The Handbook of C-Arm Fluoroscopy-Guided Spinal Injections

THE HANDBOOK OF
C-ARM
FLUOROSCOPY-GUIDED
SPINAL INJECTIONS
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HANDBOOK OF
C-ARM
FLUOROSCOPY-GUIDED
SPINAL INJECTIONS
Linda hong wang

Anne Marie McKenzie-Brown
Allen H. Hord
Boca Raton London New York
A CRC title, part of the Taylor & Francis imprint, a member of the
Taylor & Francis Group, the academic division of T&F Informa plc.
Published in 2006 by
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Library of Congress Cataloging-in-Publication Data
Wang, Linda H. (Linda Hong)

Handbook of C-arm fluoroscopy-guided spinal injections / Linda H. Wang, Anne Marie McKenzie-
Brown, Allen Hord.
p. cm.
Includes bibliographical references and index.
ISBN 0-8493-2254-5 (alk. paper)
1. Injections, Spinal--Handbooks, manuals, etc. 2. Diagnosis, Fluoroscopic--Handbooks, manuals, etc.
3. Spine--Puncture--Handbooks, manuals, etc. 4. Chronic pain--Treatment--Handbooks, manuals, etc. I.
McKenzie-Brown, Anne Marie. II. Hord, Allen. III. Title.
RC400.W32 2006
615'.6--dc22 2005051403
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is the Academic Division of T&F Informa plc. http://www.crcpress.com
Dedication
To our spouses, without whose love, support, and patience

this handbook would not have been possible.
To our children, anything is possible if you put your mind
and heart to it.
To our parents, who taught us to believe in ourselves, to aim
past the limits, to never give up, and to make each day count.
Acknowledgments
To Dr. James R. Zaidan, our department chairman, and Dr. Peter Sebel, our vice chairman, for
believing in and supporting us, as well for their dedication to graduate medical education.
To Dr. Jay Johansen for the many hours that he dedicated to helping us with the computer
software that made possible the images used throughout this book. To Drs. Randy Rizor, John
Porter, and Charles McNeill for teaching spinal injections. To Ms. Rochelle Lewis, who was a great
help with proofreading. To Mr. Jeannette Ramos, whose tireless dedication helps to make our
practice run smoothly. To Mrs. Sophia Rosene whose mastery of x-ray skills proved invaluable.
To former and current pain fellows, with particular thanks to Dr. Talal Khan and Dr. Brannon
Frank, for special assistance in the fluoroscopy images and computer editing. Your pursuit of
knowledge was instrumental in our academic growth as well.
To our pain colleagues, Drs. Patricia Baumann and Michael Byas-Smith, for supporting us in
this project.
And perhaps last, but certainly not least, to our patients, who give us their trust and, occasion-
ally, restore our faith in ourselves.
Preface
C-arm fluoroscopy-guided spinal injections have been performed widely for diagnosis and man-
agement of spine and para-spinal-related pain disorders. So often, residents and pain fellows do
not receive formal training in radiography and the related anatomy of the vertebral column. The
purposes of this handbook are to (a) illustrate spinal injections in a step-by step fashion, (b) present
fluoroscopy imaging and related spinal anatomy, and (c) describe manipulation of C-arm fluoroscopy
to get ideal images for spinal injections.
The concept of this book started off as a compilation of notes and lectures that were put
together for the educational benefit of our pain fellows as well as those residents who rotate on
the pain service. The residents spend 2 months on the service and often have a difficult time
orienting themselves to the C-arm and the resulting fluoroscopic images. While there are now quite
a few books on the market that show the final needle position for spinal injections, we felt that
there was a need for a book describing a more basic, step-by-step approach to spinal injections.
As a pain fellow, Dr. Linda Wang started collecting images and teaching tools to help her better
understand the reasoning behind the fluoroscopic images that were used for spinal injections. As
a faculty member, Dr. Wang spent a tremendous amount of time studying the relationships between
the skeletal model, the matching fluoroscopic image, and the desired needle placement in the
cervical, lumbar, and sacral spinal regions. There is often a skeleton hanging prominently in the
procedure room that is used as a reference when we perform fluoroscopically guided injections.
Dr. Wang sought to recreate those images in her chapters that effectively demonstrate the relation-
ships between the angle of the x-ray beam and the spinal column. In the chapters describing the
fluoroscopic imaging of the cervical, lumbar, and sacral spine, Dr. Wang describes in detail how
the trainee would go about obtaining the views needed to approach the spine at each level.
Dr. McKenzie-Brown has long had an interest in the cervical spine and procedures performed
around the cervical spine as well as in lumbar discography. The neck houses critical vascular
structures that affect the way in which injections around the cervical spine are performed. The
chapters that she wrote pertaining to cervical injections show a safe method for performing these
injections under fluoroscopy. As our program became more interventional in the management of
pain, Dr. McKenzie-Brown became more interested in radiation safety, and the basic tenets of
radiation safety are succinctly described in Chapter 3. Finally, the sympathetic chapters are left as
a category unto themselves. Until fairly recently, stellate and lumbar sympathetic injections were
routinely performed without fluoroscopy. Dr. Wang takes us through step-by-step approaches to
each of the sympathetic blocks with insights into how to ascertain the correct needle position at
each level. Dr. Wang was encouraged by Dr. Allen H. Hord to enter the area of pain medicine.
Dr. Hord served as a motivator and educator in the training of Dr. Wang and countless other
physicians in the area of C-arm fluoroscopic techniques. His review of this handbook proved to be
an invaluable asset.
Each of the spinal injections in this handbook is simply written. The preferred patient’s position
as well as C-arm fluoroscopy position, preferred fluoroscopic images, and related anatomic struc-
tures on the spine are described. The steps taken to get to the final placement of the needle tip are
also described. Not only are the correct needle placements illustrated from different views of the
spine, but possible incorrect needle placements are shown as well. We endeavored to provide a
handbook that will become a useful teaching aid for residents and fellows striving to improve their
skills in the performance of spinal injections for pain management.
The Authors
Linda Hong Wang, M.D., Ph.D., graduated from Capital University of

