Update of a Study of Not Ceasing Anticoagulants for Patients Undergoing Injection Procedures for Spinal Pain

Objectives To determine prevalence rates of hemorrhagic complications in patients who either ceased or continued anticoagulants during interventional pain procedures. Methods A total of 1,936 consecutive patients were prospectively monitored during a total of 12,723 injection procedures. The prevalence of hemorrhagic complications was tallied for a variety of procedures performed on patients who ceased or continued various anticoagulants. Results No hemorrhagic complications occurred in any patient who continued anticoagulants. Sufficiently large sample sizes were obtained to conclude that, in patients who continued warfarin or clopidrogel during lumbar transforaminal injections and for lumbar facet procedures, the zero prevalence of complications had 95% confidence intervals of 0% to 0.3%. This prevalence was significantly lower than the risk of medical complications in patients who ceased warfarin. Conclusions Lumbar transforaminal injections and lumbar facet injections have a very low rate of hemorrhagic complications when patients continue to take anticoagulants.

Learning curve of radiology residents during training in fluoroscopy-guided facet joint injections

Objective: To develop a simulator for training in fluoroscopy-guided facet joint injections and to evaluate the learning curve for this procedure among radiology residents. Materials and Methods: Using a human lumbar spine as a model, we manufactured five lumbar vertebrae made of methacrylate and plaster. These vertebrae were assembled in order to create an anatomical model of the lumbar spine. We used a silicon casing to simulate the paravertebral muscles. The model was placed into the trunk of a plastic mannequin. From a group of radiology residents, we recruited 12 volunteers. During simulation-based training sessions, each student carried out 16 lumbar facet injections. We used three parameters to assess the learning curves: procedure time; fluoroscopy time; and quality of the procedure, as defined by the positioning of the needle. Results: During the training, the learning curves of all the students showed improvement in terms of the procedure and fluoroscopy times. The quality of the procedure parameter also showed improvement, as evidenced by a decrease in the number of inappropriate injections. Conclusion: We present a simple, inexpensive simulation model for training in facet joint injections. The learning curves of our trainees using the simulator showed improvement in all of the parameters assessed.

Thoracic Nerve Root and Facet Injections: Computed Tomography

Thoracic back pain patients present with associated radiculopathy, degenerative disc disease, spondylosis, stenosis, scoliosis, rib fractures, tumors, or after undergoing thoracic surgery. Thoracic transforaminal or selective nerve root blocks (SNRBs) may be both therapeutic and diagnostic. Therapeutic injections may include either local anesthetics for pain relief or corticosteroids for anti-inflammatory effects. The two types of pain amenable to therapeutic SNRBs include pain caused by irritation or direct pressure on a spinal nerve and pain originating from anatomic structures that are innervated by the sinuvertebral nerve. Although these blocks are traditionally performed under fluoroscopic guidance, computed tomography (CT) and CT fluoroscopy have been increasingly used to direct needle placement and have been advocated by experts due to superior visualization of the needle tip and the ability to clearly define spinal anatomy and adjacent soft-tissues.

Basics of Computed Tomography

Computed tomography (CT)-guidance is typically used when precise needle placement is essential for a successful procedure. It uses ionizing radiation, which could pose risks to the patient and operating staff if proper technique is not used. The performing physician should adhere to all principles of minimizing radiation exposure to the patient and clinicians. Common CT-guided imaging procedures include facet injections, nerve root injections, sacroiliac joint injections, intradiscal procedures, vertebroplasty/sacroplasty, and image-guided ablation of painful bone lesions. Computed tomography is also the imaging modality of choice for aspiration of deep paraspinal soft tissues in addition to disc space or bone biopsy in acute discitis/osteomyelitis. In fluoroscopic-guided knee or shoulder joint injections, CT arthrography is a useful adjunct to better assess anatomy when MRI is contraindicated. When imaging the postoperative spine, CT myelography has some advantages over MRI, and CT is also superior to MRI in assessing par intra-articularis defects or spondylolysis.