson SWN. The induction and maintenance of central
sensitization is dependent on N-methyl- D-aspartic acid receptor activation;
Implications for the treatment of post-injury pain hypersensitivity states. Pain
1991;44:293-9.
12. Gunn CC, Milbrandt WE. Early and subtle signs in low back sprain. Spine
1978:3:267-81.
13. Kingerv WS. A critical review of controlled clinical trials for peripheral
neuropathic pain and complex regional pain syndromes. Pain 1997;73:123-39
14. Baldry P. Superficial versus deep dry needling. Acupunct Med 2002;20
(2-3):78-81.
15. Munglani R, Hunt SP, Jones JG. The spinal cord and chronic pain. In: Kaufman
L, Ginsburg R (Eds) Anaesthesia review. New York, Churchill Livingstone
1996; 12:53-76.
16. Thesleff S, Sellin LC. Denervation supersensitivity. Trends in NeuroSciences
August 1980;122-6.
Autho

INDEX

A Cerebrospinal fluid see

Intrathecal pump flow
Adhesiolysis 211
Cervical discography 269
percutaneous 211
Cervical epidural block 163-172
Articular process 22
indications 163
Alternating current 10
Amperage 6 contraindications 164
Amplitude 6 complications 168, 172
Ammonium salts 30 position 166, 168
Anticoagulants 50 procedure technique 165, 169
Anode 6 Cervical facet median branch
Antibiotic 50 block 173-178
Aspiration test 51 indications 174
Atomic structure 3 contraindications 174
Australia antigen 50 complications 177
position 177
B procedure technique 177
Complex regional pain syndrome
Blunt tip needle 343-344 100
Bodies of lumbar vertebrae 22 Collimators 13
Bupivacaine 139 Cryoablation 32
Bone scan 45 CT scan 43
Botulinum toxin 115
D
C
DC (direct current) 10
Catheter, see Intrapleural block
Discography 45, 268-280
Cathode 6
indications 269, 270, 274, 275
Caudal 179-189
contraindications 269
indications 180
complications 279
contraindications 180
position 270, 274, 275
complications 187
epidural 179 procedure technique 270, 274,
Cervical plexus see Nerve block 275
for scalp
Celiac plexus block 137-144 E
indications 138 Electric-
contraindcations 138 circuit 10
complications 142 current 10
landmark 139 Electromagnetic radiation 4
position 139 EMG (electromyelography) 46
procedure technique 139 Epiduroscopy 233, 242
362 Interventional Pain Management—A Practical Approach

indications 234 position 283

contraindications 235 procedure technique 282
complications 242 Implantation 330, 336
position 235 intrathecal 333
procedure technique 235 IMS 347-359
Epidural catheter 131 Impar ganglion 156-159
Epidurogram 236 indications 156
Ethyl alcohol 28 contraindications 159
position 157
F procedure technique 157, 159
Facet joint 173 Informed consent 39
cervical 173 INR 50
lumbar 190 Intercostal nerve block 126-129
Failed back surgery syndrome 211, Intrapleural block 130-133
234, 245 indications 130
Fluoroscopy 51 contraindications 130
Foramen ovale 73 complications 133
position 131
G procedure technique 131
Intervertebral foramen 21
Glossopharyngeal nerve 92-96 Intrathecal implantable
indications 94 devices 333-340
contraindications 94 indications 333
complications 95 contraindications 333
position 94 complications 338
procedure technique 94
position 335
Glycerol 30
procedure technique 335
Grids 13
Iohexol (omnipaque) 151

H
K
Heel effect 7
Kilo voltage 8
Herpetic neuralgia 127
Kinetic energy 4
HIV 50
Hyaluronidase 212
L
Hypertonic saline 30
Hypogastric plexus block 150-155 Laboratory investigations 51
indications 150 Lamina 12
contraindications 151 Line focus principle 6
complications 155 Lumbar facet median nerve branch
position 152 block 190-197
procedure technique 151 complications 196
post procedure monitoring 155 contraindications 192
Hypotonic solutions 30 position 193
procedure technique 192
I post procedure monitoring 196
IDET 281-291 Lumbar sympathetic block 145-149
indications 282 indications 145
complications 289 position 146
 Index 363

procedure technique 146 P

post procedure monitoring 148
Pain diagram 56
Pain mapping 62
M
Percutaneous discectomy 292-299
Magnetic resonance imaging Phenol 28
(MRI) 43 Pneumothorax 129
Mandibular nerve 82-86 Protons 3
complications 86
indications 83 R
position 84 Racz catheter 213
procedure technique 84 Radiofrequency coagulation 314
Mapping 62 trigeminal nerve block 69
Marcaine 323 median branch, cervical 173
Maxillary nerve 77-81 median branch, lumbar 190
indications 78 stellate ganglion 97
complications 81 Radiation dose 12
position 78 Radiation protection 16
procedure technique 79 Radiation counter 51
Median nerve 04 Radiation gloves 51
cervical 173-178 Rectum-ganglion of impar 156
lumbar 190-197 Resuscitation 50
Milli amperes 6 Roentgen as radiation unit 16
Monitoring 50
Morphine see Intrathecal drug S
devices 33
Multidisciplinary 54 Sacroiliac joint 198-203
Myelography 45 indications 198
position 200
procedure technique 199
N
post procedure monitoring 202
Nacl-sodium chloride 212 Spinal cord stimulation 244-256
Needles- indications 245
blunt tip needle 138, 143, 343 complications 254
spinal needle 165 position 246
tuohy needle 132, 182 procedure technique 246
Nerve block scalp 109-117 post procedure monitoring 251
procedure technique 113, 114 Sphenopalatine fossa 87-91
Neural mapping 64 indications 88
Neuromodulation 257 complications 91
NIBP 50 position 89
Procedure room 50 procedure technique 90
Scotty dog 22
Skin burn 325
O
Suprascapular nerve block 121-125
Ohms 6 indications 121
Opioids 330 complications 124
364 Interventional Pain Management—A Practical Approach

position 123 U
procedure technique 123
Ultrasound 143
Stellate ganglion 97-108
indications 100
V
complication 106
position 102 Vertebrae 19
procedure technique 102 anatomy- lumbar 22
post procedure monitoring 105 Vertebroplasty 300-307
Steroids 123 indications 300
Stimulation 62 complications 306
position 302
T procedure technique 302
Visceral pain 137
Thermography 48 Visual analogue scale 56
Thyroid shield 51 Voltage 6
Tube shielding 7
Tuohy needle 132, 182 W
Triamcinolone acetate (Kenacort)
see Watt 8
cervical 165
lumbar 181 X
caudal 181 X-ray 3-18
Trigeminal nerve block 69-76 basis 3
indications 71 circuit 6, 10
complications 75 electromagnetic radiation 4
position 72 x-ray tube 5
procedure technique 72
trigeminal ganglion 69 Z
trigeminal neuralgia 69
Tunnel vision 51 Zygomatic arch 84