Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine

251 Pages·2011·58.32 MB·English

by  James P. Rathmell MD

Atlas of Image-Guided Intervention in
Regional Anesthesia and Pain Medicine
Second Edition
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Atlas of Image-Guided
Intervention in
Regional Anesthesia
and Pain Medicine
Second Edition
James P. Rathmell, MD
Professor of Anaesthesia, Harvard Medical School
Chief, Division of Pain Medicine
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Illustrations by
Gary J. Nelson
Medical Illustrator
University of Vermont College of Medicine (Retired)
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Executive Editor: Brian Brown
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1st Edition ©2006 by Lippincott Williams & Wilkins
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Printed in China
Library of Congress Cataloging-in-Publication Data
Rathmell, James P.
Atlas of image-guided intervention in regional anesthesia and pain medicine / James P. Rathmell;
illustrations by Gary J. Nelson.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60831-704-2
I. Title.
[DNLM: 1. Pain—drug therapy—Atlases. 2. Pain—radiography—Atlases. 3. Anesthesia,
Conduction—methods—Atlases. 4. Injections—methods—Atlases. WL 17]
LC classifi cation not assigned
617.9'62—dc23
2011030918
Care has been taken to confi rm the accuracy of the information presented and to describe gener-
ally accepted practices. However, the authors, editors, and publisher are not responsible for errors
or omissions or for any consequences from application of the information in this book and make
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contents of the publication. Application of the information in a particular situation remains the
professional responsibility of the practitioner.
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dosage set forth in this text are in accordance with current recommendations and practice at the
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To those who have encouraged
my enthusiasm,
those who believed
something might come of it
James K. Rathmell, Jr.
Harry M. Schey
Robert L. Capizzi
Francis M. James, III
Richard L. Rauck
John E. Mazuzan, Jr.
Simon Gelman
Howard M. Schapiro
David L. Brown
Jane C. Ballantyne
Warren M. Zapol
Edward Lowenstein
Barbara A. Rathmell
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Preface to the Second Edition
It is now almost 20 years since I fi nished training in anes- around the world where I have taught workshops have uni-
thesiology and pain medicine. Radiographic guidance is versally found the addition of 3D-CT images to be a signifi -
now a routine part of performing many interventions used cant aid in assimilating the relevant anatomy. CT has long
in pain treatment. The fi rst edition of The Atlas of Image- been used in diagnostic evaluation of patients, including
Guided Intervention in Regional Anesthesia and Pain Medicine those with intra-abdominal malignancies such as pancreatic
has been well-received among physicians-in-training and cancer. In the fi rst edition, I included a detailed descrip-
experienced clinicians alike. The original concept of pre- tion of the use of CT for performing celiac plexus block,
senting simple, high-quality anatomic drawings alongside an approach that I still feel offers superior anatomic infor-
the most common radiographic views has proven to be mation and improves safety of the technique. However, in
intuitive and to rapidly facilitate learners’ understanding of the past few years, computerized workstations have become
the relevant radiographic anatomy. I have had the pleasure widely available beyond the radiology department and this
of watching dozens of physicians use the fi rst edition right now allows us to use the diagnostic imaging studies in the
at the bedside to rapidly review their understanding of the process of planning a precise approach to performing inter-
radiographic anatomy before performing a procedure. Two ventions. In our clinic in Boston, we can pull up any diag-
major drivers have led me to create the second edition: The nostic study for review and make detailed measurements,
fi rst edition lacked a detailed description of the quality of which we can then immediately apply in the fl uoroscopy
scientifi c evidence available about each technique, and new suite. I have added a description of the use of diagnostic CT
imaging techniques have improved our ability to conduct in planning celiac plexus block under fl uoroscopy to this
many of these interventions more safely and effectively. edition. Finally, the use of ultrasound has become common-
Pain medicine as a discipline has struggled with the place in the practice of regional anesthesia for providing
creation of scientifi c evidence regarding the usefulness of surgical anesthesia. Practitioners have found that the use
many of the techniques we employ. In this, the new era of of ultrasound guidance improves the success rate for many
evidence-based medicine, it is crucial that we all under- peripheral nerve blocks and its use has been adopted rap-
stand the level of evidence that exists for the treatments idly into daily clinical practice around the world. The use
we employ. In this edition, I have added a chart to each of ultrasound in the pain clinic has been slower to evolve,
chapter with an evidence-based recommendation regarding largely because we already have superior anatomic infor-
the use of each technique, along with a brief description mation available from fl uoroscopy. Nonetheless, there are
of the available evidence and a summary of recent expert several areas where ultrasound may simplify specifi c tech-
practice guidelines. I have made concerted efforts to fol- niques as well as enhancing their safety. In this edition, I
low internationally accepted guidelines for rating the qual- have described the ultrasound anatomy relevant to stellate
ity of the scientifi c evidence and in grading the strength of ganglion block and intercostal nerve block side by side with
the recommendations (Appendix). We are still a long way the fl uoroscopic technique. These are two techniques where
from the large-scale trials that are needed in this fi eld, but ultrasound appears to offer signifi cant advantages; others
I am strongly encouraged by the appearance of much high- will undoubtedly emerge in the years ahead.
