Functional Anesthetic - PDF document

Functional Anesthetic Functional Anesthetic Discography Discography A. Orlando Ortiz, MD, MBA, FACR A. Orlando Ortiz, MD, MBA, FACR Professor and Chairman Professor and Ch

airman Department of Radiology Department of Radiology Winthrop Winthrop - - University Hospital University Hospital Oortiz@Winthrop.org Oortiz@Winthrop.org Improving the Po

wer of Discography If the goal of discography is to identify a If the goal of discography is to identify a potentially symptomatic disc that may benefit potentially sympt

omatic disc that may benefit from a treatment intervention, then how do from a treatment intervention, then how do we improve the predictive value of this test? we improv

e the predictive value of this test? Functional anesthetic discography Functional anesthetic discography Lumbar spine Lumbar spine Functional Anesthetic Discography Coaxial

over Coaxial over - - the the - - wire technique is wire technique is used to insert a small flexible used to insert a small flexible double lumen catheter into the dou

ble lumen catheter into the nucleus pulposus of a potentially nucleus pulposus of a potentially symptomatic disc using symptomatic disc using fluoroscopic guidance fluo

roscopic guidance The FAD catheter is secured in The FAD catheter is secured in place by injecting the balloon port place by injecting the balloon port lumen and inflati

ng a tiny balloon lumen and inflating a tiny balloon at the tip of the FAD catheter at the tip of the FAD catheter The 2 The 2 nd nd lumen allows for the lumen allows for

the injection of liquid agents injection of liquid agents (anesthetic, sterile saline) into the (anesthetic, sterile saline) into the disc nucleus disc nucleus FAD Kit

: Wireless Catheter FAD Kit: Wireless Catheter FAD Procedure Discography is performed Discography is performed Potentially symptomatic Potentially symptomatic disc(s disc(

s ) identified ) identified FAD catheter placed into the disc and secured to FAD catheter placed into the disc and secured to skin surface skin surface MDCT performed MDCT

performed Patient returns to recovery room Patient returns to recovery room FAD Procedure Disc is injected with a small volume of either Disc is injected with a small volu

me of either anesthetic or sterile NS anesthetic or sterile NS Patient is asked to perform simple maneuvers which Patient is asked to perform simple maneuvers which typic

ally elicit their back symptoms typically elicit their back symptoms Patient is interrogated as to whether or not there is Patient is interrogated as to whether or not ther

e is symptomatic relief symptomatic relief When is the FAD catheter inserted? A provocative discographic response A provocative discographic response An equivocal discograp

hic response by the An equivocal discographic response by the patient with imaging evidence of abnormal patient with imaging evidence of abnormal disc morphology disc mo

rphology It may be necessary to place FAD catheters in It may be necessary to place FAD catheters in more than one disc more than one disc Perform Discogram: Coaxial Techn

iqueSTEP-BY-STEP Discogram50/50 mix sterile NS and LOCM Insert 0.09 GuidewireRemove Insert Needle Insert FAD Catheter Over Guidewire Double Lumen Catheter Passes Thru Guide

Needle Remove Guide NeedleRemove Guidewire Inflate balloon using 0.2 - 0.3 mL LOCM Our First Case 54M 54M Chronic 8/10 LBP Chronic 8/10 LBP Abnormal L5 Abnormal L5 - - S1 d

isc S1 disc Difficult patient Difficult patient Discogram provocative at L5-S1 Unable to insert FAD catheter Securing the Guide Needle FAD in patient with prior surgery 45F

45F Chronic 6/10 LBP Chronic 6/10 LBP Right Right - - sided sided component component Prior L5 Prior L5 - - S1 fusion S1 fusion L34 Discogram: 8/10 S; 2ml; 5 psi L34 Disco

gram: 8/10 S; 2ml; 5 psi L3-4 FAD Catheter FAD response at 5 minutes; complete pain relief 41F 6/10 Axial LBP Discography DiscographyL34: 2 mL at 45 psi ; 7/10 SL45: 1.5 mL

@ 23 psi, 10/10 SL5-S1: 1 mL @ 23 psi, pressure MDCT FAD catheters placed at L34, L45FAD response: 0 5 10minL34 5/10 4/10 2/10L45 10/10 6/10 2/10 49F 8/10 LBP and RLE pain 4

9F 8/10 LBP and RLE pain 18g GN; 20g IN with 18g GN; 20g IN with atraumatic atraumatic tip tip and lateral aperture and lateral aperture L4 L4 - - 5 Discogram provocati

ve: 5 Discogram provocative: 8/10 S at 1.5 mL and 10 psi 8/10 S at 1.5 mL and 10 psi Insertion of FAD catheter Insertion of FAD catheter Removal of Needles Removal of Needl

es Balloon inflated with sterile NS Balloon inflated with sterile NS Axial Recon Axial Recon FAD FAD 1 mL 4% Lidocaine 1 mL 4% Lidocaine 0 minute 0 minute 10/10 Exact pain 1

0/10 Exact pain 5 minute 5 minute 8/10 pain 8/10 pain 10 minute 10 minute 6/10 pain 6/10 pain FAD concordant with provocative discographic FAD concordant with provocative d

iscographic response at L4 response at L4 - - 5 5 False Positive Discogram False Positive Discogram �34F 5/10 LBP 1 year �34F 5/10 LBP 1 year No radiculopat

hy No radiculopathy Case courtesy of Dr. Wade Wong Case courtesy of Dr. Wade Wong Discography Discography Concordant at L5 Concordant at L5 - - S1 S1 9/10 pain 9/10 pain 1.8

mL at 10 psi 1.8 mL at 10 psi Opening pressure 4 psi Opening pressure 4 psi No pain at L3 No pain at L3 - - 4 or L4 4 or L4 - - 5 5 FAD FAD Pain worsens with forward bendin

g Pain worsens with forward bending No pain reduction following injection of 0.8 mL No pain reduction following injection of 0.8 mL 2% Lidocaine into L5 2% Lidocaine into

L5 - - S1 S1 Patient subsequently underwent a facet joint Patient subsequently underwent a facet joint injection at L5 injection at L5 - - S1 with relief of her symptoms S

1 with relief of her symptoms CONCLUSIONS Discography is a minimally invasive procedure Discography is a minimally invasive procedure which, in specific cases (i.e., non w

hich, in specific cases (i.e., non - - compressive compressive spinal pain syndromes), may provide useful spinal pain syndromes), may provide useful diagnostic informati

on about a given disc and diagnostic information about a given disc and therefore influence subsequent patient therefore influence subsequent patient management manageme

nt CONCLUSIONS FAD FAD Our experience shows value added Our experience shows value added Confirms positive discographic response Confirms positive discographic response Excl

udes questionable discographic response Excludes questionable discographic response High correlation with abnormal disc morphology High correlation with abnormal disc morpho