마취통증의학과 R2 민 진기

1. 40. Interlaminar epidural steroid injections for lumbosacral radiculopathy41. Selective nerve blocks and transforaminal epidural steroid injections for back pain and sciatica 마취통증의학과 R2 민 진기

2. 40. Interlaminar epidural steroid injections for lumbosacral radiculopathy Epidural steoid injection to treat sciatica Fluoroscopically guided caudal catheters and tansforaminal approaches to the lateral and anterior epidural space Use of cervical ESI in 1986 Controversies continue

3. Back pain and radicular pain Mechanical back pain- primarily somatic pain Annular tear continued leakage of nucleus pulposus and associated chr. Inflm. and altered central processing Radicular pain from chemical irritation and inflammation of the nerve root- swollen and edematous

4. Back pain and radicular pain Disc herniation (HNP)  release of large amounts of phospholipase A2 (PLA2) production of prostaglandins and leukotrienes from cell memb. phospholipid resultant inflm. sensitization of nerve endings, and pain generation The primary indication for ESI is radicular pain due to nerve inflm.; irritation and edema

5. Drug used for epidural injection Methylprednisolone acetate concetration; 40 or 80mg/mL therapeutic dose; 80mg Triamcinolone diacetate concetration; 25mg/mL therapeutic dose; 50mg Most anesthesiologist dilute steroid drugs with local anesthetic or N/S solution

6. Drug used for epidural injection Inj. of 6 to 10mL at the lumbar level bathe both the injured nerve roots that is adjacent to the disc pathology and additional nearby roots that are also inflamed At the cervical level 4~6ml is adequate If caudal route is selected large volume(20~25mL)

7. Mechanism of action Steroid induce synthesis of a PLA2 inhibitor, preventing release of substrate for prostaglandin synthesis can interfere with inflm. proc. at the early step than do systemic NSAIDs benefit in pts. with chemical rather than compressive radicular pain synd. and negative radiologic studies

8. Mechanism of action Steroids also block nociceptive input block transmission in C fibers but not in A fibers Steroids directly inhibit formation of adhesions and fibrosis and they produce well-known euphoric effects

9. Indication Response to ESI- nerve root irritation, recent onset of symptoms, and the absence of psychological overlay Transient relief in pts. With chr. lumbar degenerative disc disease or spinal stenosis

10. Indication Favorable response to injection 1) advanced educational background 2) primary Dx of radiculopathy 3) pain duration less than 6 months Factors correlated with treatment failure 1) constant pain 2) frequent sleep disruption 3) being unemployed due to pain

11. Indication Five most important factors influencing the outcome of ESI • accuracy of Dx of nerve root inflmmation • shorter duration of symptoms • no history of previous surgery • younger age of the patient • location of needle at the level of pathology

12. Efficacy

13. Cervical injection

14. Use of fluoroscopic guidance Needle misplacement without fluoroscopic guidance is common reason for treatment failure with ESI

15. complications complications related to epidural technique back pain at inj. site temporarily increased radicular pain and paesthesia acute anxiety, lightheadness, diaphoresis, flushing, nausea, hypotension, vasovagal syncope headache

16. complications Retinal hemorrhage- rapid, large volume inj. Significant epidural hemorrhage- rare in absence of coagulopathy Epidural hematoma early Dx and immediate surgical decompression and evacuation이 필수적 IV sedation during procedure- interfere with patient report Epidural abscess

17. complications

18. complications complications related to epidural technique temporary development of Cushing’s syndrome, Wt. gain, fluid retention, hyperglycemia, HTN, and CHF adrenal supression is well known result of ESI should be considered when major surgical sterss occcurs within 1 month after ESI neurotoxicity

19. Current role Unlikely that definitive study will be completed

20. 41. Selective nerve root blocks and transforaminal epodural steroid injections for back pain and sciatica

21. Mechanism of radiculopathy and rationale for steroin injections Pain from sciatica is not due to mechanical compression alone Chemical irritation of the nerve roots, mechanical compression, vascular compromise

22. Diagnostic nerve root injection Abnormality seen on imaging study may not correlated with patient’ symptom SNRBs can be helpful diagnostic tool elicitation of concordant pain is important in pts. with multilevel abnormalities on radiographic imaging

23. Diagnostic nerve root injection Good candidates for SNRBs • minimal or no definite imaging findings • multilevel imaging abnormalitis • 분명치 않은 신경학적 검사결과 또는 임상과 방사선 소견상의 불일치 • 설명할 수 없는 또는 복잡한 술 후 recurrent pain • pts. with combined canal and lateral stenosis

24. Technique of selective nerve root block 대부분의 interventional pain management specialists는 복와위로 술기를 시행한다 C-arm of fluoroscope with ipsilateral oblique angle Upper lumbar and lower thoracic SNRBs 시행시 artery of Adamkiewicz 주의 L5 SNRB는 iliac crest 때문에 더 어렵다 경추신경근 block시는 앙와위나 측와위로 한다

25. Technique of selective nerve root block Methylprednisolone은 보통 cervical inj.에는 쓰이지 않는다- soluble steroid인 triamcinolone나 betamethaxone이 쓰임 Comment: diagnostic local anesthetic inj. 후의 환자의 반응이 involve된 신경을 확인하는데 더 중요하다

26. Transforaminal epidural steroid injection Proposed to improve results of classic interlaminar approach to ESI

27. Transforaminal epidural steroid injection Aim of transforaminal injetions inject the steroid and diluent in the space between lat. disc herniation and nerve root Tip of needle in the “safe triangle” area superiorly by the pedicle medially by outer margin of exiting nerve root laterally by lat. border of vertebral body

28. Transforaminal epidural steroid injection

29. Transforaminal epidural steroid injection

30. Transforaminal epidural steroid injection Hyaluronidase added to the steroid to facilitate spread of the injectate through the scar tissue

31. Key points • ESI indicated in lumbosacral radiculopathy anti-inflammatory effect: inhibition of PLA2 antinociceptive: inhibit transmission of impulses through the C fibers • ESI are more effective in acute lumbosacral radiculopathy 만성일 경우 symptom-free interval이 있거나먼저와는 다른 신경근에 새로운 radiculopathy가 생겼을때

32. Key points • Pain during a SNRB is not a reliable sign facet joint, periosteum, and annulus fibrosus can cause referred pain to the leg • In the transforaminal approach, tip of needle should be placed in the area of the “safe triangle” • Compared to the interlaminar approach,better results are expected with the transforaminal approach

33. Key points • Transforaminal injections with bupivacaine-methylprednisolone are better than bupivacaine or saline injetion