Table Of ContentSpinal Injection
Techniques
Theodoros Theodoridis, MD
Director
DepartmentforSpineTherapyandOrthopedicSurgery
ViktoriaKlinik
Bochum,Germany
InstituteforSpineResearch
attheRuhrUniversity
Bochum,Germany
Juergen Kraemer, MD
ProfessorEmeritus
FormerlyOrthopedicUniversityClinic
St.JosefHospital
Bochum,Germany
InstituteforSpineResearch
attheRuhrUniversity
Bochum,Germany
397illustrations
Thieme
Stuttgart·NewYork
IV
LibraryofCongressCataloging-in-PublicationData isavailablefrom Importantnote:Medicineisanever-changingscienceundergoing
thepublisher. continualdevelopment.Researchandclinicalexperiencearecontin-
ually expanding our knowledge, in particular our knowledge of
propertreatmentanddrugtherapy.Insofarasthisbookmentions
anydosageorapplication,readersmayrestassuredthattheauthors,
LibraryofCongressCataloging-in-PublicationData editors,andpublishershavemadeeveryefforttoensurethatsuch
Theodoridis,Theodoros. referencesareinaccordancewiththestateofknowledgeatthetime
[InjektionstherapieanderWirbelsaüle.English] ofproductionofthebook.
Spinalinjectiontechniques/TheodorosTheodoridis,Juergen Nevertheless,thisdoesnotinvolve,imply,orexpressanyguaran-
Kraemer. teeorresponsibilityonthepartofthepublishersinrespecttoany
p.;cm. dosageinstructionsandformsofapplicationsstatedinthebook.
Thisbookisanauthorizedandrevisedtranslationofthe2nd Everyuserisrequestedtoexaminecarefullythemanufacturers’leaf-
Germaneditionpublishedandcopyrighted2007byGeorgThieme letsaccompanyingeachdrugandtocheck,ifnecessaryinconsulta-
Verlag,Stuttgart,Germany.TitleoftheGermanedition: Injek- tionwithaphysicianorspecialist,whetherthedosageschedules
tionstherapieanderWirbelsaüle. mentionedthereinorthecontraindicationsstatedbythemanufac-
Includesbibliographicalreferencesandindex. turersdifferfromthestatementsmadeinthepresentbook.Such
ISBN978-3-13-145071-5(alk.paper) examination is particularly important with drugs that are either
1.Injections,Spinal. I.Krämer,Jürgen,1939-II.Title. rarelyusedorhavebeennewlyreleasedonthemarket.Everydosage
[DNLM:1. BackPain--therapy.2. Anesthesia,Spinal.3. Injections, scheduleoreveryformofapplicationusedisentirelyattheuser’s
Spinalmethods. WE720T388j2009a] own risk and responsibility. The authors and publishers request
RD751.T54132009 everyusertoreporttothepublishersanydiscrepanciesorinaccura-
617.9'64--dc22 ciesnoticed.Iferrorsinthisworkarefoundafterpublication,errata
2009002210 willbepostedatwww.thieme.comontheproductdescriptionpage.
Thisbookisanauthorizedandrevisedtranslationofthe2ndGerman
editionpublishedandcopyrighted2007byGeorgThiemeVerlag,
Stuttgart,Germany.TitleoftheGermanedition:Injektionstherapie
anderWirbelsäule.
Translator:MichelleJames,Nettetal,Germany
Illustrator:HeikeHübner,Berlin,Germany
©2009GeorgThiemeVerlag, Someoftheproductnames,patents,andregistereddesignsreferred
Rüdigerstrasse14,70469Stuttgart,Germany tointhisbookareinfactregisteredtrademarksorproprietarynames
http://www.thieme.de eventhoughspecificreferencetothisfactisnotalwaysmadeinthe
ThiemeNewYork,333SeventhAvenue, text.Therefore,theappearanceofanamewithoutdesignationas
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Thisbook,includingallpartsthereof,islegallyprotectedbycopy-
Coverdesign:ThiemePublishingGroup right.Anyuse,exploitation,orcommercializationoutsidethenarrow
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PrintedinGermanybyOAN,OffizinAndersenNexö,Leipzig illegalandliabletoprosecution.Thisappliesinparticulartophoto-
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ISBN 978-3-13-145071-5 123456 films,andelectronicdataprocessingandstorage.
