Skip to main content

Conventional Image-Guided Interventions for Painful Back

  • Chapter
  • First Online:
Image Guided Interventions of the Spine

Abstract

Painful spine degeneration is extremely common and one of the leading causes of disability in the United States. Effective management requires a multidisciplinary approach, with treatment options ranging from conservative medical surveillance to surgical decompression. Since their introduction in the 1970s, spinal corticosteroid injections have progressively gained popularity as an adjunct, minimally invasive method for pain control in patients with a variety of degenerative spine conditions. With advances in spine imaging and image-guided techniques, the interventionalist is now able to precisely target and treat spinal pain generators, though not without some small risk to the patient. Consequently, a detailed understanding of spinal anatomy, specific injectable medications, and image-guided techniques is paramount in order to provide successful and safe spinal injections for patients with various degenerative spine ailments.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 179.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J. 2006;15(6):834–48.

    Article  PubMed  Google Scholar 

  2. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353–71.

    Article  PubMed  Google Scholar 

  3. Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015;90(2):284–99.

    Article  PubMed  Google Scholar 

  4. Wright A, Mayer TG, Gatchel RJ. Outcomes of disabling cervical spine disorders in compensation injuries. A prospective comparison to tertiary rehabilitation response for chronic lumbar spinal disorders. Spine (Phila Pa 1976). 1999;24(2):178–83.

    Google Scholar 

  5. Palmer WE. Spinal injections for pain management. Radiology. 2016;281(3):669–88.

    Article  PubMed  Google Scholar 

  6. Renfrew DL, Moore TE, Kathol MH, El-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol. 1991;12(5):1003–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. Furman MB, Cuneo AA. Image and contrast flow pattern interpretation for attempted epidural steroid injections. Phys Med Rehabil Clin N Am. 2018;29(1):19–33.

    Article  PubMed  Google Scholar 

  8. MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology. 2009;252(3):647–61.

    Article  PubMed  Google Scholar 

  9. Malemud CJ. Cytokines as therapeutic targets for osteoarthritis. BioDrugs. 2004;18(1):23–35.

    Article  CAS  PubMed  Google Scholar 

  10. Depo-medrol manufacturer information. LAB-0160-13.0 Revised July 2018. New York, NY: Pfizer Injectables. https://www.pfizermedicalinformation.com/en-us/depo-medrol-single-dose-vial. Accessed 10 Jan 2020.

  11. Dexamathasone sodium phosphate manufacturer information. 45799G. Revised May 2014. Lake Zurich, IL: Fresenius Kabi. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/084916s066lbl.pdf. Accessed 9 Dec 2019.

  12. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology. 2007;106(2):331–8.

    Article  CAS  PubMed  Google Scholar 

  13. MacMahon PJ, Shelly MJ, Scholz D, Eustace SJ, Kavanagh EC. Injectable corticosteroid preparations: an embolic risk assessment by static and dynamic microscopic analysis. AJNR Am J Neuroradiol. 2011;32(10):1830–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227–34.

    Article  PubMed  Google Scholar 

  15. Mehta P, Syrop I, Singh JR, Kirschner J. Systematic review of the efficacy of particulate versus nonparticulate corticosteroids in epidural injections. PM R. 2017;9(5):502–12.

    Article  PubMed  Google Scholar 

  16. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974–84.

    Article  CAS  PubMed  Google Scholar 

  17. Habib GS, Bashir M, Jabbour A. Increased blood glucose levels following intra-articular injection of methylprednisolone acetate in patients with controlled diabetes and symptomatic osteoarthritis of the knee. Ann Rheum Dis. 2008;67(12):1790–1.

    Article  CAS  PubMed  Google Scholar 

  18. Xylocaine (lidocaine HCl Injection, USP) manufacturer information. 451175A Revised Feb 2010. Schaumberg, IL: APP Pharmaceuticals. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/006488s074lbl.pdf Accessed 20 Jan 2020.

  19. Marcaine (bupivacaine HCl Injection, USP) manufacturer information. EN-2920. Lake Forest, IL: Hospira 2011. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/018692s015lbl.pdf. Accessed 10 Jan 2020.

  20. Leone S, Di Cianni S, Casati A, Fanelli G. Pharmacology, toxicology, and clinical use of new long acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed. 2008;79(2):92–105.

    Google Scholar 

  21. Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Reg Anesth Pain Med. 2004;29(6):564–75; discussion 524.

    CAS  PubMed  Google Scholar 

  22. De La Mata J. Platelet rich plasma. A new treatment tool for the rheumatologist? Reumatol Clin. 2013;9(3):166–71.

    Google Scholar 

  23. Middleton KK, Barro V, Muller B, Terada S, Fu FH. Evaluation of the effects of platelet-rich plasma (PRP) therapy involved in the healing of sports-related soft tissue injuries. Iowa Orthop J. 2012;32:150–63.

