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Spinal Injection Techniques
Second Edition
Theodoros Theodoridis, MD
Head Physician Spine Therapy
Department of Minimally Invasive and Surgical Spine Treatment
Viktoria Clinic
Chairman
Institute for Spine Research
Bochum, Germany
y
Juergen Kraemer , MD
Formerly Professor Emeritus
Orthopedic University Clinic
St. Josef Hospital
Formerly Chairman
Institute for Spine Research
Bochum, Germany
503 illustrations
Thieme
Stuttgart (cid:129) New York (cid:129) Delhi (cid:129) Rio de Janeiro
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LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscienceundergoing
Names:Theodoridis,Theodoros,author.|Kraemer,Juergen, continualdevelopment.Researchandclinicalexperiencearecontin-
1939-2011,author. ually expanding our knowledge, in particular our knowledge of
Title:Spinalinjectiontechniques/TheodorosTheodoridis,Juergen propertreatmentanddrugtherapy.Insofarasthisbookmentions
Kraemer. anydosageorapplication,readersmayrestassuredthattheauthors,
Othertitles:InjektionstherapieanderWirbelsäule.English editors,andpublishershavemadeeveryefforttoensurethatsuch
Description:Secondedition.|Stuttgart;NewYork:Thieme, referencesareinaccordancewiththestateofknowledgeatthetime
[2019]|Thisbookisanauthorizedandrevisedtranslationofthe ofproductionofthebook.
3rdGermaneditionpublishedandcopyrighted2017byGeorg Nevertheless,thisdoesnotinvolve,imply,orexpressanyguar-
ThiemeVerlag,Stuttgart,Germany. anteeorresponsibilityonthepartofthepublishersinrespecttoany
TitleoftheGermanedition:InjektionstherapieanderWirbelsäule. dosage instructions andformsofapplicationsstatedinthebook.
|Includesbibliographicalreferencesandindex.|Identifiers:LCCN Everyuserisrequestedtoexaminecarefullythemanufacturers’
2019006657(print)|LCCN 2019007236(ebook)|ISBN leafletsaccompanyingeachdrugandtocheck,ifnecessaryincon-
9783132414488()|ISBN9783132414471(hardcover)| sultationwithaphysicianorspecialist,whetherthedosageschedules
ISBN9783132414488(e-book)Subjects:|MESH:–therapy mentionedthereinorthecontraindicationsstatedbythemanufac-
|Injections,Spinal–methods|Anesthesia,Spinal|Pain turersdifferfromthestatementsmadeinthepresentbook.Such
Management examination is particularly important with drugs that are either
Classification:LCCRD771.B217(ebook)|LCCRD771.B217 rarelyusedorhavebeennewlyreleasedonthemarket.Everydosage
(print)|NLMWE720 |DDC617.5/6406–dc23 scheduleoreveryformofapplicationusedisentirelyattheuser’s
LCrecordavailableathttps://lccn.loc.gov/2019006657 ownriskandresponsibility.Theauthorsandpublishersrequestevery
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anderWirbelsäule.
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Contents
Foreword................................................................................ viii
Dr.CordeliaSchott
Foreword................................................................................ x
ProfessorRüdigerKrauspe
Foreword................................................................................ xi
ProfessorMichaelRauschmann
Preface.................................................................................. xii
Contributors............................................................................ xiii
PartIGeneralSection
1 BasicPrinciples......................................................................... 2
1.1 OrthopedicPainManagement........ 2 1.3 NociceptionandChronification....... 6
TheodorosTheodoridis,JuergenKraemer TheodorosTheodoridis,JuergenKraemer
1.2 Epidemiology........................ 4
TheodorosTheodoridis,WolframTeske
2 Diagnostics ............................................................................. 15
2.1 MedicalHistory...................... 15 2.4 LaboratoryTests..................... 25
TheodorosTheodoridis,JuergenKraemer TheodorosTheodoridis,Constantinos
Georgallas
2.2 ClinicalExamination.................. 16
TheodorosTheodoridis,Constantinos 2.5 ImagingTechniques.................. 25
Georgallas TheodorosTheodoridis
2.3 Neurological–OrthopedicExamination 20 2.6 TrialMeasuresfortheDiagnosisof
TheodorosTheodoridis,IliasNastos Pain................................. 27
TheodorosTheodoridis,JuergenKraemer
3 CausalOrthopedicPainTherapy...................................................... 28
TheodorosTheodoridis,JuergenKraemer
3.1 PositioningandTraction.............. 28 3.5 PosturalandBehavioralTraining
(BackSchool)........................ 29
3.2 OrthopedicAids ..................... 29
3.6 BackSchoolandOrthopedicPain
3.3 ManualTherapy ..................... 29
Therapy............................. 31
3.4 PhysicalTherapy..................... 29
v
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Contents
4 SymptomaticPainTherapy............................................................ 33
4.1 Introduction......................... 33 4.7 OrthokineTherapy................... 40
TheodorosTheodoridis,JuergenKraemer UlrikeTheodoridis,CordeliaSchott,
TheodorosTheodoridis
4.2 Thermotherapy...................... 33
TheodorosTheodoridis,JuergenKraemer 4.8 AdverseEffectsofOrthokine/Cortisone 43
TheodorosTheodoridis
4.3 Massage............................. 34