V
List of Contributors
AlexandrosAnastasiadis,MD SusanneStehr-Zirngibl,MD
SurgicalClinicBergmannsheil St.JosefHospital
Bochum,Germany ClinicforAnesthesiology
attheRuhrUniversity
FritjofBock,MD Bochum,Germany
PrivatePracticeforOrthopedics
Ravensburg,Germany WolframTeske,MD
St.JosefHospital
StefanHeidersdorf,MD OrthopedicUniversityClinic
PrivatePracticeforOrthopedics Bochum,Germany
Hattingen,Germany
UlrikeTheodoridis,MD
CordeliaSchott,MD St.JosefHospital
PrivatePracticeforOrthopedics NeurologicalUniversityClinic
Düsseldorf,Germany Bochum,Germany
ClemensSirtl,MD
St.JosefHospital
ClinicforAnesthesiology
attheRuhrUniversity
Bochum,Germany
VI
Foreword
“Theburdenoftheback”—backpaininallitsvariousforms monitoring” solely because the “traditional orthopedic
hasalwaysbeenandwillremainthedomainofthespecial- clinicalexamination”hasfallenintooblivion.
istfieldoforthopedics. Rather,thewiderangefoundinanestablishedortho-
Thetaskof“conquering”backpain,oratleastimple- pedic/traumasurgicaltherapyshouldbedepicted,withits
mentingadequateformsoftherapy,isbecomingincreas- provenlong-termtherapysuccess.
ingly difficult under the conditions found in the Public Thisbookmakesitclearthatallspinalinjectiontech-
HealthServiceswiththeirlackoffundingandconcepts. niqueswereandwillremainthedomainoforthopedicand
Treatmentguidelinesarestrictlymonitoredusing“evi- traumasurgery,asIGOSThasconveyedinitscourses.
dencebasedmedicine.”Thisisdefinitelyadvantageousto Aportionofthisbookisalsodedicatedtotherational
patientsandpractitioners,butcanalsoresultinthefree- pharmaceutical treatment of back pain, taking into ac-
domoftreatmentbeing“legallypatronized.”Itischarac- countnewfindingsintheareaoflocalanesthetics.
terizedbyconflictsaboutwhichlineofthoughtshouldbe Thecoreofthematterhereisthepreventionofchron-
followed,especiallybythesocieties“thatargueaboutback ification of back pain using interdisciplinary therapeutic
treatment.” approachesandaspecificearlytherapymanagement,and
During the development of pain therapy in Germany notsimplythe“managementofanever-increasingnum-
overthelast10yearswehavelearntagreatdealfromthe berofpainpatients.”
conflicts relating to back pain in all of its forms. This This book corresponds to the “golden standard” for
processmustbecontinued. spinalinjectiontherapyfromanorthopedic/traumasurgi-
This book should aid in improving confidence when cal point of view and is an excellent companion for our
treatingbackpain.Itisbasedontheworkandnewcon- courses.Itcomplementsasuccessionofremarkablespe-
cepts from the “Interdisziplinären Gesellschaft für or- cialistbookswhichhaveemergedwiththehelpofIGOST
thopädischeundunfallchirugischeSchmerztherapie”(In- overrecentyears.
terdisciplinarySocietyforOrthopedicandTraumaSurgical ItisonthispremisethatIthanktheauthorsfortheir
Pain Therapy—IGOST) and represents the pain therapy work with the IGOST and wish them success with this
section of the Deutsche Gesellschaftfür Orthopädie und book.
