Selective Nerve Root Research Articles

Treatment Effects of Ultrasound Guide Selective Nerve Root Block for Lower Cervical Radicular Pain: A Retrospective Study of 1-Year Follow-up

ObjectiveTo compare the long-term effects and advantages of ultrasound (US)-guided selective cervical nerve root block with fluoroscopy (FL)-guided transforaminal block.MethodsFrom March 2009 to November 2012, 162 patients received steroid injections for lower cervical radicular pain. A total of 114 patients fulfilled the inclusion criteria. All procedures were performed by using US or FL. We compared the intravascular injections during the procedure with the effects and functional scales at 3, 6, and 12 months after the procedure between the two groups. Successful treatments occurred when patients obtained significant pain reliefs (as measured by >50% improvements in the verbal numerical scale [VNS] score and >40% improvements in the neck disability index [NDI] score) and reported a patient satisfaction score of 3 or 4 points at 12 months after the injection. Image analysis of intravascular injection and chart review were performed. Logistic regression was performed to reveal the correlations between successful treatments and variables (patient's age, gender, duration of the disease, cause, injection method, and radiologic finding).ResultsThe VNS and NDI improved 3 months after the injection and continued to improve until 12 months for both groups. But there were no statistical differences in changes of VNS, NDI, and effectiveness between these two groups. The proportion of patients with successful treatment is illustrated as 62.5% in US-guided group and 58% in FL-guided group at 12 months. There were no significant differences between the groups or during follow-up periods. Three cases of the intravascular injections were done in FL-guided group.ConclusionThe US-guided selective cervical nerve root blocks are facilitated by identifying critical vessels at unexpected locations relative to the foramen and to protect injury to such vessels, which is the leading cause of reported complications from FL-guided transforaminal blocks. On treatment effect, significant long-term improvements in functions and pain reliefs were observed in both groups after the intervention. However, significant differences were not observed between the groups. Therefore, the US-guided selective cervical nerve root block was shown to be as effective as the FL-guided transforaminal block in pain reliefs and functional improvements, in addition to the absence of radiation and protection vessel injury at real-time imaging.

Transverse Process and Needles of Medial Branch Block to Facet Joint as Landmarks for Ultrasound-Guided Selective Nerve Root Block

BackgroundSelective lumbar nerve root block (SNRB) is generally accepted as an effective treatment method for back pain with sciatica. However, it requires devices producing radioactive materials such as C-arm fluoroscopy. This study evaluated the usefulness of the longitudinal view of transverse process and needles for medial branch block as landmarks under ultrasonography.MethodsWe performed selective nerve root block for 96 nerve roots in 61 patients under the guidance of ultrasound. A curved probe was used to identify the facet joints and transverse processes. Identifying the lumbar nerve roots under the skin surface and ultrasound landmarks, the cephalad and caudal medial branch blocks were undertaken under the transverse view of sonogram first. A needle for nerve root block was inserted between the two transverse processes under longitudinal view, while estimating the depth with the needle for medial branch block. We then injected 1.0 mL of contrast medium and checked the distribution of the nerve root with C-arm fluoroscopy to evaluate the accuracy. The visual analog scale (VAS) was used to access the clinical results.ResultsSeven SNRBs were performed for the L2 nerve root, 15 for L3, 49 for L4, and 25 for L5, respectively. Eighty-six SNRBs (89.5%) showed successful positioning of the needles. We failed in the following cases: 1 case for the L2 nerve root; 2 for L3; 3 for L4; and 4 for L5. The failed needles were positioned at wrong leveled segments in 4 cases and inappropriate place in 6 cases. VAS was improved from 7.6 ± 0.6 to 3.5 ± 1.3 after the procedure.ConclusionsFor SNRB in lumbar spine, the transverse processes under longitudinal view as the ultrasound landmark and the needles of medial branch block to the facet joint can be a promising guidance.

