Spine & Back Pain Management Injections.
Melbourne Radiology Clinic has a particular interest in the treatment of back pain, whether it be cervical (upper), thoracic (middle) or lumbar (lower) spine. Pain at the base of the spine (sacrum and coccyx) is a common complaint and can also be treated.
Most cases of back pain will settle without any need for treatment, or with a brief rehabilitation programme and/or anti-inflammatory medications.
In a minority of patients, the pain may be disabling and possibly associated with leg pain, commonly referred to as “sciatica“. Melbourne Radiology Clinic is able to assist these patients, by firstly providing an accurate diagnosis and therefore identify the cause of the pain with a CT and/or MRI scan. When the cause of the pain has been identified, an injection may be of benefit.
Types of Back/Spine Injections Available:
- Epidural Injections - cervical, thoracic, lumbar and caudal
- Facet joint injections
- Selective nerve root blocks (SNRB) / foraminal injections
- Medial Branch Blocks & Radiofrequency Ablation (RFA)
- Sacroiliac Joint Injections
- Cervicogenic Headaches - Greater occipital nerve blocks
- Pars defects injections
- Discogram Injections/Discography
- Spine biopsy
- Sacrococcygeal joint injection and ganglion impar block
Patients requiring a back or spine injection for pain management at Melbourne Radiology Clinic will first require a referral to be seen by our radiologist who will discuss the procedure and answer any questions.
The risks and benefits of the injection will be discussed, as well as any special post procedural instructions. All injections are only performed after a consent form has been signed.
The type of injection or interventional procedure (such as a facet joint, nerve root or epidural) will depend on firstly the diagnosis made on a previous CT or MRI scan, as well after being personally reviewed by our doctor.
Epidural steroid injections involve the injection of cortisone into the central canal of the spine, most commonly the lumbar spine. This would probably be the most common lumbar spine injection, as the spread of cortisone is diffuse and located near anatomic structures that commonly degenerate and become inflamed; disc, facets joints and spinal nerves. Therefore this injection is particularly useful for patients who have pain arising from multiple structures and also multiple sites of pain, such as back pain as well sciatica.
Another form of injection based treatment is to disrupt the nerve by using highly concentrated alcohol injected under ultrasound control. This is performed weekly until symptoms improve.
CT guided lumbar facet joint injection
Facet joint injections.
Facet joints are typically injected with cortisone (occasionally PRP) for the treatment of pain that is typically localised to the level of that facet joint, though vague referral into the arm (for cervical facet disease) and leg (for lumbar facet joint disease) can occur.
Facet joints most frequently undergo degeneration with age and overuse, though trauma (such as whiplash injury) and inflammatory arthritis (such as rheumatoid arthritis and spondyloarthropathies, such as ankylosing spondylitis) can irritate the facet joints and therefore require cortisone injections. In cases where patients positively respond to cortisone injections however the benefits are short lived, permanent destruction of the sensory nerves supplying the facet joints may be performed by Radiofrequency Ablation (RFA), typically providing two year relief.
Selective nerve root blocks (SNRB).
Selective nerve root blocks (SNRB) are performed to treat pain arising from exiting spinal nerves that results in pain being felt (and potentially weakness) further down along the body part supplied by that nerve. This is commonly referred to as “referred pain”, for example, “sciatica” in the leg. SNRB are almost always performed with cortisone, specifically the non-particulate cortisone dexamethasone so as to eliminate the chances of nerve damage due to embolisation.
CT RFA Needle tip position for ablation of a thoracic medical branch
Medial Branch Block (MBB) & RFA.
The medial branches of the spinal nerves supply the facet joints with their sensory innervation and therefore transmit pain signals to the brain. In the setting where patients have recalcitrant pain (or short term relief) from facet joint cortisone injections, successfully temporarily numbing these nerves with local anaesthetic (medial branch “block”) provides the referring doctor with the confidence (and clinically verified positive predictive value) to proceed with destruction of these nerves by Radiofrequency Ablation (RFA).
RFA is technically similar to medial branch block. After anaesthetising the medial branch nerves, an additional needle is introduced to the respective medial branch which is connected to a generator that heats the needle tip to 85 degrees Celsius that interrupts the function of the nerve and thus the transmission of perception of pain to the brain.