Medical Sciences (Beijing Second Medical College) in Beijing, China.
She then came to the United States and studied basic science in pain
medicine at the University of Illinois in Chicago. After she received her
Ph.D., she continued her training in anesthesia at the Mayo Clinic in
Rochester, Minnesota. She completed her anesthesiology residency at
Emory University School of Medicine, following which she spent 12
additional months there in her pain fellowship. She is currently working
in Emory’s Department of Anesthesiology in Atlanta, Georgia.
Anne Marie McKenzie-Brown, M.D., graduated from Johns Hopkins

School of Medicine and completed her anesthesiology residency at
Emory Healthcare. After spending a year in pain fellowship training at
the Johns Hopkins Department of Anesthesiology, she returned to
Emory Department of Anesthesiology, where she remains on faculty.
She is currently the director of the Division of Pain Medicine and the
director of the Pain Fellowship Program at the Emory Department of
Anesthesiology in Atlanta, Georgia.
Dr. McKenzie-Brown earned her undergraduate degree in chemistry
at the University of Virginia in Charlottesville. She went to Baltimore
and completed her doctorate of medicine at Johns Hopkins School of Medicine. After completing
a year of internship in internal medicine at St. Luke’s/Roosevelt Hospital, she came to Atlanta and
completed an anesthesiology residency at the Emory Department of Anesthesiology. She then
returned to Baltimore and spent 1 year in the Department of Anesthesiology and Critical Care in
fellowship training in pain medicine and as an assistant in the Division of Regional Anesthesia.
Following that, she came back to Atlanta as a staff anesthesiologist in the Emory Department of
Anesthesiology, dividing her time between clinical anesthesiology and pain medicine. She was the
director of the Grady Pain Clinic between 1995 and 2003, the clinical director of the Emory Center
for Pain Medicine in 2002, and the division director of Pain Medicine the following year. In 2004,
she became the program director for the Emory Pain Fellowship.
Dr. McKenzie-Brown is board certified in anesthesiology and earned the Certificate of Addi-
tional Qualifications in Pain Management. She is also board certified by the American Board of
Pain Medicine. Her interests include spinal pain, with special interest in cervical spinal pain and
sacroiliac joint pain.
Allen H. Hord, M.D., is a practicing pain consultant with Pain Con-
sultants of Atlanta. He also holds an adjunct appointment as clinical
associate professor of anesthesiology at Emory University School of
Medicine in Atlanta, Georgia. Dr. Hord earned his B.A. in chemistry
and molecular biology at Vanderbilt University in Nashville, Tennessee,
and his M.D. at the University of Kentucky School of Medicine in
Lexington, Kentucky. After graduating, he completed his internship at
Grady Memorial Hospital in Atlanta, Georgia, and his residency in
anesthesiology at Emory University School of Medicine. His fellowship
in pain was conducted at the University of Cincinnati Pain Control
Center in Cincinnati, Ohio. He is certified by the American Board of
Anesthesiology and was awarded a Certificate of Added Qualifications
in Pain Management. Dr. Hord is also certified by the American Board of Pain Medicine. Dr. Hord
was formerly director of the Center for Pain Medicine, director of the Division of Pain Medicine,
and program director of the Pain Management Fellowship at Emory University School of Medicine.
Dr. Hord’s current research is devoted to the study of neuropathic pain. He has authored and co-
authored more than 62 articles, abstracts, editorials, books, book chapters, book reviews, review
articles, and case reports concerning topics in pain management.
Table of Contents
Chapter 1. An Introduction to Spinal Injections.....................................................1
Chapter 2. Basic Radiographic Background of the Vertebral Column ...................5

C-Arm Fluoroscopy and Images........................................................................................................7
Axial Skeleton..................................................................................................................................13
Anatomy of a Typical Lumbar Vertebra ....................................................................................15
Pelvic Girdle and Sacrum ...........................................................................................................17
Classification of Bones and Typical Fluoroscopic Images of Bones .............................................18
Bibliography.....................................................................................................................................27
Chapter 3. Radiation Safety ................................................................................29

Quantification of Radiation Exposure .............................................................................................31
Steps to Minimize Radiation Exposure ...........................................................................................32
