Melbourne Radiology Clinic

This fact sheet relates to spinal injection procedures performed at Melbourne Radiology Clinic. The injection treats pain by delivering pain reducing medication to the affected area. This treatment usually stops pain stemming from an identified location by reducing inflammation in the area. A CT (Computed Tomography) scan will be used to guide the procedure.

Preparation

• There is no specific preparation required.
• It is essential that Melbourne Radiology Clinic knows in advance of any blood thinning medication.
  This must be stopped prior to the procedure (Aspirin and Warfarin for 5 days, Plavix for 7 days & Iscover for 8 days).
• We also strongly recommend that you bring a responsible person to drive you home afterwards. If you do wish to drive home despite our recommendation, then please allow 2 hours for the anaesthetic to wear off.

The Procedure

Spinal injection procedures are completed with you lying face down. You will be asked to wear a gown with the selected area exposed of the spine. We will ensure that you are as comfortable as possible.

Types of spinal injections & procedures

Facet Joint Injections

The facet joints are sliding joints at the back of the spine which allow for mobility. Like any joint, then may become arthritic and therefore cause a sore back. Pain relief is brought about by injecting a mixture or cortisone and local anaesthetic into the facet joint (or joints if more than one is to be treated). The cortisone decreases the inflammation that is produced by the arthritis. The medication is delivered by a fine needle under CT guidance by our radiologist (medical specialist trained in this area). Some discomfort will be felt for a short time until the local anaesthetic numbs the area. The effects of the treatment vary and it is impossible to predict the duration of pain relief until the procedure is performed. In some people, pain is relieved for months, others years and still for others it produces no relief at all. In the case of the latter, your doctor may recommend an alternative treatment, which may include radiofrequency ablation.

Selective Nerve Root Block (SNRB)/perineural injection

A nerve root block is used for patients who suffer from pain from a “pinched nerve”, also known as radicular pain. This may involve the arms, neck, body and legs. Radicular pain usually involves the legs where it is commonly known as sciatica. The procedure for a nerve root is similar to the information provided above for a facet joint injection except for that the needle is directed onto the nerve that is felt to be causing the pain. When gentle needle contact is made with the nerve, and if that particular nerve is the one causing you your symptoms, you will experience a brief pain that many patients describe as an “electrical, nerve-like shooting” pain. This pain will usually be in the same area of the body and/or character as the pain that you have come in to have treated. Occasionally, it may be more intense at the time of needle contact. This is common and confirms the correct position of the needle and is part of the procedure. At this point, the cortisone and local anaesthetic are injected. Just as local anaesthetic stings when it injected into the skin, so to will a stinging sensation occur in the area that the injected nerve supplies sensation to. This lasts approximately 10 seconds.

Following the procedure the body part involved may feel numb and clumsy, as the particular nerve has been anaesthetised. This is to be expected. The function and sensation of the nerve will return once the local anaesthetic wears off, usually between 20 minutes to 2 hours. Once full function has been regained and you are confident in your mobility, you are free to leave the Clinic. As for facet joint injections, the relief from this procedure is variable and usually temporary. If you require an occasional injection, such as once or twice a year, then depending on your lifestyle and preference, you may continue with repeated nerve root injections. If your pain is severe and/or the duration of pain relief obtained from the injection is short, or you feel that multiple injections are inconvenient, then you may need to consider a more permanent option, such as surgery.

Medial Branch Block & Radiofrequency Ablation

A Medial Branch Block is a test to help your doctor understand whether pain arising from your facet joints can be relieved by numbing the nerves (“medial branches”) that provide them with their sensation. If numbing these nerves results in significant pain relief, then the test is positive. Unfortunately, as only local anaesthetic is used, the pain relief is temporary and as such, a more reliable way of relieving you of your facet joint pain (as opposed to direct facet joint injection) is to then proceed to a radiofrequency ablation. As the name implies, heat is then used to destroy these small nerves that supply the facet joints and the pain relief is usually dramatic and long lasting. The nerves may grow back, in which case the pain may return and the procedure then once again easily repeated.

Epidural

This injection is used to treat neck, back, arm and leg pain, depending on which level the needle is placed and exactly where in the spine. Once again, local anaesthetic and cortisone steroid solution is used to produce an anaesthetics and anti-inflammatory response. A CT (Computed Tomography) scanner and/or C-arm may be used to locate the right location for the needle.