    PubMed  PubMed Central  Google Scholar 

  24. Wu J, Du Z, Lv Y, Zhang J, Xiong W, Wang R, et al. A new technique for the treatment of lumbar facet joint syndrome using intra-articular injection with autologous platelet rich plasma. Pain Physician. 2016;19(8):617–25.

    PubMed  Google Scholar 

  25. AHRQ. Pain Management Injection Therapies for Low Back Pain. 20 Mar 2015. Revised 10 July 2015. Rockville, MD: Agency for Healthcare Research and Quality. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id98TA.pdf. Accessed 11 Jan 2021.

  26. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199–245.

    Article  PubMed  Google Scholar 

  27. Manchikanti L, Kaye AD, Boswell MV, Bakshi S, Gharibo CG, Grami V, et al. A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician. 2015;18(4):E535–82.

    Article  PubMed  Google Scholar 

  28. Haider SJ, Na NR, Eskey CJ, Fried JG, Ring NY, Bao MH, Pastel DA. Symptomatic lumbar facet synovial cysts: clinical outcomes following percutaneous ct-guided cyst rupture with intra-articular steroid injection. J Vasc Interv Radiol. 2017;28(8):1083–9.

    Google Scholar 

  29. Allen TL, Yusuf T, Lutz GE. Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a clinical outcome study. Spine J. 2009;9(5):387–95.

    Article  PubMed  Google Scholar 

  30. Tuakli-Wosornu YA, Terry A, Boachie-Adjei K, Harrison JR, Gribbin CK, LaSalle EE, et al. Lumbar intradiskal platelet-rich plasma (PRP) injections: a prospective, double-blind, randomized controlled study. PM R. 2016;8(1):1–10; quiz 10.

    Article  PubMed  Google Scholar 

  31. Bhatia R, Chopra G. Efficacy of platelet rich plasma via lumbar epidural route in chronic prolapsed inter- vertebral disc patients-a pilot study. J Clin Diagn Res. 2016;10(9):UC05–7.

    PubMed  PubMed Central  Google Scholar 

  32. Levi D, Horn S, Tyszko S, Levin J, Hecht-Leavitt C, Walko E. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med. 2016;17(6):1010–22.

    PubMed  Google Scholar 

  33. Knezevic NN, Mandalia S, Raasch J, Knezevic I, Candido KD. Treatment of chronic low back pain - new approaches on the horizon. J Pain Res. 2017;10:1111–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. White AH, Derby R, Wynne G. Epidural injections for the diagnosis and treatment of low-back pain. Spine (Phila Pa 1976). 1980;5(1):78–86.

    Article  CAS  Google Scholar 

  35. Watanabe AT, Nishimura E, Garris J. Image-guided epidural steroid injections. Tech Vasc Interv Radiol. 2002;5(4):186–93.

    Article  PubMed  Google Scholar 

  36. Mathis JM. Epidural steroid injections. Neuroimaging Clin N Am. 2010;20(2):193–202.

    Article  PubMed  Google Scholar 

  37. Wagner AL. CT fluoroscopy-guided epidural injections: technique and results. AJNR Am J Neuroradiol. 2004;25(10):1821–3.

    PubMed  PubMed Central  Google Scholar 

  38. Lee MH, Yang KS, Kim YH, Jung HD, Lim SJ, Moon DE. Accuracy of live fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections. Korean J Pain. 2010;23(1):18–23.

    Article  PubMed  PubMed Central  Google Scholar 

  39. McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. PM R. 2009;1(7):636–42.

    Article  PubMed  Google Scholar 

  40. Ryan TM, Kavanagh EC, MacMahon PJ. Is there a need for contrast administration prior to CT-guided cervical nerve root block? AJNR Am J Neuroradiol. 2013;34(4):E45.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Dietrich TJ, Peterson CK, Zeimpekis KG, Bensler S, Sutter R, Pfirrmann CWA. Fluoroscopy-guided versus CT-guided lumbar steroid injections: comparison of radiation exposure and outcomes. Radiology. 2019;290(3):752–9.

    Article  PubMed  Google Scholar 

  42. Costello JE, Cecava ND, Tucker JE, Bau JL. CT radiation dose: current controversies and dose reduction strategies. AJR Am J Roentgenol. 2013;201(6):1283–90.

    Article  PubMed  Google Scholar 

  43. Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study. Skelet Radiol. 2013;42(1):69–78.

    Article  Google Scholar 

  44. Kao SC, Lin CS. Caudal epidural block: an updated review of anatomy and techniques. Biomed Res Int. 2017;2017:9217145.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012;15(4):E363–404.

