Spinal injection techniques PDF
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Spinal Injection Techniques Theodoros Theodoridis, MD Director DepartmentforSpineTherapyandOrthopedicSurgery ViktoriaKlinik Bochum,Germany InstituteforSpineResearch attheRuhrUniversity Bochum,Germany Juergen Kraemer, MD ProfessorEmeritus FormerlyOrthopedicUniversityClinic St.JosefHospital Bochum,Germany InstituteforSpineResearch attheRuhrUniversity Bochum,Germany 397illustrations Thieme Stuttgart·NewYork IV LibraryofCongressCataloging-in-PublicationData isavailablefrom Importantnote:Medicineisanever-changingscienceundergoing thepublisher. continualdevelopment.Researchandclinicalexperiencearecontin- ually expanding our knowledge, in particular our knowledge of propertreatmentanddrugtherapy.Insofarasthisbookmentions anydosageorapplication,readersmayrestassuredthattheauthors, LibraryofCongressCataloging-in-PublicationData editors,andpublishershavemadeeveryefforttoensurethatsuch Theodoridis,Theodoros. referencesareinaccordancewiththestateofknowledgeatthetime [InjektionstherapieanderWirbelsaüle.English] ofproductionofthebook. Spinalinjectiontechniques/TheodorosTheodoridis,Juergen Nevertheless,thisdoesnotinvolve,imply,orexpressanyguaran- Kraemer. teeorresponsibilityonthepartofthepublishersinrespecttoany p.;cm. dosageinstructionsandformsofapplicationsstatedinthebook. Thisbookisanauthorizedandrevisedtranslationofthe2nd Everyuserisrequestedtoexaminecarefullythemanufacturers’leaf- Germaneditionpublishedandcopyrighted2007byGeorgThieme letsaccompanyingeachdrugandtocheck,ifnecessaryinconsulta- Verlag,Stuttgart,Germany.TitleoftheGermanedition: Injek- tionwithaphysicianorspecialist,whetherthedosageschedules tionstherapieanderWirbelsaüle. mentionedthereinorthecontraindicationsstatedbythemanufac- Includesbibliographicalreferencesandindex. turersdifferfromthestatementsmadeinthepresentbook.Such ISBN978-3-13-145071-5(alk.paper) examination is particularly important with drugs that are either 1.Injections,Spinal. I.Krämer,Jürgen,1939-II.Title. rarelyusedorhavebeennewlyreleasedonthemarket.Everydosage [DNLM:1. BackPain--therapy.2. Anesthesia,Spinal.3. Injections, scheduleoreveryformofapplicationusedisentirelyattheuser’s Spinalmethods. WE720T388j2009a] own risk and responsibility. The authors and publishers request RD751.T54132009 everyusertoreporttothepublishersanydiscrepanciesorinaccura- 617.9'64--dc22 ciesnoticed.Iferrorsinthisworkarefoundafterpublication,errata 2009002210 willbepostedatwww.thieme.comontheproductdescriptionpage. Thisbookisanauthorizedandrevisedtranslationofthe2ndGerman editionpublishedandcopyrighted2007byGeorgThiemeVerlag, Stuttgart,Germany.TitleoftheGermanedition:Injektionstherapie anderWirbelsäule. Translator:MichelleJames,Nettetal,Germany Illustrator:HeikeHübner,Berlin,Germany ©2009GeorgThiemeVerlag, Someoftheproductnames,patents,andregistereddesignsreferred Rüdigerstrasse14,70469Stuttgart,Germany tointhisbookareinfactregisteredtrademarksorproprietarynames http://www.thieme.de eventhoughspecificreferencetothisfactisnotalwaysmadeinthe ThiemeNewYork,333SeventhAvenue, text.Therefore,theappearanceofanamewithoutdesignationas NewYork,NY10001,USA proprietaryisnottobeconstruedasarepresentationbythepub- http://www.thieme.com lisherthatitisinthepublicdomain. Thisbook,includingallpartsthereof,islegallyprotectedbycopy- Coverdesign:ThiemePublishingGroup right.Anyuse,exploitation,orcommercializationoutsidethenarrow TypesettingbyPrimustypeHurler,Notzingen,Germany limitssetbycopyrightlegislation,withoutthepublisher’sconsent,is PrintedinGermanybyOAN,OffizinAndersenNexö,Leipzig