OrthopädischeChirurgie(GermanSocietyforOrthopedics Iwishallourreadersenjoymentandsuccesswiththe
andOrthopedicSurgery—DGOOC). teachingsofthisbookandhopethattheyareabletoapply
Morethan90%ofbackpainistreatedas“nonspecific” whattheyhavelearntintheirdailywork.
simply because the therapist knows and has learnt too
little about the back. The further development of this H.E.Brunner,MD
phenomenonhastobecounteracted. GOST–IMPSPresident
Itisalsonecessarytopreventtheoveruseof“technical
methods and injection techniques under radiological
VII
Preface
Spinalinjectiontechniquesenjoyahighstatuswithinpain ourclinic:BirgitGreifenberg,SilkeBachmann,andMichael
therapyandareavaluabletreatmenttoolwhencorrectly Müller.Itwasalwaysapleasuretocombinemedicinewith
used. Performing special injection techniques from the art.Wesincerelythankyouforthis.
cervicalspinetothesacrumprofessionallyandsafelyre- SpecialthanksgototheClinicalAnatomyResearchand
quiresasoundspecialistknowledgeintopographicalanat- Education Center (Klinisch-anatomisches Forschungs-
omy. Building on this, the injection techniqueshave be- und Fortbildungszentrum—KAFFZ) at the Ruhr Univer-
comeincreasinglyrefinedovertheyears.Safetreatment sity’sAnatomicalInstituteinBochum,Germany.Thiscen-
fordoctorsandpatientscanbeachievedwhenthetechni- terisanestablishmentdedicatedtoresearchandeduca-
ques are correctly implemented. Routine radiation- tion in the clinical anatomy fields. In the last years the
chargedradiographsandcomputertomographiesarenot well-known “hands on” courses by the Interdisciplinary
necessarywhenusingthetechniquesdescribedhere. SocietyforOrthopedicTraumaandSurgicalPainTherapy
Basic principles, diagnostics, causal and symptomatic (InterdisziplinäreGesellschaftfürOrthopädischeundUn-
paintherapyforspinalsyndromes,aswellasthenewIRAP fallchirurgischeSchmerztherapie—IGOST)havebeenheld
(EOT)methodare,amongstothers,extensivelydescribed hereincooperationwiththeOrthopedicUniversityClinic.
in the theoretical section of the book. New concepts in The directors of the Anatomical Institute, Professor Rolf
multimodal pharmaceutical pain therapy are likewise Dermietzel, MD, and Professor Hans-Georg Mannherz,
demonstrated. MD,andtheiremployees,ClaudiaSchneiderandHelmut
Theatlassectionconveysdetailedanatomicalknowl- Riese,havegivenustheconsiderableopportunityofclar-
edge.Theinjectiontechniquesareclearlydescribed“step- ifyinganatomicallyrelevantdetailsrelatedtothespecial
by-step”usingseriesofphotographicmaterial.Thebookis injectiontechniques.
divided into regions of the body for easy reference of WesincerelythankthestaffofThiemePublishersfor
special techniques. The diagnosis and management of theirexcellentconstructiveinputandassistancewiththe
therapy side effects and treatment complications are bookandthepleasantcollaboration.
clearly arranged according to injection and area of the We encourage all our readers to use spinal injection
body. therapy more intensively without the use of diagnostic
Over30yearsofexperienceusinginjectiontechniques imaging and to implement thisto their patients’ advan-
alongthespinehavebeenincorporatedintothisbook. tage.
Wethankallofourpatientswhowerewillingtocon- Goodluck!
