Download Chapter 9 – MUSCLE TISSUE

Chapter
25
Peripheral Joint,
Soft
Tissue
&
Spinal Injection
Alireza Ashraf, M.D.
Professor of Physical Medicine & Rehabilitation
Shiraz Medical school
1901
Cathelin----epidural with cocain
1951
Hollander-----------------------hydrocortisone
1957
Lievre-------------------------------------------------------------
-----------epidural with corticosteroid
&
Capra---------------------S1
Robecchi
Pain sources within joints:
capsule, tendons, ligaments,
synovium and periosteum.
Common spine pain :
facet joint, sacroiliac joint, nerve
root (spinal nerve) and
intervertebral disk.
Rheumatoid arthritis,Osteoarthritis
Spondyloarthropathies,Gout,
Pseudogout,Bursitis,Adhesive
capsulitis,Tendonitis,Axial spine
pain, Sympathetic-mediated
disorders and Radiculopathy.
INJECTION
MATERIALS


.The mechanism that allows local
anesthetics to provide pain relief
is the reversible neural blockade…
blocking sodium channels…….
Local anesthetics
Local anesthetics can have side
effects locally or systemically
 seizures,respiratory
arrest,convulsions,confusion,death
,tremor,sluggishness,twitches,
drowsiness,blurred vision,incoherent
speech,light-headedness,cardiac
depression,malignant hypertension,
and anaphylaxis.

Corticosteroid

Corticosteroids have two
mechanisms:
antiinfiammatory &
immunosuppressive.


Corticosteroids have been utilized for treatment
of musculoskeletal pain because of
their antiinflammatory
properties……………………………………………….
They have also been reported to have a direct
membrane-stabilizing effect, which leads to
decreased afferent ectopic discharges at the
neural membrane…………..
There is a reversible inhibition of
nociceptive C-fiber transmission with
local application of
corticosteroids.there has been no
demonstration of AorB fiber
transmission interruption………………..
 Corticosteroids have a modulation
effect on spinal cord……………………….

Betamethasone,
Dexamethasone,
Hydrocortisone,
Methylprednisolone,
Prednisolone
and
Triamcinolone.
Adverse corticosteroid
reactions
Skin hypopigmentation,subcutaneous
fat atrophy,tendon rupture,fluid
retention,
flushing,hyperglycemia,change in
taste, insomnia,malaise and
dyspepsia…………………………………………
Systemic suppression of the adrenal glands
can happen after a local injection of
corticosteroids into any structure………
Repeated injections of corticosteroids can
lead to a cushingoid appearance…………….



Non-ionic contrast agents include metrizamide
(Amnipaque), iopamidol (Isovue), and iohexol
(Omnipaque)…………….
These are used in conjunction with fluoroscopy for
needle tip localization in performing spinal injection
procedures and some peripheral joint
injections………………..
The use of contrast significantly reduces
the risk of an unintended injection into a
vascular area, blood vessel or
subarachnoid space………………
The adverse effects that can result from the use of
contrast agents are due to local tissue toxicity and to
anaphylaxis……………………………………………………..
 Greater than 90% of adverse reactions occur within the
first 15 min…………………………………………………….
 other side effects :nausea, headache, and emesis…..


Pretreatment is recommended with steroids
and antihistamines 12 h, and again at 2 h,
prior to the procedure in patients with an
allergic reaction history……………….

Gadolinium is a viable alternative for
patients with contrast material
allergies, and provides adequate
visualization for spinal injection
procedures………………………
GENERAL
CONSIDERATIONS



Answer all questions. provide the patient with
a clear explanation of the risks and
benefits………………………………………………
Caution should always be used to avoid the
risk of bleeding. Patients using aspirin
should discontinue it for at least 7 days. If
patients cannot tolerate being off aspirin, a
non-selective NSAID can be substituted for at
least the 3 days prior to any injection…
Women who are pregnant or suspected to be
pregnant should avoid radiation exposure
from fluoroscopy………………….

