Spinal Injections for Pain Management

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification for enrollments starting after March 18, 2024:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Computed Tomography: 1.00
Procedures: 1.00
Head, Spine, and Musculoskeletal: 1.00

Magnetic Resonance Imaging: 1.00
Procedures: 1.00
Neurological: 1.00

Radiography: 1.00
Procedures: 1.00
Head, Spine and Pelvis Procedures: 1.00

Registered Radiologist Assistant: 3.50
Patient Care: 0.50
Patient Management: 0.25
Pharmacology: 0.25
Procedures: 3.00
Musculoskeletal and Endocrine Sections: 3.00

Outline

1. Introduction
2. Corticosteroid Properties
3. Interaction with Patients
   1. The Interview
   2. The Blow-by-Blow
   3. The Teachable Moment
   4. The Discharge
4. Role of Imaging in Procedural Selection
5. Pearls and Pitfalls of Fluoroscopy-guided Injections
   1. Risk and Risk Mitigation
   2. Procedural Tips and Techniques
6. Conclusion

Objectives

Upon completion of this course, students will:

1. identify the decade during which epidural steroid injection became a cornerstone in the management of low back pain and sciatica
2. list the imaging modalities that helped spur growth of interventional procedures in the spine
3. list the procedures added to lumbar and cervical ESIs as fluoroscopic techniques evolved
4. describe the increase in lumbar ESI rates for spinal stenosis from 1994 to 2011
5. identify common nonparticulate corticosteroid preparations
6. identify the particulate corticosteroid preparation which has the largest particles
7. identify the particulate corticosteroid preparation which has the smallest particles
8. list the structured interactions that take place while the patient lies on the fluoroscopy table
9. list the goals of the patient interview described by the author
10. describe the patient complaint that warrants a facet cyst rupture procedure
11. describe the patient complaint for which Baastrup syndrome should be considered
12. identify unresolvable issues that should be uncovered during the patient interview
13. list the individuals who should be informed and engaged by the blow-by-blow
14. describe when the teachable moment begins
15. describe how long it typically takes for an injected particulate corticosteroid to reach full effectiveness
16. describe the length of time for which steroid injection can break the inflammation cycle and relieve pain
17. identify the recommended treatment option if dermatomal information reveals a specific pain generator in older patients with chronic unilateral radiculopathy
18. describe the leading reason for spinal surgery
19. identify the recommended procedure when MR imaging shows multi-level stenosis
20. identify the spinal level where the radiologist should inject in patients with chronic nonlocalizing low back pain
21. compare CT and fluoroscopy for needle placement during spine procedures
22. list the factors that increase the risk for bleeding during a spinal procedure
23. describe the greatest threat during a spinal procedure that requires surgical intervention to prevent permanent neurologic sequelae
24. list the options for patients with known or suspected reactions to iodinated contrast material
25. describe why digital subtraction fluoroscopy is a useful technique when using gadolinium-based contrast agents
26. identify the spinal level where vascular cannulation during lumbar NRBs is more than twice as likely to occur
27. describe the length of time that diabetic patients should monitor their blood glucose levels after a spine procedure
28. list the negative outcomes from repeated injections of particulate steroids at short intervals
29. list appropriate anesthetics for spine procedures
30. list the patient groups in which anesthetics should be used with caution
31. describe the patient positioning for the majority of spine procedures
32. identify the spinal procedure for which 6-9 mg of betamethasone acetate is the recommended corticosteroid dosage
33. identify the spinal procedure for which 40 mg of triamcinalone acetonide mixed with an anesthetic is the recommended corticosteroid dosage
34. describe the systematic maneuvers during fluoroscopic setup for a spine procedure
35. list the reasons for archival of fluoroscopic images obtained during spine procedures
36. describe the anatomic space bounded by the pedicle, the exiting nerve, and the vertebral body
37. describe the anatomic space bounded by the facet joint, the exiting nerve, and the caudal vertebral body
38. list the agents injected during selective lumbosacral NRB
39. list the vessels that may be in the needle path during fluoroscopy-guided cervical NRB with an anterolateral approach
40. describe the needle length for a cervical transforaminal NRB
41. identify the spinal level that has the least dorsal epidural fat in normal spines
42. describe the critical juncture during lumbar interlaminar ESI
43. describe the volume of contrast agent that can cause injection pressure to increase unexpectedly during lumbar interlaminar ESI
44. identify the spine procedure with the goal of diffuse epidural spread of the injectate
45. list potential causes of facet-related pain in patients with early osteoarthritis