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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Suprascapular Neuropathy
KEY FACTS
TERMINOLOGY
• Suprascapular nerve impingement with muscle denervation
IMAGING
• Suprascapular nerve impingement may occur at either
spinoglenoid or suprascapular notch
• Spinoglenoid notch: Between neck and blade of scapula,
roofed by spinoglenoid ligament
○ Entrapment affects infraspinatus muscle only
Peripheral Nerve and Plexus
• Suprascapular notch: At superior border of scapula, roofed
by superior transverse ligament
○ Entrapment affects both supraspinatus and infraspinatus
muscles
• Denervation edema is 1st sign on MR
○ Uniformly increased signal intensity of muscle
• Fatty atrophy occurs later
TOP DIFFERENTIAL DIAGNOSES
• Cervical radiculopathy
(Left) Coronal graphic shows a
suprascapular nerve coursing
through the suprascapular
notch , after which it gives
rise to motor branch to
supraspinatus muscle st. The
nerve then passes through the
spinoglenoid notch and
innervates the infraspinatus
muscle ſt. (Right) Coronal
T2WI FS MR shows an
elongated, multilocular cyst
st extending from a
posterosuperior glenoid labral
tear ſt through the
spinoglenoid notch. The
infraspinatus muscle shows
a mild, homogeneous increase
in signal intensity.
• Parsonage-Turner syndrome (brachial neuritis)
• Rotator cuff tear
• Traction neuropathy
• Neural tumor
PATHOLOGY
• Paralabral cyst due to tear of posterosuperior glenoid
labrum
• Mass or venous varicosities compressing nerve
• Posttraumatic scar or heterotopic ossification
CLINICAL ISSUES
• Young or middle-aged patients, M > F
• Overhead throwing athletes
DIAGNOSTIC CHECKLIST
• Denervation edema best seen on sagittal fluid-sensitive
sequences
430
(Left) Axial PD FSE FS MR in
the same patient shows the
cyst at the level of the
spinoglenoid notch ſt.
Denervation edema is less
visible on this sequence than
on T2 FS or STIR. (Right)
Sagittal T2WI FS MR in the
same patient shows the cyst
st at the spinoglenoid notch.
The sagittal image most
readily shows the abnormal
signal intensity of the
infraspinatus relative to
the supraspinatus ſt muscle.
Median Neuropathy
KEY FACTS
Peripheral Nerve and Plexus
TERMINOLOGY
• Pronator syndrome: Nerve entrapment at pronator teres
• Carpal tunnel syndrome: Nerve entrapment at carpal
tunnel
IMAGING
• Nerve enlargement distal to region of entrapment
○ Fascicles indistinct
• Perineural enhancement
• ± mass compressing nerve
• Denervation changes in muscles distal to entrapment
TOP DIFFERENTIAL DIAGNOSES
• Cervical radiculopathy
• Tenosynovitis
• Peripheral nerve sheath tumor
• Thoracic outlet syndrome
PATHOLOGY
• Overuse
• Arthritis
• Tumors
• Fractures
• Anatomic variants
CLINICAL ISSUES
• Tinel sign: Tingling along course of nerve when nerve
tapped at point of entrapment
• Electrodiagnosis standard for diagnosis
DIAGNOSTIC CHECKLIST
• Imaging diagnosis challenging
○ Nerve normally high signal intensity (in carpal tunnel) on
FSE T2WI
○ Nerve normally flattened at level of hook of hamate
• Diagnosis usually made on EMG, not MR
(Left) Graphic of the anterior
elbow shows the median nerve
passing anterior to the
brachialis muscle. It extends
between the heads of the
pronator teres and beneath
the biceps aponeurosis ſt.
Entrapment of the nerve in
this region is rare compared to
carpal tunnel syndrome. It
usually presents with
numbness with repeated
pronation/supination of the
forearm. (Right) Coronal
graphic of carpal tunnel shows
the median nerve at the
ventral margin of the carpal
tunnel, superficial to the
flexor tendons.
(Left) Axial T2 FS MR
performed at the wrist
demonstrates a ganglion cyst
ſt in the carpal tunnel,
exerting mass effect on the
median nerve . (Right) Axial
T1WI MR reveals a lipoma
within the carpal tunnel. The
flexor tendons are
displaced ulnarly, and the
median nerve st is
compressed.