The patient is properly positioned on the
procedure table before beginning the
injection…………………………………………………
Prepare and drape the injection site in a
sterile manner with povidone-iodine
(Betadine), chlorhexidine gluconate
(Hibiclens), and/or isopropyl alcohol………….

Sterile gloves are worn during the injection


procedure………………………………….
Gown, cap, and mask are used when
performing myelography and diskography….


Intravenous or oral antibiotics are used
when performing injection procedures
in patients with implanted prosthetic
devices or with a history of mitral valve
prolapse…….
The injection site can be anesthetized
for patient comfort with a vapocoolant
spray OR anesthetic cream prior to
injection………………….


The needle is always aspirated via the
syringe before the injection to avoid an
intravascular or, in the case of some spinal
procedures, an intrathecal injection…………
Avoid injecting into a ligament, a
tendon, or the periosteum. This means
repositioning the needle if there is significant
resistance………………………………

Avoid needle contact with articular
cartilage surfaces during joint
injections…………………………………………..
The injection is given slowly, with steady
pressure…………..
 A dressing is applied to the injection site
after the injection is completed……….



The patient is encouraged to rest the
area after the injection for several
days, especially if it is a major weightbearing joint……………
All patients should be driven home and
should not drive for the next…………
CONTRAINDICATIONS

Absolute contraindications
Bacteremia***
Joint infection***
Cellulitis***
Skin ulcerations***
Osteomyelitis***
Infectious arthritis***
Epidural abscess***
Joint injections requiring fluoroscopy in the
pregnant patien**********************
Relative contraindications
Chronic infection distant from the injection**
Allergy to the injection solution **
Latex allergy **
Diabetes mellitus **
Allergy to contrast agents for
fluoroscopically **
Altered anatomy( surgery or congenital ) **
Tendons and ligaments can be
ruptured if corticosteroids are
injected directly into them (this is
estimated to occur in less than 1% of
such cases)…………………………..


Patients requiring anticoagulation
medication or with a known bleeding
diathesis should be approached with a
great deal of caution…………………………..
Coagulation parameters should be
evaluated in these cases, including :
prothrombin time,,,,activated
partial thromboplastin time,,,,
international normalized ratio
(INR) and platelet level count……
 Injections
should be avoided
with prolonged bleeding
times, an INR greater than 1.2
and a platelet count of less
than 100 000 per ml…….
EFFICACY

Improvement in rheumatoid
synovitis has been seen to last for
as long as 3 months after
injecting glucocorticoids, with
improvement in pain and in knee
extensor
strength…………………………………….

intraarticular injections of
hyaluronan (hyaluronic acid,,,,,,
hyaluronate) were more effective
than placebo in reducing pain and
improving joint function from
osteoarthritis of the
knee……………

A small randomized controlled
trial found no significant
difference between intraarticular
injections of methylprednisolone
plus lidocaine (lignocaine) versus
lidocaine alone for the treatment
of shoulder pain, although there
was a small improvement in pain
and range of motion in both
groups at 24
weeks……………………………….
Acromioclavicular joint

The injection is performed with
the patient in the seated position
with the upper limb resting
comfortably……………………………….
The acromioclavicular joint is
located at a depressed and soft
region distal to the end of the
clavicle……………………………………..

The injection site is anterior and
superior to acromioclavicular joint
………………………………………
The needle is then advanced
inferiorly into the joint……………..
Glenohumeral joint


The glenohumeral joint is typically
injected from either an anterior or a
posterior approach………………………
In the anterior approach, a needle
is inserted lateral to the coracoid
process while avoiding the
thoracoacromial artery .The needle is
then directed dorsally and medially
into the joint space…………

The posterior approach is set up
by placing the patient's hand
across the chest on the opposite
shoulder. The needle is inserted 23 cm below the posterolateral
aspect of the acromion. The needle
is then advanced toward the
coracoid process in an anterior and
medial direction into the joint.
Subacromial bursa


The subacromial bursa lies above the
supraspinatus tendon and under the
acromion……………………………………………..
A posterolateral approach is used to
place the needle into the subacromial
space.The needle is inserted underneath
the palpable posterolateral cornerof the
acromion and advanced toward the
coracoid process,which places the needle
tip under the acromion………………………….
Ulnohumeral(elbow)joint


The elbow joint consists of three
articulations between the humerus, ulna
and radius, with the true elbow joint
formed by the humerus and ulna………….
Injection of the ulnohumeral joint is
accomplished from a posterolateral or
posterior approach with the elbow
flexed between 50 and 90°…………………..


