Are facet injections better than epidural

Injection treatment on the lumbar spine

Injection therapy on the lumbar spine

Lumbar spinal nerve analgesia (LSPA)

principle
Posterolateral injection of a local anesthetic (possibly mixed with steroids) into the foramino-articular region of the movement segment.

The angle of insertion and guidance of the needle are determined by topographical-anatomical palpation points. The main difference to the techniques of Reischauer (1953) and Macnab (1971) is that the needle direction is not sagittal, but an inclined one. With a puncture point 8-10 cm lateral to the medial line and advancing the needle at an angle of about 60 degrees, bone contact is always achieved in the posterolateral portion of the lumbar vertebra.

indication
The main indication for LSPA is all acute and chronic local and radicular lumbar syndromes. Irritation in the lumbar movement segment, caused by osteoporotic sintering, spondylolysis, tumor-related pain, spinal canal stenosis and inflammatory changes, especially in the area of ​​the vertebral joint capsule, also respond well to this Treatment method.

technology
The needle length is 10-15 cm, usually 12 cm, depending on the soft tissue sheath. The intervertebral foramina of the lower lumbar spine is best reached from a puncture site that is 8 cm to the side of the medial line at the level of the iliac crests.

Depending on the root concerned, one then selects different degrees of angle in the 60 ° angle position and in the vertical plane. To infiltrate the L3 root, insert the needle at an angle of 0 ° until it makes contact with the bone.

For the L4 root, choose a 30 ° position in the vertical plane. The needle is passed 1-2 cm above the transverse process L5 until it makes contact with the bone. The tip of the needle is then on the side facet, directly next to the intervertebral foramen or on the side wall of the vertebral body. In addition to the ramus ventralis, the branches of the ramus dorsalis, ramus meningeus and ramus communicans run to the trunk.

To infiltrate the exiting root L5 in the intervertebral foramen L5 / S1, the needle tip is lowered further under the transverse process L5, with an angle of about 50 ° -60 ° degrees in the vertical plane. The needle is advanced until it makes contact with the bone on the lateral vertebral body or on the side facet.

As CT-controlled spinal nerve analgesia have shown, the injection solution diffuses through the intervertebral foramen to the traversing S1 root, namely at the point where it may be pressurized by the disc L5 / S1 on the disc plane.

During the advancement of the needle, especially in the final phase, aspiration attempts must be made continuously, because there is the possibility of puncturing a root pocket in the intervertebral foramen. Upon contact with the nerve root, the patient reports lightning-like pain radiating into the leg. This unpleasant phenomenon can largely be avoided by proceeding slowly while constantly injecting and aspirating. It is therefore advisable to take a total of 10 ccm of a low-concentration local anesthetic solution for the injection, because at the end of the day only 4-5 ccm are usually available for the actual injection on site. Once the needle position has been secured, a long-lasting local anesthetic (bupivacaine) or (and) a glucocorticoid (e.g. 10 mg triamcinolone) can be added, depending on the clinical situation.

Effect of the LSPA
Despite the application of the local anesthetic from the posterolateral direction, nociceptors on the posterior longitudinal ligament, in the dorsal annulus fibrosus and in the vertebral joint capsule can also be reached indirectly via the meningeal branch. As our contrast agent examinations in the CT have shown, part of the injected solution diffuses to the proximal parts of the spinal nerve, including both the dorsal root ganglion and the communicating ramus. Only part of the injected solution reaches the epidural space through the intervertebral foramen.

After paravertebral lumbar spinal nerve analgesia, the patient feels a reduction in back and leg pain, which lasts for an average of 3 1/5 hours when using a 0.5-1% local anesthetic solution. In addition, around 50% of the patients we interviewed (Krämer, 1997) have a pronounced feeling of relaxation with subjectively felt warming in the back and the affected leg. Temporary symptoms of paralysis or feelings of lameness in the leg are to be expected in 8% of the cases. One must make the patient aware of this beforehand and take appropriate precautions.

The goal of the LSPA is not the complete analgesia and paralysis of the lumbar spinal nerves, as in preparation for the operation, but a pain reduction and desensitization of irritated neural structures in the lumbar movement segment.