The three main types of epidural treatment are:

1. An interlaminar epidural is used to mainly treat the lower back at a specific level.
2. A caudal epidural is used to treat back pain and sciatica and targets multiple levels at once. This procedure is therefore useful in patients who have multiple levels that contribute to their pain.
3. A transforaminal epidural is when the injection is delivered to a specific nerve root to assist in relieving sciatica and is similar to a selective nerve root block/perineural injection.

Example:

CT guided caudal epidural injection in a patient with severe intractable back pain following spinal surgery. The needle is demonstrated within the sacral epidural space, with contrast injected to confirm position. The procedure is used in patients with multiple levels of impingement.

Discogram

A discogram involves injecting x-ray dye (contrast) into the centre of a disc. The dye injected stretches the disc and the test is positive if the procedure reproduces the patient’s pain. In this way, a discogram can determine whether back pain is due to disc disruption (discogenic back pain) and also assists in identifying the correct level prior to any contemplated surgery or other procedure. Further to this, a discogram assess the type of disc disruption and whether it causes pressure on adjacent structures, especially nerves. Following discography, a CT is performed to also provide a 3-Dimensional view of the discs filled with dye. Usually multiple levels are injected in one sitting.

IDET & Biaculoplasty

IDET (IntraDiscal ElectroThermal Therapy) and Biaculoplasty are similar procedures aimed at treating small tears in discs, known as annular fissures, which cause back pain. Patients in this group do not have a major component of leg pain, if at all. The procedure is usually performed following an MRI scan which demonstrates the annular fissure and/or a positive discogram. Both procedures involve gaining access to the disc, with one needle used in IDET and two needles for Biaculoplasty. Then a heating system is used whereby the small nerves in the annular fissure which are causing the patient’s pain are destroyed. Patients seeking this procedure should have failed at least three months of all other treatments, such as epidural injections, physiotherapy and medications.

Percutaneous Disc Decompression

This procedure is used to treat leg pain (sciatica) due to a disc bulge or herniation which is pressing upon a nerve. The procedure is performed if other injections, such as a transforaminal epidural or selective nerve root block, have not resulted in resolution of the patient’s symptoms. Percutaneous disc decompression is considered to lie somewhere in between these injections and surgery. It involves gaining access to the disc via a needle, through which a smaller needle is then passed and removes some of the disc material. Usually only 1cc of disc material is required to be removed to alleviate the pressure on the affected nerve, as this loss of disc volume encourages the remaining disc to contract in size. Apart from the benefit of being minimally invasive and not requiring general anaesthesia, unlike surgery, the procedure only removes a tiny fragment of the disc so that the disc left behind can continue to perform its function of cushioning the vertebral bodies.

Sacroiliac Joint Injections

The technique of a sacroiliac joint injection is similar to that described for the facet joints. The sacroiliac joints are at the lower part of the spine, where the sacral spine segments (the part of the spine below the lumbar spine) connects with the pelvic bones flanking the sacrum, known as the iliac bones. The joint is complex, with the lowermost level targeted for injection of cortisone. Sacroiliac joint pain is often vague and variable, such that it may be difficult to determine whether these joints are causing the patient’s pain or not. As clinical tests for sacroiliac joint pain may be unreliable, frequently a trial injection is performed to see if the pain is alleviated. Other treatment options following a response to a cortisone injection include destroying the nerves which supply the joint with radiofrequency ablation (similar to that described for the facet joints) as a more long lasting option.

Important information to tell your doctor prior to treatment

Serious side effects are rare, however if you have an existing condition, this must be discussed with your referring doctor before having treatment. People with local skin or systemic infections are at greater risk of having an infection spreading into the spine after spinal injection treatment. Therefore if you have infections including wounds, boils or rashes, please tell your doctor or arrange to have the procedure performed at a later date.
Please discuss any medical illnesses with your doctor before booking the recommended procedure.

Follow up

The radiologist conducting the spinal injection will send your referring doctor a report.

• Please ensure that you make a follow up appointment with your referring doctor or health care provider to discuss your results.

Whilst every effort is made to keep your appointment time, the special needs of complex cases, elderly and frail patients can cause unexpected delays. Your consideration and patience in these circumstances is appreciated.