In posterolateral approach, the
needle is inserted in the posterolateral
triangle formed by the palpable olecranon,
lateral epicondyle and radial head
…………………………………………………
The needle is directed medially away from
the ulnar nerve and proximally toward the
head of the radius. A lack of resistance
indicates entry of the needle tip into the
joint………………………………….

The posterior approach to the
elbow joint involves inserting the
needle in between the posterior
olecranon and lateral epicondyle,
advancing the needle until there
is a loss of tissue resistance
(indicating that the needle tip is
within the
joint)………………………….
Medial and lateral epicondyle

Medial epicondylitis or
'golfer's
elbow', results from tendonosis or
degenerative changes at the tendon
attachment of the wrist flexor and
pronator muscle groups. The elbow is
positioned in abduction,with the forearm
in supination.A needle is inserted at the
site of tenderness along the medial
epicondyle and advanced until there is
contact with the periosteum.The needle is
slightly withdrawn before the
injection……………

Lateral epicondylitis or
'tennis elbow', is a tendonosis
from repetitive wrist extension
and forearm supination. The
elbow is flexed to 45° and the
forearm is placed in pronation. A
needle is inserted at the point of
tenderness along the lateral
epicondyle and advanced to the
periosteum………..
Olecranon bursa


Olecranon bursitis or
'draftsman's
elbow', occurs in RA, crystal
arthropathies, and repetitive trauma. The
needle is directed toward the olecranon
bursa, which is superficial to the
olecranon and external to the elbow joint
………………….
Injection of the olecranon bursa should be
preceded with aspiration and no
corticosteroids should be injected if there
is a purulent discharge……………….
Carpal tunnel

Injection of the carpal tunnel can be
approached in ulnar or radial
orientation, based on positioning
relative to the palmaris longus
tendon…………………………………………..

The ulnar approach is preferred. it is
less likely to injure the median nerve
during the injection. The wrist can be
flexed to increase the prominence of
the palmaris longus tendon…………….

A needle is inserted with the wrist in a
neutral position at a 30° angle ulnar to
the palmaris longus tendon at the
distal wrist crease .The needle is then
advanced in a distal and radial
direction underneath the transverse
carpal ligament. The needle is
withdrawn if paresthesias are
experienced during the insertion, and
redirected within the tunnel……..
Abductor and extensor pollicis
tendon

De Quervain's tenosynovitis is an
inflammatory disorder of the wrist
involving the abductor pollicis longus and
extensor pollicis brevis tendons. The
needle is placed 1cm proximal to the
styloid process at a 45°angle to the
forearm alongside either tendon …………
The needle is repositioned before the
injection if there are any paresthesias
encountered from the radial nerve during
needle insertion………………………
Greater trochanter and ischial
bursae
The patient is placed in the lateral
decubitus position, with the
affected hip upright and the knees
flexed to relax the
hamstrings……..
 The lateral hip and inferior
buttock areas are palpated for the
point of greatest tenderness over
the greater trochanter and the
ischial tuberosity,
respectively………………

For both injection procedures, the
needle is inserted through the
skin and advanced until contact is
made with the
periosteum……………………………..
 The needle is then slightly
withdrawn so that the tip lies
within the bursa………………………

Hip joint

Intraarticular injections of the hip joint
require fluoroscopic guidance and
contrast enhancement, whether using a
lateral or an anterior approach. Anterior
approach, the patient is placed in the
supine position with the lower limb in
external rotation. The needle is inserted
at a site just inferior to the mid
trochanteric line…………………………………

