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Perivenous flow during cervical adhesiolysis

David Bryce on October 16, 2017 at 4:26 pm
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    • David BryceDavid Bryce
      Participant
      Joined: May 7, 2016
      Posts: 1
      #41766

      CASE STUDY FOR PAINCAST

      52-year-old laborer presented with a history of neck and arm pain since 2015. It was not associated with trauma. The pain radiates down the arms and is associated with numbness in the hands. It is relieved by rest and NSAIDs. He has had physical therapy and chiropractic with minimal benefit patient, steroid injections in the shoulders with only minimal benefit as well. Physical exam showed no focal findings. EMG in the past was negative. MRI scan of the cervical spine on 3/21/2017 demonstrated disc and osteophyte changes throughout the spine worse at C5-6 and C6-7. At C5-6 there was severe left and moderate left neural foraminal stenosis. At C6-7 there was severe left and moderate left cervical stenosis.
      Patient is also complaining of increasing shoulder pain as well. Two intralaminar cervical epidural steroid injections with catheters placed at C5-6 did not produce prolonged relief. Patient was brought back for lysis of adhesions with catheter placed on the symptomatic left side at C5-6.

      During the adhesiolysis procedure, the catheter was placed on the symptomatic left side. There was initial flow from C4 covering C7. Rotation and flexion of the head was performed during the initial injection. The second time it was injected there was. Perivenous flow to the other side indicating high pressure. Patient did complain of neck pain and headache during the injection. Vigorous flexion and rotation of the head was carried out with flow demonstrated contrast outside of the neural foramina as well as flow restored to the symptomatic left side.

      Patient initially had pain after the procedure was then it subsided.

      Picture number 3-1 is the injection on the first day. Dr. Ratz noted that the tip of the catheter was in the midline epidural space. I did not appreciate that the catheter was in the middle of the epidural space at the time of the initial injection. This position of the catheter may have contributed to PVS. “

      Picture # 1-2 jpeg is the contrast flow after the second injection twelve hours later showing perivascular contralateral flow. The second injection is the injection following vigorous flexion rotation of the Neck rotation of the neck to right with traction on the Left arm, opening the neuroforamena on the left side.

      Picture 2-preview 1-png was the contrast flow following picture 1-2 after flexion and rotation showing flow out of the neuroforamena.

      Questions for Dr. Racz:
      1. How prevalent is contralateral perivenous spread? It is an indication of high pressure in the cervical epidural space. Would it be a frequent occurrence and just not recognized or under reported?

      2. Regarding patients with tight cervical central and neural foraminal stenosis: they can become symptomatic after epidural administration of medications especially in the cervical space. Is it safe to perform these procedures on patients with tight central stenosis or neural foraminal stenosis? It appeared that vigorous flexion and rotation of the neck helped relieve the pressure and allow contrast to flow out of the neural foramina. Thank you Dr. Racz for your comments.

       

       

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      • Gabor B RaczGabor B Racz
        Participant
        Joined: Mar 28, 2016
        Posts: 30
        #41913

        1. Peri-venous spread means that the high pressure fluids do not completely exit through the ipsilateral foramina, but also crosses the canal to exit through the contralateral side. This lateral spread normally allows pressure to return to normal. However, if this lateral spread is not allowed, pressure can increase on both sides of the spinal canal, exceeding the capillary perfusion pressure, causing ischemic pain. This can also cause numbness, weakness, secondary paralysis, and necrosis of neural structures. I have seen this in syrinx formation in three weeks’ time. A major warning sign can be pain from an injection, and you will also see accumulation in the lateral recesses as well as the contrast spreading across the spinal canal in form of peri-venous counter spread (PVCS). Weakness and numbness can occur rapidly. The overall incidence of cord injury is rare, and it is easily prevented by cervical motion and “Neural Flossing.” Flexion with rotation increases the size of neural IVF via the inferior pars sliding over the superior pars. Specific stretching force (Neural Flossing) on the involved nerve enhances nerve root mobility within the IVF. Without adequate runoff, even small injectate volumes can be deleterious. Extra space can be obtained by a fluid foraminotomy. This is easily performed by advancing a catheter into the IVF. Contrast in injected to observe proper placement, followed by hyaluronidase, and the anesthetic/steroid mixture. This will enhance venous drainage and runoff

        2. Reference PainCast neural flossing, and Techniques of Neurolysis 2nd Edition.
        Patients with severe cervical spinal stenosis should never be inject midline. The MRI report should be examined. Spinal fluid needs to be visible around the entire cord. The site of injection must be lateral to the dura, in the lateral recess. A small volume injection is started with ½ to 1cc of contrast followed by 1-2cc hyaluronidase, and the fluid spread needs to be observed. If the fluid spread follows the peri-venous route to the other side, the patient may complain of pain. Again, if there is pain, have the patient perform flexion with rotation (chin to shoulder). This will open the IVF and lower the pressure on the spinal cord.

        Epidural hematomas are relatively common from needle sticks. Therefore avoid the higher venous density areas of the upper C-spine (T1-T3). The transitional area (C7-T1) is where the cervical, ventral venous plexus converts to dorsal, thoracic venous plexus.

        Answer: Cervical neuroplasty is one of the most effective and safe procedures, even in severe cases of spinal stenosis. However, there is a challenging learning curve for the procedure, and the patient follow up is extremely important. Patients must keep in contact with the treating physician and must understand the importance of flexion-rotation as a mechanism of reducing intra-spinal canal pressure as well as Neural Flossing as their physical therapy. Therefore the physician must demonstrate these modalities in the office while explaining the importance of continuing the physical therapy at home (frequency and duration are case dependent).

        Attached are both images of the contrast accumulation and flexion rotation.

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          • David BryceDavid Bryce
            Participant
            Joined: May 7, 2016
            Posts: 1
            #43674

            Here is another picture of PVCS. This patient had pain and parasthesias in both legs for a few days after the procedure that resolved. This was taken before I realized that flexion and rotation was so important. This gentleman had neck and Left UE pain with headaches. He had exacerbation of headaches and bilateral pain which resolved after two weeks following this procedure. No flexion extension was performed and symptoms were increased without a change in neurological status.

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