431
Common Peroneal Neuropathy
KEY FACTS
TERMINOLOGY
• Synonyms: Common peroneal nerve (CPN) palsy, CPN
entrapment
• Common peroneal nerve entrapment at fibular head
IMAGING
• CPN swelling, abnormal T2 hyperintensity
○ Fascicular architecture preserved in milder cases
(neuropraxic injury)
Peripheral Nerve and Plexus
○ Loss of internal fascicular architecture in more severe
cases (axonotmetic, neurotmetic)
• EMG: Anterior compartment (tibial anterior, peroneus
longus muscles) muscle denervation
• Nerve conduction velocity: Conduction block at fibular head
TOP DIFFERENTIAL DIAGNOSES
• Ganglion cyst
• Viral neuritis
• Nerve sheath tumor
(Left) Coronal graphic depicts
the normal course of the
common peroneal nerve (CPN)
originating from the sciatic
nerve, around the fibular
head, into the leg. Note the
vulnerable position of the CPN
as it courses around the
fibular head ſt. (Right) Axial
T1WI MR demonstrates
atrophy and fatty infiltration
of the right anterolateral
compartment muscles
innervated by the CPN. Mild
fascicular enlargement within
the right CPN ſt is not as
conspicuous on T1WI as it is on
T2WI FS MR or STIR MR.
• Direct acute CPN trauma
PATHOLOGY
• Usual etiology is entrapment or sequelae of continued
pressure on CPN at fibular head level
• Edematous/indurated CPN ± thickened "fibular tunnel" at
surgery
CLINICAL ISSUES
• Foot drop, sensory abnormality along anterolateral leg
• Prognosis variable; frequently good recovery following
conservative management
• Surgical decompression reserved for recalcitrant cases
DIAGNOSTIC CHECKLIST
• Focal CPN enlargement, abnormal T2 hyperintensity at
fibular head suggests CPN neuropathy
• MR more sensitive for detecting acute than chronic nerve
injuries
432
(Left) Axial T2WI FS MR
reveals abnormal T2
hyperintensity in some of the
anterolateral compartment
muscles , confirming
ongoing denervation
superimposed on chronic
denervation. The right CPN ſt
is mildly enlarged, with
swollen, hyperintense
fascicles. (Right) Axial STIR MR
confirms abnormal T2
hyperintensity in some
anterolateral compartment
muscles . The CPN ſt
shows mild enlargement and
abnormal T2 signal intensity
with preservation of intrinsic
fascicular architecture.
Tibial Neuropathy
KEY FACTS
Peripheral Nerve and Plexus
TERMINOLOGY
• Tarsal tunnel syndrome
IMAGING
• Denervation of affected plantar intrinsic muscles
○ Uniform high signal intensity on fluid-sensitive
sequences
• Mass in tarsal tunnel
○ Ganglion cyst: Follows fluid signal intensity,
homogeneous, ± thin rim of enhancement with
gadolinium
○ Nerve sheath tumor: Round or ovoid shape, often shows
tail where it arises from nerve, diffuse enhancement
○ Venous varicosities: Serpentine, enlarged vessels in tarsal
tunnel, can be followed beyond tunnel
• Scar: Amorphous material around tibial nerve
• Osseous impingement: Fracture malunion, subtalar
coalition
TOP DIFFERENTIAL DIAGNOSES
• Radiculopathy
• Diabetic neuropathy
• Calcaneal stress fracture
• Isolated fatty atrophy of plantar muscles
PATHOLOGY
• Up to 50% of cases are idiopathic
CLINICAL ISSUES
• Burning, tingling pain, numbness at plantar aspect of foot
DIAGNOSTIC CHECKLIST
• Fatty atrophy of plantar intrinsic muscles can be incidental
finding, increasing with age
• Intramuscular edema is most reliable sign of muscle
denervation
(Left) Graphic shows that the
inferior flexor retinaculum st
forms a superficial border of
the tarsal tunnel and the floor
is composed of the talus &
calcaneus. The tibial nerve is
vulnerable to compression
from behind the medial
malleolus to the midfoot. The
lateral calcaneal nerve ſt
arises in the proximal tarsal
tunnel. The tibial nerve divides
into the medial and lateral
plantar nerves. (Right)
Sagittal T1WI MR shows a
mass st in the tarsal tunnel.
The mass has a small tail ſt,
characteristic of nerve sheath
tumors.
