J Korean Med Assoc.  2014 Apr;57(4):308-317. 10.5124/jkma.2014.57.4.308.

Nonoperative interventions for spinal pain

• Shin DA
• Kim HI

• KMID: 2064888
• DOI: http://doi.org/10.5124/jkma.2014.57.4.308

Abstract

Spinal pain is a common symptom that motivates visiting a physician. However, the natural course is usually benign and few patients need invasive treatment. Even though history taking, neurological examination, and imaging studies provide useful information for understanding the etiology of spinal pain, the pain chart is the most important tool for decision making regarding spinal interventions. Invasive treatments for chronic spinal pain refractory to conservative management include surgery as well as established interventions such as medial branch blocks, nerve root blocks, the sacroiliac joint block, and radiofrequency neurotomy, as well as emerging procedures such as pressure-controlled discography and percutaneous epidural adhesiolysis. Surgery should be considered for patients with a progressive neurologic deficit including significant radiculopathy, failure of spinal interventions, or an uncertain or serious diagnosis.

Keyword

Pain management; Spine; Injections; Review

MeSH Terms

Decision Making
Diagnosis
Humans
Nerve Block
Neurologic Examination
Neurologic Manifestations
Pain Management
Radiculopathy
Sacroiliac Joint
Spine

Figure

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  Figure 1 Lumbar medial branch block. (A) Anterior-posterior view. The target points lie against the lateral surface of the superior articular process (SAP), at the most medial end of the transverse process (TP). (B) Lateral view. The target points rest on the superior surface of the transverse processes. (C) Oblique view. The target points lie on the bisecting regions of the superior articular processes and tranverse processes. SN, spinal nerve; P, pedicle.

• 

  Figure 2 Cervical medial branch block. (A) An anterior-posterior radiograph shows the dots which rest on the concave lateral surface of the articular pillar (ap) of the each cervical vertebrae. (B) A lateral view of the cervical spine. The dot shown by the thin arrow indicated the target point for block of the C5 medial branch which rests on the intersection point of two crossing lines. (A,B) The target point of the C7 medial branch rests on upper border of the transverse process (TP) in the AP view and the superior articular process in the lateral view (the thick arrow).

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  Figure 3 Third occipital nerve block. A lateral view of the upper cervical spine showing the target points for third occipital nerve blocks. The three target points lie on an axial ine that bisects the C2 and C3 articular pillars. The three target points lie at the intersections of the axial ine and transverse lines through the apex of the C3 superior articular process, tangential to the bottom of the C2-3 intervertebral foramen, and midway between these first two lines.

• 

  Figure 4 Lumbar transforaminal epidural block. (A) Anterior-posterior (AP) view. The target point lies immediately below the pedicle and above the exit root (the safety triangle). (B) Lateral view. The targe point lies just posterior to the vertebra and below the pedicle. (C) Oblique view of the target zone. A needle should be inserted and directed towards the safety triangle which is bordered by the lower margin of the pedicle (P) and the upper margin of the exit root. Sacroiliac joint block. (A) An AP view of the sacroiliac joint in which the posterior margins of the joint are maximally crisp over the lower one-third of the joint (narrow arrow). The target point for an intra-articular injection is marked with a dot and a thick arrow. NF, neural foramen; SAP, superior articular process; TP, transverse process.

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  Figure 5 Cervical transforaminal epidural block. (A) Anterior-posterior view. The target point lies opposite the sagittal bisector of the articular pillar. (B) Oblique view. The target rests on the postserior wall of the cervical neural foramen (NF) at its middle third.

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  Figure 6 Percutaneous epidural adhesiolysis. (A) A cervical epidurogram performed after the placement of the Racz cervical catheter. The tip of the catheter is indicated by the arrow. The C6 nerve root (NR) is not visualized before adhesiolysis. (B) After mechanical and hydrostatic adhesiolysis, the C6 nerve root is well visualized in the re-performed epidurogram.

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