Usefulness of Three Dimensional Proset MR Images for Diagnosis of Symptomatic L5-S1 Foraminal and Extraforaminal Stenosis

ObjectiveTo suggest a new useful diagnostic technique, principles of the selective excitation technique-magnetic resonance images (Proset-MRI), and to know the precise radiologic findings that can prove symptomatic foraminal and extraforaminal stenosis at L5-S1.MethodsNineteen patients with symptomatic L5-S1 stenosis were checked by Proset-MRI. Four patients were performed decompressive surgery and 15 patients were performed selective nerve root block (SNRB) at L5. The pain scale of patients was checked by Visual Analogue Scale (VAS) scores at the pre- and post-treatment state.ResultsProset-MRI findings of patients with symptomatic stenosis are root swelling (RS) and indentation. The comparisons with VAS scores had a meaningful statistical result at each RS (p<0.01) and indentation (p<0.01). However, the findings of RS combined with indentation lacked statistical significance (p=0.0249). In addition, according to a comparison with the treatment modalities, reducing of VAS scores had statistical meaningful significance in decompressive surgery cases (p<0.01), and also in SNRB cases (p<0.01) after a 3-month follow-up period.ConclusionThe three dimensional Proset-MRI is very useful and sensitive technique to diagnose the symptomatic foraminal and extraforaminal stenosis at L5-S1.

Large Spinal Meningioma with Hemorrhage after Selective Root Block in the Thoraco-Lumbar Spine

Spinal meningioma accounts for 25% of all spinal cord tumors and occurs mostly in the thoracic region. Spontaneous intraspinal bleeding associated with spinal meningioma has rarely been reported. Most cases of hemorrhage associated with meningiomas are extratumoral and subarachnoid, whereas subdural and intratumoral hemorrhage cases have been reported to occur rarely. We experienced a case of a 58-year-old woman with thoracolumbar spinal meningioma accompanied by intraspinal subdural hematoma. She presented with progressively worsened back pain and newly developed weakness in the right lower extremity after a selective nerve root block in the lumbar spine. She underwent the operation and progressively showed neurological recovery during the postoperative course. We report a thoracolumbarspinal meningioma with subdural and intratumoral hemorrhage after a spinal procedure that caused a sudden neurological deterioration.

The Short Term Results of Selective Nerve Root Block in Spinal Stenosis by Contrast Pattern

.Conclusions: There was a short term effect of selective nerve root block (sNRB) in patients with spinal stenosis regardless of their contrast pattern, type I group showing a stronger correlation. In regards to spinal canal dimension, patients with larger spinal canal sizes not only showed a significant decrease in VAS score after selective nerve root block (sNRB) but also showed differences depending on the contrast pattern. On the contrary, there was no significant difference in VAS score before and after selective nerve root block (sNRB) in patients with small spinal canal sizes, and there was also no difference in the outcome depending on the contrast pattern in patients with small spinal canal sizes. Therefore, when performing selective root nerve block (sNRB), the operator should remember to manipulate the angle and position of the spinal needle when injecting the appropriate drug after confirming that the contrast material reached the spinal canal. The operator should also consider surgical management when performing selective nerve root block (sNRB) in patients with severe central spinal stenosis.

The Prediction of Prognosis After the Treatment of Selective Nerve Root Blocks for a Lumbar Canal Stenosis and Lumbar Disc Herniaton

Selective nerve root blocks are used for diagnosis and treatment of degenerative lumbar disorders. In previous studies, they had a 30% - 60% positive effect, with pain lessening over a period of 1 to 2 years. However, multiple injections for patients who had no effect caused complications, such as nerve injury. It’s important that we know the difference between patients with positive effect and patients with no effect of selective nerve root blocks. However, there are few reports about the difference between the both.

Effective Dose of CT-Guided Epidural and Periradicular Injections of the Lumbar Spine: A Retrospective Study

Spinal injection procedures can be performed blindly or, more accurately, with fluoroscopic or computed tomography (CT) guidance. Radiographic guidance for selective nerve root blocks and epidural injections allows an accurate needle placement, reduces the procedure time and is more secure for the patient, especially in patients with marked degenerative changes and scoliosis, resulting in a narrowing of the interlaminar space. Limiting factors remain the availability of scanners and the radiation dose. Interventional CT scan protocols in axial CT-acquisition mode for epidural and periradicular injections help to limit the radiation dose without a significant decrease of image quality. The purpose of this retrospective study was to analyze the effective radiation dosage patients are exposed during CT-guided epidural lumbar and periradicular injections. A total amount of n=1870 datasets from 18 months were analyzed after multiplying the dose length product with conversion factor k for each lumbar segment. For lumbar epidural injections (n=1286), a mean effective dose of 1.34 mSv (CI 95%, 1.30-1.38), for periradicular injections (n=584) a mean effective dose of 1.38 mSv (CI 95%, 1.32-1.44) were calculated.