(Left) Sagittal STIR MR in the
same patient shows that the
mass ſt is heterogeneously
high in signal intensity. The
degree of heterogeneity is
greater than expected for a
synovial cyst. There is
denervation edema in the
abductor hallucis muscle .
(Right) Sagittal T1WI MR
shows a lobular ganglion cyst
in the tarsal tunnel
adjacent to the posterior tibial
vein st. (This patient
presented with tibial
neuropathy.)
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SECTION 14
Image-Guided Procedures
Cervical Spine
Medial Branch Block, Cervical Spine 436
Facet Joint Injection, Cervical Spine
Selective Nerve Root Block, Cervical Spine
Epidural Steroid Injection, Cervical Spine
Medial Branch Block, Thoracic Spine 444
Facet Joint Injection, Thoracic Spine
Epidural Steroid Injection, Thoracic Spine
Thoracic Spine
438
440
442
446
450
Lumbar Spine
Medial Branch Block, Lumbar Spine 452
Facet Joint Injection, Lumbar Spine
Selective Nerve Root Block, Lumbar Spine
Epidural Steroid Injection, Lumbar Spine
454
456
458
Vertebral Body
Vertebroplasty 460
Kyphoplasty
Sacroplasty
Vertebral Biopsy
462
464
466
Intervertebral Disc
Percutaneous Discectomy 468
Intradiscal Electrothermal Therapy
Nucleoplasty
Disc Aspiration/Biopsy
470
471
472
Pelvis
Pelvis Anatomy 474
Sacroiliac Joint Injection
Sacral Nerve Root Block
Piriformis Steroid Injection
476
478
480
Medial Branch Block, Cervical Spine
KEY FACTS
TERMINOLOGY
• Selective anesthesia of cervical nerve medial branch in
diagnosis of cervical facet joint pain
PREPROCEDURE
• Facet joint pain
○ Useful in selecting patients for medial branch
radiofrequency ablation procedure
Image-Guided Procedures
○ Need to block level above and below facet joint for
effective anesthesia
PROCEDURE
• Preferred patient position: Supine
• Preferred imaging plane: True lateral view
• C2/3: 3rd occipital nerve block
○ Target: Immediately above and below C2/3 facet joint
• C3/4-C6/7 MBB
○ Target: Midportion of articular pillar above and below
facet joint
(Left) Parasagittal graphic
shows the radiographic target
for a C3-C7 medial branch
block at the midportion of the
articular pillar above and
below the facet joint. A direct
lateral approach or
posterolateral approach can
be utilized. (Right) Oblique
fluoroscopic image shows the
needle tip against the cortex
at the midpoint of the
articular pillar ſt for C6 and
C7 medial branch block (MBB)
vs. at the junction of the T1
superior articular process and
transverse process for C8
MBB.
• C8 MBB
○ Target: Junction of superior articular process and T1
transverse process
POST PROCEDURE
• Document pain before, during, and after injection
○ < 100% pain relief decreases likelihood of successful
rhizotomy
• If corticosteroid injected, maximal benefit will be in 48-72
hours
OUTCOMES
• Possible problem: Failure of pain relief
• Complications
○ Stroke
○ Dural puncture: Spinal cord injury, CSF leak
○ Ataxia (upper cervical injections, particularly C2/3)
○ Phrenic nerve blockade (C3/4, C4/5, C5/6)
Radiographic Target Needle Position
436
Needle Placement: PA View Shoulder Summation Artifact
(Left) PA fluoroscopic spot
radiograph shows the needle
tip against the lateral surface
of the right C5 articular pillar
ſt. Oblique fluoroscopy is
helpful to ensure that the tip
lies against the lateral cortex.
(Right) Lateral fluoroscopic
image shows the needle tip ſt
against the mid/lower 1/3 of
the C5 articular pillar. Note
the shadow caused by
shoulder summation, partially
obscuring radiographic
visualization of landmarks
(e.g., C5/6 facet joint ).
Maneuvers to lower shoulders
are often required for blocks
caudal to C5.
