Spinal Interventions

Facet, Transforaminal, Epidural, and Sacro-iliac joint injections

​

• Patient in positioned prone on the CT table (either head first or feet first) for the lumbar, thoracic, and sacro-iliac spine. Supine and head first for transforaminal cervical spine injections (can be angled 45 degrees with support).

• The region of interest is exposed and a radiopaque marking grid is placed over the spine.

• AP and Lateral scout images are acquired, and a planning scan is performed.

• The facet joints, nerve roots, or epidural space are identified on the slice and the distance is measured, ensuring that the depth is less than 10 cm for a standard spinal needle, or else a longer 12-15 cm spinal needle may be required.

• The CT table is moved to the table position to mark the patient's skin.

• The proceduralist prepares the area with antiseptic solution and local anaesthetic, followed by inserting the spinal needle.

• Using a "step and shoot" technique, the radiographer or proceduralist acquires CT slices (usually three), to demonstrate the spinal needle position.

• Spinal needle position can be confirmed using a small injection of contrast, followed by injection of the steroid medication.

​

​

Lumbar Puncture (LP)

​

• This procedure is indicated for patients with suspicion of meningitis, subarachnoid hemorrhage (SAH), nervous system diseases such as Guillain-Barré syndrome and carcinomatous meningitis, and therapeutic relief of pseudotumor cerebri.

• Patient in positioned prone on the CT table (either head first or feet first) for the lumbar spine.

• The region of interest is exposed and a radiopaque marking grid is placed over the spine.

• AP and Lateral scout images are acquired, and a planning scan is performed from the third lumbar vertebrae to the first sacral vertebrae (L3 - S1).

• The epidural space is identified on the slice and the distance is measured.

• The CT table is moved to the table position to mark the patient's skin.

• The proceduralist prepares the area with antiseptic solution and local anaesthetic, followed by inserting the spinal pajunk needle.

• Using a "step and shoot" technique, the radiographer or proceduralist acquires CT slices (usually three), to demonstrate the spinal pajunk needle position in the spinal canal.

• Spinal needle position can be confirmed by aspirating cerebrospinal fluid (CSF) from the spinal canal via the spinal needle and extension tube. Samples are sent to pathology.

• Patient bed rest and flat for a minimum of 2 hours is recommended.

​

​

Epidural blood patch

​

• This procedure is indicated for patients with persistent headaches following a spinal procedure, due to an epidural leak.

• Prior to positioning the patient, a canula is inserted for venous blood access.

• Patient in positioned prone on the CT table (either head first or feet first) for the lumbar spine.

• The region of interest is exposed and a radiopaque marking grid is placed over the spine.

• AP and Lateral scout images are acquired, and a planning scan is performed from the third lumbar vertebrae to the first sacral vertebrae (L3 - S1).

• The epidural space is identified on the slice and the distance is measured.

• The CT table is moved to the table position to mark the patient's skin.

• The proceduralist prepares the area with antiseptic solution and local anaesthetic, followed by inserting the spinal pajunk needle.

• Using a "step and shoot" technique, the radiographer or proceduralist acquires CT slices (usually three), to demonstrate the spinal pajunk needle position in the spinal canal.

• Spinal needle position can be confirmed by aspirating cerebrospinal fluid (CSF) followed by aspirating 20 mL of venous blood and injecting this into the spinal canal via the spinal needle and extension tube.

• Patient bed rest and flat for a minimum of 2 hours is recommended.

​

Discography

​

• Patient is positioned prone with right side up with a 45 degree sponge.

• The patient's back is exposed and the interventional radiologist marks the lumbar disc levels under fluoroscopic guidance with an angiography machine.

• The radiographer operates the C-am in an left anterior oblique (LAO) orientation to obtain an oblique view of the Lumbar spine (Scotty dog appearance).

• The discs are marked (for example, L3/4, L4/5, and L5/S1) and local anaesthetic is administered, followed by long spinal needles (20g/15 cm or 20cm).

• The spinal needles are positioned within the nucleus pulposis of the intervertebral discs to be investigated.

• The radiographer adjusts the oblique angle, cranial or caudal angulation (to superimpose the vertebral body endplates), and collimation of the C-arm.

• The interventional radiologist injects contrast into the discs, and verbal communication from the patient is required to measure the level of pain with each injection.

• Healthy discs should not be symptomatic, however herniated discs or discs with tears can provoke back pain and/or sciatica pain symptoms.

• Final x-ray images with the C-arm in the PA and Lateral projections using the C-arm with fluoroscopic image capture or single shot mode.

​

Vertebroplasty

​

• Percutaneous vertebroplasty is indicated for painful, non-healing osteoporotic or neoplastic vertebral compression fractures that are unresponsive to conventional therapy.

• Patient is positioned prone on the angiography table with both arms supported above and to the side of their head.

• The patient's back is exposed and prepared with antiseptic solution and a sterile drape. Conscious sedation is administered.

• The radiographer operates the angiography machine and centres the x-ray on the vertebrae requiring treatment, using the ribs to count the vertebrae around the thoracic, thoraco-lumbar, and lumbar spine region. A slight right anterior oblique (RAO) is used to visualize the pedicles.

• The interventional radiologist marks the pedicle and local anaesthetic is administered.

• The vertebroplasty needle is navigated down through the pedicle. The angiography machine is moved from AP (ensure that the needle is central) and Lateral projections (ensure that the needle directs towards the anterior-inferior border of the vertebral body).

• Once needle position is satisfactory, the vertebroplasty cement kit is prepared and the timer is started.

• When the vertebroplasty cement is prepared, the trocar needle is removed and local anaesthetic is injected through the vertebroplasty needle. Then the vertebroplasty cement kit is connected to the vertebroplasty needle and is slowly injected into the vertebral body.

• The radiographer positions the x-ray in the Lateral position, using a previously acquired images (without cement) as a Reference image, to check for paravertebral venous filling during the fluoroscopically-guided cement injection.

• The vertebral body will fill up with the cement, appearing as a dark radiopaque density on x-ray. Cement filling is checked in PA and Lateral projections. When the vertebral body is adequately filled, the vertebroplasty system is removed, and final AP and Lateral fluoroscopy image stores or Single shot captures are acquired to confirm final images. A post-vertebroplasty CT scan of the treated vertebrae can be performed.

​