illegalandliabletoprosecution.Thisappliesinparticulartophoto- statreproduction,copying,mimeographing,preparationofmicro- ISBN 978-3-13-145071-5 123456 films,andelectronicdataprocessingandstorage. V List of Contributors AlexandrosAnastasiadis,MD SusanneStehr-Zirngibl,MD SurgicalClinicBergmannsheil St.JosefHospital Bochum,Germany ClinicforAnesthesiology attheRuhrUniversity FritjofBock,MD Bochum,Germany PrivatePracticeforOrthopedics Ravensburg,Germany WolframTeske,MD St.JosefHospital StefanHeidersdorf,MD OrthopedicUniversityClinic PrivatePracticeforOrthopedics Bochum,Germany Hattingen,Germany UlrikeTheodoridis,MD CordeliaSchott,MD St.JosefHospital PrivatePracticeforOrthopedics NeurologicalUniversityClinic Düsseldorf,Germany Bochum,Germany ClemensSirtl,MD St.JosefHospital ClinicforAnesthesiology attheRuhrUniversity Bochum,Germany VI Foreword “Theburdenoftheback”—backpaininallitsvariousforms monitoring” solely because the “traditional orthopedic hasalwaysbeenandwillremainthedomainofthespecial- clinicalexamination”hasfallenintooblivion. istfieldoforthopedics. Rather,thewiderangefoundinanestablishedortho- Thetaskof“conquering”backpain,oratleastimple- pedic/traumasurgicaltherapyshouldbedepicted,withits mentingadequateformsoftherapy,isbecomingincreas- provenlong-termtherapysuccess. ingly difficult under the conditions found in the Public Thisbookmakesitclearthatallspinalinjectiontech- HealthServiceswiththeirlackoffundingandconcepts. niqueswereandwillremainthedomainoforthopedicand Treatmentguidelinesarestrictlymonitoredusing“evi- traumasurgery,asIGOSThasconveyedinitscourses. dencebasedmedicine.”Thisisdefinitelyadvantageousto Aportionofthisbookisalsodedicatedtotherational patientsandpractitioners,butcanalsoresultinthefree- pharmaceutical treatment of back pain, taking into ac- domoftreatmentbeing“legallypatronized.”Itischarac- countnewfindingsintheareaoflocalanesthetics. terizedbyconflictsaboutwhichlineofthoughtshouldbe Thecoreofthematterhereisthepreventionofchron- followed,especiallybythesocieties“thatargueaboutback ification of back pain using interdisciplinary therapeutic treatment.” approachesandaspecificearlytherapymanagement,and During the development of pain therapy in Germany notsimplythe“managementofanever-increasingnum- overthelast10yearswehavelearntagreatdealfromthe berofpainpatients.” conflicts relating to back pain in all of its forms. This This book corresponds to the “golden standard” for processmustbecontinued. spinalinjectiontherapyfromanorthopedic/traumasurgi- This book should aid in improving confidence when cal point of view and is an excellent companion for our treatingbackpain.Itisbasedontheworkandnewcon- courses.Itcomplementsasuccessionofremarkablespe- cepts from the “Interdisziplinären Gesellschaft für or- cialistbookswhichhaveemergedwiththehelpofIGOST thopädischeundunfallchirugischeSchmerztherapie”(In- overrecentyears. terdisciplinarySocietyforOrthopedicandTraumaSurgical ItisonthispremisethatIthanktheauthorsfortheir Pain Therapy—IGOST) and represents the pain therapy work with the IGOST and wish them success with this section of the Deutsche Gesellschaftfür Orthopädie und book. OrthopädischeChirurgie(GermanSocietyforOrthopedics Iwishallourreadersenjoymentandsuccesswiththe andOrthopedicSurgery—DGOOC). teachingsofthisbookandhopethattheyareabletoapply Morethan90%ofbackpainistreatedas“nonspecific” whattheyhavelearntintheirdailywork. simply because the therapist knows and has learnt too little about the back. The further development of this H.E.Brunner,MD phenomenonhastobecounteracted. GOST–IMPSPresident Itisalsonecessarytopreventtheoveruseof“technical methods and injection techniques under radiological