September-October 2017
Figure from Murphy

Image-Guided Spine Pain Management

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Vinil Shah

It is my pleasure to serve as the guest editor of this edition of the AJNR News Digest, which focuses on the topic of image-guided spine pain management. Disorders of the spine have a tremendous impact on society—directly through the morbidity of afflicted individuals and indirectly through lost productivity and increased health care costs. In 1998, total U.S. health care expenditures for low back pain were estimated at $90 billion.1 Since that time, costs of low back and neck pain care have risen substantially, at a rate higher than that observed for overall health expenditures.2 In the United States, an estimated 149 million work days are lost every year because of low back pain.3

Spinal injections of steroids have been widely used in the management of back pain for more than 50 years.4 Image-guided spine injections (when performed for appropriate indications) and using contemporary techniques can provide significant benefits in relation to pain relief, disability, and quality of life in these patients, identify the specific pain generator, and help avoid surgery. These injections have a low-risk profile compared with alternative treatments and are effective when used as part of a multimodal treatment plan that includes physical therapy, exercise, and activity modifications.

Between 1994 and 2001, the use of epidural steroid injections increased by 271% and facet joint injections by 231% among Medicare beneficiaries.5 Medicare payments for spinal injections expanded 629% during that time period.5 More recent data indicate continued rapid growth in the use of spinal injection therapies. The success of spinal injections in alleviating symptoms depends on the ability to deliver the anti-inflammatory medication (corticosteroid) precisely to the specific site of inflammation. For example, with disc herniations, the inflammatory response (and hence the site of pain generation) is at the interface of the herniated disc and traversing neural tissue. This site is frequently within the ventral epidural space, subarticular zone, or neural foramen. For this reason, transforaminal epidural steroid injections (TFESIs) may be more effective than interlaminar epidural steroid injections (ILESIs) in targeting the specific pain generator in the setting of an acute disc herniation.

Image-guided spinal injections have a high safety profile; however, appropriate risk mitigation techniques are necessary to avoid extremely rare, catastrophic complications, such as direct spinal cord or vascular injury or CNS infarcts.6 Risk mitigation techniques include thoroughly reviewing preprocedure imaging (to identify the pain generator and vulnerable soft tissue structures), using appropriate imaging … more »


Intraforaminal Location of Thoracolumbar Radicular Arteries Providing an Anterior Radiculomedullary Artery Using Flat Panel Catheter Angiotomography

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Lydia Gregg

We chose this research topic after noting that previous studies of the intraforaminal location of radicular arteries providing an anterior radiculomedullary artery (ARMA) were limited by 1) the field of view investigated, 2) the use of the cadaveric materials, or 3) the inability to specify whether the studied vessels were radicular branches providing an ARMA, a different artery, or even … more »


CT Fluoroscopic Cervical Transforaminal Epidural Steroid Injections: Extraforaminal Needle Tip Position Decreases Risk of Intravascular Injection

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Gerritt Lagemann

Transforaminal epidural steroid injections (TFESIs) are commonly performed in the evaluation and treatment of radicular neuropathy. Although TFESIs are widely performed in the lumbar spine, many proceduralists are reluctant to perform cervical TFESIs due to the risk of rare but serious complications such as posterior circulation stroke and spinal cord infarct. These complications are commonly thought to be caused by … more »


Deleterious Effects of Intra-arterial Administration of Particulate Steroids on Microvascular Perfusion in a Mouse Model

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Jean-Denis Laredo

Ninety severe and sometimes fatal neurologic events occurring immediately after epidural injection of suspensions of particular glucocorticoids were reported to the FDA between 1997 and 2014, most being foraminal injections.1 Our team reported 5 cases of paraplegia complicating selective injections of particulate steroids in the lumbar spine.2

The almost immediate onset of neurologic deficit, as well as the MR findings performed … more »


Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance

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Peter Kranz

CT fluoroscopy (CTF) is a powerful technology for performing image-guided procedures. It marries the benefits of cross-sectional imaging with real-time intraprocedural imaging to allow for highly precise image guidance. Procedures can usually be performed as quickly as conventional fluoroscopy-guided procedures and with equivalent or decreased radiation doses. CTF particularly excels in cases of difficult anatomy or patients with larger body … more »


Treatment of 213 Patients with Symptomatic Tarlov Cysts by CT-Guided Percutaneous Injection of Fibrin Sealant

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Kieran Murphy

I began treating patients with symptomatic Tarlov cysts 12 years ago at the Johns Hopkins Hospital. At Toronto Western Hospital (University of Toronto), I see 4–7 women a week with Tarlov cysts. Many cannot sit and stand through the patient encounter. I was reluctant initially, but these patients were suffering and some were suicidal. These patients suffer from sacral and … more »


Percutaneous Injection of Radiopaque Gelified Ethanol for the Treatment of Lumbar and Cervical Intervertebral Disc Herniations: Experience and Clinical Outcome in 80 Patients

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Matteo Bellini

Sciatica due to a lumbar disc herniation and nerve root irritation is a huge public health problem not yet benefiting from an unequivocal treatment approach. Even cervical hernias with brachialgia afflict a substantial range of the population.

Medical and physical therapies represent the first therapeutic steps. When these fail, minimally invasive treatments may play an important role; percutaneous techniques can be … more »