Figure 1827

Dorn Spinal Therapy

Spine Healing Therapy

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Transforaminal epidural injection, lumbar, lateral view.

Procedure Use of fluoroscopy is fundamental for the proper execution of this procedure. The target for the needle tip is in close proximity to the spinal nerve and its vessels and other vital structures, such as the pleura or the spinal cord, depending on the spinal segment. In the cervical spine the target point is the midpoint of the dorsal aspect of the intervertebral foramen in a lateral view and the midfacet pillar line in an anterior-posterior view.

In the thoracic spine the target point for the location of the needle tip is the intervertebral foramen medial to the pleural lines. In the lumbar spine the target point for the location of the needle tip is the midpoint of the infrapedicle area in the so called "six o'clock position" in the "safe triangle" (Figures 18-26 and 18-27). The "safe triangle" is the area limited between the lateral border of the vertebra, the spinal nerve, and the pedicle.

Selective Spinal Nerve Sleeve Steroid Injection

Deposition of a steroid and local anesthetic solution at the spinal nerve sleeve near the intervertebral neural foramen.

Indications The principal indication is for the deposition of steroids in the vicinity of a specific spinal nerve that is causing pain. The effect of the steroids is expected at the level of the spinal nerve and the DRG. Frequently, multiple nerves are selectively injected if they are involved in symptom generation. The common pathologies affecting the spinal nerves are herniated discs and foraminal stenosis.

Procedure The placement of the needle is similar to the transfo-raminal approach, except the needle tip is placed more distally in the foramen at the level of the cervical and lumbar spine. The knowledge of the anatomical position of the spinal nerve in relation to the pedicle and the SAP is important to obtain good coverage of the specific spinal nerve. This relationship varies at different anatomical levels. In the lumbar spine the course of the spinal nerve as it exits from the intervertebral foramen is becoming less vertical and more transverse in the lower lumbar levels (see Figures 18-1 through 18-4).

Z Joint Intra-articular Injection

Deposition of a steroid and anesthetic solution into the joint.

Indications Painful conditions originating in the Z joint such as synovitis or arthritis, and localized by a previous block, can be controlled by intra-articular injection of steroids. These injections can be repeated, but if the effect is only temporary than radiofrequency neu-rotomy of the medial branches may give a longer pain relief period.

Procedure Intra-articular injections can be done at the cervical, thoracic, and lumbar levels. At times it is difficult to place the needle into the joint as it might be deformed from an arthritic process or be very curved in a transverse plane. It might be easier in these cases to place the needle in the inferior recess of the joint (see Figures 187 through 18-9). Use of contrast is helpful in confirming the intraarticular placement of the needle tip. Less than 1 mL of contrast is necessary to obtain a characteristic arthrogram. Volume of less than 1 mL of steroid is usually sufficient as therapeutic modality.

SI Joint Intraarticular Injection

Deposition of a steroid and anesthetic solution into the joint.

Indications Pain originating from the SI joint diagnosed by previous SI joint block is the indication for an SI joint intra-articular injection. Steroids or hyaluronidase can be injected intra-articularly to control the pain.

Procedure Use of fluoroscopy is necessary to place the needle tip in the distal centimeter of the joint line (see Figures 18-5 and 18-6). About 1 mL of contrast will demonstrate an arthrogram and confirm intra-articular placement of the needle.

RF Neurotomy

RF energy is used to coagulate the nerves involved in the pain pathway.

Indications The indications for RF neurotomy are painful conditions originating in the Z or SI joints or a spinal nerve. Neurotomy of the two medial branch nerves innervating the affected joint will reduce the pain for many months or years. RF neurotomy of a spinal nerve is done in rare cases and only after a diagnostic block has confirmed and localized the level of the painful nerve. Usually this is done at the C2 and C3 nerves. Paresthesias occur in the related dermatome. Neuritis or formation of a neuroma are possible complications.

Procedure The RF needle is placed as close as possible to the nerve to ablate. Sensory stimulation at 50 Hz followed by motor stimulation at 2 Hz is necessary to eliminate possible damage to intact spinal nerves and to confirm optimal positioning of the RF needle near the involved nerve (Figure 18-28). The needle tip is than heated to 80°C for one minute. Three or four lesions are necessary at each level to improve the chances of an effective neurotomy. Sacral medial branch neurotomy at several levels is necessary to denervate the SI joint.

IntradiscalElectrothermal Therapy (IDET)

Thermal energy is brought into the "painful" invertebral lumbar disc and applied under controlled conditions.

Indications The main indication for IDET is discogenic pain. A discogram is required to show internal disc disruption or annular tear with "bulging" of the disc or a nonextruded herniated disc.

FIGURE 18-28 RF neurotomy, C2.

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