The needle is inserted at a site
just inferior to the mid
trochanteric line. The needle is
inserted 45° toward the femoral
neck, and advanced under
fluoroscopic guidance through the
capsule until contact with the
periosteum………………………………
…..
Knee joint


The knee joint is the most common joint
site for both injection and aspiration.
There are three possible approaches:
medial, lateral, and anterior. The patient
is positioned supine for aspiration, with
the knee fully extended or slightly flexed.
The superior medial or superior lateral
approaches are generally held to be the
best for arthrocentesis……………..
The patella is located by palpation and is
the main landmark for localizing the entry
site……………………………………………


For the superior lateral approach, the
entry site is about 1 cm superior and lateral
to the patella. The skin is penetrated using a
large-gauge needle directed at 45° and
advanced under the patella toward the medial
side of the joint…………………………….
The needle is advanced into the joint, while
applying negative syringe pressure, until
synovial fluid starts to enter the syringe. The
fluid aspiration can be aided by applying
pressure to the medial aspect of the joint to
displace the effusion toward the direction of
the needle……………………….
For the superior medial approach,
needle entry is 1 cm superior and
medial to the
patella…………………..
 The needle is directed under the
patella and advanced toward the
opposite patella midpole, midway
between the medial border of the
patella and the
femur………………….

The advantage of the anterior
approach is greater ease of entry
into knees with advanced
osteoarthritis, as well as for
patients who cannot fully extend
their
knees…………………………………
 The downside to this approach is
a greater risk for meniscal and
articular cartilage injury……………..




For injections of corticosteroids without
synovial fluid aspiration, the patient is
positioned as described or with 90° of
knee flexion……………………………………….
The entry site for injection with the knee
in the flexed position can be on either the
medial or the lateral aspect of the patellar
tendon……………………………..
The joint is entered inferior to the patella,
using a needle directed superiorly toward
the intercondylar
notch…………………………………………………

The inferior medial approach is
technically easier for injection
than the lateral approach if the
patient can only slightly flex the
knee…………………………………………
.
pes anserine bursa
The pes anserine bursa is located
between the medial collateral ligament
and the confluence of the sartorius,
gracilis, and semi-tendinosus tendon
insertion at the proximal medial tibia
just distal to the joint
line…………………………………..
 A needle is inserted at the site of
greatest palpable tenderness
perpendicular to the tibia, and
advanced until contact is made with
the periosteum………………………………

prepatella bursae


The prepatellar bursa is located between
the skin and the anterior surface of the
patella. The needle is inserted at the
midportion of the superior patellar
pole………………………….
The bursa can be significant is size from
inflammation, which often allows for fluid
aspiration that can be aided by direct
pressure over the patella before
injection…………………………………………….
ANKLE JOINT



The ankle joint is formed by the tibia and
talus (tibiotalar mortise), and is not one of
the more commonly injected
joints…………………………………………………
The main indication for injecting the ankle
is for pain secondary to
osteoarthritis…………………………………..
The two approaches for performing an
ankle joint injection are the anterior
medial and anterior lateral……………...

The talus is palpated with the foot
in the neutral position. A
horizontal line can be drawn
between the medial and lateral
sides of the ankle, just above the
malleoli……………………………………



For the anterior medial approach, a
soft spot is identified medial to the
anterior tibial tendon and lateral to the
medial malleolus………………………………..
The needle is inserted perpendicular to
the tibial joint surface and advanced
slightly laterally, superiorly, and
posteriorly…………………………………………
The injection is then given slowly after
there is a decrease in tissue resistance
indicating that the needle has entered the
joint…………………………………………….



