Diagnostic and interventional imaging
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Diagn Interv Imaging · Sep 2012
Approaches in injections for radicular pain: the transforaminal, epidural and transfacet approaches.
Spinal injections must be carried out adhering to very strict conditions. However, these procedures have almost come to be seen as everyday and may be practised under quite questionable conditions. The recent reports of new and extremely serious neurological complications have changed the attitudes of those making referrals as well as the attitudes of the interventional radiologists carrying out these procedures. ⋯ Where the transforaminal approach is still used, the needle must be positioned extremely accurately. A prior radioopaque contrast medium injection is essential from a safety perspective. The transforaminal epidural injection via the transfacet approach looks to be a promising alternative that is strictly avascular.
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In this case series, out of 823 ultrasound-guided injections carried out over a period of one and a half years, 60% were of the lower limb (LL). In the hip (61% of LL injections), the main indications were pathologies of the gluteal tendons and bursae (80%) and pathologies of periprosthetic soft tissue; in the knee (15% of LL punctures), these procedures were for cysts (51%), tendinopathies and bursopathies (18%), and joint aspirations (7%); in the calf, haematoma drainage; in the foot and the ankle (24% of LL punctures), Morton's neuroma (47%), tenosynovitis (22%), pathologies of the plantar fascia (13%), cysts (7%), joint aspirations (5%), and bursopathies. For each of these indications, we will detail the specific technique and equipment used, useful tips, and post-procedure care.
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Transforaminal injections are widely used. Serious complications including strokes and paraplegia have been reported after transforaminal injections of corticosteroids, and the Afssaps (2011) has issued a warning about their use [1]. The needle must be positioned in the posterior aspect of foramen, and its correct placement validated by an injection of contrast product. ⋯ This procedure is simple, reproducible, and durably effective in 60 to 70% of cases. Complications and adverse effects are rare but potentially serious: allergies, blood pressure surge, vasovagal syncope, transient exacerbation of pain, infection, stroke, and paraplegia. The aim of this course is to stress the need for rigor - in the indication, the technical performance of the procedure, and the overall management of the patient.