Spinal Injection Techniques, 2nd ed

Abstract

With 20.4% of the US population suffering from chronic pain, Theodoridis and Kraemer’s, second edition, text aims to address the most sizable subset of these patients, those with spine-related complaints.1,2 The techniques described serve as a bridge between conservative and surgical therapies and are especially well suited for aging populations, the subgroup most likely to suffer these pain diagnoses. The editor’s goal was to create a text that simplifies the challenging day-to-day work of caring for back pain patients in the form of a prescriptive cookbook, but in many ways, they go beyond that objective, and it is appreciated. The book contains 2 sections: part 1 describes an overview of pain with requisite definitions, descriptions of pain pathways, physical examination techniques, and a description of imaging modalities. The attention to chronification and central sensitization is an insightful inclusion often overlooked. The choice to weave this concept through the introductory chapters with descriptive examples represents recognition of a contemporary understanding of chronic pain as a syndrome. The section dedicated to “Back School,” including mention of behavioral therapy, is similarly refreshing; including a simplified prescriptive approach not only serves as an introduction to the concept but also facilitates immediate clinical translation. Balance seems absent elsewhere, with 10 pages of the pharmacotherapy chapter dedicated to orthokine therapy, while only 1 paragraph highlights anticonvulsants, despite their position as one of the most prescribed pharmacotherapeutics, with use exceeding that of aspirin or acetaminophen.3 The bulk of the textbook is contained within part II, the Atlas, which opens with many of the useful anatomic diagrams needed in a reference text. Without exception, the photographs are crisp and illustrative, though it was painful to see some of the injections performed without the use of gloves. Careful attention was paid to the anatomic dissections, which are presented sequentially and often accompanied by cross-sectional cuts of the same target. Photographic overlays are demonstrative of the learning points, without too many extraneous labels to prove bothersome. The entire book contains more than 500 photographs, though dedicating images to placement of skin dressings could have been omitted. Missing was the universal use of procedural image guidance, including the absence of higher risk injections. While the thin patient pictured undergoing the landmark-guided cervical facet injection may have done so without incident, her surface anatomy is unlikely to represent the body habitus of the majority of patients undergoing interventional procedures. Here, there are concerns in the text as well; an intraarticular joint injection in the cervical spine would certainly be unable to accommodate the 2 mL of the injectate recommended. The transforaminal epidural injection, a procedure performed over 1 million times per year in US Medicare beneficiaries, was conspicuously absent.4 Instead, the technique of an “epi-peri or epidural perineural injection” is included. If you are unfamiliar, this involves spearing the dura, the nerve root, or both to deliver injectate into the anterior epidural space. At least there was mention that patients would feel intraprocedural “lightning-like” pain into the leg, and that “every further manipulation of the needle and injection of fluid [would] cause the patient more pain.” I would suggest that the transforaminal approach would most often be a better option. We appreciate the mention that the use of particulate steroid is off-label, but greater emphasis is needed to show how many of the approaches are divergent from 13 multisociety recommendations for safety (absent injection of contrast, no extension tubing, and missing face masks).5 The editor states that he encourages practitioners to comprehensively explore performing spinal techniques without the use of image guidance, but the advantages of this practice philosophy are not elaborated upon sufficiently enough to consider abandoning it. While the editors’ stated goal was for the book to serve as an injection technique “cookbook,” we applaud them for going above the call and including more than just the recipes. We concur that there lies significant value in diagnostic procedures that contribute to understanding pain generators of back pain, though in the absence of image guidance, specificity is eroded.6 Perhaps this text fills a gap for the developing world where a lack of intraprocedural imaging guidance would entirely preclude interventional care, making landmark-based techniques imperative. While not exclusively focused on spine intervention techniques, other texts include fluoroscopic or ultrasound imaging with overlapping subject matter.7–9 Overall, the reader will certainly grow their fund of knowledge from having read the text, and we would just recommend it be considered alongside supplemental learning material from other references that include intraprocedural imaging as well. Robert B. Bolash, MDDepartments of Pain Management and Evidence Based Pain ResearchCleveland ClinicCleveland, Ohio[email protected]Victor Foorsov, MDDepartment of Orthopaedic Surgery/Regional Medical GroupNorthwestern MedicineWarrenville, Illinois