Shielding...........................................................................................................................................39
Bibliography.....................................................................................................................................39
Chapter 4. Basic Steps for Spinal Injections .......................................................41

Bibliography.....................................................................................................................................54
Chapter 5. Fluoroscopic Images of the Lumbar Spine ........................................55

Positioning the Patient .....................................................................................................................57
Anterior/Posterior View of the Lumbar Spine ................................................................................57
Oblique View of the Lumbar Spine.................................................................................................59
Lateral View of the Lumbar Spine ..................................................................................................62
Suggestions on How to Check the Needle Depth...........................................................................67
Bibliography.....................................................................................................................................69
Chapter 6. Lumbar Spinal Injections ...................................................................71

Lumbar Spinal Injections.................................................................................................................73
Lumbar Medial Branch Block .........................................................................................................73
Lumbar Medial Branch Denervation ..........................................................................................87
Lumbar Transforaminal Epidural Steroid Injection ........................................................................88
Special Considerations of Oblique Views ..................................................................................94
Rules for Getting Oblique Views of the Lumbar Spine..................................................................95
Lumbar Transforaminal Epidural Steroid Injection
at the Level of L5/S1 .....................................................................................................................111
Lumbar Discography......................................................................................................................124
Introduction ...............................................................................................................................124
Manometry .....................................................................................................................................127
Patient Preparation ....................................................................................................................127
Sedation .....................................................................................................................................127
Preparation for Needle Placement .......................................................................................128
Patient Position..........................................................................................................................128
C-Arm Position .........................................................................................................................129
Needle Placement......................................................................................................................130
Potential Difficulties with Needle Placement
(Annular Placement of the Needle) ..........................................................................................132
Contrast Injection within the Disc Space .................................................................................136
Mechanically vs. Chemically Sensitive Discs ..........................................................................141
Discography at L5/S1 ....................................................................................................................141
Positioning C-Arm Fluoroscopy ...............................................................................................142
Needle Insertion ........................................................................................................................142
Confirming the Needle Placement ............................................................................................145
Injecting Contrast ......................................................................................................................146
Post-Procedure ...............................................................................................................................147
Bibliography...................................................................................................................................148
Chapter 7. Fluoroscopic Images of the Cervical Spine .....................................151

