Radicular Pain Avoidance During Needle Placement in Lumbar Diskography
Vibhu Kapoor1,
William E. Rothfus1,
Stephen Z. Grahovac1 and
Richard E. Latchaw1,2
1 Department of Radiology, Division of Neuroradiology, University of Pittsburgh
Medical Center, 200 Lothrop St., Pittsburgh, PA 15213.
2 Present address: Department of Radiology, University of California–Davis
Medical Center, Ste. 3100, 4860 Y St., Sacramento, CA 95817.
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Fig. 1. —36-year-old man with L4 radiculopathy undergoing L4–L5
diskography. Oblique fluoroscopy image of random needle placement shows X-ray
tube angled 25–35° laterally to medially. This image depicts pedicle
(P), superior articular facet (F), and lateral margin of intervertebral disks.
Needle entry zone is box with vertical sides formed by line joining lateral
margin of disk (x) and line along lateral margins of pedicle (y), and
horizontal sides formed by superior (a) and inferior (b) endplates. Shaded box
is needle entry zone for superior placement; needle (arrowhead)
placement in this patient is inferior.
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Fig. 2. —29-year-old woman with lower back pain. L3–L4 diskogram
obtained in lateral plane shows inferior needle placement
(arrows).
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Fig. 3. —40-year-old woman with L4 and L5 radiculopathy. Lateral
L3–L4 diskogram shows superior needle placement. Outer 20-gauge
(arrowhead) and inner 25-gauge (arrows) needles are
distinctly seen.
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Fig. 4A. —23-year-old man with tingling and paresthesia of right foot
who underwent MRI of lumbar spine. Axial unenhanced T1-weighted image (TR/TE,
500/25) obtained at superior portion of L5–S1 intervertebral disk level
shows that distance between right superior articular facet
(arrowhead) and adjacent exiting nerve (arrow) is
approximately 1.5 mm.
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Fig. 4B. —23-year-old man with tingling and paresthesia of right foot
who underwent MRI of lumbar spine. Unenhanced axial T1-weighted image (500/25)
obtained at inferior portion of L5–S1 intervertebral disk level shows
distance between right superior articular facet (arrowhead) and
adjacent exiting nerve (arrow) to be approximately 7 mm.
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Fig. 4C. —23-year-old man with tingling and paresthesia of right foot
who underwent MRI of lumbar spine. Unenhanced axial T1-weighted image (500/25)
obtained at inferior L5–S1 intervertebral disk level shows benefit of
using curved inner 25-gauge needle as opposed to straight needle. Curved
needle (a) pierces posterolateral aspect of intervertebral disk at 90°
with final position of its tip in posterior third of nucleus pulposus, as
opposed to straight needle (b) that pierces disk tangentially with final
position of its tip in annulus of disk. Alternatively, straight inner needle
that is tangential to disk margin may get deflected (c) and pass lateral
relative to intervertebral disk. Curved arrow marks outer 20-gauge needle, and
straight arrow marks exiting nerve.
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Fig. 5A. —40-year-old man with L5 radiculopathy undergoing lumbar
diskography with needle placement through safe window. Oblique radiograph of
lumbar spine obtained during L4–L5 diskography, shows safe window
(triangle) to be formed by superior articular facet medially,
superior endplate of lower vertebra inferiorly, and imaginary line joining tip
of superior articular facet and superolateral tip of vertebral body.
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Fig. 5B. —40-year-old man with L5 radiculopathy undergoing lumbar
diskography with needle placement through safe window. Oblique radiograph of
lumbar spine obtained during L4–L5 diskography, without shaded triangle,
shows outer 20-gauge straight needle (straight arrow) in safe window.
Arrowhead marks superior articular facet, and curved arrow marks superior
endplate of lower vertebra.
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Fig. 5C. —40-year-old man with L5 radiculopathy undergoing lumbar
diskography with needle placement through safe window. Oblique radiograph of
lumbar spine during L4–L5 diskography shows paths of outer 20-gauge
8.89-cm straight needle (arrow) and inner 25-gauge 15-cm hand-curved
spinal needle (arrowhead) through safe window.
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Fig. 5D. —40-year-old man with L5 radiculopathy undergoing lumbar
diskography with needle placement through safe window. Anteroposterior
radiograph of lumbar spine obtained during L4–L5 diskography shows final
position of tips of outer 20-gauge straight needle (arrow) and inner
25-gauge curved spinal needle (arrowhead).
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Fig. 6. —Three-dimensional modified image of lumbar spine shows site
of needle entry through safe window into posterolateral aspect of
intervertebral disk during diskography.
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Copyright © 2003 by the American Roentgen Ray Society.
