Conventional Image-Guided Procedures for Painful Spine

Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.

Percutaneous Spinal Interventions for Chronic Pain Management

Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.

Image-Guided Spine Interventions for Pain: Ongoing Controversies

An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.

Radiation dose of fluoroscopy-guided versus ultralow-dose CT-fluoroscopy-guided lumbar spine epidural steroid injections

OBJECTIVE

Compare radiation dose of lumbar spine epidural steroid injections (ESIs) performed under fluoroscopy guidance and ultralow-dose CT-fluoroscopy guidance.

MATERIALS AND METHODS

Retrospective review of consecutive lumbar ESIs performed using fluoroscopy, between May 2017 and April 2019, and using ultralow-dose CT-fluoroscopy, between August 2019 and February 2021, was performed. Ultralow-dose CT-fluoroscopy technique omits a planning CT scan, utilizes CT-fluoroscopy, and minimizes radiation dose parameters. Patient characteristics (age, sex, height, weight, body mass index (BMI)), procedural characteristics (anatomic level, type of ESI, procedure time, pain reduction, complications, trainee participation), and radiation dose were compared. Chi-square tests and two-sample t-tests were performed for statistical analysis.

RESULTS

One hundred and forty-seven patients (mean age 55.8 ± 16.7; 85 women) underwent ESIs using fluoroscopy. Sixty-six patients (mean age 60.9 ± 16.7; 33 women) underwent ESIs using ultralow-dose CT-fluoroscopy. The effective dose for the fluoroscopy group was 0.30 mSv ± 0.34, compared to 0.15 mSV ± 0.11 for ultralow-dose CT-fluoroscopy (p < 0.001). The average age in the CT-fluoroscopy group was older (p = 0.04), and there was more trainee participation in the fluoroscopy group (p < 0.001); otherwise there was no statistically significant difference in patient or procedural characteristics between the conventional fluoroscopy group and the ultralow-dose CT-fluoroscopy group. There was no statistically significant difference in immediate post-procedure pain reduction between the groups (p = 0.16). Four intrathecal injections occurred only in the fluoroscopy group, though this difference was not significant (p = 0.18).

CONCLUSION

Ultralow-dose CT-fluoroscopy technique for image-guided lumbar spine ESIs can lower radiation dose compared to fluoroscopy-guided technique.

Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta-analysis

Supplemental Digital Content is Available in the Text.

In this systematic review and meta-analysis, ultrasound-guided lumbar medial branch blocks and facet joint injections were associated with significant risk of incorrect needle placement.

There is great interest in expanding the use of ultrasound (US), but new challenges exist with its application to lumbar facet–targeted procedures. The primary aim of this systematic review and meta-analysis was to determine the risk of incorrect needle placement associated with US–guided lumbar medial branch blocks (MBB) and facet joint injections (FJI) as confirmed by fluoroscopy or computerized tomography (CT). An a priori protocol was registered, and a database search was conducted. Inclusion criteria included all study types. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the National Heart, Lung, and Blood tool for assessing risk bias for observational cohort studies. Pooled analysis of the risk difference (RD) of incorrect needle placement was calculated. Pooled analysis of 7 studies demonstrated an 11% RD (P < 0.0009) of incorrect needle placement for US-guided MBB confirmed using fluoroscopy with and without contrast. Pooled analysis of 3 studies demonstrated a 13% RD (P < 0.0001) of incorrect needle placement for US-guided FJI confirmed using CT. The time to complete a single-level MBB ranged from 2.6 to 5.0 minutes. The certainty of evidence was low to very low. Ultrasound-guided lumbar MBB and FJI are associated with a significant risk of incorrect needle placement when confirmed by fluoroscopy or CT. The technical limitations of US and individual patient factors could contribute to the risk of incorrect needle placement.

Shifting Spine Interventional Pain Injections From the Hospital to a Clinic Setting: Increased Efficiency and Decreased Health System Costs

OBJECTIVE

Spine interventional pain injections have dramatically increased in volume in the past three decades. High referral volumes at our institution necessitated using both a hospital-based interventional suite and a clinic-based suite scheduled on a first-come, first-served basis. We sought to determine whether the clinic-based suite provided benefits in efficiency and health system cost in comparison with the hospital suite without compromising quality of care.

METHODS

To investigate differences between outpatient procedures performed in hospital-based procedure rooms (HBPRs) and clinic-based procedure rooms (CBPRs), we reviewed all consecutive outpatient spine interventional pain procedures performed by the interventional neuroradiology service over a 12-month period. We analyzed procedure complexity, fluoroscopic times, procedural times, patient wait times, and health system costs for each case, as well as any complications.

RESULTS

Our analysis demonstrated similar procedural complexity between sites with decreased average fluoroscopic time (112 seconds versus 163 seconds, P = .002), procedural time (17 min versus 28 min, P < .001), and wait time (20 min versus 38 min, P < .001) in the CBPR versus the HBPR. In cases without trainee involvement, procedural and wait times were decreased (P < .001, P = .008) with no difference in fluoroscopy time (P = .18). There were no complications at either site. The analysis of cost to the health system demonstrated that procedures in the HBPR cost >14 times the amount to perform than in the CBPR.

DISCUSSION

Performing spine interventional pain procedures in a CBPR adds value by decreasing procedural, fluoroscopic, wait times, and health system cost compared with an HBPR without compromising safety.