Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities

Abstract

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.

Keywords: interventional radiology; interventional ultrasonography; intervertebral disc degeneration; low back pain; lumbar osteoarthritis; magnetic resonance imaging; multidetector computed tomography; pain management; pulsed radiofrequency treatment.

Figure 1

Proposed flowchart for management of patients with degenerative lumbar pain. Main Clinical findings (yellow).

Figure 2

(A,B) Lateral and frontal view on fluoroscopic images of a lumbar intersomatic disc puncture with a 22G needle.

Figure 3

A 25-year-old patient with L5 discogenic pain treated with ozone therapy; notice the tip of the needle is located in the lumbar disc (black arrow).

Figure 4

Ultrasound-guided (Panel A) and CT-guided (Panel B) lumbar paraganglionic drug injection. Blue arrow = needle visualized on ultrasound. Dotted blue arrow = ganglion root. s = spinous process, a = posterior articular complex.

Figure 5

(A,B) Frontal and lateral view on fluoroscopic images of lumbar transforaminal injections with 22G needles.

Figure 6

A 67-year-old male with severe lumbar facet joint arthritis underwent CT-guided L5-S1 right posterior joint corticosteroid injection.

Figure 7

Oblique “Scotty dog” approach for intra-articular injection: notice the end-on view of the needle in the middle of the facet joint (blue arrow).

Figure 8

L4-L5 intradiscal oxygen–ozone chemonucleolysis. (A) Intradiscal puncture on lateral view; (B) intradiscal; and (C) intraforaminal oxygen–ozone mixture injection.

Figure 9

Lateral fluoroscopic views obtained after intraforaminal oxygen–ozone mixture injection: notice the propagation of the oxygen–ozone along the epidural space (“white” opacity).

Figure 10

(A) AP fluoroscopic view of four bilateral facet joint puncture; and (B–D) oxygen–ozone mixture intra-articular injection: notice the propagation of oxygen–ozone along the psoas muscle fibers due to pulling the needle back under high pressure.

Figure 11

Ultrasound-guided pulsed radiofrequency treatment of L5 dorsal roots ganglion in a 75-year-old female patient with persistent low back pain and chronic sciatica.

Figure 12

A 55-year-old patient with lumbosacral discogenic pain treated with bilateral pulsed radiofrequency; the needles are located at around 5 mm close to the L5 ganglion bilaterally (blue arrows).