The anterior lateral approach is
done with the patient positioned with the
foot in plantar flexion…………………….
The needle is inserted from the anterior
lateral position and directed posteriorly
toward the medial malleolus………………..
The needle again is advanced until there
is a drop in tissue resistance confirming
entry into the joint……………..
Tarsal tunnel


The patient is placed in a lateral
decubitus position with the symptomatic
foot down……………………..
The posterior tibial nerve is posterior to
the posterior tibialis tendon, which is
identified by resisting foot inversion. The
needle is inserted behind the medial
malleolus posterior to the tendon,at a 30°
angle, and advanced a few centimeters
before the
injection……………………………………………
Plantar fascia
Plantar fasciitis is the most common
problem of the hind foot, with inflammation
that occurs at its medial attachment to the
calcaneus…………………
 The needle is inserted at this location
perpendicular to the calcaneus, and
advanced until it hits periosteum. The
needle is then repositioned and advanced
distal to the plantar surface of the bone,
placing the needle tip superior to the
plantar fascia……………………………………….


The injection is then performed in this
position, which avoids the superficial
fat pad, the subcutaneous tissue, and
the fascia that could otherwise lead
to fat pad atrophy or tissue necrosis
or rupture of the
fascia……………………..
Achilles (retrocalcaneal,
retro-Achilles) bursae

The retrocalcaneal bursa is
located between the calcaneus
and the Achilles tendon, whereas
the retroAchilles bursa is located
between the Achilles tendon and
the skin.Either of these disorders
can be mistaken for Achilles
tendonitis or occur in combination
with Achilles tendonitis (Haglund
syndrome)…
An injection of the bursa should be considered only
in severe, disabling cases after failure of
conservative treatment……………………………………..
 The patient is forewarned about Achilles tendon
rupture as a possible side effect of the
corticosteroid injection……………………………………..
 To locate the area of maximum tenderness, the
Achilles tendon insertion site is palpated deep,
superficial, and at the tendon. The retrocalcaneal
bursa is injected deep to the tendon, whereas the
retroAchilles bursa is injected superficial to the
tendon……………………………………………………….

Morton's neuroma
Morton's neuroma is actually a
perineural fibrosis of the common
digital nerve as it passes between
the metatarsal
heads………………….
 The neuroma most commonly
occurs at the distal aspect of the
third metatarsal
space………………..


A needle is passed through the
dorsal surface of the foot and
advanced about 1 cm proximal to
the metatarsal web space. The
needle is advanced deep enough
to place the tip at the level of the
neuroma, while at the same time
avoiding the plantar fat
pad…………………
SPINAL
INJECTION
TECHNIQUES
Indications
Radiculopathy******************
 SI joint************************
 Facet joint*********************
 Epidurography******************
 Diskography********************
 Myelography********************
 Sympathetic procedures*******

EPIDUROGRAPHY

Epidurography is utilized during
epidural procedures to determine
proper needle placement and to
avoid intravascular or intrathecal
injections………………………………….
.
MYELOGRAPHY
Myelography is a diagnostic
procedure commonly combined
with computed tomography (CT)
for the evaluation of spinal
pathology, including:::::::::::::::::::::::
 disk herniations,
 stenosis,
 tumors,
 infection……………………………………

DISKOGRAPHY
Diskography is a procedure used to identify
whether or not an intervertebral disk(s) is
generating axial spine pain in the cervical,
thoracic, or lumbar regions…
 Diskography is recommended after there
has been no response to conservative
treatment and traditional diagnostic
modalities, such as (MRI), CT, myelography
and EDX are unremarkable or not
diagnostic……………..





Diskography is also used for surgical
planning when considering an
intradiskal procedure, such as
intradiskal electrothermal therapy*
fusion*****************************
artificial disk replacement*********
complications
Intravascular or
subarachnoid****
 Allergic reaction*****************
 Anaphylactic reaction************
 Vasovagal syncope**************
 Dural
puncture*******************
 Spinal headache*****************
 Epidural
abscess*****************

ALLERGY--------------ANAPHYLAXY


Allergic or anaphylactic reactions can
occur from either corticosteroids or
radio-logic contrast
material………………………….
Typically, contrast allergies occur at
the time of the injections, and can
quickly progress to an anaphylactic
reaction with respiratory
compromise………………..