 


Radiculography

principle
Exposure and anesthesia of the spinal nerve root paravertebrally, immediately after emerging from the intervertebral foramen.

This form of local injection as a single application serves on the one hand as a diagnostic local injection to identify the affected nerve root, and on the other hand for differential indication in surgical procedures with the question of whether a root decompression is possible in addition to a fusion.
Originally conceived by Macnab (1971) as a diagnostic measure, this type of perineural infiltration was later also used for therapeutic purposes by van Akkerveeken (1989).

technology
The patient is prone with a pillow under the abdomen to delordose the lumbar spine.
Under the control of the image converter in the operating room, a long, thin puncture cannula is advanced to the transverse process L5 and then to the nerve root L5 above (L4) or below it. After triggering the typical radiation of pain (memory pain), the perineural tube is filled with contrast medium to see the needle position and to confirm the correct root level. The needle is then minimally withdrawn and, after aspiration, 2-5 ccm of local anesthetic is infiltrated perineurally in order to switch off the pain that has been caused. If the operation is not planned immediately, 10 mg of cortisone crystal suspension can also be injected.

 


Lumbar facet infiltration

principle
Elimination of nociceptors in the lumbar vertebral joint capsules through temporary blockade with a local anesthetic, possibly with the addition of steroids.

indication
Complaints arising from the vertebral joints, d. H. Facet syndromes, hyperlordosis lower back pain, pseudoradicular syndromes.

technology
The patient sits or is prone with a pillow under the abdomen to delordose the lumbar spine. The vertebral joint capsules are reached by vertically advancing a thin 6-8 cm cannula, 2-2.5 cm paravertebrally between the spinous processes. When the cannula tip lands in the joint or in the joint capsule, the patient reports his typical referred pain. An intra-articular needle position is not necessary, a periarticular-pericapsular infiltration is usually completely sufficient.

The lower 4 or 6 lumbar vertebral joints are usually infiltrated at the same time. 2 ml of a local anesthetic with cortisone crystal suspension are taken in each case. In the case of injections at shorter intervals, you limit yourself to a depot of local anesthetic. In connection with facet infiltration, flexion therapy must always be carried out to delordose the lumbar spine: e.g. step position and exercises from the relief posture, flexion orthosis.

After securing the needle tip position and injecting contrast medium with epidural spread, the anti-inflammatory agent infiltrates the epidural space (without image converter control). An injection under the control of an X-ray image converter is not required with this technique and with some practice. In order to reach the dorsal vertebral joint complex, facet infiltration can be carried out with simultaneous sonographic control (Grifka, 1992).

 


Ligamentous infiltration of the sacroiliac joint (ISG block)

principle
Elimination of irritated nociceptors at the transitions from the ligament to the bone on the dorsal ligamentous apparatus of the sacroiliac joints and at the attachments of the iliolumbar ligament.

indication

  • ISG blockage
  • Local lumbar syndromes
  • ISG syndromes
  • Pseudoradicular lumbar syndromes
  • Accompanying chiropractic therapy
  • Sacroiliitis

technology
The dorsal ligamentous apparatus in the SI joint area is best reached from a puncture point that is exactly in the median line at the level of the equilateral posterior superior iliac spine (SIPS) and the spinous process S1.

The syringe then punctures the marked area at an angle of approx. 45 ° to the skin level.

Reliable distribution of the LA in the entire dorsal ligamentous apparatus of the SIJ with ligamentous-bony contact of the needle with corresponding lowering and lifting of the syringe.

effect
If the ligamentous apparatus at the sacroiliac joint is exposed to a long-lasting stimulus due to tension or pressure, which can also arise as part of a blocking process, the nociceptors at the transition from the ligament to the bone are activated and more often lead to local or pseudoradicular spine or SI joint syndromes. While the described ligamentous infiltration in the SI joint area should not cause any great difficulties, the intra-articular injection of a sacroiliac joint is more difficult and should ideally take place under the control of an image converter. However, this injection is subject to a particularly strict indication, because ligamentous-periarticular infiltration often proves to be sufficient in the area of ​​the SIJ.