TheodorosTheodoridis,JuergenKraemer 4.9 ClinicalResults....................... 48
TheodorosTheodoridis
4.4 Electrotherapy....................... 35
TheodorosTheodoridis,JuergenKraemer 4.10 Conclusion .......................... 49
TheodorosTheodoridis
4.5 Acupuncture......................... 36
TheodorosTheodoridis,JuergenKraemer, 4.11 MultimodalMedicationConcomitant
ConstantinosGeorgallas Therapy............................. 49
4.6 TherapeuticLocalInjectionTreatment SusanneStehr-Zirngibl
(TLIT)................................ 37
TheodorosTheodoridis,JuergenKraemer
PartIIAtlasSection
5 TheSpine:Anatomy,Nociception,andtheDistributionofPainSignals.......... 66
TheodorosTheodoridis,JuergenKraemer
5.1 Terminology......................... 66 5.2 NociceptionandtheDistributionof
PainSignalsintheSpine.............. 66
6 SpecialOrthopedicInjectionTherapy:ContraindicationsandPatient
Information............................................................................. 74
TheodorosTheodoridis
6.2 PatientInformation.................. 74
6.1 Contraindications.................... 74
7 CervicalInjectionTherapy............................................................. 77
7.1 SpecializedCervicalNeuroanatomy ... 77 7.3 SpecialTherapyforCervicalPain...... 80
TheodorosTheodoridis,JuergenKraemer TheodorosTheodoridis,JuergenKraemer
7.2 BasicTherapyforCervicalPain........ 78 7.4 CervicalInjectionTherapy ............ 83
TheodorosTheodoridis,JuergenKraemer
8 ThoracicInjectionTherapy ............................................................ 120
8.1 SpecializedThoracicNeuroanatomy... 120 8.3 ThoracicInjectionTherapy............ 121
TheodorosTheodoridis,JuergenKraemer TheodorosTheodoridis,FritjofBock
8.2 ClinicalPicture....................... 120
TheodorosTheodoridis,JuergenKraemer
vi
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Contents
9 LumbarInjectionTherapy............................................................. 146
TheodorosTheodoridis,JuergenKraemer
9.1 SpecializedLumbarNeuroanatomy.... 146 9.4 LumbarInjectionTherapy............. 157
9.2 BasicTherapyforLumbarPain........ 147
9.3 SpecialTherapyforLumbarPain...... 150
10 GeneralandSpecificComplicationsandTreatmentMeasures .................... 255
10.1 VasovagalSyncope................... 255 10.8 SpecialComplicationsandSideEffects
ClemensJ.H.Sirtl ofCervicalSpinalNerveAnalgesia
(CSPA)............................... 260
10.2 IntravascularAdministrationofLocal
TheodorosTheodoridis,WolframTeske,
AnestheticsandGlucocorticoids ...... 255
JuergenKraemer
ClemensJ.H.Sirtl
10.9 SideEffectsandComplicationsof
10.3 IntrathecalAdministrationofLocal
CervicalEpiduralInjections........... 262
AnestheticsandGlucocorticoids ...... 256
LluisAguilariFernàndez,WolframTeske,
ClemensJ.H.Sirtl,TheodorosTheodoridis,
TheodorosTheodoridis
IliasNastos
10.10 SideEffectsandComplicationsof
10.4 AnaphylactoidReaction—Anaphylactic
ThoracicInjectionTechniques......... 263
Shock............................... 257
WolframTeske
ClemensJ.H.Sirtl
10.11 SideEffectsandComplicationsof
10.5 PostduralPunctureSyndrome ........ 258
LumbarSpinalNerveAnalgesia ....... 263
ClemensJ.H.Sirtl,TheodorosTheodoridis,
WolframTeske,JuergenKraemer,Cordelia
IliasNastos
Schott,TheodorosTheodoridis
10.6 BacterialInfection ................... 259 10.12 SideEffectsandComplicationsof
WolframTeske,TheodorosTheodoridis
LumbarEpiduralInjections ........... 264
10.7 Bleeding............................. 260 WolframTeske,CordeliaSchott,Theodoros
WolframTeske,TheodorosTheodoridis Theodoridis,JuergenKraemer
10.13 Summary............................ 264
11 MultimodalSpinalTherapy ........................................................... 265
TheodorosTheodoridis,JuergenKraemer
11.1 OutpatientMinimallyInvasiveSpinal 11.3 MultimodalProgram................. 269
Therapy............................. 265 TheodorosTheodoridis,JuergenKraemer
TheodorosTheodoridis,JuergenKraemer
11.4 MultimodalPainManagement........ 274
11.2 InpatientMinimallyInvasiveSpinal SusanneStehr-Zirngibl,PriskaLaubenthal
Therapy............................. 267
TheodorosTheodoridis,JuergenKraemer
12 Summary................................................................................ 275
TheodorosTheodoridis
12.1 CervicalSpine ....................... 275 12.3 LumbarSpine/Sacrum................ 277
12.2 ThoracicSpine....................... 277 12.4 Conclusion .......................... 283
Bibliography............................................................................ 285
Index .................................................................................... 290
vii
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Foreword
Foreword
Determining appropriate treatment for the cervical, revoking the spinal therapist’s freedom to render
thoracic, and lumbar spine pain is a constant chal- treatmentandmakedecisions.Instead,wemustaim
lengeforphysicianstoday.Regardlessofthecircum- tooffercurativetreatmentusingtargeted,competent,
stancesofourhealthcaresystem,thelackoffunding andearlytherapymanagementwithinterdisciplinary
andconcepts,thepolicydebateassociatedwithback treatmentapproachesinorder topreventbackpain
pain,thestrugglesbetweenthevariousfactions,and frombecomingchronic.
