Spinal interventional procedures

Last revised by Assoc Prof Craig Hacking on 19 Aug 2021

Back pain is a common condition that is often difficult to treat. Lumbar degenerative facet joints, lumbar disc disease and sacroiliac joint pain account for nearly 70% of cases of lower back pain.

Unfortunately, as the incidence of degenerative changes in the spine is so high (e.g. disc abnormalities are found in 25% of individuals below the age of 60, and over 50% in those over the age of 60), it is sometimes difficult to confidently identify the cause of pain, without careful correlation with clinical findings and potentially diagnostic injections. The other role of spinal injections is to treat non-operative back pain.

Procedures include:

All these procedures require precise needle tip position and therefore are performed with imaging guidance, either fluoroscopy or CT.

The following are general contraindications to elective spinal international procedures:

  • active sepsis
  • known allergy to local anesthetic/steroids/contrast agents
  • pregnancy
  • bleeding tendencies
  • anticoagulation
  • particulate steroids should be avoided in cervical spine epidural injections
  • intra-arterial injection can results in spinal cord or brain stem infarction
  • neural compression or ischemia
  • benzyl alcohol has caused necrosis and apoptosis of retinal pigment epithelial cells
  • direct nerve trauma
  • bleeding with possible epidural hematoma requiring evacuation or resulting in weakness and other sequelae
  • air embolism
  • infection with possible epidural abscess requiring evacuation or resulting in weakness and other sequelae
  • osteomyelitis
  • discitis
  • repeated steroid injections may result in epidural lipomatosis
  • gastritis (especially if the patient is on concurrent NSAIDs)
  • intrathecal injection of steroids may result in arachnoiditis; this is mainly due to excipients such as polyethylene glycol
  • decrease in diabetic control
  • tachon syndrome
  • allergic reaction to contrast agents
  • allergic reaction to anesthetic products

As in everything, there are many variations on this theme:

  • spinal needle for deep injection (typically a 22G or 25G)
  • skin needle for local anesthetic
  • local anesthetic to skin and superficial structures, e.g. lidocaine 1% or 2%
  • therapeutic injection
    • local anesthetic, e.g. bupivacaine 0.2% to 0.5%, 1-2 mL
    • steroid approved for epidural injection, e.g. dexamethasone

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Cases and figures

  • Case 1: transforaminal neural block
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  •  Case 2: vertebroplasty
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  • Case 3: vertebroplasty
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  • Case 4: interlaminar epidural steroid injection
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