quality evidence in the short interval since the fi rst edition As in the fi rst edition, the choice of techniques included
appeared in 2006. is arbitrary and based on my own perceptions about which
Newer imaging modalities have emerged in the past sev- among them are performed most commonly. It is my ongoing
eral years and developed to the point where they are now hope that this atlas will help to educate and guide practitioners
very useful in training and in making daily management toward a more uniform approach to performing pain treatment
decisions, foremost among them are computed tomogra- techniques in the safest possible manner. With more consis-
phy and ultrasound. Three-dimensional reconstruction of tent methodology, we can continue the work of assembling
high-quality computed tomography data (3D-CT) is an scientifi c trials to determine which among these techniques
extraordinary tool in visualizing the relevant anatomy as are most useful in aiding our patients suffering with pain.
trainees learn new techniques. For each technique, I have
included a 3D-CT image rotated to the same orientation James P. Rathmell, MD
that is shown in the adjacent fl uoroscopic images. My own Boston, Massachusetts
trainees here at Mass General and trainees at many venues July 2011
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Preface to the First Edition vii
Preface to the First Edition
During the course of my own training in pain medicine, Using radiographic guidance, we are able to visualize
now well over a decade ago, radiographic guidance was bony structures directly and in real time. We can see the
used infrequently—it was reserved for major procedures needle within the radiographic fi eld and use simple geom-
such as neurolytic celiac plexus block. In the years since my etry to guide the needle directly from the skin’s surface to
training, I have experienced two forces at work. First, pain its destination. During that same ASRA meeting in 1999,
practitioners are now being called on to serve as diagnosti- I was introduced to Dr. David Brown, an anesthesiologist
cians. Patients and referring practitioners expect pain physi- and author of several texts on regional anesthesia. He was
cians to have familiarity with imaging modalities and their then editor in chief of Regional Anesthesia and Pain Medicine
usefulness in diagnosing pain conditions. At the same time, (RAPM), and he was in search of a young and enthusiastic
pain practitioners have come to realize the usefulness of Associate Editor to head a new section in RAPM on imaging.
radiographic guidance in achieving precise anatomic place- Although Dr. Brown’s well-known text, An Atlas of Regional
ment of needles and catheters. Although the evidence sup- Anesthesia, has sold innumerable copies without anything
porting the need for routine radiographic guidance is still more than a brief mention of radiographic guidance, he
evolving, the intuitive appeal of this more precise approach clearly recognized that imaging modalities of all sorts—
has caught fi rm hold—to the point where the majority of plain radiography, computed tomography (CT), magnetic
practitioners now perform at least a portion of their injec- resonance imaging, and ultrasound—held untapped poten-
tions using fl uoroscopic guidance. In some cases, such as tial for advancing the accurate conduct of neural blockade.