Positioning the Patient ...................................................................................................................153
Positioning the C-Arm Fluoroscopy..............................................................................................154
A/P (P/A) View and Lateral View of the Cervical Spine .............................................................155
Comparison of Cervical Vertebrae and Lumbar Vertebrae ...........................................................156
Lateral and Oblique Views of the Cervical Spine.........................................................................158
Cervical Intervetrebral Foramina and the Cervical Spinal Nerve Roots ......................................165
Bibliography...................................................................................................................................167
Chapter 8. Cervical Injections ...........................................................................169

Preparation for the Performance of Cervical Injections ...............................................................171
Cervical Facet Injections ...............................................................................................................172
Intra-Articular Facet Injections......................................................................................................174
C1/C2 Joint Injection ................................................................................................................174
C2/C3 to C6/C7 Intra-Articular Joint Injections ......................................................................180
Cervical Medial Branch Injections ...........................................................................................186
Cervical Medial Branch .................................................................................................................191
Radiofrequency Denervation.....................................................................................................191
Radiofrequency Denervation: (C3 to C8) Medial Branches ....................................................192
Cervical Epidural and Selective Nerve Root Injections................................................................196
Cervical Transforaminal Injections...........................................................................................196
C2 Dorsal Root Ganglion Injection..........................................................................................198
C3 to C7 Transforaminal Injections .........................................................................................201
Selective Nerve Root Injection or Epidural Steroid Injection .................................................210
Interlaminar Epidural Steroid Injections ..................................................................................216
Bibliography...................................................................................................................................218
Chapter 9. Fluoroscopic Images of the Sacrum and Pelvis...............................221

Posterior View of the Pelvis and the Sacrum................................................................................223
A/P View of Fluoroscopic Image of the Sacrum ..........................................................................224
Bibliography...................................................................................................................................228
Chapter 10. Pelvic and Sacral Injections...........................................................229
Sacroiliac Joint Injection ...............................................................................................................231
Caudal Epidural Steroid Injection .................................................................................................238
Bibliography...................................................................................................................................246
Chapter 11. Sympathetic Blocks.......................................................................247

