Figure 1721

Epidural hematoma folowing cervical corpectomy (A) T1 and (B) T2 FSE MRI of the cervical spine following C5 corpectomy with C4 through C6 fixation, showing a compressive epidural hematoma. Note also the high signal within the spinal cord indicating myelomalacia.

postoperative symptoms, such as root and facet blocks, sacroiliac joint injection, and discography (Figure 17-22). These diagnostic injections may complement the investigation of the symptomatic patient after surgery. Whereas root or facet blocks are intended to abolish the pain originating from the "blocked" anatomical structures, and thus imply that surgery on these structures will help the patient's symptoms, discography is intended to provoke the pain typically experienced by the patient. Again, performing surgery on the painful disc—be it fusion surgery, dynamic stabilization, or disc replacement—will abolish the patient's symptoms.

Selective nerve root blocks are performed to better localize the source of pain from an irritated or compressed spinal nerve root. Facet blocks or sacroiliac joint injections are used to identify the source of pain from these structures, because the radiological appearance of these joints alone is not diagnostic in localizing the pain source.

Discography must not only recreate the patient's concordant pain at a certain level, but it must also fail to reproduce the patient's symptoms at a different level. It is an interactive test that allows the patient's input when CT and MRI are equivocal in identifying the source of pain or when multilevel pathology is present. In addition to the reproduction of concordant pain, disc morphology may be evaluated by post-discography CT. Posterior annular tears will allow the contrast dye to leak into the epidural space, usually toward the side with radiculopathy, and confirm that a certain level is producing the patient's symptoms. Although some authors consider discography controversial at best, others claim a 94% clinical correlation between lumbar MRI and discography in degenerative lumbar disc disease. Similar data for cervical discography are still scarce.


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Fluoroscopically guided precision injections can aid both in localizing the pain-generating structures (diagnostic) and in the treatment of several painful conditions (therapeutic) of the spine. The concept of diagnostic precision injection blocks was developed with the increasing popularity of the fluoroscope and the realization that there are no diagnostic tools to precisely determine pain-generating pathology or structures. The use of fluoroscopy is absolutely necessary; it was documented that up to 30% of nonfluoroscopically (blind) simple interlaminar injections are off the target. It is inconceivable that facet joints or sacroiliac joints could be blocked reliably in a blind fashion. Using a diagnostic workup protocol and flow sheet can standardize spine pain workup and serve as a base for treatment and for reproducible research.

For therapeutic injections the precise localization of the needle tip is necessary if complications are to be avoided and smaller, more circumscribed pathologies, such as neurotomy of the medial branch of the posterior division of the spinal nerve or drainage of a facet joint synovial cyst, are to be treated.

Common diagnostic injections will be discussed first, followed by examples of therapeutic injections.

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