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The goal of endovascular treat- ment remains devascularization prior to a planned surgery or biopsy (Fig- ure 16 cheap 50 mg seroquel with mastercard. Embolization significantly reduces the blood loss and improves the surgical resection. An embolization can on rare occasion lead to tumor necrosis, with subsequent swelling and spinal cord compression. An endovascular or direct percutaneous embolization of a vertebral body metastasis or malignant tumor can be achieved. The latter can be performed under CT or fluoroscopic guidance,39 with the use of NBCA, PMMA, or dehydrated ethanol. Spinal images of an 11-year-old boy who presented with intractable neck pain associ- ated with an aneurysmal bone cyst after a football match. Note the involvement of the vertebral and neuronal foramina and extension into the lateral recess. C D 313 F G H I 314 Recommended Technique for Spinal Angiography and Intervention 315 Recommended Technique for Spinal Angiography and Intervention This brief overview of techniques and intervention is not intended to re- place standard textbooks in this field. Generally speaking, contrary to popular opinion, with modern catheter techniques in the hands of trained physicians, spinal diagnostic workup should have no complica- tions higher than that of a diagnostic angiography of the peripheral vas- cular system. Infrequently, minor asymptomatic iliac or aortic dissec- tions may be encountered in patients with significant arteriosclerosis. It is often pertinent to locate the artery of Adamkiewicz or radicularis magna as the major supply to the anterior spinal cord. However, if a vascular le- sion, especially a dural arteriovenous malformation (fistula), is sus- pected, a more thorough angiogram may be required. This would in- clude an angiogram of the aortic arch, the descending aorta, the abdominal aorta, and the pelvic system, and in the case of a cervical spinal cord malformation, the vertebral arteries, the thyrocervical trunk, and the deep and ascending cervical arteries. More recent mag- netic resonance angiographic (MRA) studies have shown improved sensitivity in depicting dural AVFs and defining the level of the blood supply. An aortogram can be accomplished best by using a 5-Fr pigtail- configured catheter and a standard amount of contrast material (30–40 mL), which is injected over 2 seconds by means of a high-pressure pump. This helps occasionally in finding the level of the feeding arteries of the expected vascular lesion and may serve as a map for the selective spinal angiography, especially in patients with several missing intercostal or lumbar arteries.
We do not inject local anesthetic into the cervical or upper thoracic epidural spaces because it could result in the complication of high cervical anesthesia and potential respiratory suppression order seroquel 100 mg mastercard. Cervical epidural injections are safest at the C7-T1 level, where the dorsal epidural space is most capacious. The injected materials typically will migrate cephalad into the cervical epidural compartment, as demon- strated by the distribution of contrast media. Selective Nerve Blocks Selective lumbar nerve root injections are performed by using the tech- nique described for transforaminal epidural injections. The undersur- face of the pedicle is profiled from a posterior oblique angle (Figure 9. For a selective nerve root block, however, the goal is to avoid re- fluxing the therapeutic injectate into the epidural space. Rather, mini- mal epidural reflux is achieved by directing the needle slightly lateral to the 6 o’clock position relative to the pedicle. In this fashion, a lim- ited amount of the mixture of contrast and therapeutic agents is in- jected to achieve primarily nerve sheath infiltration with minimal epidural reflux (Figure 9. After contact with the lamina for depth control, the needle is guided over the su- perior margin of the lamina into the dor- sal epidural space. The films are obtained in the AP and oblique projections to doc- ument distribution of contrast media prior to the installation of local anesthetic and water-soluble steroid suspension. Usually, less than 2 mL of the therapeutic mixture is injected to avoid significant epidural reflux. If there is significant epidural reflux, selectivity is lost, and a positive re- sponse cannot reliably be attributed to blockade of the intended nerve. Therefore, if contrast injection reveals significant epidural reflux, the nee- dle should be repositioned more laterally and additional contrast injected prior to filming and the injection of therapeutic substances. An S1 nerve block is performed by using the technique described for a transforaminal S1 injection (Figure 9. A limited amount of the mix- ture of contrast and therapeutic agents is injected, however, to avoid significant epidural reflux.