Imaging-guided injection techniques with fluoroscopy and CT for spinal pain management

Efficacy of epidural injections of Kenalog and Celestone in the treatment of lower back pain

OBJECTIVE

Epidural corticosteroid injections have been used extensively to treat lower back pain, but the relative effectiveness of one corticosteroid versus another has never been reported in a large patient series. We retrospectively reviewed 597 patients who had epidural corticosteroid injections to determine any difference in Kenalog or Celestone efficacy.

MATERIALS AND METHODS

We reviewed charts and self-reported pain score evaluations of 597 patients who received either Kenalog or Celestone Soluspan as an epidural injection for the treatment of lower back pain from 1997 to 2002 at our university hospital and affiliated Veterans Affairs hospital. Kenalog was used for the initial 2 years and Celestone was used for the next 3 years. Fluoroscopic guidance was used to confirm epidural location, and each patient was injected with a mixture of 5 mL of 0.5% preservative-free lidocaine and 2 mL of either Kenalog 40 mg/mL (triamcinolone acetonide injectable suspension) or Celestone Soluspan 6 mg/mL (betamethasone sodium phosphate and betamethasone acetate injectable suspension). Each patient was given a standardized pain evaluation sheet that used an 11-point scale for initial pain severity. Scoring of pain compared with baseline during the following 14 days was based on a 5-point scale of pain improvement or worsening.

RESULTS

On days 0-3 after the procedure, no statistical significance in improvement of lower back and buttock pain was seen between groups. On day 7, 59% of Celestone recipients and 73% of Kenalog recipients showed improvement in lower back pain (p = 0.002, Pearson's chi-square test), and 58% of Celestone recipients and 75% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). On day 14, 54% of Celestone recipients and 71% of Kenalog recipients showed improvement in lower back pain (p < 0.001), and 54% of Celestone recipients and 71% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001).

CONCLUSION

The epidural injection of Celestone Soluspan and Kenalog reduced lower back and radicular pain in more than half the patients, although Kenalog reduced pain in a significantly larger number of patients than Celestone Soluspan at 1 and 2 weeks after injection.

Diagnosis and treatment of arthrosis of cervical articular facet joints in Scottish Deerhounds: 9 cases (1998-2002)

OBJECTIVE

To determine diagnostic features and efficacy of treatment of arthrosis of the cervical articular facet joints between C2 and C3 in Scottish Deerhounds.

DESIGN

Retrospective study.

ANIMALS

9 client-owned dogs.

PROCEDURE

Medical records of affected dogs were reviewed. Diagnosis was confirmed by results of clinical examination (signs of severe pain from unilateral or bilateral flexion of the cervical vertebral column), radiography, myelography, and computed tomography. Treatment consisted of fluoroscopy-guided intra-articular injection of corticosteroids and lidocaine.

RESULTS

Unilateral or bilateral arthrosis of the cervical facet joints between C2 and C3 was detected in all dogs. In 7 dogs, signs of pain were elicited by flexion of the side of the neck in which affected joints were detected radiographically. Two dogs had signs of pain during right lateral flexion, although bilateral lesions were detected. Five dogs had unilateral lesions, and 4 dogs had bilateral lesions; sclerosis and hypertrophy of the articular process were common. Two dogs had bridging of the articular space. Use of computed tomography confirmed the diagnosis. Myelography did not reveal abnormalities of the spinal cord or canal. After treatment, 8 dogs had rapid marked improvement of clinical signs, and 7 dogs remained free of clinical signs for > 4 months.

CONCLUSIONS AND CLINICAL RELEVANCE

Arthrosis of the cervical facet joints in Scottish Deerhounds is a severely painful condition for which conventional radiography is a useful screening test. Intra-articular administration of corticosteroids and anesthetic is efficacious, long-lasting, and minimally invasive.

Can quantitative sensory testing predict the outcome of epidural steroid injections in sciatica? A preliminary study

Quantitative Sensory Testing (QST) is a psycho-physiological test used to identify dysfunction of individual nerve fiber types. In the present study, we investigated whether selective nerve fiber dysfunction, as assessed by QST, correlates with the effectiveness of epidural steroid injections (ESI) in patients with lumbar radiculopathy. Twenty patients with unilateral painful sciatica caused by disc herniation participated in this open study. Before ESI, quantitative thermal and mechanical sensory testing was conducted at the most painful dermatome and the contralateral dermatome. The primary outcome measure used was the self-recording of pain intensity twice daily with a 0-10 numerical pain scale (NPS). Secondary efficacy measures included the Short Form of the McGill Pain Questionnaire, the straight leg raising test, and the lumbar range of motion. A significant difference in all types of sensory thresholds between the affected and the contralateral dermatomes was detected at baseline. All outcome measures improved subsequent to the ESI. A significant positive correlation was found between the increase in cold sensation thresholds of the affected dermatome (Adelta-fiber dysfunction) and the improvement in NPS. The increase in touch and vibration thresholds (Abeta-fiber dysfunction) was found to be inversely correlated with the improvement in NPS. No correlation was found between heat sensation thresholds (C fibers) and any of the outcome measures. These results suggest that QST has the potential to be an important tool in the selection of the appropriate treatment (e.g., ESI versus surgery) for patients with sciatica and may assist in identifying the mechanisms of pain generation in these patients.

Sacroiliac joint injections performed with sonographic guidance

OBJECTIVE

To investigate the feasibility and effectiveness of sonographic guidance for therapeutic intra-articular sacroiliac joint injections in patients with sacroiliitis.

METHODS

Thirty-four consecutive patients with sacroiliitis were enrolled in this study. The synovial portions of 60 sacroiliac joints received injections under sonographic guidance. For treatment, a mixture of a corticosteroid and a local anesthetic was injected intra-articularly. Fluoroscopic spot images were obtained to assess the accuracy of the sonographically guided technique.

RESULTS

Of the 60 sonographically guided injections, 46 (76.7%) were successful (i.e., intra-articular), and 14 (23.3%) were missed. The successful intra-articular injection rate was 60% in the first 30 injections, and it gradually improved, reaching 93.5% in the last 30 injections. The mean procedure time was 9 minutes.

CONCLUSIONS

Our initial experience suggests that sonographically guided therapeutic injections to sacroiliac joints could be valuable alternatives to other guidance modalities in patients with sacroiliitis. In the hands of experienced radiologists, this technique is safe, rapid, and reproducible.

Interactive and interventional sports medicine imaging

The concepts and clinical potential of interactive magnetic resonance imaging (MRI) in which an examiner manipulates the joint of interest during MRI, and of interventional sports medicine imaging in which radiological guidance is used for targeted therapy of injuries and masses are described. As illustrated by a series of clinical cases, we believe that with further development, interactive MRI will play an important role in the comprehensive evaluation of patients with shoulder pain or dysfunction as well as other joint derangements. Interventional sports medicine takes advantage of the increasingly sophisticated diagnostic value of MRI and the radiologist's ability to use imaging to guide percutaneous therapy. We review our recent experience treating a wide variety of disorders such as cysts, hematomas, and inflammatory disorders, focusing on techniques utilizing ultrasound and MR guidance.