VII Preface Spinalinjectiontechniquesenjoyahighstatuswithinpain ourclinic:BirgitGreifenberg,SilkeBachmann,andMichael therapyandareavaluabletreatmenttoolwhencorrectly Müller.Itwasalwaysapleasuretocombinemedicinewith used. Performing special injection techniques from the art.Wesincerelythankyouforthis. cervicalspinetothesacrumprofessionallyandsafelyre- SpecialthanksgototheClinicalAnatomyResearchand quiresasoundspecialistknowledgeintopographicalanat- Education Center (Klinisch-anatomisches Forschungs- omy. Building on this, the injection techniqueshave be- und Fortbildungszentrum—KAFFZ) at the Ruhr Univer- comeincreasinglyrefinedovertheyears.Safetreatment sity’sAnatomicalInstituteinBochum,Germany.Thiscen- fordoctorsandpatientscanbeachievedwhenthetechni- terisanestablishmentdedicatedtoresearchandeduca- ques are correctly implemented. Routine radiation- tion in the clinical anatomy fields. In the last years the chargedradiographsandcomputertomographiesarenot well-known “hands on” courses by the Interdisciplinary necessarywhenusingthetechniquesdescribedhere. SocietyforOrthopedicTraumaandSurgicalPainTherapy Basic principles, diagnostics, causal and symptomatic (InterdisziplinäreGesellschaftfürOrthopädischeundUn- paintherapyforspinalsyndromes,aswellasthenewIRAP fallchirurgischeSchmerztherapie—IGOST)havebeenheld (EOT)methodare,amongstothers,extensivelydescribed hereincooperationwiththeOrthopedicUniversityClinic. in the theoretical section of the book. New concepts in The directors of the Anatomical Institute, Professor Rolf multimodal pharmaceutical pain therapy are likewise Dermietzel, MD, and Professor Hans-Georg Mannherz, demonstrated. MD,andtheiremployees,ClaudiaSchneiderandHelmut Theatlassectionconveysdetailedanatomicalknowl- Riese,havegivenustheconsiderableopportunityofclar- edge.Theinjectiontechniquesareclearlydescribed“step- ifyinganatomicallyrelevantdetailsrelatedtothespecial by-step”usingseriesofphotographicmaterial.Thebookis injectiontechniques. divided into regions of the body for easy reference of WesincerelythankthestaffofThiemePublishersfor special techniques. The diagnosis and management of theirexcellentconstructiveinputandassistancewiththe therapy side effects and treatment complications are bookandthepleasantcollaboration. clearly arranged according to injection and area of the We encourage all our readers to use spinal injection body. therapy more intensively without the use of diagnostic Over30yearsofexperienceusinginjectiontechniques imaging and to implement thisto their patients’ advan- alongthespinehavebeenincorporatedintothisbook. tage. Wethankallofourpatientswhowerewillingtocon- Goodluck! tributetothedevelopmentofthisbook. TheodorosTheodoridis Alargenumberofthephotographswerepreparedby JuergenKraemer thefollowingmembersofthephotographicdepartmentat VIII Table of Contents I General Section 1 █ BasicPrinciples 3 OrthopedicPainTherapy................. 3 SecondaryPain......................... 8 NociceptionandChronification ........... 4 MixedPainSyndrome................... 9 StagesintheDevelopmentofPain ........ 5 ChronicPainSyndrome.................. 10 MovingfromAcutetoChronicPain: NociceptorSensitization................. 6 2 █ Diagnostics 13 MedicalHistory......................... 13 LaboratoryTests........................ 17 ClinicalExamination..................... 14 ImagingTechniques..................... 18 Neurological–OrthopedicExamination..... 16 TrialMeasuresfortheDiagnosisofPain.... 18 3 █ CausalOrthopedicPainTherapy 19 PositioningandTraction................. 19 PosturalandBehavioralTraining;Back OrthopedicAids ........................ 