Sacroiliac Joint Injections.
The sacroiliacs joints are the joints formed at the junction of the conjoined spinal segments below the lumbar spine (sacrum) and pelvis, converting the vertical load from the spine above, to horizontally oriented forces to each side of the pelvis. Pain arising from these joints may often be difficult to diagnose and therefore may frequently be injected as both a trial and diagnostic procedure to then evaluate a clinical response.
A portion of the nerves supplying these joints can be destroyed with Radiofrequency Ablation (RFA) in order to provide longer lasting relief when the response from cortisone injections is short lived.
- Greater occipital nerve blocks.
Headaches have many causes and similarly many different types of injection based therapies (as part of the treatment options available to patients). One specific injection is Greater Occipital Nerve (GON) injection (also knowns as “block”) with cortisone and local anaesthesia to alleviate headaches occurring due to irritation of the occipital nerve (including occipital neuralgia). The GON arises from the upper cervical spine and in conjunction with the Lesser Occipital and Third Occipital Nerves, supplies the posterior (back) part of the head, extending to the forehead.
The procedure can be performed either under ultrasound or CT guidance, with CT offering an additional advantage of also injecting facet joints that may be suspected (or confirmed) to be contributing to the GON irritation/inflammation.
Pars Defects Injections.
Pars interarticularis defects (chronic developmental fractures, typically of the lower lumbar spine) are an important cause of chronic spinal pain. Though this condition usually occurs during skeletal maturation, cortisone injections are typically reserved for adults when the condition may result in delayed symptoms of back pain in adulthood.
The injections may be performed in order to alleviate severe pain arising from these fractures prior to any intended surgery, as well as also for long term maintenance of pain in patients who demonstrate long term response to the injections.
CT Guided 14 gauge core biopsy T4 vertebral body spine biopsy
CT Guided soft tissue biopsy of sacrum
Spine biopsies are performed under CT guidance for patients with bone and soft tissue lesions of the spine that are suspected of being tumours, or where a tumour warrants exclusion.
A detailed knowledge of the nerve supply of the spine and surrounding structures enables this procedure to be performed with minimal discomfort and without sedation, nor general anaesthesia.
A Discogram procedure (also known as provocative discography) is a spinal injection procedure that is rarely performed in modern times following the widespread use of MRI. The concept of the procedure is to attempt to replicate the patient’s pain by provoking pain fibres within the disc following introducing a needle into it and then injecting fluid to increase the pressure within. The procedure is used to determine which disc (or discs) is felt to be the main source of the patient’s pain and therefore guide the level (or levels) that require surgical intervention.
Sacrococcygeal joint injection
& ganglion impar block
The sacrococcygeal joint is located at the lowermost part of the spine, at the junction of the sacrum and coccyx (“tailbone”). The joint is typically injected with cortisone in patients who have pain that can be specifically located to this region. This condition is most commonly seen in middle aged to elderly females, presumably related to pelvic biomechanics that is different from the male patient as well as previous pregnancy/pregnancies which undoubtedly stress the joint. The joint can also be extremely painful long after direct trauma, such as a fall directly on the buttocks, which is another indication for the procedure.
Where additional pain relief is required, the ganglion impar, a small cluster of nerves immediately in front of the sacrococcygeal joint that serves as the main pain gateway of the region, can be blocked with anaesthetic and cortisone. If successful, the ganglion impar can then be destroyed using Radiofrequency Ablation (RFA).
The diagnosis of piriformis syndrome can be enigmatic and as such the piriformis muscle is often injected simply on the basis that it is suspected of causing a patient’s symptoms. Predicting piriformis syndrome symptoms simply by evaluating the muscle with MRI has been disappointing as the syndrome may be caused simply due to abnormal function (such as spasm) of the muscle and not due to anatomic abnormalities of the muscle (though admittedly these do exist) .
The injection can either involve injecting the muscle with local anaesthetic and cortisone or a paralysing agent such as botulinum toxin. If the patient’s symptoms of sciatica are consequently relieved, then the clinical diagnosis of piriformis syndrome may be made.
Referring doctors are welcome to discuss with our radiologists the imaging and interventional radiology needs of their patients and whether an interventional procedure is suitable for their patient’s medical condition.