Table Of ContentInterventional Radiology of the Spine
I
NTERVENTIONAL
R S
ADIOLOGY OF THE PINE
I -G P T
MAGE UIDED AIN HERAPY
Edited by
J. K M G ,
EVIN C RAW MD
Riverside Methodist Hospital,
Columbus, OH
SPRINGER SCIENCE+BUSINESS MEDIA, LLC
© 2004 Springer Science+Business Media New York
Originally published by Humana Press Inc. in 2004
Softcover reprint of the hardcover 1st edition 2004
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Cover Illustrations: Figure 5B from Chapter 13, “Treatment of Discogenic Back Pain,” by Jeff S. Silber, J. Kevin McGraw, and John A. Lippert; Figure
7 from Chapter 3, “Magnetic Resonance Imaging of the Spine,” by Eiran Mandelker, Gretchen G. Cordero, Dennis H. Son, and J. Kevin McGraw; Figure
10A from Chapter 8, “Selective Nerve Root Blocks,” by Dennis J. Griffin; and Figure 10 from Chapter 14, “Spinal Biopsy Techniques,” by Thomas
M. Davis.
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10 9 8 7 6 5 4 3 2 1
ISBN 978-1-61737-419-7 ISBN 978-1-59259-418-4 (eBook)
DOI 10.1007/978-1-59259-418-4
Library of Congress Cataloging-in-Publication Data
Interventional radiology of the spine: image-guided pain therapy / edited by J. Kevin McGraw.
p. cm.
Includes bibliographical references and index.
1. Interventional radiology. 2. Spine--Diseases--Treatment. 3. Backache--Treatment. 4. Spine--Imaging.
RD33.55.I585 2003
616.7'306--dc21
2003041650
Dedication
To my parents,
James and Christine McGraw,
my wife Lisa,
and our sons Reed and Ryan.
v
Preface
The last century witnessed many changes in the Part II: Interventional Spinal Procedures. Topics
practice of medicine. As we move into the 21st cen- in Part I include basic spinal anatomy, CT, MRI,
tury, we will see more and more procedures performed and nuclear medicine of the spine, and the clinical
with minimally invasive, image-guided techniques. At evaluation of the spine patient. Topics in Part II
the forefront of this revolution is the specialty of include discussion of the history of spinal procedures,
interventional radiology. Interventional radiology tra- review of the pharmacology of medications used
ditionally involves the treatment of vascular disease, in injection procedures, selective nerve root blocks,
but has grown to include nonvascular intervention and, epidural injections, facet injections, sacroiliac joint
recently, the treatment of spinal disorders. injections, discography, treatment of discogenic back
The objective of Interventional Radiology of the pain, spinal biopsy techniques, percutaneous verte-
Spine: Image-Guided Pain Therapy is to provide the broplasty, and transcatheter therapy for tumors of
practicing interventional radiologist with a single the spine.
source for evaluating and treating the patient with back The topics covered in this book should provide the
pain. This includes discussion of interventional spinal reader with a useful, comprehensive, state-of-the-art
procedures, spinal imaging, and the clinical evaluation reference on minimally invasive, image-guided spinal
of the spine patient. The practicing pain specialist will procedures, as well as a review of anatomy and imag-
also find this work useful because radiological spinal ing findings in spinal disorders. The hope is that
imaging is included, a topic most pain management Interventional Radiology of the Spine: Image-Guided
textbooks lack. Imaging has become an essential ele- Pain Therapywill allow more interventionalists to fully
ment in the evaluation of patients with back pain. employ the skill and expertise that they possess to the
The book is divided into two sections: Part I: Spi- evaluation and treatment of patients with back pain.
nal Anatomy, Imaging, and Clinical Evaluation; and J. Kevin McGraw, MD
vii
Acknowledgments
I would first like to acknowledge my parents. reason I attended the University of Virginia for radiol-
They instilled in me a strong work ethic and a desire ogy residency with the intent of doing an interven-
to succeed. They provided me with the firm founda- tional fellowship under his tutelage. I was fortunate to
tion on which my career has been built. My wife, have worked with him during residency until he met
Lisa, has been the cornerstone of my career. It was an untimely death during my fourth year. Had it not
her love and support that allowed me to survive been for Dr. Alan H. Matsumoto, I doubt that my
medical school, surgical internship, radiology career would have been as rewarding and successful
residency, and interventional fellowship. Our sons, as it is today. He taught me the technical skills and
Reed and Ryan, have given me the true meaning expertise to perform minimally invasive procedures,
for all of the years of hard work. I hope to make but more importantly, he provided me with a strong
all of their dreams come true, as my parents did clinical background in patient care. He emphasized
for me. that virtually anyone could be a technician and per-
I also wish to thank my mentors. As a medical stu- form procedures, but it took a physician to provide
dent, Dr. Stephen I. Schabel at the Medical University clinical care for the patient.