tributetothedevelopmentofthisbook. TheodorosTheodoridis
Alargenumberofthephotographswerepreparedby JuergenKraemer
thefollowingmembersofthephotographicdepartmentat
VIII
Table of Contents
I General Section
1 █ BasicPrinciples 3
OrthopedicPainTherapy................. 3 SecondaryPain......................... 8
NociceptionandChronification ........... 4 MixedPainSyndrome................... 9
StagesintheDevelopmentofPain ........ 5 ChronicPainSyndrome.................. 10
MovingfromAcutetoChronicPain:
NociceptorSensitization................. 6
2 █ Diagnostics 13
MedicalHistory......................... 13 LaboratoryTests........................ 17
ClinicalExamination..................... 14 ImagingTechniques..................... 18
Neurological–OrthopedicExamination..... 16 TrialMeasuresfortheDiagnosisofPain.... 18
3 █ CausalOrthopedicPainTherapy 19
PositioningandTraction................. 19 PosturalandBehavioralTraining;Back
OrthopedicAids ........................ 20 School................................. 22
ManualTherapy ........................ 20 BackSchoolandOrthopedicPainTherapy.. 22
PhysicalTherapy........................ 21
4 █ SymptomaticPainTherapy 25
Introduction ........................... 25 MultimodalMedicationConcomitant
Thermotherapy......................... 26 Therapy ............................... 36
Massage............................... 27 Introduction ........................... 36
Electrotherapy.......................... 28 PainMeasurementandDocumentation.... 36
Acupuncture ........................... 29 WHOAnalgesicLadder .................. 37
TherapeuticLocalInjectionTreatment ..... 30 OpioidManagement .................... 46
Interleukin-1ReceptorAntagonistProtein AdjuvantAnalgesics..................... 46
(IL-1Ra)................................ 33 LocalAnesthesia........................ 49
TableofContents IX
II Atlas Section
5 █ TheSpine:Anatomy,Nociception,andtheDistributionofPainSignals 53
Terminology ........................... 53 NerveRoot............................. 55
NociceptionandtheDistributionofPain NociceptivePainArisingfromthe
SignalsintheSpine ..................... 53 ZygapophysealJoints.................... 57
Pain-SensitiveStructuresintheVertebral Muscles ............................... 57
MotorSegment......................... 53 MixedPainSyndromesintheSpine....... 59
SpinalNerve ........................... 54 ChronicPainArisingfromtheVertebrae ... 59
PosteriorLongitudinalLigament .......... 55
6 █ SpecialOrthopedicInjectionTherapy:ContraindicationsandPatientInformation 61
Contraindications....................... 61 PatientInformation ..................... 62
7 █ CervicalInjectionTherapy 65
SpecializedCervicalNeuroanatomy........ 65 PainTherapyforthePosttraumaticCervical
BasicTherapyforCervicalPain............ 66 Syndrome ............................. 71
SpecialTherapyforCervicalPain.......... 68 CervicalInjectionTherapy................ 72
LocalCervicalPainSyndrome............. 68 CervicalSpinalNerveAnalgesia........... 72
PainTherapyfortheCervicobrachial CervicalEpiduralInjection ............... 81
Syndrome ............................. 70 CervicalFacetInfiltration(CxFI)........... 89
TreatmentofCervicalHeadaches CervicalTriggerPointInfiltrationandSkin
(CervicocephalicSyndrome).............. 71 Infiltration............................. 95
8 █ ThoracicInjectionTherapy 99
SpecializedThoracicNeuroanatomy....... 99 ThoracicSpinalNerveAnalgesia .......... 101
ClinicalPicture ......................... 100 ThoracicFacetInfiltration(TxFI) .......... 107
ThoracicInjectionTherapy ............... 101 CostotransverseBlock(CTB).............. 110
9 █ LumbarInjectionTherapy 113
SpecializedLumbarNeuroanatomy........ 113 DecompensatedSpinalCanalStenosis ..... 121
BasicTherapyforLumbarPain............ 115 PainTherapyforProblemPatientsWho
SpecialTherapyforLumbarPain .......... 118 HaveUndergoneSpinalSurgery .......... 122
LocalPainSyndromesinthe PainFollowingLumbarSpondylodesis..... 124
LumbarSpine(LocalLumbarSyndrome, LumbarInjectionTherapy................ 125
NonspecificBackPain)................... 118 LumbarSpinalNerveAnalgesia........... 125
TreatmentofAcuteLowBackPain ........ 119 Radiculography......................... 139
TreatmentofChronicLowBackPain....... 119 LumbarFacetInfiltration................. 139
PainTherapyfortheLumbarNerveRoot LigamentInfiltrationattheSacroiliac
Syndrome ............................. 120 Joint(SIJBlock)......................... 149
PainTherapyforLumbarSpinalCanal LumbarEpiduralPainTherapy............ 157
Stenosis ............................... 121
