Image Guided Back Pain Management

This article discusses the options offered by interventional radiology for controlling back pain. Written for an audience of physicians and other health care professionals, it nonetheless offers insights for anyone interested in back pain management or seeking back pain relief.

Determining the etiology

Back pain is one of the most common conditions for which patients seek care. As many structures in the 'back' can cause pain, the etiology should be determined with certainty. In addition to a thorough history and physical, imaging can aid in diagnosing a spinal etiology, such as impres­sion by bone, disk or even post-op scar in or adjacent to the spinal canal.

The majority of back pain cases resolve spontaneously and only a minority of these requires surgical intervention. Therefore, at first, conservative treatment is usually sought.

Administering image-guided relief

A select group of patients may benefit from a direct administration of steroids (and local anesthetic) to remove the extra-inflammatory burden, superimposed on the mechanical compression. The relief achieved from these injections, in treating both localized pain and radiculopathy, can be dramatic, but may add diagnostic information for the referring physician.

Injection options include:

• Epidural steroid injections have been performed for over a century without image guidance, utilizing patient positioning, landmarks and a 'loss of resis­tance' to the syringe, as the endpoint. However, other nearby anatomic struc­tures into which the needle can traverse may mimic that sensation, including the thecal sac. With the advent of image guidance and the use of a minimal contrast agent for epidurography we can achieve a more accurate delivery of the pharmaceuticals to the appropriate region.
• Selective nerve root injections are indicated if the radiculopathy originates lateral to the epidural space, or from within the neural foramina. Fluoroscopic control and 'radiculography' where contrast is injected into the nerve root sheath for positional confirmation, is important, to insure selectivity and avoid epidural reflux. Although the latter may also achieve relief, response to blockade of a specific nerve can be important for diagnostic purposes as well. Moreover, in the cervical spine, needle position is critical as injectate placed into the nearby vertebral artery, thecal sac or spinal cord, etc. can be potentially lethal.
• Other image-guided steroid injections are similarly intended to relieve back pain emanating from associated joint spaces, including the Sacro-iliac joints and Facet joints. In the latter, the innervating median branch of the Dorsal Ramus is also treated (wherein neurolysis or radiofrequency ablation can then be considered.)

With proper utilization of these image-guided back pain injections, immediate and even potentially long term relief can be experienced. However, they are intended to supplement other phases of management prescribed by physicians whose patients suffer with back pain.

Therapeutic and diagnostic image-guided services at SJMH

These and other therapeutic and diag­nostic image-guided services – includ­ing vertebroplasty, myelography, IDET and discography – are offered in the St. John Macomb Hospital, Department of Interventional Radiol­ogy and can be scheduled directly by contacting Central Scheduling at 586-573-5160.