of South Carolina fostered my interest in diagnostic I would also like to acknowledge the contributors
radiology through his wit and intellect. He told me to this book who have toiled numerous hours prepar-
about interventional radiology when my interests ing their chapters. They have all done a remarkable
turned to the surgical subspecialties, but also encour- job. I would also like to thank my group members in
aged me to do a surgical internship prior to my resi- Riverside Radiology Associates for their unyielding
dency. Dr. Charles J. “Tunk” Tegtmeyer was the support in my professional endeavors.
ix
Contents
DEDICATION.............................................................. v 7 Pharmacology of Medications Used
in Spinal Injection Procedures.............. 101
PREFACE .................................................................vii
John A. Lippert
ACKNOWLEDGMENTS ..............................................ix 8 Selective Nerve Root Blocks.................... 119
CONTRIBUTORS......................................................xiii Dennis J. Griffin
9 Epidural Steroid Injections ....................... 127
I. SPINAL ANATOMY, IMAGING,
Dennis J. Griffin
AND CLINICAL EVALUATION
10 Facet Joint Injections ................................ 137
1 Spinal Anatomy............................................. 3 Jeffrey M. Boorstein and J. Kevin McGraw
Robert M. DePhilip and J. Kevin McGraw 11 Sacroiliac Joint Injections......................... 143
2 Computed Tomography of the Spine.......... 21 Jeffrey M. Boorstein and J. Kevin McGraw
Stephen F. Futterer 12 Discography .............................................. 149
3 Magnetic Resonance Imaging John A. Carrino and J. Kevin McGraw
of the Spine............................................. 41 13 Treatment of Discogenic Back Pain......... 167
Eiran Mandelker, Gretchen G. Cordero, Jeff S. Silber, J. Kevin McGraw,
Dennis H. Son, and J. Kevin McGraw and John A. Lippert
4 Nuclear Medicine of the Spine ................... 65 14 Spinal Biopsy Techniques ........................ 181
John E. Baumert, Jr. Thomas M. Davis
5 Clinical Evaluation of the Spine Patient..... 73 15 Percutaneous Vertebroplasty .................... 197
L. Mark Dean David F. Kallmes, Mary E. Jensen,
and J. Kevin McGraw
II. INTERVENTIONAL SPINAL PROCEDURES 16 Transcatheter Therapy for Tumors
of the Spine........................................... 215
6 History and Overview
Peter J. Pema and Ronald F. Budzik
of Spinal Procedures............................... 93
J. Kevin McGraw INDEX.................................................................... 225
xi
Contributors
JOHN E. BAUMERT, JR.,MD, Director, Department DENNIS J. GRIFFIN,MD,Interventional Radiology,
of Nuclear Medicine, Riverside Methodist Radiology Imaging Associates/Invision Medical
Hospital, Columbus, OH Imaging, Denver, CO
JEFFREY M. BOORSTEIN,MD,PhD, Director, MARY E. JENSEN,MD, Director, Interventional
Neuroradiology, Decatur Memorial Hospital, Neuroradiology, Associate Professor of Radiology
Decatur, IL, and Clinical Associate Professor and Neurosurgery, University of Virginia Health
of Radiology, Medical College of Ohio, Toledo, OH Systems, Charlottesville, VA
RONALD F. BUDZIK,MD, Interventional DAVID F. KALLMES,MD, Assistant Professor
Neuroradiology, Riverside Methodist Hospital, of Radiology, Senior Associate Consultant,
Columbus, OH Department of Radiology, Mayo Clinic,
JOHN A. CARRINO,MD,MPH, Assistant Professor Rochester, MN
of Radiology, Harvard Medical School; Clinical JOHN A. LIPPERT,MD,Co-Director, Vascular
Director, Magnetic Resonance Therapy Program, and Interventional Radiology, Riverside
Co-Director, Spine Intervention Service, Methodist Hospital, Columbus, OH
Department of Radiology, Brigham and Women’s EIRAN M. MANDELKER,MD,Director, MR
Hospital, Boston, MA Outpatient Imaging, Riverside Methodist
GRETCHEN G. CORDERO,MD,Radiologist, Riverside Hospital, Columbus, OH
Methodist Hospital, Columbus, OH J. KEVIN MCGRAW,MD,Co-Director, Vascular
THOMAS M. DAVIS,MD,Vascular and Interventional and Interventional Radiology, Riverside
Radiology, Riverside Methodist Hospital, Methodist Hospital, Columbus, OH,
Columbus, OH and Clinical Assistant Professor,
L. MARK DEAN,MD, Director, Interventional Medical College of Ohio, Toledo, OH