 


Lumbar epidural pain therapy

There are several ways to reach the lumbar epidural space with a cannula:

The interlaminar access is used in anesthesia for lumbar spinal and peridural anesthesia. Peridural catheters are inserted interlaminar. Apart from the errors and dangers emanating from longer catheter treatment (Donner, 1995), the main disadvantage for orthopedic pain treatment is that the patient cannot take part in many measures of the accompanying physiotherapeutic program. In orthopedic pain therapy, epidural single injections are used in the so-called "single shot" technique. Commonly used is the interlaminar approach for the conventional epidural injection with the "loss of resistance" technique or as an epidural-perineural injection in the new 2-needle technique for the anterior epidural space.

The access route via the sacral hiatus is widespread in pain therapy and is mainly used for lower lumbar root syndromes (Bush, 1991).
In principle, there is still the possibility of reaching the lumbar epidural space indirectly via the intervertebral disc in the case of a dorsally perforated annulus fibrosus. We make use of this possibility if the discography shows a drainage of contrast medium into the epidural space and the planned chemonucleolysis is not an option. The cortisone applied intra-discally in these cases flows from the intervertebral disc directly into the ventral epidural space in the area where the nerve root is compressed.
Access to the lumbar epidural space via the intervertebral foramen is only possible under CT control and is reserved for individual situations, e.g. in the case of therapeutic postdiscotomy syndrome with compression of the emerging nerve root.

 


Epidural-Sacral Injection

principle
Injection into the lumbar epidural space via the sacral hiatus. This access is used, for example, to infiltrate the lower part of the sacral plexus with a local anesthetic. The insensitivity brought about in this way is generally limited to the roots S3-S5 in the sense of breeches anesthesia. The injected agent e.g. B. NaCl and cortisone crystal suspension, but can also rise higher when the pelvis is elevated and develop its effect in the epidural space of the lower lumbar spine.

indication
It arises primarily in coccygodynia or in S1 sciatica and postoperative complaints in the context of a postdiscotomy or postfusion syndrome.

technology
The sacral canal is the continuation of the vertebral canal. It begins at the level of the 1st sacral vertebra and ends between the sacrum and coccyx. Its dorsal boundaries are the fused transverse and spinous processes of the first 4 sacral vertebrae and their periosteum, and ventrally the periosteum of the 5 sacral vertebrae.

The articular processes of the 5th sacral vertebra form the cornua sacralia. The hiatus sacralis, the exit port of the sacral canal, lies between the two cornua sacralia. The cornua sacralia are easy to palpate in the slim patient.

The sacral hiatus is located at the caudal tip of an equilateral triangle derived from the line connecting the posterior superior iliac spine (SIPS). Among other things, this is an orientation aid for looking for the puncture site, e.g. in obese patients.

An 8-10 cm long puncture needle is pushed into the sacral canal in the lateral or knee-elbow position through the connective tissue connection plate. Aspiration ensures that neither blood vessels nor the subarachnoid space containing liquor are punctured.

Effect of the epidural-sacral injection
We use epidural anesthesia over the sacral hiatus (caudal anesthesia), especially in the treatment of postdiscotomy or postfusion syndromes. The sacral hiatus is the only access to the lumbar epdural space in the post-fusion state, when the interlaminar access is obstructed by bone chips.

The disadvantage of the sacred technique is that you have to apply larger amounts in order to flood the affected nerve roots in the desired concentration. Image intensifier-controlled sacral epidural injections with contrast medium showed an even distribution of the injected fluid in the epidural space with larger accumulations, especially in the lower lumbar spine.

Another disadvantage of the sacred technique is the deep seat of the cannula in the anal fold and the associated higher risk of infection.

