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.

Bibliography

Ashkenazi E, Smorgick Y, Rand N, Millgram MA, Mirovsky Y, Floman Y Anterior decompression with combined corpectomies and discectomies in the management of multilevel cervical myelopathy: A hybrid decompression fixation technique. J Neurosurg Spine 3: 205-209, 2005.

Blumenthal SL, Gill K: Can lumbar spine radiographs accurately determine fusion in postoperative patients? Correlation of routine radiographs with a second surgical look at lumbar fusions. Spine 18: 1186-1189, 1993.

Boden SD, Davis DO, Dina TS, Parker CP, O'Malley S, Sunmer JL, Wiesel SW: Contrast-enhanced MR imaging performed after successesful lumbar disc surgery: Prospective study Radiology 182: 59-64, 1992.

Brantigan JW, Steffee AD, Lewis ML, Quinn LM, Persenaire JM: Lumbar interbody fusion using the Brantigan I/F cage for posterior lumbar interbody fusion and the variable pedicle screw placement system: Two year results from a Food and Drug Administration investigational device exemption clinical trial. Spine 25: 1437-1450, 2000.

Burton K, Kirkaldy-Willis WH, Yong Hing K, Heitoff KB: Causes of failure of surgery on the lumbar spine. Clin Orthop Rel Res 157: 191-199, 1981.

Coskun E, Suzer T, Topuz O, Zencir M, Pakdemirli E, Tahta K: Relationship between epidural fibrosis, pain, disability, and psychological factors after lumbar disc surgery. Eur Spine J 9: 218-223, 2000.

Davis RA: A long-term outcome of 984 surgically treated herniated lumbar discs. J Neurosurg 80: 415-421, 1994.

DePalma AF, Rothman RH: The nature of pseudoarthrosis. Clin Orthop Rel Res 59: 113-118, 1968.

Deutsch AL, Howard M, Dawson EG, et al: Lumbar spine following successful surgical discec-tomy Magnetic resonance imaging features and implications. Spine 18: 1054-1060, 1993.

Dixon AK, Bannon RP: Computed tomography of the post-operative lumbar spine: The need for, and optional dose of, intravenous contrast medium. Brit J Radiol 60: 215-222, 1987.

Dreyfuss P, Schwartzer AC, Lau P, Bogduk N: Specificity of lumbar medial branch and L5 dorsal ramus blocks. A computed tomography study. Spine 22: 895-902, 1997.

Fandino J, Botana C, Viladrich A, Gomez-Bueno J: Reoperation after lumbardisc surgery. Results in 130 cases. Acta Neurochir 122: 102-104, 1993.

Findlay GF, Hall BI, Musa BS, Oliverira MD, Fear SC: A 10-year follow-up of the outcome of lumbar microdiscectomy. Spine 23: 1168-1171, 1998.

Glickstein MF, Sussman SK: Time dependent scar enhancement in magnetic resonance imaging of the postoperative lumbar spine. Skeletal Radiol 20: 333-337, 1991.

Gundry CR, Heithoff KB: Epidural hematoma of the lumbar spine: 18 surgically confirmed cases. Radiology 187: 427-431, 1993.

Hirabayashi K, Satomi K: Operative procedure and results of expansive open-door laminoplasty. Spine 13: 870-876, 1988.

Jinkins JR: Magnetic resonance imaging of benign nerve root enhancement in the unoperated and postoperative lumbosacral spine. Neuroimaging Clin N Am. 3: 525-541, 1993.

Kostuik JP: Failures after spinal fusion in Frymoyer JW, ed.: The adult spine: Principles and practice, 2nd edition. Lippincott-Raven, 1997.

Linson MA, Crowe CH: Comparison of magnetic resonance imaging and lumbar discography in the diagnosis of disc degeneration. Clin Orthop Rel Res 250: 160-163, 1990.

Maldjian C, Mesgarzadeh M, Tehranzadeh J: Diagnostic and therapeutic features of facet and sacroliac injections. Radiol Clin N Am 36: 497-508, 1998.

Mullin WJ, Heitoff KB, Gilbert TJ, Renfrew DL: Magnetic resonance evaluation of recurrent disk herniation: Is gadolinium necessary? Spine 25: 1493-1499, 2000.

Nachemson AL: Lumbar discography—where are we today Spine 14: 555-557, 1989.