Repetitive transforaminal steroid injections in cervical radiculopathy: a prospective outcome study including 140 patients

Study design: Prospective case series.Objective: To evaluate the effect of three repetitive transforaminal steroid injections in a large series of selected patients with cervical radiculopathy caused by spondylosis.Methods: Consecutively, 140 patients with long-lasting medical history, clinical findings, and MRI indicating a cervical nerve root origin based on degenerative disease and a positive selective transforaminal diagnostic nerve root blocks with local anesthetics resulting in at least 50% temporary arm pain reduction were included.Before treatment started, patients underwent a clinical examination by a neurosurgeon. All patients were followed-up and evaluated by one physiotherapist at the neurosurgery outpatient clinic. A designed outcome questionnaire including Neck Disability Index (NDI), Symptoms Frequency Index, and Visual Analog Scale for pain intensity were used.A series of three transforaminal steroid injections, with 3 weeks in between, were performed by a neuroradiologist using image intensifier guidance in an x-ray suite. At 12–14 weeks after the first injection, follow-up was performed. Criteria for positive response to the treatment was >50% radicular arm pain reduction. Except for occasional painkillers, no other treatment was given to the patients.Results: Positive response to the treatment was achieved in 49% (n = 69) with a significant difference in NDI and pain intensity between responders and nonresponders.Conclusions: Repetitive transforaminal steroid injections may reduce symptoms (frequency, intensity, and fewer limitations of daily living activities) of radiculopathy in patients with degenerative disease in the cervical spine at a short time follow-up.Final class of evidence-treatmentStudy design RCT Cohort Case control Case series•Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥85%• Adequate sample size Control for confoundingOverall class of evidenceIVThe definiton of the different classes of evidence is available on page 63.

Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report

IntroductionAlthough uncommon, selective cervical nerve root blocks can have serious complications. The most serious complications that have been reported include cerebral infarction, spinal cord infarction, transient quadriplegia and death.Case presentationA 40-year-old Japanese woman with a history of severe right-sided cervical radicular pain was scheduled to undergo a right-sided C6 selective cervical nerve root block using a transforaminal approach under fluoroscopic guidance. An anterior oblique view of the C5-C6 intervertebral foramen was obtained, and a 23-gauge spinal needle, connected to the normal extension tube with a syringe filled with contrast medium, was introduced into the posterior-caudal aspect of the C5-C6 intervertebral foramen on the right side. In the anteroposterior view, the placement of the needle was considered satisfactory when it was placed no more medial than halfway across the width of the articular pillar. Although the spread of the contrast medium along the C6 nerve root was observed with right-sided C6 radiculography, the subdural flow of the contrast medium was not observed with real-time fluoroscopy. The extension tube used for the radiculography was removed from the spinal needle and a normal extension tube with a syringe filled with lidocaine connected in its place. We performed a negative aspiration test and then injected 1.5 mL of 1.0% lidocaine slowly around the C6 nerve root. Immediately after the injection of the local anesthetic, our patient developed acute flaccid paralysis, complained of breathing difficulties and became unresponsive; her respiratory pattern was uncoordinated. After 20 minutes, she regained consciousness and became alert, and her muscle strength in all four limbs returned to normal without any sensory deficits after receiving emergent cardiorespiratory support.ConclusionsWe believe that confirming maintenance of the appropriate needle position in the anteroposterior view by injecting local anesthetic is important for preventing central needle movement. Because the potential risk of serious complications cannot be completely eliminated during the use of any established selective cervical nerve root block procedure, preparation for an emergency airway, ventilation and cardiovascular support is indispensable in cases of high spinal cord anesthesia.

Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: A randomized, blinded, controlled study

To compare the short-term effects and advantages of ultrasound-guided selective nerve root block with fluoroscopy-guided transforaminal epidural block for radicular pain in the lower cervical spine through assessment of pain relief, functional improvement, and safety. A total of 120 patients with radicular pain from cervical spinal stenosis or cervical herniated disc were enrolled. All procedures were performed using a fluoroscopy or ultrasound apparatus. The subjects were randomly assigned to either the fluoroscopy (FL) or ultrasound (US) group. The complication frequencies during the procedures, treatment effects, and functional improvement of the nerve root block were compared at 2 and 12weeks after the procedures. Verbal Numeric Pain Scale (VNS) improved 2weeks and 12weeks after the injections in both groups. Statistical differences were not observed in VNS, Neck Disability Index (NDI), and effectiveness between the groups. In 21 patients at US, vessels were identified at the anterior aspect of the foramen. Eleven patients had a critical vessel at the posterior aspect of the foramen and five patients had on artery continue medially into the foramen, forming, or joining a segmental feeder artery. In both cases, the vessels might well have been in the pathway of the needle correctly positioned under fluoroscopic guidance. Five cases of intravascular injections were observed only in FL without significant difference between the groups. The US-guided method may facilitate identifying critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical transforaminal injections. On treatment effect, using either method of epidural injections to deliver steroids for cervical radicular pain, secondary to herniated intervertebral disc or foraminal stenosis, significant improvements in function and pain relief were observed in both groups after the intervention. However, significant difference was not observed between the groups. Therefore, the ultrasound-guided method was shown to be as effective as the fluoroscopy-guided method in pain relief and functional improvement, in addition to the absence of radiation and avoiding vessel injury at real-time imaging.

CT-Guided Lumbar Nerve Root Injections: Are We Using the Correct Radiation Dose Settings?

Selecting a lower tube current for CT fluoroscopic spine injections is a method of radiation dose reduction. Ideally tube current should be tailored to the patient's body habitus, but a greater influence on tube current may be the proceduralist's personal preference. The purpose of this study was to compare tube current and fluoroscopy time of different proceduralists for lumbar spine CT-guided selective nerve root blocks, and to correlate image quality to patient diameter and tube current. Eighty CT-guided SNRBs performed by 4 proceduralists were retrospectively reviewed for tube current and fluoroscopy time. Patient body habitus was evaluated by measuring anteroposterior diameters on scout images. Image quality was evaluated objectively and subjectively: noise was measured in the psoas muscle and images were graded on a 3-point scale. The mean tube current was 59 ± 20 mA and mean fluoroscopy time was 10.4 ± 7.5 seconds. The mean tube current between proceduralists differed by almost 2-fold, and there was greater than 2-fold difference in mean fluoroscopy time (P < .0001 and .01, respectively). Mean AP body size was 27 ± 5 cm. When categoric data of tube current and AP diameter were analyzed, only AP diameter was a statistically significant variable influencing image noise (P = .009). Twenty of 23 patients with AP diameter ≤30 cm had adequate to excellent image quality, even with lower tube current of ≤40 mA. Wide variability in tube current selection between proceduralists calls for a more objective method of selecting tube current to minimize radiation dose. Body size, measured by AP diameter, had the greatest influence on image quality. This could be used to identify patients for lower tube current selection.

CT-Guided Transforaminal Epidural Injections with Local Anesthetic, Steroid, and Tramadol for the Treatment of Persistent Lumbar Radicular Pain