with patients with intractable pain associated with meta- After a brief discussion, I took the post as Associate Editor,
static cancer, radiographic guidance has proven invaluable and I have now solicited, written, and reviewed many arti-
in the planning and implementation of therapy directed cles for the Imaging Section in RAPM. These articles have
toward pain relief. There are numerous excellent atlases for helped establish the clear-cut benefi t of imaging in the con-
practitioners of regional anesthesia. However, there remains duct of regional anesthetic techniques in pain medicine, and
no single, comprehensive and well-illustrated atlas for the images from many of the articles are included in this atlas.
pain practitioner that both describes the injection tech- The atlas is designed to serve as a practical guide to prac-
niques and illustrates the relevant radiographic anatomy. titioners who perform (or want to learn how to perform) a
Atlas of Image-Guided Intervention in Regional Anesthesia and wide range of different treatments for acute, chronic, and
Pain Medicine is an atlas designed to fi ll this void. cancer-related pain with the assistance of radiographic
In 1999, I attended the annual meeting of the American guidance. It is meant to be a useful resource for a range of
Society of Regional Anesthesia and Pain Medicine (ASRA) practitioners. Those already familiar with regional anesthe-
in Philadelphia to present a paper on a study I had con- sia but wanting to learn more about the use of radiographic
ducted with a radiologist colleague and a medical student. guidance will fi nd the techniques they know illustrated
We examined the distribution of injectate in a series of with images encountered when the same techniques are
patients who received epidural steroid injections for radicu- carried out using radiographic guidance. Practitioners
lar pain associated with a new herniated disc. To our sur- already well versed in the use of radiographic imaging will
prise, the injectate often spread to the side opposite the disc fi nd clinically relevant details, including an overview of
herniation. In retrospect, this is not at all surprising; if a disc each technique, a detailed and illustrated review of the rel-
herniation is present on one side, this might well obstruct evant anatomy, technical aspects of each treatment, and a
the fl ow of fl uid through the relatively confi ned epidural description of the complications associated with these pain
space. The fl uid would follow the path of least resistance, treatment modalities.
spreading preferentially to the contralateral, unaffected The atlas begins with an overview of basic techniques
side and exiting the contralateral intervertebral foramina. for using image guidance to guide needle placement, radia-
This study and others that emerged at about the same time tion safety, clinical use of radiographic contrast agents, and
challenged the conventional wisdom that suspending the the pharmacology of the most common agents used for
steroid in a modest volume was suffi cient to consistently these injection treatments. The bulk of the atlas is devoted
produce spread of the injectate to the affected levels, regard- to descriptions of individual techniques. For each tech-
less of where the solution was placed within the epidural nique, concise summaries of common clinical applications,
space. Perhaps the blind loss-of-resistance technique is not technical details, adverse events, and clinical outcomes are
the best way to deliver steroid to the site of infl ammation. included. Each technique is illustrated using a simple line
vii
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viii Preface to the First Edition
drawing and the plain x-ray images encountered when the technique, but all too often these data are scant. Precisely
technique is carried out using radiographic guidance. The because of this lack of outcome data, I have chosen to omit
radiographs are displayed without labels side by side with a several emerging technologies, including epidural lysis of
detailed overlay on the same image that illustrates the rel- adhesions and epiduroscopy. The choice of techniques
evant anatomic structures. When published reports suggest included, although arbitrary, was based on my own percep-
that CT might be particularly useful in performing a specifi c tion of those that are performed most commonly. It is my
technique (e.g., neurolytic celiac plexus block), details of hope that the atlas will help educate and guide practitioners
the CT-guided technique and accompanying CT images are toward a more uniform approach to performing these tech-
included. niques. With more consistent methodology, we can begin
The fi eld of pain medicine suffers from a lack of well- the much-needed work of assembling randomized con-
controlled studies to guide our choice of the most effec- trolled trials to determine which among these techniques
tive therapies. Indeed, many of the techniques described in are most useful in aiding those with intractable pain.