Stellate Ganglion Block (Right Side)............................................................................................249
Lumbar Sympathetic Block ...........................................................................................................253
Superior Hypogastric Plexus Block...............................................................................................261
Bibliography...................................................................................................................................267
Index...............................................................................................................................................269
Chapter
An Introduction to
Spinal Injections
1
1
An Introduction to Spinal Injections 3
In 1994, the International Association for the Study of Pain (IASP) defined pain as “an unpleasant
sensory and emotional experience associated with actual or potential damage or described in terms
of such damage.” Spinal pain is still a leading cause of disability in the industrialized world. Spinal
injections are common procedures for both the diagnosis and treatment of pain related to the spine.
This book utilizes a step-by-step approach to illustrate routinely performed fluoroscopically guided
spinal injections and procedures at the cervical, thoracic, and lumbosacral regions. This is done in
an attempt not only to introduce trainees to the basic interventional techniques but also to assist
instructors in their pursuit of demonstrating the techniques of spinal injections in a clear and simple
manner.
All of the commonly performed spinal injections involve placing the needle in or around the
vertebral column. Mastery of the technique of spinal injections involves learning where along the spine
to place the needle. Figure 1.1 and Figure 1.2 demonstrate the wide variety of spinal injections that
are commonly performed in pain practices. Figure 1.1 represents the axial view, while Figure 1.2
shows the oblique view of the spinal column.
Transforaminal epidural
steroid injection
Medial branch
block
Interlaminar
epidural steroid
injection
Discography
Lumbar sympathetic block
FIGURE 1.1
Axial view of needle placements for spinal injections.
4 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections
Transforaminal epidural steroid injection
Intraarticular
facet Medial branch
injection block
Lumbar
sympathetic
block
Discography
Interlaminar
epidural steroid
injection
FIGURE 1.2
Oblique view of needle placements for spinal injections.
We will guide readers in a step-by-step fashion through injections commonly performed around
the cervical spine, including intra-articular cervical facet and medial branch injections, radio-
frequency ablations, and cervical transforaminal and interlaminar epidural steroid injections.
Chronic pain is among the most common forms of low back pain that we entcounter in our
practice. We will help readers to understand the details of commonly performed lumbar spinal
injections, such as lumbar media branch block and transforaminal epidural steroid injection.
The more commonly performed procedures in the sacral region that we will discuss include
sacroiliac and caudal injections.
We will also describe commonly performed sympathetic blocks including stellate ganglion
blocks, lumbar sympathetic blocks, and performance of the superior hypogastric plexus block.
Chapter
Basic Radiographic Background
of the Vertebral Column
2
5
Basic Radiographic Background of the Vertebral Column 7
It is essential to be familiar with fluoroscopic images and related anatomy of the human vertebral
column in order to perform spinal injections. In this chapter we will go over basic fluoroscopic
images of human bones, including human vertebrae.
C-Arm Fluoroscopy and Images

A C-arm fluoroscope consists of an x-ray tube, a C-arm arch, an image intensifier, a control panel
with a footswitch, and a computerized image display system (Figure 2.1). In C-arm fluoroscopy,
a fluoroscopic beam, usually coming from below, penetrates the spine, sending an image to the
intensifier. The image is then displayed on a TV screen for review (Figure 2.2). The C-arm can be
rotated in different directions in order to view an object from different angles (Figure 2.3). The
control panel allows us to adjust how images are generated and displayed by pressing function
keys. The footswitch, also part of the control panel, offers more flexibility. The image system not
only displays fluoroscopic photos but also stores fluoroscopic images for review and comparison.
Intensifier Image display system
Control panel
Footswitch X-ray tube
FIGURE 2.1
Photograph of a C-arm.
A short bone
The fluoroscopic
photo is displayed
The short bone is on the TV screen
placed between the
x-ray tube and
the intensifier
A fluoroscopic image
of the short bone
FIGURE 2.2
FIGURE 2.3
C-arm rotations.
A photograph (Figure 2.4) and a fluoroscopic image (Figure 2.5) are both two-dimensional
pictures. However, each has striking differences. Because our goal is to inject appropriate medica-
tions in or around the target areas of the spine, it is essential to understand the fluoroscopic images
of the spine and the relationship between needle placement and the target area.
FIGURE 2.4
Regular picture of the spine, anterior view.
FIGURE 2.5
Fluoroscopic photo of the lumbar spine.
A fluoroscopic image of a cylinder from the side, for example (Figure 2.6), is a rectangular-
shaped image regardless of the angle of the beam. We cannot view the cylinder from the ends. The
TV screen of C-arm fluoroscopy is only able to display one image at a time. By reviewing a series
of images of this object (Figure 2.7), we are able to mentally construct a three-dimensional picture
of this cylinder.
X-ray tube
A cylindrical object
FIGURE 2.6
Fluoroscopy does not show a 3-D picture.
X-ray tube
X-ray tube
X-ray tube
FIGURE 2.7
Creating 3-D images mentally.
If the fluoroscopic beam goes through a cube (Figure 2.8), the TV screen displays a square.
However, we are unable to identify the properties of this cube.
A cube
A fluoroscopic
image of the cube
FIGURE 2.8
If a cylinder is placed on top of the cube, a fluoroscopic picture is merely a square with a
circle in the middle (Figure 2.9). We are unable to judge the exact relationship between the cylinder
and the cube.
A cube
A fluoroscopic
image of the
cylindrical object and the cube
FIGURE 2.9
A fluoroscopic picture of these objects (Figure 2.10) is complicated. We cannot describe their
exact relationships without adding another picture of these objects from a different view.
A fluoroscopic
image of three objects
FIGURE 2.10
The basic steps of a fluoroscopy-guided spinal injection include the following (see Chapter 4 for
details):
1. Identifying a target point in the area of the spine or the pelvis