 


Epidural-dorsal injection

principle
Injection through the interlaminar window into the dorsal epidural space of the affected lumbar movement segment. The interlaminar access with an injection cannula to the dorsal epidural space of the lumbar spinal canal is common both in anesthesia for performing epidural anesthesia and in orthopedic pain therapy for the treatment of lumbar root syndromes. In contrast to epidural anesthesia, in which the sensation of pain is completely eliminated by flooding primarily healthy nerve roots with a more concentrated local anesthetic via a peridural catheter, the goal of orthopedic pain therapy is to flood distressed nerve roots by, if necessary, repeated individual injections with an additional anti-inflammatory agent low concentrated local anesthetic to reduce pain sensitivity

indication
With the dorsal / interlaminar injection technique, several roots can be reached at the same time, possibly on both sides. The main indications are therefore central spinal stenoses and polyradicular syndromes.

technology
Depending on the affected root, the interlaminar approach L5 / S1, L4 / L5 or higher is selected. For spinal canal stenosis, we usually take L3 / L4 or L4 / L5. The a.p.-lumbar spine recordings should be seen on the screen in order to see the interlaminar window of the corresponding segment and whether it is configured differently on the sides. If there is no interlaminar gap, e.g. B. by overlapping the laminae one chooses the more accessible neighboring floor from the start. For a targeted segmental / epidural injection, the procedure is the same as for a lumbar puncture: When the patient is seated, a stylet-containing needle (or the syringe needle system directly) is pushed between the spinous processes of the affected segment through the ligamentum flavum to the epidural space. The dura should not be pierced. In order not to puncture the dural sac, the stylet is removed shortly before or when the ligamentum flavum is perforated, a syringe filled with liquid is attached and the needle is pushed forward while continuing to press the punch until the injection pressure suddenly decreases (loss of resistance). When the needle position is secured, saline solution with cortisone crystal suspension and, if necessary, local anesthetics are injected.

The disadvantage of the dorsal / epidural injection technique is that larger amounts have to be applied in order, among other things, to flood the affected nerve roots in the desired concentration. CT-controlled dorsal / epidural injections with contrast medium accordingly showed an even distribution of the injected fluid in the epidural space with larger accumulations, especially in the dorsal section.

 


Epidural perineural injection

principle
Injection of small amounts of steroids and local anesthetics into the ventrolateral epidural space via an oblique interlaminar access with the double needle technique.

indication
Monoradicular lumbar root irritation due to displaced intervertebral disc tissue and (or) due to osseous pressure in the case of lateral spinal stenosis. The technique also allows targeted periradicular infiltration in the event of root irritation due to postoperative scars (postdiscotomy syndrome).

technology
The injection is carried out with the patient seated. An introducer cannula is advanced 1 cm below and 1 cm contralaterally at an angle of 10-20 ° up to the ligamentum flavum or just before it. A 12 cm long 29 G cannula is pushed into the introducer cannula until the tip of the needle makes contact with the bone. With early bone contact (lamina), the puncture angle must be changed depending on the situation in the frontal or sagittal plane.

As with the dorsal injection technique, it is advisable to have a lumbar spine a.p. image of the patient in front of you in order to see the extent of the interlaminar window. About 20% of the patients report a slight radiation of pain, which is however limited when using the thin 29 G cannula. 1 cc of local anesthetic (Naropin 2 mg / ml or Chirocain 2.5 mg / ml and 5 mg Triancinolone) are injected. This injection can be carried out under CT control for training purposes (learning curve) and for scientific documentation.

Relatively small infradiscal prolapse with pressure on the right S1 nerve root, which appears flattened compared to the opposite side. The vertebral canal is normally wide and filled epidurally with sufficient fat (light). By decongesting the nerve root and shrinking the prolapse, there are good prospects for success through non-surgical measures, such as. B. by an epidural perineural injection.

Effect of epidural perineural injection
When applied to the anterolateral epidural space, the spinal nerve roots emerging from the dural sac can be reached in the L4 / L5 and L5 / S1 segments in the lateral recess. The local anesthetic also passes through the intervertebral foramen to the spinal ganglion. The small amounts of the low-concentration local anesthetic usually achieve a reduction in back and leg pain without motor disorders. Temporary symptoms of paralysis or feelings of paralysis in the area are to be expected in less than 5% of cases. One must make the patient aware of this and take appropriate precautions.

The goal of the epidural / perineural injection is not the complete analgesia and paralysis of the epidurally running spinal nerves, such as in preparation for surgery, but a pain reduction and desensitization of irritated neural structures in the lumbar movement segment, directly at the point of pain development.