    Article  PubMed  Google Scholar 

  46. Deer TR, Grider JS, Pope JE, Falowski S, Lamer TJ, Calodney A, et al. The MIST guidelines: the lumbar spinal stenosis consensus group guidelines for minimally invasive spine treatment. Pain Pract. 2019;19(3):250–74.

    Article  PubMed  Google Scholar 

  47. Manchikanti L, Kay AD, Manchikanti K, Boswell M, Pampati V, Hirsch J. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5:e23139.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Honorio BT, Huntoon MA, Rathmell JP. Improving safety of epidural steroid injections. JAMA. 2015;313(17):1713–4.

    Article  Google Scholar 

  49. Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018;9(5):773–89.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine (Phila Pa 1976). 2009;34(7):731–9.

    Article  Google Scholar 

  51. Diehn FE, Murthy NS, Maus TP. Science to practice: what causes arterial infarction in transforaminal epidural steroid injections, and which steroid is safest? Radiology. 2016;279(3):657–9.

    Article  PubMed  Google Scholar 

  52. Park JW, Nam HS, Cho SK, Jung HJ, Lee BJ, Park Y. Kambin’s triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med. 2011;35(6):833–43.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Gill JS, Aner M, Nagda JV, Keel JC, Simopoulos TT. Contralateral oblique view is superior to lateral view for interlaminar cervical and cervicothoracic epidural access. Pain Med. 2015;16(1):68–80.

    Article  PubMed  Google Scholar 

  54. Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Radiology. 2007;245(2):584–90.

    Article  PubMed  Google Scholar 

  55. Kamble PC, Sharma A, Singh V, Natraj B, Devani D, Khapane V. Outcome of single level disc prolapse treated with transforaminal steroid versus epidural steroid versus caudal steroids. Eur Spine J. 2016;25(1):217–21.

    Article  PubMed  Google Scholar 

  56. Shim E, Lee JW, Lee E, Ahn JM, Kang Y, Kang HS. Fluoroscopically guided epidural injections of the cervical and lumbar spine. Radiographics. 2017;37(2):537–61.

    Article  PubMed  Google Scholar 

  57. Wald JT, Maus TP, Geske JR, Carter RE, Diehn FE, Kaufmann TJ, et al. Safety and efficacy of CT-guided transforaminal cervical epidural steroid injections using a posterior approach. AJNR Am J Neuroradiol. 2012;33(3):415–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Manchikanti L, Singh V, Pampati V, Damron KS, Barnhill RC, Beyer C, Cash KA. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician. 2001;4(4):308–16. Erratum: Pain Physician. 2002;5(1):114.

    Google Scholar 

  59. van Eerd M, Patijn J, Lataster A, Rosenquist RW, van Kleef M, Mekhail N, Van Zundert J. 5. Cervical facet pain. Pain Pract. 2010;10(2):113–23.

    Article  PubMed  Google Scholar 

  60. Weishaupt D, Zanetti M, Boos N, Hodler J. MR imaging and CT in osteoarthritis of the lumbar facet joints. Skelet Radiol. 1999;28(4):215–9.

    Article  CAS  Google Scholar 

  61. Carrino JA, Lurie JD, Tosteson AN, Tosteson TD, Carragee EJ, Kaiser J, et al. Lumbar spine: reliability of MR imaging findings. Radiology. 2009;250(1):161–70.

    Article  PubMed  Google Scholar 

  62. Falco FJ, Manchikanti L, Datta S, Sehgal N, Geffert S, Onyewu O, et al. An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician. 2012;15(6):E869–907.

    Article  PubMed  Google Scholar 

  63. Peh W. Image-guided facet joint injection. Biomed Imaging Interv J. 2011;7(1):e4.

    PubMed  PubMed Central  Google Scholar 

  64. Wu T, Zhao WH, Dong Y, Song HX, Li JH. Effectiveness of ultrasound-guided versus fluoroscopy or computed tomography scanning guidance in lumbar facet joint injections in adults with facet joint syndrome: a meta-analysis of controlled trials. Arch Phys Med Rehabil. 2016;97(9):1558–63.

    Article  PubMed  Google Scholar 

  65. Kennedy DJ, Shokat M, Visco CJ. Sacroiliac joint and lumbar zygapophysial joint corticosteroid injections. Phys Med Rehabil Clin N Am. 2010;21(4):835–42.

    Article  PubMed  Google Scholar 

  66. Dussault RG, Nicolet VM. Cervical facet joint arthrography. J Can Assoc Radiol. 1985;36(1):79–80.

    CAS  PubMed  Google Scholar 

  67. Dory MA. Arthrography of the lumbar facet joints. Radiology. 1981;140(1):23–7.

    Article  CAS  PubMed  Google Scholar 

  68. Bykowski JL, Wong WH. Role of facet joints in spine pain and image-guided treatment: a review. AJNR Am J Neuroradiol. 2012;33(8):1419–26.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Lilius G, Laasonen EM, Myllynen P, Harilainen A, Grönlund G. Lumbar facet joint syndrome. A randomised clinical trial. J Bone Joint Surg Br. 1989;71(4):681–4.