Background: A substantial number of patients with persistent lumbar radicular pain are treated with a multimodal spectrum of conservative therapies without lasting effect. The duration of pain is certainly a risk factor for chronification. There is evidence that guided periradicular infiltrations are a valid option in the treatment of radiculopathies. Usually a combination of local anesthetic and/or corticosteroid is injected. Tramadol is being used for perioperative analgesia and has been shown to provide effective, long-lasting pain relief after epidural administration. Objective: The aim of this pilot study was to evaluate the efficacy of serial CT-guided transforaminal nerve root infiltrations with a supplement of tramadol for patients with persistent, radicular pain. Study Design: Interventional cohort study. Setting: Outpatient department for interdisciplinary pain medicine. Methods: 37 patients who had radicular leg pain for over 9 weeks received up to 3 CTguided transforaminal nerve root infiltrations at intervals of 2 weeks as long as their level of pain was over 3 on a numerical rating scale from 0 to 10. 50 mg of Tramadol were added to a combination of local anesthetic (Ropivacain, 2 mg) and corticosteroid (Triamcinolon, 40 mg). Evaluations were carried out 24 hours after the Infiltration as well as 2 weeks, 3 and 6 months after the treatment series. The intensity of their radicular pain was measured by a numerical rating scale (NRS). Pain reduction of at least 50% was defined as successful outcome. Results: In total, 65 infiltrations were carried out with pain relief in more than 90% of the patients within 24 hours and an average pain reduction of 64%. Six months post-injection 23 of 34 patients available for follow-up (67.6%) had a successful pain reduction of 84% on average. No adverse effects ascribable to the use of tramadol were noted. Limitations: Due to the lack of a control group we cannot make any statement if tramadol improves short-term pain reduction. Conclusion: Fast and lasting pain relief is the key to optimize rehabilitation for patients with radicular pain. There is a physiological rationale that the opioid receptors at the spinal level could be used to optimize the analgetic effect of guided periradicular injections. In our case series, serial CT-guided selective nerve root infiltrations with the supplement of tramadol were found to be highly effective in the treatment of persistant radiculopathies. Randomized controlled trials will be necessary to clarify the possible benefit of the supplement of an opioid. Key words: Serial, nerve root infiltration, tramadol, chronic pain, outcome.

The Efficacy and Persistence of Selective Nerve Root Block under Fluoroscopic Guidance for Cervical Radiculopathy

Study DesignRetrospective study.ObjectivesTo investigate the outcomes of fluoroscopically guided selective nerve root block as a nonsurgical treatment for cervical radiculopathy.Overview of LiteratureOnly a few studies have addressed the efficacy and persistence of cervical nerve root block.MethodsThis retrospective study was conducted on 28 consecutive patients with radicular pain due to cervical disc disease or cervical spondylosis. Myelopathy was excluded. Cervical nerve root blocks were administered every 2 weeks, up to 3 times. Outcomes were measured by comparing visual analogue scale (VAS) scores, patient satisfaction, and medication usage before the procedure and at 1 week and 3, 6, and 12 months after the procedure. In addition, complications associated with the procedure and need for other treatments were evaluated.ResultsThe average preoperative VAS score was 7.8 (range, 5 to 10), and this changed to 2.9 (range, 1 to 7) at 3 months and 4.6 (range, 2 to 7) at 12 months. Patient satisfaction was 71% at 3 months and 50% at 12 months. Five patients used medication at 3 months, whereas 13 used medication at 12 months. Average symptom free duration after the procedure was 7.8 months (range, 1 to 12 months). Two patients were treated surgically. Only two minor complications were noted; transient ptosis with Horner's syndrome and transient causalgia.ConclusionsAlthough selective nerve root block for cervical radiculopathy is limited as a definitive treatment, it appears to be useful in terms of providing relief from radicular pain in about 50% of patients at 12 months.

Effectiveness of Selective Nerve Root Block for the Treatment of Radiculopathy in Degenerative Lumbar Scoliosis

Effectiveness of Selective Nerve Root Block for the Treatment of Radiculopathy in Degenerative Lumbar Scoliosis

