In this installment of our transforaminal technical series, we'll explore a range of techniques - from straightforward subpedicular approaches suitable for younger patients with typical spines to more complex strategies designed for elderly patients with deformed spines. We'll also discuss how to rescue incomplete transforaminal injections targeting the subpedicular area.
It's unfortunate to note that the effectiveness of transforaminal injections is often underestimated by many in the neurosurgical and orthopedic fields. I have encountered numerous patients who did not experience relief following transforaminal injections. Upon reviewing the details of their procedures, it becomes evident that the contrast spread during their injections was either suboptimal or completely unsuccessful, leading to inadequate pain relief. Some patients have even reported increased pain after the procedure, making them reluctant to consider similar future interventional treatments.
This technical series provides the details and insights needed to refine your technique, enhancing your ability to administer effective transforaminal injections in your practice. Remember, the primary goal of pain intervention isn't to change the structural abnormalities observed in protruding discs or stenosis cases but to provide acute relief from the severe pain these conditions can cause. With the right approach, many patients can return to a tolerable level of discomfort or even become pain-free, allowing them to resume their normal lives. Through this series, let's work together to improve your skills and make a positive impact on the lives of those you treat
Injection therapy can offer significant relief from pain by using steroids, various other injectants, or the mechanical pressure applied by fluids or needles. This therapy can reduce pain to manageable or baseline levels when performed correctly. After the acute pain is mitigated, patients often enjoy prolonged relief. This long-term comfort can be particularly sustained if patients embrace changes in their lifestyle or participate in specialized exercise routines designed to maintain their comfort levels.
As you carry out procedures in your practice, please take note of the specific needle type I employ to reach the target area accurately. I prefer a 25-gauge, 9cm Quincke-type spinal needle due to its flexibility and the ease with which its direction can be adjusted by modifying the needle tip. If you choose to use a stiffer, larger bore needle-such as a 22-gauge or even an 18-gauge-you may encounter increased difficulty in manipulation and control. These stiffer needles tend to advance persistently, lacking the subtle maneuverability that you observe in the demonstrations provided in my video.
In today's session, we will examine a refined technique for improving the suboptimal L5 subpedicular needle approach in the deformed spine, focusing on utilizing contralateral oblique C-arm imaging and adjusting the target point effectively.
In the upcoming patient case, you'll encounter a spine deformity and a constricted window for needle trajectory. These factors introduce difficulty maneuvering the needle despite the consistent basic procedural sequences. Reaching the ideal final needle position becomes a formidable task, often demanding a shift in strategy to ensure precise needle placement. Be prepared to navigate anatomical variations, which may include the downward extension of the transverse process, lateral expansion of the superior articular process, or situations that necessitate significant cranial tilting of the C-arm. In the ensuing series, I will walk you through various case scenarios you may encounter.
Our upcoming patient scenario introduces a distinct set of challenges. Due to a high iliac crest and a lower transverse process, a steep AP needle advancement and an inferior direction in needle progression are unavoidable. When examining the AP view, the small superior articular process would allow straightforward insertion into the subpedicular 6 o'clock position. However, the insertion window in this instance was obstructed by a non-visible structure, often the transverse process.
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26 авг 2024
