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Download Lumbar Spine Fluoroscopy and Needle Placement
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Lumbar Spine Fluoroscopy and Needle Placement David Schultz MD Medical Advanced Pain Specialists David Schultz MD 1 Overview • • • • Historical perspective Fluoroscopic anatomy Principles of needle placement Specific procedures Medical Advanced Pain Specialists David Schultz MD 2 The expert interventionalist should be: • • • • • • Safe Accurate Painless Fast Ethical Wise Medical Advanced Pain Specialists David Schultz MD 7 To be safe and accurate, you must: • • • Understand anatomy Know how to use the fluoroscope Know how to steer needles within tissue Medical Advanced Pain Specialists David Schultz MD 8 To be safe, you also must: • Know your needle tip position before you inject your active medication • Particulate steroid injected into a spinal artery can cause paralysis and death Medical Advanced Pain Specialists David Schultz MD 9 Know and Understand the Anatomy and Pathophysiology Medical Advanced Pain Specialists David Schultz MD 10 Lumbar Anatomy AP and Lateral Landmarks pedicles spinous process pedicle pedicles nerve root spinous process spinous process Lumbar Anatomy Oblique Landmarks superior articulating processes superior articulating processes superior articulating processes Spinal Cord Blood Supply Medical Advanced Pain Specialists David Schultz MD 26 Cervical radicular arteries L and R vertebral arteries thoracic radicular artery great radicular artery of Adamkiewicz Ascending sacral radicular artery posterior spinal arteries posterior radiculomedullary artery radiculomedullary artery anterior spinal artery segmental artery Use Fluoroscopy for Precision and Safety Medical Advanced Pain Specialists David Schultz MD 32 First position the patient Medical Advanced Pain Specialists David Schultz MD 33 Then orient the fluoroscope Medical Advanced Pain Specialists David Schultz MD 35 AP view of spine on monitor Medical Advanced Pain Specialists David Schultz MD 39 Visualize the target Medical Advanced Pain Specialists David Schultz MD 42 Choose the skin insertion point Medical Advanced Pain Specialists David Schultz MD 47 Direct the needle to the target Medical Advanced Pain Specialists David Schultz MD 50 Confirm needle tip position with x-ray contrast Medical Advanced Pain Specialists David Schultz MD 55 Inject active medication Medical Advanced Pain Specialists David Schultz MD 57 How do we determine needle tip position? • Tissue feel – Soft tissue – Bone • Fluoroscopic visualization – AP – Lateral – Oblique • Radiopaque contrast Medical Advanced Pain Specialists David Schultz MD 58 Tissue feel • Bone is our friend: – When you are on bone you cannot be in a blood vessel, nervous tissue or intrathecal space – Touching a bone offers a unique opportunity to know needle tip position – You must understand skeletal and fluoroscopic anatomy Medical Advanced Pain Specialists David Schultz MD 59 To determine needle tip location you must have: • Two fluoroscopy views: – AP – Lateral or • One fluoroscopy view and contact with a bony landmark that you have identified Medical Advanced Pain Specialists David Schultz MD 60 When you contact a bone with your needle tip: • Identify it Medical Advanced Pain Specialists David Schultz MD 61 Use of radiopaque contrast: • Water soluble contrast is benign even if injected: – Intravascular – Intrathecal • However, contrast will obscure your view for further needle placement Medical Advanced Pain Specialists David Schultz MD 62 Optimal needle placement: • Know and understand the anatomy • Use a combination of tissue feel and fluoroscopic viewing to place needles • Once the needle is in place, confirm location with contrast injection • Document needle position with two fluoroscopic views Medical Advanced Pain Specialists David Schultz MD 63 Specific lumbar procedure examples • • • • • • • • Interlaminar epidural Transforaminal epidural Facet joint injection Medial branch block Sympathetic block Discogram Sacroiliac joint injection Hypogastric plexus block Medical Advanced Pain Specialists David Schultz MD 64 Lumbar Transforaminal Epidural L4 Lumbar Discogram Lumbar Facet Injection Lumbar Medial Branch Block Lumbar Sympathetic Block END