Cervical Transforaminal Epidural Injection in the Management of a Stinger

A “stinger,” otherwise known as a “burner,” is a transient, reversible peripheral nerve injury of the upper limb caused by injury to the cervical spine and shoulder. This injury usually occurs during participation in contact sports [1-3]. Stingers are considered to be underreported by athletes and are most common in American-style football, hockey, gymnastics, and wrestling [4]. In a study of collegiate American-style football players, Levitz et al [5] reported that stingers occur in 50%-65% of these athletes during the course of their career; they also reported high rates of recurrence. Mechanisms of injury include traction, compression, and direct blows [4,6-9]. Traction injuries result from ipsilateral shoulder depression and contralateral neck flexion, effectively resulting in traction on the nerve root and/or brachial plexus. At the high school level, football players are more likely to have traction injuries. Conversely, compression injuries are more likely sustained at the collegiate and professional levels [10]. Compression injuries of the nerve root stem from a combination of forced hyperextension with ipsilateral rotation and lateral flexion leading to transient neuroforaminal narrowing. Finally, a direct blow to the supraclavicular region (Erb point), where the brachial plexus is most superficial, can result in direct trauma to the plexus. Most stingers, according to the Seddon classification scheme, are characterized as firstor second-degree peripheral nerve injuries, which refer to neurapraxia (demyelination) or axonotmesis (axonal loss), respectively. A third-degree injury, or neurotmesis (complete nerve transection), is not considered within the spectrum of this disorder [11,12]. Because tackling and blocking are the two most common mechanisms of stingers, defensive backs and offensive linemen are most susceptible [10]. Symptoms appear immediately after contact [1] and generally affect the upper trunk of the brachial plexus or C5/C6 erve roots [6-8,13-15]. The primary symptom is burning pain referring to the upper limb, hich may be accompanied by weakness, numbness, and paresthesias [1,16]. Symptoms typically do not last more than 24 hours [2]. A wide range of clinical courses have been described after a stinger injury, ranging from full recovery in seconds or hours to the development of a chronic syndrome [1,5]. The distribution of weakness is dependent on the source of the nerve injury, but whether it is the root (C5 or C6) or upper trunk of the brachial plexus, the most common pattern of muscle weakness involves the deltoid, supraspinatus, and/or infraspinatus for several weeks after the injury [17]. Conflicting views exist regarding the location of the neurological lesion [13]. Some authors who included an electrodiagnostic evaluation in their studies reported a greater incidence of brachial plexus involvement [8,14,15,18]. However, Slipman et al [19] demonstrated that diagnostic cervical selective nerve root blocks frequently provoke symptoms outside the classic dermatomal distribution in nonathletes. Thus it is plausible that injury to a single nerve root can produce a more circumferential pattern of symptoms in the upper limb [20]. Several factors suggest that most stingers are caused by cervical nerve root injury [5,21]. It has been shown that there is a statistically significant 10%-13% decrease in neuroforaminal diameter when the neck is positioned in 20°-30° of extension, as is common during a stinger injury [22]. Anatomically, the cervical nerve roots appear to be more vulnerable to injury than the brachial plexus because of their orientation and

Interventional Spine Procedures in Athletes

Back pain is common in athletes and a source of missed time from practice and competition. Pain generators include muscle (strain), ligament (myofascial sprain and strain), intervertebral disc (herniation and degeneration), nerve (radiculopathy), joint (facet and sacroiliac (SI) joint), and bones (pars interarticularis defect). The goal of treatment of an athlete with back pain is to relieve symptoms and facilitate safe but rapid return to play with no change in performance. Initial conservative treatment includes relative rest, anti-inflammatory medications, and physical therapy. The use of interventional spine procedures in athletes with back pain has gained popularity as a nonoperative treatment option. Although there is lack of high-quality evidence of these procedures specifically in athletes, this article will discuss the utility of selective nerve root blocks, epidural steroid injections, intradiscal injections, pars interarticularis injection, facet joint interventions (intraarticular injection, medial branch block, and radiofrequency neurotomy), and SI joint interventions (intraarticular injection and radiofrequency neurotomy).

Value of 3D MR Lumbosacral Radiculography in the Diagnosis of Symptomatic Chemical Radiculitis

