Spinal Injection Procedures: A Review of Concepts, Controversies, and Complications
Section snippets
Medications for spinal injection therapy
The objective of percutaneous spinal injection procedures is to diagnose the causative etiology of spinal pain and, if possible, offer therapy. Because it often is difficult to determine the origin of spinal pain, patients typically are advised that targeted diagnostic procedures may not be effective if the pain generator is elsewhere. Through a series of targeted injections, there is a greater likelihood of determining the correct source of pain. Injections should not affect more than one
Controversy
Nerve root injections are of limited use in the evaluation of spinal disorders with radicular features. The variability in their technique and the heterogeneity in causative etiologies does not allow for critical appraisal of the existing data.
Spinal pain can be a result of neural dysfunction. The pathophysiology of spinal radicular pain is a subject of ongoing research and controversy. Pathogenic mechanisms that have been implicated include direct physical contact and compression of a nerve
Controversy
Long-term efficacy of ESIs has not been shown, with lack of a preferred method for administration of medications.
The number and frequency of ESIs is arbitrary. Patients should not receive more than three injections in total.
Epidural injections have been around for many decades. 1930 marked the first time an intrasacral epidural injection was performed for the treatment of sciatica.135 Direct epidural injection of corticosteroids for treatment of cervical and lumbar spinal pain syndromes was
Controversy
Intra-articular facet blocks and medial branch blocks are equivalent when assessing a patient for facet denervation procedures. However, the false-positive rates for both procedures are too high for them to be useful.
Rhizotomy procedures for facet-mediated pain do not provide sufficient long-term relief to justify their use. The methods for evaluating which patients will benefit from these procedures are flawed, with no uniformity in how these procedures are performed.
The zygapophyseal joints
Controversy
CT fluoroscopy adds nothing to percutaneous spinal injection procedures and only increases radiation exposure to the patient and operator.
Radiation exposure during the performance of spinal injection procedures is a very real concern. Although there are interesting reports of sonographically guided needle procedures in the spine,192, 193, 194 injection procedures typically use CT or fluoroscopy for guidance. Fluoroscopy is often preferred to CT because of its increased availability, dynamic
Controversy
Symptomatic synovial cysts are best managed surgically.
Juxtafacet cysts are uncommon causes of spinal pain, with two types of cystic alteration occurring in the zygapophyseal joints of the spine.211, 212 Ganglion cysts have a collagen capsule or fibrous wall without a synovial lining and typically contain myxoid material. Synovial cysts are lined by synovial cells and typically contain thin, straw-colored fluid. Although they can occur after trauma, these cysts tend to develop in the setting of
Controversy
Spinal injection procedures can be associated with potentially devastating complications and should not be performed because there are limited data to support their efficacy as diagnostic and therapeutic procedures.
When performing spinal injection procedures, one must weigh the benefit of the procedure against the potential for complications. However, the risk profile is not the same for all spinal procedures. Likelihood of complications is also related to the use and quality of imaging being
The Future
Controversy will continue to surround the topic of image-guided spinal injection procedures. The importance of good clinical assessment and long-term follow-up cannot be understated, as well as understanding the natural history of the spinal disease being investigated or treated. Current state-of-the-art imaging techniques may improve the accuracy of detection of sources of pain, and large double-blinded studies hopefully will provide answers to questions currently not addressed through the
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