Epidural Spinal Injections are used for
- contrast injection for CT
- injection of radionuclide for nuc med scans
- injection of chemo meds into spinal canal
- injection of steroid or medicine for pain management (spinal stenosis, disc herniation, degenerative disc disease)
Lumbar Puncture procedure patient prep
Patient is changed into gown, pants off underwear on
Patient will lie prone on the table with a bolster under the lower abdomen to slightly straighten the lordotic curve of the lumbar spine
A towel or blue pad is tucked into the underwear and then lowered to the level of the psis
Lumbar Puncture Procedure
- rad Fluoros to see the condition of the spine and decide the entry point for the needle
- area is then prepped using surgical asepsis, draped and local anesthetic is injected under the skin
- under Fluoro guidance the needle is inserted to a shallow depth
- tech then moves c-arm under the table for a shoot through lateral
- under Fluoro the rad will confirm the location and advance the needle to the required but safe depth
- contrast is injected to confirm needle location
- a sample of CSF may be taken if needed
- the steroid may then be injected or for a CT myelogram the required amount of contrast is injected and the patient is sent to CT
Extra precautions for lumbar spine injections include
Chemo drugs - they are toxic and require special handling
Radionuclides - require special handling and be brought in a special lead holder and syringe to protect staff
Post Lumbar Puncture Procedure
- patient is transferred to a stretcher and must remain for 15-30 minutes depending on site
- steroid patients may have the head of the stretcher raised
- ct myelogram patients must remain supine to prevent contrast from traveling up the spinal canal before their exam
- these are timed so they patient can have their CT done quickly after the injection
what is a Facet injection
Injection of a local anesthetic directly into the facet joints causing the pain
Steroid sometimes is also injected into the joint
Provides immediate pain relief if the facet joint is the cause of the back pain
Facet Injection Procedure
- Patient is placed in a RAO or LAO position
- facet joints are localized under Fluoro
- the skin is prepped and draped
- local freezing is injected
- a spinal needle is directed toward the facet and a small amount of contrast is injected to confirm location
- the joint anesthetic and steroid are injected into the joint
- often more than one level will be treated at the same time (L1-L3 facets)
What is a medial Branch Block
Each facet joint is connected to 2 small medial nerves that send pain signals to the brain
MBB is often performed if facet injections have been performed but not resulted in long term pain relief
If the MBB is successful the patient will have immediate pain relief
Medial Branch Block procedure
- the procedure is similar to the facet joint in terms of positioning
- the skin is prepped and draped and local freezing injected
- under Fluoro the rad localizes the medial branch nerve area with a very small needle
- contrast is injected to confirm the location of the nerves
- anesthetic is then slowly injected onto the nerves
- a positive result is no pain with movement that previously caused discomfort
- temporary (about 24hrs)
What is a Epidural Steroid Injection (ESI) and what is it used for
- injection into the space surrounding an exiting nerve root
- can help with pain traveling down the leg
- usually done in conjunction with an MRI or CT scan to determine the affected roots
- converts a wide area around the injection site to try and help with symptoms
- pain management injection*
ESI Approaches Transforaminal procedure
- simply means through the hole
- a needle is guided into the foramen to access the epidural space
- position C-arm to show the pedicles in profile which can result in some cephalad, caudad, and lateral angulation
- 3 main angles involved are target, AP, and X-table lateral
Inter laminar ESI approach
- used if transforaminal approach isn’t accessible
- involves guiding a needle through the the space b/w vertebra to access the nerve root in question
- initial positioning involves opening up the space b/w the vertebra so a caudad tilt should be used on the c arm. A small lateral tilt can also visualize the side that’s to be injected
- 3 positions involved with the injection: target, AP, and x-table lateral
Caudal ESI approach
- used as a last resort when 2 other positions can’t be done or have not achieved desired results
- the needle is inserted through the sacral hiatus into the terminal end of the dural sac
- this approach delivers meds into eh cauda equina which makes up the sacral and coccygeal nerves as well as the lower lumbar region
- 2 views needed: AP and lateral
What is a Selective Nerve Root Block (SNRB)
Similar to a ESI
The target is the same areas as a transforaminal ESI
It is a much more localized injection and a higher concentration of anti-inflammatory
Positing is the same as the transforaminal approach
What is a Medial Branch Block (MBB)
MBB is a special type of injection that is precursor to what’s call an RFN
Involves freezing tow small nerves supplying feeling to corresponding lumbar facet joint
Positioning is the same as for a facet joint injection
Usually done twice to guarantee the efficacy of the first injection
This injection only lasts for a few hours 4-6 but it is common to get a record of pain scores from the pt at intervals of time after the injection for a period of 24 hrs (1,2,3,6,24)
Specialized Meds for Spine Procedures
Preservative free - helps reduce the risk of bleeding, infection, and spinal leaking
Solubility is important so the meds do not precipitate and cause an embolization of an artery
Dexamethsone and betamethasone are commonly used steroid in special spines as they are freely dissolvable in water (used in 10mg/ml in a 1cc single dose vial)
Examples of special meds for spine procedures
Xylocaine 1-2% used to locally freeze the skin and muscle tissue
Visipaque 320 - CA used to show placement of needle in the epidural space
Bupivicaine 0.25% - preservative free type of margarine for injection with dexa.
Preservative free saline - used to help push or spread the meds when performing the injection