multiple treatment guidelines, conservative treat- Evenifoneassumesthatthebodyofevidenceon
mentofspinaldisordersisanintegralcomponentof spinal injection therapy is inadequate, this does not
orthopedicsandtraumasurgeryandwillcontinueto changethefactthatspinalinjectiontherapyisoneof
play a central role in the foreseeable future. The themostcommonandmostefficienttherapyforms,
InterdisciplinarySocietyforOrthopedicandTrauma playing an absolutely key role in daily treatment of
Surgery/International Musculoskeletal Pain Society backpainpatients.Anytherapistwhohasusedinjec-
(IGOST/IMPS)hasconveyedthismessageinitsinjec- tiontherapytosuccessfullyrelieveapatient’spainina
tioncoursesfromdayone.BasedontheworkofIGOST, short periodof timeknowsjusthowimportantand
as the representative of the DGOOC pain therapy howefficientthistreatmentoptionis.Inmanycases,
section and of DGOU, this book intends to improve thetechniquespresented here are indispensablefor
thesafetyandreliabilityofbackpaintherapy. performing differential diagnosis and/or for treat-
Policies on “back pain therapy” widely diverge. A ment planning, including surgical options. Often,
whole range of professional societies have stakes in using the techniques even allows surgery to be
thisarea.Varioustreatmentandotherguidelinesare avoidedaltogether.
under development, some of them contradictory, During my timeworkingunder Professor Juergen
causingincreasing uncertaintyamong bothpatients Kraemer,Ihadtheprivilegetoobservethetechniques
andtreatingphysicians,andintheirwake,legalreg- described in this book on a daily basis, to learn,
ulationsandrestrictionsaswellaslimitationsonso- perform,andteachthem,andtofollowupthetreat-
called“therapeuticalfreedom,”inotherwords,phy- mentsuccessesformanyyearsandreportaboutthem
sicians’ freedom to prescribe what they deem the in scientific publications. For over 15 years, I have
most appropriate therapy. There are calls for strict beenpersonallyactiveintheIGOST’shands-oninjec-
monitoring along thelines ofevidence-based medi- tion courses. In my daily practice, the injections
cine.Atthesametime,thefactthatcommonlyused described here constitute a substantial share of my
corticoids are not approved as pharmaceuticals for work. Based on a large part of the life work of my
treatingspine-related ailments isalsothesubjectof mentorProfessorJuergen Kraemer, this book repre-
politicaldebate.Discussionsareemergingaboutthe sentsthecontinuationofhisideasaboutconservative
requiredpresenceorabsenceofimaging,aboutwhich spinaltherapy.Inthissecondedition,theauthorshave
payershavetocoverwhichbenefits,andaboutwhois lovinglyupdatedandexpandedonthislegacy.
allowed to refer what patient to which treatment Thetherapypresentedinthisbookisconsideredto
provider.Inthecontextofthisdebate,painmanage- bethegoldstandardforspinalinjectiontherapyinthe
menthasadvancedandthisprogressmustcontinue. framework of orthopedics and trauma surgery and
Atthesametime,weneedtocounteractthetendency ideally complements our IGOST courses. The book’s
to declare some 90% of all back pain “unspecific” depiction of the anatomical landmarks and the
owing to the fact that treatment providers’ training instructionsforlocatingthemmakeitveryusefulfor
simplydoesnotpermitmoredetaileddifferentiation. spinaltherapistsperformingconservativetherapyas
We also need to prevent excessive use of technical wellasforsurgeons.Thebookthusjoinstheranksof
methodsandradiologicalimagingjustforthesakeof notablereferenceworksthathavealsobeenproduced
routine or for purely financial reasons, in so doing withtheassistanceofIGOST.
viii