2. Obtaining fluoroscopic images
3. Inserting a needle
4. Verifying correct needle placement by using the fluoroscopic images
5. Injecting the appropriate medication into the target area
It is important to review the anatomy of the vertebral column and the anatomy of the pelvic girdle.
Axial Skeleton
There are 206 separate bones that form the adult human skeletal system — the framework of the
entire human body. The adult skeletal system is divided into the axial skeleton and the appendicular
skeleton. The axial skeleton has a total of 80 bones that lie on or near the central axis of the human
body, including the skull, vertebral column, ribs, and sternum. The vertebral column (Figure 2.11)
consists of 26 vertebrae and includes 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae,
1 sacrum, and 1 coccyx.
Axial skeleton (total 80 pieces)
— Skull
— Hyoid
— Auditory ossicles
• Cervical (7)
— Vertebral column
• Thoracic (12)
— Thorax
• Lumbar (5)
• Sacrum (1)
• Coccyx (1)
FIGURE 2.11
There are 126 separate bones in the appendicular skeleton (Figure 2.12).
— Shoulder girdle
— Upper extremities
— Pelvic girdle
— Lower extremities • Hip bone (2)
FIGURE 2.12
Anatomy of a Typical Lumbar Vertebra
A typical vertebra consists of the vertebral body and the vertebral ring (Figure 2.13 through Figure
2.17). Each vertebral body is roughly cylindrical in shape and is connected to the vertebral arch
by the pedicle on each side. The vertebral arch is composed of two pedicles, two laminae that are
fused at the midline and extend a spinous process posteriorly, two superior articular processes, two
inferior articular processes, and two transverse processes. In the vertebral column, the superior
vertebral notch and the inferior vertebral notch form the intervertebral foramina through which
spinal nerves and blood vessels traverse. The inferior articular process and the superior articular
process on each side form a joint called a zygapophyseal joint. The zygapophyseal joint is most
frequently called a facet. These pictures of the lumbar vertebra are essential to the understanding
of the interpretation of fluoroscopic images necessary for appropriate needle placement.
Figure 2.13 to 2.17: (1) Vertebral body; (2) pedicle; (3) lamina; (4) spinous process; (5) superior
vertebral notch; (6) inferior vertebral notch; (7) superior articular process; (8) inferior articular
process; (9) transverse process.
1 1
2 4 2
4 3
7
9 7
1
4
1 2
2
1 2 4
3
9
9 4
FIGURE 2.13
Superior/oblique view of the lumbar vertebrae.
7 5
2 1
6
8
FIGURE 2.14
Lateral view of the lumbar vertebra.
9
3
6 4
FIGURE 2.15
Oblique view of the lumbar vertebra.
3
4
9
8
FIGURE 2.16
Posterior view of the lumbar vertebra.
FIGURE 2.17
Anterior view of the lumbar vertebra.
Pelvic Girdle and Sacrum
Spinal injections involving the areas of the pelvic girdle and the sacrum include sacroiliac joint
injections, caudal epidural steroid injections, sacral transforaminal injections, and so forth. There-
fore, we need to be familiar with some anatomic structures of the pelvic girdle and the sacrum
(Figure 2.18 through Figure 2.20).
FIGURE 2.18
Lateral view of pelvis and sacrum; (5), posterior superior iliac spine.
4
5
5
5
2 3 2 3
FIGURE 2.19
Posterior view of the pelvis. (1) Posterior sacral foramina, (2) sacral cornu, (3) sacral hiatus, (4) superior articular process,
(5) posterior superior iliac spine.
Classification of Bones and Typical Fluoroscopic Images