Radiology, Dayton Veterans Administration PETER J. PEMA,MD,Departments of Interventional
Medical Center, Dayton, OH, and Interventional Neuroradiology and Radiology, Riverside
Radiologist, Riverside Methodist Hospital, Methodist Hospital, and The Ohio State
Columbus, OH University, Columbus, OH
ROBERT M. DEPHILIP,PhD, Associate Professor, JEFF S. SILBER,MD, Department of Interventional
Division of Anatomy, The Ohio State University, Radiology, Doylestown Hospital,
Columbus, OH Doylestown, PA
STEPHEN F. FUTTERER,MD, Assistant Professor DENNIS H. SON,MD, Radiology Resident,
of Radiology, Division of Neuroradiology, University of Southern California, Keck School
Northwestern University, Chicago, IL of Medicine,Los Angeles, CA
xiii
CHAPTER 1 / SPINAL ANATOMY 1
S A , I
PINAL NATOMY
I , C
MAGING AND LINICAL
E
VALUATION
CHAPTER 1 / SPINAL ANATOMY 3
1
Spinal Anatomy
ROBERTM. DEPHILIP,PhD ANDJ. KEVIN MCGRAW,MD
INTRODUCTION heights of the vertebral bodies increase from the cervical
to the lumbar regions, reflecting the fact that the bodies
The human spine is a study in contrasts. It provides carry the weight of the trunk, upper limbs, and head (Fig. 2).
static support for the head and trunk, while providing a Adjacent vertebral bodies in the cervical, thoracic, and
kinetic mechanism for flexible movement. Both of these lumbar regions articulate via intervertebral discs. An ex-
functions are accomplished while providing essential pro- ception to this pattern occurs in the cervical spine. The C1
tection for the enclosed spinal cord, spinal roots, and vertebra, the atlas, does not contain a body and articulates
nerves. Accurate diagnosis of spinal disorders depends on with the C2 vertebra, the axis, via bilateral synovial joints
a clear understanding of spinal anatomy, and interven- between the lateral masses of the atlas and the lateral
tional approaches to the spine will proceed with fewer masses of the axis.
complications if spinal anatomy is well understood.
This chapter highlights features of anatomy that permit INTERVERTEBRAL DISCS
the spine to function normally and that predispose the The intervertebral discs consist of a centrally placed
spine to certain disease processes. It draws attention to nucleus pulposus and a circumferentially arranged annu-
recent discoveries (1), often made with modern imaging lus fibrosis. Typically, descriptions of the vertebral bod-
techniques, that have implications for therapeutic inter- ies emphasize their weight-bearing function, but it should
vention. be emphasized that the union between vertebral bodies
via the intervertebral discs gives the anterior segment of
SPINAL OSTEOLOGY the spine a great deal of flexibility that is restricted prima-
rily by the joints of the vertebral arch (Fig. 3).
The structural unit of the spine is the vertebra. There
are 33 vertebrae in the human spine: 7 cervical, 12 tho- THE VERTEBRAL ARCH
racic, 5 lumbar, 5 sacral, and 4 coccygeal. The 5 sacral The vertebral arch consists of two pedicles, two lami-
vertebrae are fused and form a composite bone, the nae, and seven processes. The pedicles project posteriorly
sacrum, and the 4 coccygeal vertebrae are usually fused to from the vertebral body and reach the laminae. There are
form the coccyx. The sacrum and the coccyx may or may three processes at the junction of the pedicle and its cor-
not be fused to each other (Fig. 1). responding lamina. A transverse process projects later-
ally and acts as a lever and attachment point for intrinsic
A TYPICAL VERTEBRA
muscles of the back. A superior articular process projects
A typical vertebra consists of a body and an arch. The superiorly and articulates with the inferior articular pro-
body is classified as a long bone with a waistlike diaphy- cess of the vertebra above. Similarly, an inferior articular
sis, or shaft, situated between two ends, or epiphyses. The process projects inferiorly and articulates with the supe-
rior process of the vertebra below (Fig. 4). The pars
interarticularis is the isthmus of bone between the supe-
From:Interventional Radiology of the Spine
Edited by J. Kevin McGraw © Humana Press Inc., Totowa, NJ. rior and the inferior articular processes and is often the
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