Spinal Injection Procedures: A Review of Concepts, Controversies, and Complications

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The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.

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

References (284)

  • I.H. Lieberman

    Disc bulge bubble: spine economics 101

    Spine J

    (2004)
  • A.J. Haig et al.

    Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression

    Arch Phys Med Rehabil

    (2006)
  • D.J. Mazanec et al.

    Lumbar canal stenosis: start with nonsurgical therapy

    Cleve Clin J Med

    (2002)
  • D.S. Fenton et al.

    Image-guided spine intervention

    (2003)
  • M. Leonardi et al.

    Injection studies in spinal disorders

    Clin Orthop Relat Res

    (2006)
  • P.M. Peloso et al.

    Medicinal and injection therapies for mechanical neck disorders: a Cochrane systematic review

    J Rheumatol

    (2006)
  • J.A. Saal et al.

    The natural history of lumbar intervertebral disc extrusions treated nonoperatively

    Spine

    (1990)
  • M.V. Boswell et al.

    Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain

    Pain Physician

    (2007)
  • M.V. Boswell et al.

    Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines

    Pain Physician

    (2005)
  • W.W. Pang et al.

    Application of spinal pain mapping in the diagnosis of low back pain–analysis of 104 cases

    Acta Anaesthesiol Sin

    (1998)
  • L. Manchikanti et al.

    Evaluation of the relative contributions of various structures in chronic low back pain

    Pain Physician

    (2001)
  • H. Sandmark et al.

    Validity of five common manual neck pain provoking tests

    Scand J Rehabil Med

    (1995)
  • M.A. Seffinger et al.

    Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature

    Spine

    (2004)
  • M. Revel et al.

    Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints

    Spine

    (1998)
  • A.C. Schwarzer et al.

    The value of the provocation response in lumbar zygapophyseal joint injections

    Clin J Pain

    (1994)
  • H.C. Tong et al.

    Comparing pain severity and functional status of older adults without spinal symptoms, with lumbar spinal stenosis, and with axial low back pain

    Gerontology

    (2007)
  • M. Laslett et al.

    Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain

    BMC Musculoskelet Disord

    (2005)
  • G.B. Andersson et al.

    Treatment of intractable discogenic low back pain. A systematic review of spinal fusion and intradiscal electrothermal therapy (IDET)

    Pain Physician

    (2006)
  • D. Appleby et al.

    Meta-analysis of the efficacy and safety of intradiscal electrothermal therapy (IDET)

    Pain Med

    (2006)
  • J.N. Gibson et al.

    Surgery for degenerative lumbar spondylosis: updated Cochrane Review

    Spine

    (2005)
  • J.N. Gibson et al.

    The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis

    Spine

    (1999)
  • A.C. Schwarzer et al.

    Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?

    Spine

    (1994)
  • A.C. Schwarzer et al.

    Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain

    Ann Rheum Dis

    (1995)
  • L. Manchikanti et al.

    Prevalence of lumbar facet joint pain in chronic low back pain

    Pain Physician

    (1999)
  • L. Manchikanti et al.

    The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents

    Curr Rev Pain

    (2000)
  • L. Manchikanti et al.

    The inability of the clinical picture to characterize pain from facet joints

    Pain Physician

    (2000)
  • L. Manchikanti et al.

    Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions?

    Pain Physician

    (2003)
  • L. Manchikanti et al.

    Is there correlation of facet joint pain in lumbar and cervical spine? An evaluation of prevalence in combined chronic low back and neck pain

    Pain Physician

    (2002)
  • L. Barnsley

    The prevalence of chronic cervical zygapophysial joint pain after whiplash

    Spine

    (1995)
  • S.M. Lord et al.

    Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study

    Spine

    (1996)
  • C.W. O'Neill et al.

    Disc stimulation and patterns of referred pain

    Spine

    (2002)
  • R. Derby et al.

    Comparison of intradiscal restorative injections and intradiscal electrothermal treatment (IDET) in the treatment of low back pain

    Pain Physician

    (2004)
  • W.J. Mixter et al.

    Rupture of the intervertebral disc with involvement of the spinal canal

    N Engl J Med

    (1934)
  • S. Rosen et al.

    Radiofrequency stimulation of intervertebral discs

    Pain Physician

    (2003)
  • W.J. Mixter et al.

    Herniation or rupture of the intervertebral disc into the spinal canal

    N Engl J Med

    (1935)
  • H.V. Crock

    A reappraisal of intervertebral disc lesions

    Med J Aust

    (1970)
  • A.H. Wheeler et al.

    Chronic lumbar spine and radicular pain: pathophysiology and treatment

    Curr Pain Headache Rep

    (2002)
  • N.A. Ebraheim et al.

    Computed tomographic findings in patients with persistent sacroiliac pain after posterior iliac graft harvesting

    Spine

    (2000)
  • V. Katz et al.

    The sacroiliac joint: a potential cause of pain after lumbar fusion to the sacrum

    J Spinal Disord Tech

    (2003)
  • J.Y. Maigne et al.

    Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks

    Eur Spine J

    (2005)
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