Medial Branch Block, Cervical Spine
TERMINOLOGY
Abbreviations
• Medial branch block (MBB)
Definitions
• Selective anesthesia of cervical nerve medial branch(es) in
diagnosis of cervical facet joint pain
PREPROCEDURE
Indications
• Chronic cervical pain
○ Referable to facet joints
○ Not referable to cervical nerve root dermatome
○ Useful in selecting patients for medial branch
radiofrequency ablation procedure
Contraindications
• Severe allergy to injectate component(s)
• Coagulopathy
○ Patients undergoing anticoagulation or antiplatelet
therapy
Getting Started
• Things to check
○ Correct level(s)
– Effective block requires injection of levels above and
below facet joint
□ E.g., C3/4 facet joint requires block of both C3 and
C4 medial branches
○ Laboratory data
– Assess coagulation parameters as indicated
• Medications
○ ± corticosteroid
– Used for therapeutic block
○ Long-acting anesthetic
– Combined with corticosteroid for therapeutic block
○ Short-acting anesthetic
– Local anesthesia
○ Myelography-safe contrast
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Supine
– True lateral fluoroscopic view
– For lower cervical levels, shoulders may obscure view
○ Some prefer lateral decubitus view
– Side to be injected is up
Procedure Steps
• Perform preprocedure "time-out"
○ Verify correct patient
○ Correct side to be injected
○ Correct procedure
○ All necessary equipment is available
• Conscious sedation as indicated
• Carefully determine correct level(s) and mark skin
○ C2/3: 3rd occipital nerve block
Image-Guided Procedures
– Radiographic target immediately above and below
C2/3 facet joint
□ 1 needle tip will contact C2 inferior articular process
cortex just above facet joint
□ Another needle tip will contact C3 superior articular
process immediately posterior to midportion of
facet joint on true lateral view
○ C3/4-C6/7 MBB
– Radiographic target is midportion of articular pillar
above and below facet joint
○ C8 MBB
– Radiographic target is junction of superior articular
process and transverse process of T1
• Provide local anesthetic
• Advance spinal needle under intermittent fluoroscopy
• Remove stylette and observe needle hub for blood
• Attach contrast tubing/syringe and gently aspirate to
confirm extravascular placement
• Inject small amount of contrast during fluoroscopy
• Attach injectate syringe and inject slowly
Findings and Reporting
• Level(s) injected
• Pain scale before, during, and after injection(s)
POST PROCEDURE
Expected Outcome
• Significant reduction in pain corresponding to facet joint(s)
injected
○ May be short duration of pain relief with anesthetic only
○ If corticosteroid injected, maximal benefit will be in 48-
72 hours
• Verification of pain-generating level suggested by clinical
examination
• < 100% pain relief decreases likelihood of successful
rhizotomy
Things to Avoid
• Intravascular injection
• Suboptimal needle positioning (false-negative/falsepositive block)
OUTCOMES
Problems
• Failure of pain relief
○ Technical failure
– Incorrect level injected
– Injection not correctly localized to medial branch
○ Clinical failure
– Facet joint not source of pain
• Vasovagal reaction
Complications
• Most feared complication(s)
○ Stroke
– Vertebral artery injection
– Air embolism if introduced during contrast injection
○ Dural puncture
– Spinal cord injury
– Cerebrospinal fluid leak
437
Facet Joint Injection, Cervical Spine
KEY FACTS
TERMINOLOGY
• Anesthetic ± corticosteroid injection into cervical facet joint
○ Diagnostic study for pain referable to cervical facet joint
PREPROCEDURE
• Indications
○ Chronic or acute on chronic cervical facet osteoarthritis
○ Posttraumatic osteoarthritis
Image-Guided Procedures
• Preprocedure imaging
○ Correlate imaging abnormality with patient symptoms
○ Assess degree of bone overgrowth and best place to
access joint
PROCEDURE
• Supine, decubitus, or prone depending on level to be
injected/anatomic relationships
• Craniocervical junction
○ Occiput/C1: Lateral approach with patient supine or
decubitus
(Left) Sagittal graphic shows
the oblique orientation of the
subaxial cervical facet joints
ſt. Note the relationship of
the vascular structures to
the exiting nerve roots
within the cervical neural
foramina. (Right)
Anteroposterior fluoroscopic
spot radiograph obtained
after needle placement
within the left C1/2 facet joint
with confirmatory contrast
injection shows a linear,
smooth contrast collection ſt
characteristic of an
intraarticular injection.