    Article  CAS  PubMed  Google Scholar 

  70. Pendleton B, Carl B, Pollay M. Spinal extradural benign synovial or ganglion cyst: case report and review of the literature. Neurosurgery. 1983;13(3):322–6.

    Article  CAS  PubMed  Google Scholar 

  71. Kursumovic A, Bostelmann R, Gollwitzer M, Rath S, Steiger HJ, Petridis AK. Intraspinal lumbar juxtaarticular cyst treatment through CT-guided percutaneus induced rupture results in a favorable patient outcome. Clin Pract. 2016;6(4):866.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Chazen JL, Leeman K, Singh JR, Schweitzer A. Percutaneous CT-guided facet joint synovial cyst rupture: success with refractory cases and technical considerations. Clin Imaging. 2018;49:7–11.

    Article  PubMed  Google Scholar 

  73. Huang AJ, Bos SA, Torriani M, Simeone FJ, Chang CY, Pomerantz SR, Bredella MA. Long-term outcomes of percutaneous lumbar facet synovial cyst rupture. Skelet Radiol. 2017;46(1):75–80.

    Article  Google Scholar 

  74. Lutz GE, Nicoletti MR, Cyril GE, Harrison JR, Lutz C, Solomon JL, et al. Percutaneous rupture of zygapophyseal joint synovial cysts: a prospective assessment of nonsurgical management. PM R. 2018;10(3):245–53.

    Article  PubMed  Google Scholar 

  75. Cambron SC, McIntyre JJ, Guerin SJ, Li Z, Pastel DA. Lumbar facet joint synovial cysts: does T2 signal intensity predict outcomes after percutaneous rupture? AJNR Am J Neuroradiol. 2013;34(8):1661–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. Ortiz AO, Tekchandani L. Improved outcomes with direct percutaneous CT guided lumbar synovial cyst treatment: advanced approaches and techniques. J Neurointerv Surg. 2014;6(10):790–4.

    Article  PubMed  Google Scholar 

  77. Malik AS, Cairns KD. Percutaneous rupture of a symptomatic facet joint synovial cyst using 2-needle distention. Reg Anesth Pain Med. 2015;40(5):635–8.

    Article  PubMed  Google Scholar 

  78. 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.

    Article  CAS  PubMed  Google Scholar 

  79. Sembrano JN, Polly DW Jr. How often is low back pain not coming from the back? Spine (Phila Pa 1976). 2009;34(1):E27–32.

    Article  Google Scholar 

  80. Rashbaum RF, Ohnmeiss DD, Lindley EM, Kitchel SH, Patel VV. Sacroiliac joint pain and its treatment. Clin Spine Surg. 2016;29(2):42–8.

    Article  PubMed  Google Scholar 

  81. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976). 1996;21(22):2594–602.

    Article  CAS  Google Scholar 

  82. Kasliwal PJ, Kasliwal S. Fluoroscopy-guided sacroiliac joint injection: description of a modified technique. Pain Physician. 2016;19(2):E329–38.

    Article  PubMed  Google Scholar 

  83. Egund N, Jurik AG. Anatomy and histology of the sacroiliac joints. Semin Musculoskelet Radiol. 2014;18(3):332–9.

    Article  PubMed  Google Scholar 

  84. Puhakka KB, Melsen F, Jurik AG, Boel LW, Vesterby A, Egund N. MR imaging of the normal sacroiliac joint with correlation to histology. Skelet Radiol. 2004;33(1):15–28.

    Article  CAS  Google Scholar 

  85. Chauhan G, Hehar P, Loomba V, Upadhyay A. A randomized controlled trial of fluoroscopically-guided sacroiliac joint injections: a comparison of the posteroanterior and classical oblique techniques. Neurospine. 2019;16(2):317–24.

    Article  PubMed  Google Scholar 

  86. Gupta S. Double needle technique: an alternative method for performing difficult sacroiliac joint injections. Pain Physician. 2011;14(3):281–4.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Justin E. Costello .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Costello, J.E., Peckham, M.E., Hutchins, T.A., Shah, L.M. (2021). Conventional Image-Guided Interventions for Painful Back. In: Khan, M., Kushchayev, S.V., Faro, S.H. (eds) Image Guided Interventions of the Spine. Springer, Cham. https://doi.org/10.1007/978-3-030-80079-6_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-80079-6_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-80078-9

  • Online ISBN: 978-3-030-80079-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics