Spinal interventional procedures

Last revised by Henry Knipe on 20 Oct 2023

There are a number of different spinal interventional procedures that can help diagnose and manage low back pain. Lumbar degenerative facet joints, lumbar disc disease and sacroiliac joint pain account for nearly 70% of cases of lower back pain.

Unfortunately, as the incidence of degenerative changes in the spine is so high (e.g. disc abnormalities are found in 25% of individuals below the age of 60 and over 50% in those over the age of 60), it is sometimes difficult to confidently identify the cause of pain, without careful correlation with clinical findings and potentially diagnostic injections. The other role of spinal injections is to treat non-operative back pain.

All these procedures require precise needle tip position and therefore are performed with imaging guidance, either fluoroscopy or CT.

The following are general contraindications to elective spinal international procedures:

  • active sepsis

  • known allergy to local anesthetic/steroids/contrast agents

  • pregnancy

  • bleeding tendencies

  • anticoagulation

  • repeated injections: maximum 3-4 per year recommended to avoid complications such as osteoporosis 6

  • upcoming surgery: increased post-operative infection rates of an epidural corticosteroid injection has been performed within 1-3 months of surgery 6

  • intra-arterial injection can results in spinal cord or cerebral infarction

  • neural compression or ischemia

  • benzyl alcohol has caused necrosis and apoptosis of retinal pigment epithelial cells

  • direct nerve trauma

  • repeated steroid injections may result in epidural lipomatosis and osteoporosis 6

  • steroid flare with worsening pain for 2-3 days 6

  • gastritis (especially if the patient is on concurrent NSAIDs)

  • intrathecal injection of steroids may result in arachnoiditis; this is mainly due to excipients such as polyethylene glycol

  • decrease in diabetic control

  • tachon syndrome

  • allergic reaction to contrast agents, medications, etc.

Typical equipment required includes but varies depending on procedure, patient and proceduralist preferences 6:

  • skin wash and sterile drape

  • hypodermic needle with syringe for local anesthetic to skin and soft tissues

  • spinal needle with syringe for target injection

    • cervical and thoracic injections: 21-25G, 4-8 cm length

    • lumbar injections: 20-21G, 7-12 cm length

  • target injection

    • local anesthetic, e.g. 1 mL 0.5% bupivacaine, 1 mL 0.2% ropivacaine

    • non-particular steroid (e.g. dexamethasone) preferred for spinal injections

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Cases and figures

  • Case 1: transforaminal neural block
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  •  Case 2: vertebroplasty
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  • Case 3: vertebroplasty
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  • Case 4: interlaminar epidural steroid injection
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