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Injections in Spine Practice: introductory concerns
This document provides an overview of spinal injections in neurosurgical practice, including important ethical concerns, techniques, materials, and complications. It discusses the learning objectives, principles of obtaining consent and disclosure, clinical assessment, appropriate supervision, documentation requirements, and injection types, materials, and indications. Complications addressed include intravascular injection, allergic reaction, vasovagal response, dural puncture, epidural hematoma, and abscess. Efficacy of different injection approaches is summarized. Proper patient positioning, sterile technique, needle aspiration, and post-injection care are emphasized.
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Injections in Spine Practice: introductory concerns
- 1. Spinal Injections inNeurosurgical Practice Important introductory & Ethical Concerns Mohamed M. Mohi Eldin, Professor of Neurosurgery, Faculty of Medicine, Cairo University One-Day Spine Clinic 1st workshop & hands-on March 2nd 2016
- 2. Learning Objectives • ReachingWISDOM in spine management. • Spinal injections an important TOOL in diagnosis and management. • Mastering the different techniques, with no harm to the patients.
- 3. GENERAL PRINCIPLES !! Readyto answer all questions Provide the patient with a clear explanation of the risks and benefits
- 4. Professionalism Prioritization Seeing the woodsthrough the trees
- 6. Honesty first Surgical teamethics Families: Breaking bad news Error disclosure and risk management
- 7. Different Clinical Assessment Theunseen FACET joints The forgotten SACROILIAC joint Which level claimed in multilevel affection False normal MRIs
- 8. Appropriate supervision Clinical decisionmaking Procedures Follow-up
- 9. Documentation Spinal injections asthe first step on MIS career will learn you the importance of documentation Not only medicolegal The most important step in decision making process
- 10. Documentation • Documenting anEffective history • Documenting a discharge summary • Legal aspects of medical documentation – Timing and timeliness of notes – Critical events documentation – Altering the medical record – Call schedule as legal document • Procedure consent – Procedure – Alternatives – Risks (*Description of risks that would influence a reasonable person in the same circumstances)
- 11.
- 12. Neurosurgical Patient: CaseScenarios Injections are integral parts of the case scenarios, in both diagnosis and management
- 13. Making the Incision Thesurgical environment Sterile technique and preparation
- 14. The Manager whenthere is no manager Asked for help (Canada, Ireland…etc.) Wellness of patients
- 15. Which is themore important imaging modality here? Patient’s Finger
- 16. Patient’s Finger • Imagesare just pictures • Images don’t necessarily tell you what is the pain generator • The patient’s finger may be more useful and cost effective and accurate than any x-ray, CT, MRI or bone scan • Get comfortable looking at the images you order
- 17. Only the needleknows…
- 18. INJECTION TYPES • Jointinjections (Facet & SIJ) are preceded by an aspiration withdrawing joint fluid or blood. Most of the injections can be followed by a booster injection 2 to 4 weeks later. • “Trigger point" injection is done to a tendon area or into the bursa surrounding such joints. These follow the same guidelines as articular injections as far as frequency. • Epidural steroid injection is useful for a variety of back conditions including sciatica, arthritis, degenerative disc problems, and spinal stenosis. – Lumbar epidural is relatively simple technique and is unlikely to be accompanied by complications except, perhaps a headache. – Cervical epidural is a very specialized technique done only by skilled and experienced.
- 19. INJECTION MATERIALS Local anesthetics Corticosteroid Non-ioniccontrast agents Others
- 20. INJECTION MATERIALS Local anesthetics PainRelief Reversible neural blockade Blocking sodium channels
- 21. Local anesthetics sideeffects • 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.