Radiologic methods for the diagnosis of chemical radiculitis associated with anular tears in the lumbar spine have been rare. Provocative diskography is one of the methods for diagnosing diskogenic chemical radiculitis but is invasive. A reliable imaging method for replacing provocative diskography and diagnosing chemical radiculitis is required. Our aim was to investigate the value of 3D MR radiculography depicted by rendering imaging in the diagnosis of symptomatic chemical radiculopathy associated with anular tears. The study population consisted of 17 patients (age range, 32-88 years) with unilateral radiculopathy. Symptomatic chemical radiculopathy was confirmed with provocative CT diskography and/or provocative selective nerve root block for agreement of sides and levels. Through adhering to the principles of selective excitation (Proset imaging), we acquired 3D coronal FFE sequences with selective water excitation. Morphologic changes in the ipsilateral symptomatic nerve root caused by chemical radiculopathy were compared with those in the contralateral nerve root on 3D MR lumbosacral radiculography. Pain reproduction at the contrast-leak level during diskography (n = 4) and selective nerve root injection (n = 13) showed concordant pain in all patients. All patients with symptomatic chemical radiculopathy showed nerve root swelling in both ipsilateral levels and sides on 3D MR radiculography. The most common nerve root affected by the chemical radiculopathy was the L5 nerve root (n = 13), while the most common segment exhibiting nerve root swelling was the exit nerve root (n = 16). All patients with radicular leg pain caused by chemical radiculopathy showed nerve root swelling on 3D MR radiculography. We believe that in cases without mechanical nerve root compression caused by disk herniation or stenosis in the lumbar spine, nerve root swelling on 3D MR radiculography in patients with radiculopathy associated with an anular tear may be relevant in the diagnosis of symptomatic chemical radiculopathy.

Interventional spinal procedures guided and controlled by a 3D rotational angiographic unit

The aim of this paper is to demonstrate the usefulness of 2D multiplanar reformatting images (MPR) obtained from rotational acquisitions with cone-beam computed tomography technology during percutaneous extra-vascular spinal procedures performed in the angiography suite. We used a 3D rotational angiographic unit with a flat panel detector. MPR images were obtained from a rotational acquisition of 8s (240 images at 30fps), tube rotation of 180° and after post-processing of 5s by a local work-station. Multislice CT (MSCT) is the best guidance system for spinal approaches permitting direct tomographic visualization of each spinal structure. Many operators, however, are trained with fluoroscopy, it is less expensive, allows real-time guidance, and in many centers the angiography suite is more frequently available for percutaneous procedures. We present our 6-year experience in fluoroscopy-guided spinal procedures, which were performed under different conditions using MPR images. We illustrate cases of vertebroplasty, epidural injections, selective foraminal nerve root block, facet block, percutaneous treatment of disc herniation and spine biopsy, all performed with the help of MPR images for guidance and control in the event of difficult or anatomically complex access. The integrated use of "CT-like" MPR images allows the execution of spinal procedures under fluoroscopy guidance alone in all cases of dorso-lumbar access, with evident limitation of risks and complications, and without need for recourse to MSCT guidance, thus eliminating CT-room time (often bearing high diagnostic charges), and avoiding organizational problems for procedures that need, for example, combined use of a C-arm in the CT room.

Magnetic Resonance Imaging–Guided Spine Injections

Magnetic resonance (MR)-guided spine injections describe techniques for selective spine injection procedures, in which MR imaging is used to visualize spinal targets and needle placement, monitor the injected drugs, and detect spread to potentially confounding nearby structures. The introduction of clinical high-field wide-bore MR imaging systems has increased the practicability and availability of MR-guided spine injections. The use of 1.5-T field strength, modern coils, and parallel imaging technology increases the MR signal, which can be utilized for faster temporal image acquisition, higher image resolution, better image contrast, or combinations thereof. Magnetic resonance imaging guidance provides excellent osseous and soft-tissue detail of spinal structures and is well suited to avoid radiation exposure. In this article, we discuss the technical background of interventional MR imaging, review the literature, and illustrate interventional MR imaging techniques of commonly performed spinal injection procedures, including sacroiliac joint injections, lumbar facet joint injections, selective spinal nerve root infiltration, and percutaneous drug delivery to the lumbar sympathetic nerves.

Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis

Cervical spondylosis is a common and disabling condition. It is generally felt that the initial management should be nonoperative, and these modalities include physiotherapy, analgesia and selective nerve root injections. Surgery should be reserved for moderate to severe myelopathy patients who have failed a period of conservative treatment and patients whose symptoms are not adequately controlled by nonoperative means. A review of the literature supporting various modalities of conservative management is presented, and it is concluded that although effective, nonoperative treatment is labour intensive, requiring regular review and careful selection of medications and physical therapy on a case by case basis.