○ C1/C2: Posterior approach with patient prone
○ CT imaging is preferred by some interventionalists in
upper cervical region
• Subaxial cervical spine (C3-C7): Generally lateral approach
with patient supine or decubitus
POST PROCEDURE
• Reproduction of pain with injection
○ Concordant or discordant pain
○ Pain intensity before, during, and after injection
Normal Anatomy Intraarticular Injection: AP View
438
Intraarticular Injection: AP View Needle Placement: C3/4 Facet Injection
(Left) AP view during right
C6/7 facet injection shows the
needle hub st superimposed
on the needle shaft in a "down
the barrel" view of the needle.
Note the contrast
spreading away from the
needle tip and along the
anomalous course of the facet
joint ſt. (Right) Lateral
fluoroscopic radiograph in a
postoperative patient shows
the needle tip within the facet
joint st entering from a
lateral approach. Note
contrast spreading throughout
the joint space in a linear
fashion with some pooling in
the inferior recess ſt.
Facet Joint Injection, Cervical Spine
TERMINOLOGY
Definitions
• Anesthetic ± corticosteroid injection into cervical facet joint
PREPROCEDURE
Indications
• Chronic cervical facet osteoarthritis
Contraindications
• Local or systemic infection
• Allergy to injectate
Getting Started
• Things to check
○ Coagulation parameters
– In anticoagulated patients
□ Prothrombin time, activated partial thromboplastin
time, international normalized ratio, platelet count
□ Complete blood count (CBC) (platelets,
hemoglobin, hematocrit)
○ Informed consent
Image-Guided Procedures
○ "Walk" needle gently to joint space
• Feel "pop" into joint space
• Remove stylette
○ Observe hub of needle to ensure no return of blood
• Attach preloaded, air-free contrast syringe and extension
tubing
○ Aspirate gently to confirm extravascular needle tip
position
• Inject only enough contrast to confirm intraarticular needle
tip position
• Remove contrast tubing, and attach injectate syringe
○ Quickly remix injectate prior to injection
• Inject slowly, as patient will likely experience significant
reproduction of pain
○ Note patient pain before, during, and immediately
following injection
Alternative Procedures/Therapies
• Radiologic
○ Median branch block
○ Epidural steroid injection
○ Selective nerve root block
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Supine or prone depending on level to be
injected/anatomic relationships
– Craniocervical junction
□ Occiput/C1: Lateral approach
□ C1/2: Most amenable to posterior approach with
patient prone
– Subaxial cervical spine (C3-C7): Lateral approach
□ Patient may be positioned supine or decubitus with
affected side up
– In mid to lower cervical spine, shoulders are often
problematic
– In severely degenerated subaxial cervical facet joints
□ Prone or lateral positioning with targeting of
inferior joint recess
□ May require CT guidance to achieve intraarticular
needle positioning
□ Rotational flat-panel imaging/angiographic CT can
also be performed (if equipment available)
Procedure Steps
• Procedural "time out"
○ Correct patient, level, and side(s) for injection
• Some advocate use of conscious sedation
○ Patient reaction to procedure must be reliably
determined throughout procedure
○ Nonsedated patients can provide more reliable
assessment of pain before, during, and after injection
• Perform sterile prep, drape, local anesthetic
• Slowly advance needle under intermittent fluoroscopy to
facet joint
○ Must avoid puncture of spinal canal
• If bone is encountered prior to entering joint space, stop
and assess tip placement
○ Often lower 1/3 of joint space is easier to access
POST PROCEDURE
Expected Outcome
• Reproduction of pain with injection
• Improvement in pain following injection
OUTCOMES
Problems
• Failure to improve/alleviate clinical symptoms
○ Technical failure
– Incorrect level injected
□ Multiple level injection may be necessary
– Extraarticular injection
○ Clinical failure
– Incorrect level determined by clinical exam
– Facet joint not source of patient pain
• Vasovagal reaction
Complications
• Most feared complication(s)
○ Vascular injury/stroke
○ Spinal cord injury
– Direct puncture
– Compression from hematoma
○ Meningitis
SELECTED REFERENCES
1. Manchikanti L et al: Comprehensive review of neurophysiologic basis and
diagnostic interventions in managing chronic spinal pain. Pain Physician.
12(4):E71-120, 2009
2. Boswell MV et al: A systematic review of therapeutic facet joint
interventions in chronic spinal pain. Pain Physician. 10(1):229-53, 2007
3. Boswell MV et al: Accuracy of precision diagnostic blocks in the diagnosis of
chronic spinal pain of facet or zygapophysial joint origin. Pain Physician.
6(4):449-56, 2003
439