- 22. INJECTION MATERIALS Corticosteroid Musculoskeletal PainRelieve Mechanisms: Anti-inflammatory direct membrane-stabilizing effect Modulation effect on spinal cord Immuno-suppressive
- 23. Corticosteroid Types Betamethasone (Long-acting) Dexamethasone(Long-acting) Methylprednisolone (Intermediate-acting) Prednisolone (Intermediate-acting) Triamcinolone (Intermediate-acting) Hydrocortisone (Short-acting)
- 24. Corticosteroid side effects •Skin hypopigmentation, • subcutaneous fat atrophy, • tendon rupture, • fluid retention, • flushing, • hyperglycemia, • change in taste, • insomnia, malaise and dyspepsia • Systemic suppression of the adrenal glands
- 25. Corticosteroid side effects SystemicSide-effects Facial Flushing Menstrual Irregularity Hyperglycaemia Suppress pituitary-adrenal axis Emotional upset Anaphylaxis Local Side-effects Post-injection flare of pain Skin depigmentation Subcutaneous atrophy Bleeding Infection Steroid Arthropathy Tendon rupture/atrophy Soft tissue calcification
- 26. Repeated injections ofcorticosteroids can lead to a cushingoid appearance Because of the long list of side effects, these drugs shouldn’t be taken lightly, and many doctors limit the number of injections per year to 3 or 4 max. Always remember that the effects are usually temporary. A good limit is three injections over a three-month period of time (an injection to another location can be done at any time) Prolonged steroid injection is associated with osteonecrosis
- 27. INJECTION MATERIALS Non-ionic contrastagents Under fluoroscopy for needle tip localization Reduces risk of injection into a blood vessel or subarachnoid space include metrizamide (Amnipaque), iopamidol (Isovue), iohexol (Omnipaque)
- 28. Contrast agents sideeffects local tissue toxicity nausea, headache, and emesis Anaphylaxis 90% occur within the first 15 min
- 29. Patients with contrastallergic reaction history Steroids and antihistamines 12 h, and 2 h prior to the procedure in is recommended Gadolinium is a viable alternative
- 30. GENERAL CONSIDERATIONS Caution toavoid the risk of bleeding Aspirin discontinue at least 3-7 days before Pregnant women or suspected to be pregnant should avoid radiation exposure from fluoroscopy
- 31. GENERAL TECHNICAL POINTS1 General Preparation Proper positionng on the table first Sterile drapping the injection site Sterile gloves during the injection Gown, cap, and mask are used specially if myelography or discography is done Antibiotics are used specially in patients with implanted prosthetic devices or mitral valve prolapse
- 32. GENERAL TECHNICAL POINTS2 Local Preparation Prior to injection The injection site can be anesthetized for patient’s comfort with: Local injection vapocoolant spray anesthetic cream
- 33. GENERAL TECHNICAL POINTS3 Needles The syringe needle is always aspirated first to avoid intravascular or, intrathecal injection Avoid needle contact with articular cartilage surfaces during injections The injection is given slowly, with steady pressure
- 34. Avoid injecting intoligaments, tendons, or periosteum Tendons and ligaments can be ruptured if corticosteroids are injected directly into them (less than 1% of cases) Repositioning the needle if there is significant resistance
- 35. GENERAL TECHNICAL POINTS4 Post-injection A dressing is applied to the injection site Rest for several days No driving for 3 days
- 36. GENERAL CONTRAINDICATIONS Absolute Bacteremia Joint infection Cellulitis Skinulcerations Osteomyelitis Infectious arthritis Epidural abscess Fluoroscopy in pregnancy
- 37. GENERAL CONTRAINDICATIONS Relative • Septicfocus (distant chronic infection) • Allergy to – Injection material – Contrast agents • Latex allergy • Diabetes mellitus • Altered anatomy (surgery or congenital)
- 38. GENERAL CONTRAINDICATIONS Great dealof CAUTION Patients requiring anticoagulation medication or with a known bleeding diathesis Avoid if Prothrombin time (prolonged) activated partial thromboplastin time international normalized ratio (INR >1.2) platelet level count (<100 000/ml)
- 39. GENERAL INDICATIONS SPINAL INJECTIONTECHNIQUES • Radiculopathy (Transforaminal Injection) • SI Joint Syndrome (SIJ Injection) • Facet Joint Syndrome (FJ Injection) • LDP (Epidurography, Epidural injection, VCD) • Discography • Myelography • Sympathetic procedures
- 40. GENERAL COMPLICATIONS • Intravascularor subarachnoid • Allergic reaction • Anaphylactic reaction • Vasovagal syncope • Dural puncture • Spinal headache • Epidural abscess • Epidural hematoma
- 41. GENERAL COMPLICATIONS ANAPHYLACTIC SHOCK FROMcorticosteroids or contrast material Typically, contrast allergies occur at the time of the injections, and can quickly progress to an anaphylactic reaction with respiratory compromise Corticosteroid anaphylactic reactions often occur within 2-6 h after the injection (respiratory compromise, no reported fatalities)
- 42. GENERAL COMPLICATIONS ALLERGIC REACTIONS Corticosteroidallergic reactions are often delayed by up to a week, present as an intense hot, erythematous flushing involving the neck, face, and occasionally the chest area.
- 43. GENERAL COMPLICATIONS VASOVAGAL EPISODES Noxiouseffect 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
- 44. GENERAL COMPLICATIONS DURAL PUNCTURES Duralpuncture headaches can occur 1-2 days after injections, with low incidence Avoided by use of smaller gauge needles with conical noncutting tips
- 45. GENERAL COMPLICATIONS INTRATHECAL &INTRAVASCULAR INJECTIONS Risk is proportional to the injected volume Lead to periorbital numbness, disorientation, light- headedness, nystagmus, tinnitus, complete sensory or motor block, muscle twitching, respiratory depression, and seizures
- 46. GENERAL COMPLICATIONS EPIDURAL HEMATOMA Rarewith normal clotting factors Increases with anticoagulation & with Spinal stenosis Can potentially lead to caudal equina or cord compression Epidurals should be avoided in platelet count less than 100 000 per ml a spinal canal midsagittal diameter less than 12 mm
- 47. GENERAL COMPLICATIONS EPIDURAL ABSCESS Rareand is more common with the use of an indwelling catheter Present with severe back pain, fever, and chills
- 48. GENERAL EFFICACY • Thelargest 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
- 49. • Only 22%of sacroiliac joint injections are successfully performed without fluoroscopic guidance
- 50.