Corticosteroid allergic reactions are
often delayed by up to a week, and present
as an intense hot, erythematous flushing
involving the neck, face, and occasionally
the chest area.
 Corticosteroid anaphylactic reactions often
occur within 2-6 h after the
injection………………………………………………
 While there is concern regarding
respiratory compromise, there have been no
reported fatalities…………………………….
VASOVAGAL EPISODES


Vasovagal episodes can occur with any
type of injection procedure, whether it is a
joint injection or a spinal procedure, due
to the noxious stimulation effect from the
needle. Patients typically become
diaphoretic, hypotensive, and
bradycardic………………………………………
Treatment is primarily supportive,
including fluids and oxygen, but begins
with getting rid of the noxious stimulation
by removing the needle…….
DURAL PUNCTURES




Dural punctures have a low reported
incidence…………………………………………..
Headaches resulting from dural puncture
have been reported to range from 7.5% to
75%.....................................
The use of smaller gauge needles with
conical noncutting tips has been
associated with fewer episodes of
headaches…………………………………………
Dural puncture headaches can occur 1-2
days after a translaminar or
transforaminal epidural……………………….
SUBARACHNOID
---------INTRAVASCULAR
INJECTION


A subarachnoid or intravascular
anesthetic injection can lead to
periorbital numbness, disorientation, lightheadedness, nystagmus, tinnitus,
complete sensory or motor block, muscle
twitching, respiratory depression, and
seizures…………………….
The risk of complications from intrathecal
and intravascular injections of local
anesthetic is proportional to the
injected volume………………………
EPIDURAL ABSCESS
An epidural abscess is rare from
an injection, and is more common
with the use of an indwelling
catheter……………………………………
.
 Patients with an abscess present
with severe back pain, fever, and
chills………………………………………..

EPIDURAL HEMATOMA



The risk of epidural hematoma increases
with anticoagulation but is rare in the
presence of normal clotting
factors………………………………………………
A hematoma can potentially lead to
caudal equina compression in the lumbar
spine, or cord compression in the cervical
and thoracic spine…………..
The presence of spinal stenosis increases
this compression risk………….

Epidurals should be avoided in
patients with a platelet count less
than 100 000 per ml and a
spinal canal midsagittal diameter
less than 12 mm………………………
Complications of transforaminal
epidural steroid injections (TFESIs)
Infection*************************
 Allergic
reaction******************
 Bleeding
*************************


Injury to the radicular artery,
particularly the artery of
Adamkiewicz (lower thoracic and
upper lumbar levels), or other
collateral arteries within the
foramen is believed to occur as a
result of spasm, puncture,
thrombosis, or embolization by
corticosteroid particulate
matter.

This complication might be
reduced or eliminated by inserting
needles into the posterior portion
of the foramen, while avoiding
injections in the presence of
significant foraminal stenosis,
using blunt tip needles, and
injecting with non-particulate
corticosteroids...............................
.
Complications from cervical facet
injection
Vertebral artery puncture***************************
Motor and sensory block****************************
Phrenic and recurrent laryngeal nerve paralysis*****
Spinal cord trauma**********************************
Spinal anesthesia***********************************
Dural puncture**************************************
Intravascular injection******************************
Chemical meningitis********************************
Hematoma formation*******************************
Pneumothorax**************************************
Infection*******************************************
complications of SIJ injection
Posterior leakage of contrast into
the dorsal sacral foramina,can
affect the nearby neural
structures such as L5
&lumbosacral plexus**
 Trauma to the sciatic nerve******
 Infection*************************
 Adverse drug reactions***********

complications from stellate
ganglion blocks
Pneumothorax*******************
*
 central nervous system
toxicity***
 low blood
pressure****************
 phrenic nerve
block***************
 brachial plexus block*************


This procedure is rarely
performed bilaterally, because of
the risk of blocking the phrenic
and recurrent laryngeal
nerve………….
Complications from lumbar
sympathetic blocks
lumbar plexus block**************
 renal
injection********************
 genitofemoral
neuralgia***********
 Hypotension*********************
*
 postdural puncture headache*****
 spinal block**********************

complication from a myelogram

Postdural puncture headache is
the most common complication
from a
myelogram……………………….



Epidural hemorrhage is a reported
complication of myelography……………….
Spinal cord puncture is another
potentially serious complication when
cervical myelography is performed with a
lateral Cl, C2 approach……………………..
This risk can be eliminated by using a
lumbar puncture to instill contrast for a
cervical myelography………………………….
complications from diskography


diskitis, nerve root injury,
bleeding, allergic reaction,
subarachnoid puncture, soft
tissue infection and chemical
meningitis………………………………………
The incidence of diskitis can be reduced
with meticulous aseptic technique,
prophylactic antibiotics and two-needle
technique…………………………………………..
EFFICACY
The largest number of epidural
outcome studies has been
reported for lumbar epidural
steroid injections followed by
cervical epidural steroid
injections………………………………….
.
 There are no published
randomized studies for thoracic
epidural steroid
injections…………..




The evidence for caudal epidurals is
strong for short-term relief and moderate
for long-term relief………………
The findings for interlaminar epidurals
are moderate for short-term relief and
limited for long-term relief of symptoms.
The results for TFESIs are strong for
both short- and long-term relief…………..


There is a 10-30% prevalence of
sacroiliac joint dysfunction as the cause
of low back pain.There are no definitive
historical, physical examination, or
diagnostic findings that are specific for
sacroiliac joint pain……………………………
Only 22% of sacroiliac joint injections are
successfully performed without
fluoroscopic guidance ………………………..
 Epidurography is an integral
part of performing interlaminar
and transforaminal steroid
injections. Epidurography is used
to confirm needle placement in
the epidural space prior to
instilling therapeutic agents and
to avoid intravascular or
intrathecal
injection……………………………………
.

Epidurography is also used to
evaluate the status of the
epidural space, such as in the
postoperative spine
patient…………
 Myelography is a diagnostic
imaging study in which
radiopaque contrast material is
injected into the intrathecal
space under direct fluoroscopic
observation. Multiple x-rays are
obtained after contrast injection
to evaluate specific areas of the
spinal canal……………..
Myelography is helpful
(particularly when combined with
CT) in the evaluation of
intrathecal pathology, such as


tumors***************************
arachnoiditis*********************
 disk pathology*******************
 nerve root compression**********
 spinal
Myelography with flexion and
extension views allows for a
dynamic spine evaluation under
fluoroscopy that is not possible
with MRI or
CT……………………………
 Myelography is also used when
MRI or CT are
inconclusive………….

 Diskography has demonstrated a
60% prevalence of diskogenic neck pain
in the post-traumatic chronic neck pain
population…………………………………..

Diskography has detected a 40%
prevalence of diskogenic pain in patients
with 6 months of chronic low back pain,
who have had an otherwise unremarkable
diagnostic workup including imaging
studies …………………..
Cervical
thoracic
lumbar
********************
epidural injection
Interlaminar approach


Imaging studies (MRI or CT) of the
cervical and thoracic spine are
recommended to evaluate any possible
compromise to the epidural space prior to
performing an interlaminar epidural
injection at the cervical, thoracic, and
upper lumbar levels…………………………….
The same applies to mid and lower lumbar
levels in the postoperative
patient……………………………………………….




The patient is positioned prone on the
fluoroscopy table ………………………………
The entry level for the cervical spine is
typically at the C7-T1 level………………..
At the site of pathology for the thoracic
and lumbar spine……………………………….
Epidural injections are avoided at sites of
previous posterior spine surgery, due to
the obliteration of the epidural space and
the subsequent increased risk of
intrathecal penetration……………………..
An epidural needle is advanced through the skin
using a paramedian approach under intermittent
fluoroscopy until contact is made with the lamina
The needle is 'walked off' the laminar edge on to the
ligamentum flavum…………………………………….
 A 2-3cc volume of non-ionic contrast is slowly
injected under fluoroscopy after negative aspiration
to produce an epidurogram to confirm appropriate
needle placement…………………………...
 A 1-cc test dose of lidocaine (lignocaine) is injected,
after which the anesthetic and corticosteroid
solution is slowly injected into the epidural
space………………………………………………….