the atlas lack clear evidence to support their effi cacy. Even
so, the techniques described are in widespread clinical use. James P. Rathmell, MD
I have made every effort to provide a clear summary of Burlington, Vermont
the current evidence available supporting the use of each March 2005
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Acknowledgments
This project would not have been possible without the help request permissions, or fi eld calls from the many others
of many people. First among those who have made this atlas helping with the project.
more than a compendium of x-ray images is Gary Nelson, The atlas began in 2001, after a discussion with Craig
retired medical illustrator at the University of Vermont. I Percy, then an Acquisitions Editor with Lippincott Williams &
have worked with Gary for many years and was delighted Wilkins during the annual meeting of the American Soci-
that he was willing to emerge from retirement to complete ety of Anesthesiologists. Brian Brown moved into that same
the illustrations for this second edition, now in color. Gary role during the latter stages of fi nalizing the fi rst edition,
couples a detailed understanding of anatomy with an abso- and I am now proud to call Brian “my editor.” Brian has
lute attention to detail. When he did not understand a helped me with many projects, large and small, and he has
given technique, Gary would venture to my offi ce or to the remained a patient friend at all times. Other key people at
operating room to see the technique being performed. We Lippincott Williams & Wilkins who brought the project to a
would often spend long evening hours by telephone per- close include Nicole Dernoski, Developmental Editor, who
fecting the details. The results speak for themselves, mak- ferried the fi nal submission toward production, and Keith
ing this atlas uniquely suited as a practical reference for Donnellan, who moved into Nicole’s role as the second edi-
reviewing the anatomy of each technique as you are about tion was nearing completion.
to perform the block. The encouragement to tackle an entire book on my own
The images are almost solely from my own practice, came from two people. As Editor in chief of Regional Anes-
including many produced in the course of daily patient thesia and Pain Medicine, David Brown helped me learn how
care by my partners in practice. In Vermont: Michael to assemble an article and make it teach something of value
Borrello, Jerry Tarver, Rayden Cody, and Anne Marie to practitioners. This atlas is, quite purposefully, styled
Munoz; in Boston: Shihab Ahmed, Gary Brenner, Lucy after Dr. Brown’s Atlas of Regional Anesthesia: concise, well
Chen, Christopher Gilligan, Padma Gulur, Jianren Mao, illustrated, and meant for everyday use in real clinical prac-
Gary Polykoff, and Brian Wainger. All my colleagues tice. I have been involved in many projects with Dr. Brown
have helped in choosing the best images and critiquing in more recent years, and he serves as a trusted sounding
the manuscript. Smith Manion worked for a year after his board. Despite an impossibly busy schedule, he always
pain fellowship as a research fellow in our division and, as seems to answer the phone whenever I call for advice. My
Esther Benedetti did for the fi rst edition, he spent many friend and Chair of the Department of Anesthesia at the
hours reviewing and sorting through thousands of images University of Vermont, Howard Schapiro, has encouraged
to fi nd those best illustrating each technique for this edi- me through just about every project I have done and is the
tion. Josh Hirsch, Bill Palmer, and Stuart Pomerantz, my one who keeps me out of trouble. Dr. Schapiro reminds me
colleagues in radiology, were invaluable in providing their that contracts and costs are a reality, and he generously sup-
expertise and open access, including the use of the com- plied me with time for an unconventional sabbatical, the
puted tomography workstation; they have served as valu- fi rst in many years in our department, to work on the fi rst
able clinical and research collaborators throughout my edition of this text.
time in Boston. Adrian Desjardins with Philips Medical Finally, but foremost, I thank my family—my wife, Bobbi,
Systems, now a research scientist at University College and my children, Lauren, James, and Cara. They have sim-
London, offered technical expertise and helped ensure that ply stared in amazement as I sat day after day, week after
my discussion and illustration of radiation exposure dur- week, month after month in my home offi ce—reading, writ-
ing C-arm use was sound. ing, and working with images. They have come to under-
Those in my academic offi ce, most notably Linda Castel- stand that this is something of a passion for me, and they
lano, have made sure that I was organized and reasonably on have provided all the encouragement I needed to complete
time. She has helped whenever asked to revise manuscripts, another project of this size.
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