20 School................................. 22 ManualTherapy ........................ 20 BackSchoolandOrthopedicPainTherapy.. 22 PhysicalTherapy........................ 21 4 █ SymptomaticPainTherapy 25 Introduction ........................... 25 MultimodalMedicationConcomitant Thermotherapy......................... 26 Therapy ............................... 36 Massage............................... 27 Introduction ........................... 36 Electrotherapy.......................... 28 PainMeasurementandDocumentation.... 36 Acupuncture ........................... 29 WHOAnalgesicLadder .................. 37 TherapeuticLocalInjectionTreatment ..... 30 OpioidManagement .................... 46 Interleukin-1ReceptorAntagonistProtein AdjuvantAnalgesics..................... 46 (IL-1Ra)................................ 33 LocalAnesthesia........................ 49 TableofContents IX II Atlas Section 5 █ TheSpine:Anatomy,Nociception,andtheDistributionofPainSignals 53 Terminology ........................... 53 NerveRoot............................. 55 NociceptionandtheDistributionofPain NociceptivePainArisingfromthe SignalsintheSpine ..................... 53 ZygapophysealJoints.................... 57 Pain-SensitiveStructuresintheVertebral Muscles ............................... 57 MotorSegment......................... 53 MixedPainSyndromesintheSpine....... 59 SpinalNerve ........................... 54 ChronicPainArisingfromtheVertebrae ... 59 PosteriorLongitudinalLigament .......... 55 6 █ SpecialOrthopedicInjectionTherapy:ContraindicationsandPatientInformation 61 Contraindications....................... 61 PatientInformation ..................... 62 7 █ CervicalInjectionTherapy 65 SpecializedCervicalNeuroanatomy........ 65 PainTherapyforthePosttraumaticCervical BasicTherapyforCervicalPain............ 66 Syndrome ............................. 71 SpecialTherapyforCervicalPain.......... 68 CervicalInjectionTherapy................ 72 LocalCervicalPainSyndrome............. 68 CervicalSpinalNerveAnalgesia........... 72 PainTherapyfortheCervicobrachial CervicalEpiduralInjection ............... 81 Syndrome ............................. 70 CervicalFacetInfiltration(CxFI)........... 89 TreatmentofCervicalHeadaches CervicalTriggerPointInfiltrationandSkin (CervicocephalicSyndrome).............. 71 Infiltration............................. 95 8 █ ThoracicInjectionTherapy 99 SpecializedThoracicNeuroanatomy....... 99 ThoracicSpinalNerveAnalgesia .......... 101 ClinicalPicture ......................... 100 ThoracicFacetInfiltration(TxFI) .......... 107 ThoracicInjectionTherapy ............... 101 CostotransverseBlock(CTB).............. 110 9 █ LumbarInjectionTherapy 113 SpecializedLumbarNeuroanatomy........ 113 DecompensatedSpinalCanalStenosis ..... 121 BasicTherapyforLumbarPain............ 115 PainTherapyforProblemPatientsWho SpecialTherapyforLumbarPain .......... 118 HaveUndergoneSpinalSurgery .......... 122 LocalPainSyndromesinthe PainFollowingLumbarSpondylodesis..... 124 LumbarSpine(LocalLumbarSyndrome, LumbarInjectionTherapy................ 125 NonspecificBackPain)................... 118 LumbarSpinalNerveAnalgesia........... 125 TreatmentofAcuteLowBackPain ........ 119 Radiculography......................... 139 TreatmentofChronicLowBackPain....... 119 LumbarFacetInfiltration................. 139 PainTherapyfortheLumbarNerveRoot LigamentInfiltrationattheSacroiliac Syndrome ............................. 120 Joint(SIJBlock)......................... 149 PainTherapyforLumbarSpinalCanal LumbarEpiduralPainTherapy............ 157 Stenosis ............................... 121
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