All of the following procedures are done under precise fluoroscopic control with the very finest equipment available in the world. Dr. Wendell Gibby, a neuroradiologist, heads up a team of neuroradiologists who have fifteen years experience providing these services. Dr. Gibby has written many chapters and books on these subjects, and has been an invited speaker at numerous national meetings and symposia teaching these procedures to other physicians.
Selective Nerve Root Blocks
This procedure is utilized in patients having radicular pain and/or focal nerve root compression who may not be an appropriate candidate for operative surgery. A long-acting steroid mixed with long-acting anesthetic is injected providing several months of pain relief. Selective nerve blocks can be performed at any level of the cervical, thoracic, or lumbar spines.
Epidural Steroid Injection
In this case, a water-soluble steroid solution mixed with anesthetic is injected into the epidural space. This procedure is typically indicated for patients with multi-level spinal disease with back and/or radicular pain in which a selective nerve root block may not be adequate.
Occipital Nerve Root Blocks
Occipital neuralgia is an under-recognized source of unexplained occipital headache. Injection of the greater occipital nerve as it passes through the atlantoaxial fascia can often provide prolonged, and in some cases, permanent relief for patients who experience headache over the back of the head. It is an under-recognized problem associated with previous whiplash injury.
Cervical and Lumbar Discography
Unlike static cross-sectional images, discography provides a dynamic assessment of the disc as well as a provocative pain response. In a subset of patients having discogenic or radicular symptoms unexplained by MRI scans, discography can be very useful. Furthermore, it can help ascertain which of multiple levels may the source of a patent's symptoms.
In this procedure, a small cannula is inserted under fluoroscopic control through the pedicles of the spine and into the vertebral bodies. Patients having osteoporotic compression fractures and/or malignant compression fractures can receive near instantaneous relief of their pain through internal stabilization of the bone. This results in much faster mobilization, particularly in the elderly for whom persistent inactivity may lead to undesirable complications.
For young patients with contained disc herniations unresponsive to conservative treatment, this minimally invasive procedure can be a tremendous boon. A small 2mm reciprocating cannula is inserted under fluoroscopic control into the disc, and the disc is internally decompressed. Unlike other percutaneous procedures such as laser, chemonucleolysis, and intradiscal electrotherapy (IDET), the amount of disc removal can be carefully controlled and the risk of complication is extraordinarily small.
A significant number of patients suffer low back and radicular pain as a result of facet arthropathy. The advent of high resolution enhanced MRI scans with fat suppression has shown a much higher proportion of arthritic change in the spine than previously recognized. There as a growing understanding of the importance of the facet joints as part of the spinal tripod structural unit. Both diagnostic and therapeutic results can be achieved through facet injections with a long-acting steroid and anesthetic mixture.
Medial Branch Rhizotomy
For some patients, facet arthropathy causes persistent, debilitating back and radicular pain. If a facet injection is successful in alleviating their pain, they may be good candidates for a rhizotomy of the medial branch nerve that supplies sensation to the facet joints. This is done with radio frequency thermal ablation under precise fluoroscopic control.
Interventional Bone Biopsies of Suspicious Lesions
These can be performed under either fluoroscopic or CT guidance for rapid and accurate evaluation of spinal lesions.
Percutaneous Drainage of Perineurial Cysts and Tarlov Cysts
While usually asymptomatic, these small cysts form on the nerve sheaths; especially in the sacral foramina. These can be drained and ablated percutaneously.
Epidural Blood Patch
Patients who have had a nerve root injury or prior needle stick of the arachnoid space may experience a chronic CSF leak leading to debilitating spinal headaches. This can often be treated quickly using an autologous blood patch.
For patients with prior surgery and fixation hardware or those with complex spinal disease, cervical myelography may be very helpful for diagnosing ongoing symptoms.