Palestro CJ, Torres MA. Radionuclide imaging in orthopedic infections. Semin Nucl Med 28: 334-345, 1997.

Post MJD, Sze G, Quencer RM, Eismont FJ, Green BA, Gahbauer H: Gadolinium-enhanced MR in spinal infection. J Comput Assist Tomogr 14: 721-729, 1990.

Ross JS: Newer sequences for spinal MRI: Smorgasbord or succotash of acronyms? Am J Neuro-radiol 20: 361-373, 1999.

Ross JS, Masaryk TJ, Modic MT et al.: Lumbar spine: Postoperative assessment with surface coils MR imaging. Radiology 164: 851-860, 1987.

Ross JS, Masaryk TJ, Modic MT et al.: MR imaging of lumbar arachnoiditis. Am J Roentgenol 149: 1025-1032, 1987.

Ross JS, Masaryk TJ, Modic MT, Delamater R, Bohlman H, Wilbur G, Kaufman B: MR imaging of lumbar arachnoiditis. Am J Roentgenol 149: 1025-1032, 1987.

Ross JS, Masaryk TJ, Schrader M, Gentili A, Bohlman H, Modic MT: MR imaging of the postoperative lumbar spine: Assessment with gadopentetate dimeglumine. Am J Roentgenol 155: 867-872, 1990.

Ross JS, Masaryk TJ, Schrader M, et al.: MR imaging of the postoperative lumbar spine: assessment with gadopentate dimeglumine. Am J Neuroradiol 11: 771-776, 1990.

Ross JS, Robertson JT, Fredrickson RCA, Petrie JL, Obuchowski N, Modic MT, de Tribolet N: Association between peridural scar and recurrent radicular pain after lumbar discectomy: Magnetic resonance evaluation. Neurosurgery 38: 855-863, 1996.

Rudisch A, Kremser C, Peer S, Katherin A, Judmaier W, Daniaux H: Metallic artifacts in magnetic resonance imaging of patients with spinal fusion: A comparison of implant materials and imaging sequences. Spine 23: 692-699, 1998.

Schellhas K, Smith M, Grundy C, Pollei S: Cervical discogenic pain: Prospective correlation of MRI and discography in asymptomatic subjects and pain sufferers. Spine 21: 300-312, 1996.

Schubiger O, Valavanis A: CT differentiation between disc herniation and postoperative scar formation. The value of contrast enhancement. Neuroradiology 22: 251-254, 1980.

Schwartz AJ: Imaging of the degenerative cervical spine, in Floman Y, Onesti ST, Ashkenazi E: Degenerative disc disease of the cervical spine. Spine: State of the Art Review 14: 545-570, 2000.

Schwarzenbach O, Berlemann U, Jost B, Visarius H, Arm E, Langlotz F, Nolte LP, Ozdoba C: Accuracy of computer-assisted pedicle screw placement: An in vivo computed tomography analysis. Spine 22: 452-458, 1997.

Tehranzadeh J: Discography 2000. Radiol Clin N Am 36: 463-495, 1998.

Teplick JG, Haskin ME: Computed tomography of the postoperative lumbar spine. Am J Roentgenol 141: 865-884, 1983.

Teplick JG, Haskin ME: CT of the postoperative lumbar spine. Radiol Clin N Am 21: 395-420, 1983.

Thalgott JS, Xiongsheng C, Giuffre JM: Single stage anterior ccervical reconstruction with titanium mesh cage, local bone graft and anterior plating. Spine J 3: 294-300, 2003.

Vanderburg DF, Kelly WM: Radiographic assessment of discogenic disease of the spine. Neuro-surg Clin N Am 4: 13-33, 1993.

Van Goethem JWM, Van de Kelft E, Biltjes IGGM, et al.: MR findings after successful lumbar discectomy. Neuroradiology 38: S90-S96, 1996.

Watanabe N, Ogura T, Komori K, et al.: Epidural hematoma of the lumbar spine, simulating extruded lumbar disk herniation: Clinical, discographic and enhanced magnetic resonance imaging features. Spine 22: 105-109, 1997.

Zinreich SJ, Long DM, Davis R, Quinn CB, McAfee PC, Wang H: Three dimensional CT imaging in postsurgical "failed back" syndrome. J Comput Assist Tomogr 14: 574-580, 1990.

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.

0 0

Post a comment