of Bones
Each of the 206 bones of the human body can be classified according to its shape (Figure 2.20
through Figure 2.24): long bone, short bone, flat bone, or irregular bone. It is not difficult to
understand a typical fluoroscopic image of a long bone, a short bone, or a flat bone (Figure 2.20
through Figure 2.22).
FIGURE 2.20
Long bone: radius and its fluoroscopic photo.
FIGURE 2.21
Short bone: first phalange and its fluoroscopic photo.
A rib shadow
patella
FIGURE 2.22
Flat bones: patella and rib and their fluoroscopic photos.
However, it is difficult to identify anatomic structures on fluoroscopic images of irregular bones

(Figure 2.23).
FIGURE 2.23
Irregular lumbar bone: vertebra and facial bones and their fluoroscopic photos.
It is also easy to visualize a fluoroscopic image of two overlapping bones (Figure 2.24),
although this image cannot show the exact relationship between them. And, we cannot judge the
spatial relationship between these bones.
FIGURE 2.24
Fluoroscopic photo of a rib on top of the patella.
The outer shell of most bones is composed of hard or dense bone tissue known as compact
bone (Figure 2.25). The shaft of a long bone, and possibly of a short bone, is hollow, and it is
called the medullary cavity. In the adult, this cavity usually contains fatty yellow marrow.
Compact Bone
Bone marrow
FIGURE 2.25
Each vertebra is an example of an irregular bone. We will consider the fact that each vertebra
is built up by several blocks (pieces of flat bones and short bones) (Figure 2.26). The lamina, for
example, is a flat block — a flat bone similar to a piece of the rib. Each pedicle, a Latin term
meaning “little foot,” is a small block with a cylindrical shape (a piece of short bone) pointing out
from the vertebral body posteriorly on each side. Let us illustrate how to “build a typical lumbar
vertebra” using building blocks in order to understand the typical fluoroscopic image of a lumbar
vertebra.
Spinous process
Superior articular process
Lamina
Pedicle
Transverse process
Inferior articular process
Vertebral body
FIGURE 2.26
An x-ray beam penetrates a patient in a prone position. A typical anterior–posterior (A/P)

fluoroscopic image of a single lumbar vertebra is shown in Figure 2.27.
Patient in a prone A fluoroscopic photo of anterior-posterior view

position (A/P view) of a single lumbar vertebra
X-Ray tube
FIGURE 2.27
In order to understand how to get an A/P-view fluoroscopic image of a single lumbar vertebra,
we must first take apart a lumbar vertebra (Figure 2.28).
X-ray tube
X-ray
FIGURE 2.28
Figure 2.29 illustrates how to create a two-dimensional A/P fluoroscopic image of the lumbar
vertebral body with two pedicles only. The two-dimensional picture of the lumbar vertebral body
is a rectangle, and the two-dimensional picture of each pedicle is a circle.
2-D image of
vertebral body
shadow
2-D image of pedicle shadow
2-D image of vertebral

body shadow
Pedicles
X-ray tube
X-ray tube
FIGURE 2.29
A two-dimensional image of the vertebra is like a puzzle. A two-dimensional image of each

piece of the vertebra is a single puzzle piece (Figure 2.30).
2-D image of spinous process
2-D image of inferior articular process 2-D image of lamina 2-D image of superior articular
process
2-D image of transverse process
2-D image of vertebral body

2-D image of
pedicles
X-ray
X-ray
FIGURE 2.30
Taking an A/P fluoroscopic image of a single lumbar vertebra is like putting the pieces of the
vertebra back together (Figure 2.31). A two-dimensional image of the pedicles and the vertebral
arch, including the lamina, the spinous process, the superior and inferior processes, and the
transverse processes, brings together a unique puzzle picture (Figure 2.31).
X-ray
FIGURE 2.31
An A/P fluoroscopic image of a single lumbar vertebra or multiple vertebrae is illustrated in