Transforaminal approach

The patient is positioned in the
supine position for a cervical
TFESI, and the C arm or the
patient is positioned obliquely
until there is a clear view of the
foramen…………………………………..

The patient is positioned in the
prone position for a thoracic or
lumbar TFESI, and the C arm or
the patient is positioned obliquely
until the tip of the ipsilateral
subjacent superior articular
process divides the pedicle in
half.

At least 0.5 cc of non-ionic
contrast is injected under
fluoroscopy………………………………
Syringes are exchanged for the
anesthetic and steroid mixture…..
The solution is slowly injected
after a negative 1-cc test dose……
Caudal injection

A spinal needle penetrates the
skin at a 45° angle between the
sacral cornu, and is advanced
until it contacts the sacrum. The
needle is slightly withdrawn and
advanced at a shallow 10° angle
through the sacrococcygeal
ligament into the epidural
space….

After negative aspiration, contrast
is injected under fluoroscopy into
the epidural space, followed by
the injectate
solution………………………..
Sacroiliac joint injection
technique
The needle pierces the posterior
sacroiliac ligament and then
enters the joint at the hyperlucent
area………………………………………….
.
 Contrast is injected after negative
aspiration to produce an
arthrogram to confirm needle tip
placement…………………………………
.

Myelography injection technique



The patient is placed prone on the
fluoroscopy table, with the head of the
table elevated 5-10°……………………………
The skin and subcutaneous tissue are
anesthetized with 1% lidocaine
(lignocaine)……………………………………….
A spinal needle is placed midline at the
L2, L3 level to ensure the introduction of
contrast above the L3 vertebral level.
The spinal needle is advanced
under fluoroscopy………………………
 There is resistance as the needle
enters the ligamentum flavum,
which decreases as it passes
through the ligament into the
subarachnoid
space……………………




The needle tip bevel is turned cephalad,
and there is flow of CSF after removing
the stylet…………………………………………..
If there is no CSF flow, a lateral
radiographic view is recommended to
check the needle depth………………………
If the needle depth is correct, the patient
is asked to perform Valsalva's
maneuver, which inevitably leads to flow
of CSF through the needle……………
Approximately 18-20 cc of
contrast is injected to complete
the myelogram, after which x-rays
are obtained, including
anteroposterior, lateral, oblique,
flexion and extension views ……….
 A CT scan is performed
afterward to complement the
myelogram……………………………
…

For cervical and thoracic myelography, the
contrast is injected in the same manner
into the lumbar subarachnoid space. The
patient is then placed into Trendelenburg's
position to allow for flow of contrast into
the cervical and thoracic
areas…………………………………………………..
 Care is taken to avoid contrast flow into the
foramen magnum…………………………….
 CT and regular x-rays are performed after
the myelogram injection………………………..


Routine postmyelography instructions
include head elevation at 30-45°
above the horizontal plane for 12-24 h
and oral fluids……………..
Diskography injection
Intravenous antibiotics and
light intravenous sedation are
given to the patient prior to
starting the
procedure………………..
 Intradiskal antibiotics can be
given as an alternative or in
addition to the intravenous
antibiotics for prevention of
disk
infection…………………………..

The patient is positioned in a
modified lateral decubitus
position when performing thoracic
and lumbar diskography, with the
symptomatic side
down………………
 The needles are then placed
into the disks from the
asymptomatic side…………………



Although the needle site entry for cervical
diskography can be performed with the
same methodology, this is not as critical,
because the needles are being placed
through the anterior portion of the
neck……………………………..
In addition, needle insertion from the
left side carries a greater risk of
esophageal puncture………………………