쉽게하는 요추 신경차단술 - 척추전문의 남기세

쉽게하는 요추 신경차단술

남기세병원

원장 남기세

내가 꼭 할 필요가 있나 ? 진짜로 효과가 있나 ? 어떻게 해야 쉽게 하나 ?

요추 신경차단술

요통은 약 50% 가 1 주내에 회복되고 , 95% 가 3 개월 내에 회복되며

좌골 신경통 ( 추간판 탈출증 , 디스크 ) 은 약 50% 가 1 개월 내에 회복되고 , 75% 정도가 3 개월 내에 회복된다 . (Bush K : Spine, 1992)

요통의 자연 경과

일반적으로 보존적 치료와 수술적 치료의 중간적 치료형태로 간주

보존적 치료에 실패한 환자들에게 수술의 위험과 합병증을 피할 수 있는 장점 등으로 인하여 수술에 선행하는 치료


약 , 물리치료 < 비수술적 치료 ? 비수술치료 = 경막외 주사치료 ? 빠른 효과 ? 현재 경막외 차단술 (epidural block) 은

흔히 시행되고 있는 매우 중요한 치료방법

허리가 아플때 마취통증과에서 ?

심사평가원 기준

요양급여비용 ( 점수 ) 진찰료 208.86 물리치료

표층열치료 10.32경피적 전기신경자극치료 41.79

주사치료Caudal, Epidural block 444.38Transforaminal epidural block 1,492.52

장점 1

저렴한 ? 가격 5 - 10 만원 비침습적 , 쉽게 할수 있다 빠른 효과로 환자와 Rapport 형성 혹시 효과가 없어도 괜찮다

“밑져야 본전”

장점 2

생역학적 요인 (biome-chanical factor) 생화학적 요인 (biochemical factor) 복합적으로 작용하여 유발

척추에서 기인하는 통증 및 방사통

통증 전도 경로 차단 환자의 통증에 대한 인지도를 감소

신경근 주변의 phospholipase A2 를 억제염증반응 등을 감소 , 통각 축색을 억제

혈류를 증가대사를 촉진 , 염증유발물질 세척

국소마취제통증전달 억제작용 , 항염작용

통증이 장기간 감소되는 기전

Disc herniation : GoodCaudal, interlaminar, and transforaminal

Spinal stenosis : FairCaudal, interlaminar, and transforaminal

Axial or discogenic pain : FairCaudal, and Interlaminar

Post surgery syndrome : Fair caudal epidural injections

Level A: Good scientific evidence Level B: At least fair scientific evidence Level C: At least fair scientific evidence bal-

ance between benefits and risks are too close

Level D: At least fair scientific evidence risks of the clinical service outweighs poten-tial benefits.

Level I: Scientific evidence is lacking

Categories of recommendationsThe U.S. Preventive Services Task Force uses

TFEB provides short term (2-4 weeks) relief in proportion of patients.Level of recommendation :A

Interlaminar injectionLevel of recommendation :C

Long term effect more than 1 yearnot clear

Lumbar Epidural Steroid Injec-tion for HIVD with Radiculopathy

Lumbar EPI or caudal injectionshort term(2-6 weeks) Sx. Relief .For neurogenic claudication or radiculopathyNo clear effect for long term reliefLevel of evidence : B

Multiple injection ?Modification of natural course of spinal stenosis with medical and interventional management ?Level of evidence : C

Lumbar Epidural Steroid Injec-tion for Spinal Stenosis

Patient unwilling True allergy to the local anesthetic, corticos-

teroid, or contrast agent Infection at the site of injection Coagulopathy (INR>1.5 or platelets

<100,000/mm3) Pregnancy (d/t teratogenic effect of radia-

tion)

Contraindications

Bleeding from epidural vein → epidural hematoma

Infection Dural perforation → headache Intradural injection → spinal anesthesia, aller-

gic reaction Temporary adrenal suppression for 2-3 weeks

(Jacobs, Anesthesia, 1983) Neurologic compromise

angiospasm or embolism of ant. spinal artery

Complications

Interlaminar Caudal Transforaminal

Lumbar Injection Therapy

For Local anesthesia 5cc syringe + 25G, 1.5 inch needle , 1% lidocaine 3cc

For epidural confirmation3cc syringe needle 없이 아이오브릭스 3cc,

For epidural injection10cc syringe1% lidocaine or 0.25% bupivacaine 4cc, Dexamethasone 1cc, normal saline 4cc, 하이렉스 0.5cc

Epidural needle 22G, 4 inch, orSpinal needle 22G, 4inch

준비물

Interlaminar Epidural Injection

Prone w/ lumbar straigthening C-arm or fluoroscopy Identification of interlaminar space Loss of resistance: negative pressure Contrast administration ( 아이오브릭스 )

Interlaminar Epidural In-jection

Caudal Epidural Injection

Prone w/ internal rotation of both L/E C-arm or fluoroscopy Identification of sacral cornua and hiatus Midgluteal creft Epidural needle w/ 45 deg angle Advancement(0.5-1cm) of needle until loss

of resistance: negative pressure

Caudal Epidural Injection

Transforaminal Epidural Injec-tion

Prone C-arm or fluoroscopy w/ or w/o lateral

oblique (15-20 degree) Identification of target point

below the pedicle at 6’clock position 22G, 4-inch spinal needle



↑ Head

Lateral

Transv. process

Pedicle

Lateral margin of isthmus

1st post sacral foramen


Cohen, Regional Anesthesia and Pain Medicine. 2013.

Anterior Epidural vs Posterior Epidural Injection

spinal epidural lipomatosis, cauda equina syndrome, paraplegia, calcification, spinal cord infarction,

methylprednisolone, betamethasone

Triamcinolone-related serious adverse events

Awareness that the larger a particle occluding a blood vessel

Dexamethasonemaller than red blood cells, no aggregation.

Triamcinolonevaried greatly in size, extensive aggregations.

Betamethasonevaried greatly in size, extensive aggregations

Methylprednisolonesmaller than red blood cells, did not form very many aggregations.

Steroid particle

Caudal epidural injectionwith local anesthetic with or without steroidseffective in 120 patients with disk herniation or radiculitis

First and second procedures was signifi-cantly higher in the steroid group at 1-year follow-up.

With or without steroids

Interlaminar EI : 5-10cc 주사Bupivacaine 4 mL, dexamethasone 1 mL, N/S 4cc

Caudal EI : up to 20 mLBupivacaine 8mL, dexamethasone 2 mL, N/S 8cc

TFEB : 3-4 or 5-10mLBupivacaine 4 mL, dexamethasone 1 mL, N/S 4cc

스테로이드 사용방법

Nonparticulated steroidDexamethasone 5mg 1ccBupivacaine or 1% lidocaine 4 cc Normal saline 4cc,

Under C-arm control Transforaminal epidural block 6 개월내에 3 회까지 , 2 주간격

Conclusion

감사합니다

쉽게하는 요추 신경차단술 - 척추전문의 남기세

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