Figure 2.32 and Figure 2.33. The two-dimensional image of pedicles is shown in the fluoroscopic
images but not in regular photos of vertebrae.
6
2
5 3
4 6
5
4
3
6
2 1 1
1 1
6
4
3 4 5
5 3
FIGURE 2.32
(1) Pedicles, (2) superior articular process, (3) spinous process, (4) inferior process, (5) lamina, and (6) transverse process.
2
2
6
6 5
3 5 3 4
4
2 2
6 1 6 1
3 5
5 3
4
FIGURE 2.33
(1) Pedicles, (2) superior articular process, (3) spinous process, (4) inferior process, (5) lamina, and (6) transverse process.
Bibliography
Bontrager, K.L. and Anthony, B.T., Eds., Textbook of Radiographic Positioning and Related Anatomy, 2nd ed.,
C.V. Mosby Company, St. Louis, MO, 1990.
Brown, D.L., Ed., Atlas of Regional Anesthesia, 2nd ed., W.B. Saunders, Philadelphia, 1999.
Clemente, G.D., Ed., Gray’s Anatomy, 13th ed., Lea & Febiger, Philadelphia, 1984.
Fenton, D.S. and Czervionke, L.F., Eds., Image-Guided Spine Intervention, W.B. Saunders, Philadelphia, 2003.
Netter, F.H., Ed., Atlas of Human Anatomy, Ciba Geigy Corporation, 1989.
Waldman, S.D., Ed., Atlas of Interventional Pain Management, 2nd ed., W.B. Saunders, Philadelphia, 2004.
Chapter
Radiation Safety 3
29
Radiation Safety 31
As pain medicine becomes increasingly interventional, the use of fluoroscopy has become more
prevalent in the performance of spinal and other injections for the diagnosis and relief of chronic
pain. Fluoroscopy is even being used, in some instances, in the performance of peripheral injections,
e.g., piriformis muscle injections for chronic pain. A basic understanding of radiation safety is an
important part of the pain practitioner’s knowledge base, as it facilitates optimal care for our patients.
While some of the spinal injection procedures described in this book may also be performed under
computed tomography (CT) guidance, all of the procedures described are performed under fluoro-
scopic guidance; specifically, fluoroscopy using a C-arm. This chapter will briefly review practical
safety concepts to minimize the risk of complications from exposure to ionizing radiation.
Ionizing radiation can come from x-rays or gamma rays; the radiation being referred to in this
chapter is due to x-rays. While gamma rays naturally occur from radioactive atoms, x-rays are
those that we deal with in clinical practice — those that are emitted from machines. The principles
of fluoroscopy for pain procedures include maximizing patient benefit while minimizing risk to
both patient and staff using the ALARA (as low as reasonably achievable) principle.
The routine use of fluoroscopy has dramatically increased with the rise in procedures performed
by interventional radiologists, cardiologists, and pain physicians. Approximately 500,000 or more
procedures for chronic pain are performed annually under fluoroscopic guidance.1 The fluoroscop-
ically guided procedures performed by pain physicians utilize relatively lower amounts of fluoros-
copy time in comparison to the other fluoroscopically guided therapeutic procedures, e.g. coronary
angioplasty, transjugular intrahepatic portosystemic shunts, and so forth. The vast majority of
procedures performed by pain practitioners are generally performed within 1 to 2 min or less of
fluoroscopy time, even at teaching facilities. The exposure of physicians to scatter decreases with
increased experience.2
Quantification of Radiation Exposure

When a human body is exposed to ionizing radiation, there is an interaction with the human atoms
that results in energy transfer (absorption). The absorbed dose is the quantity used to evaluate the
amount of radiation energy that is deposited into an absorbing medium, for example, human tissue.1
This absorbed dose is described in gray (Gy) units (International System) or the older radian (rad)
units (United States). One gray (1 J/kg) is equivalent to 100 rad. Rem (rad equivalent man) is a
unit of exposure, vs. Gy, which is a unit of energy. Rem is monitored using the radiation badges
worn by hospital personnel. One rem is equivalent to 0.01 sievert (Sv). The annual limits of exposure
to health care workers are 5000 mrem to the body; 15,000 mrem to the lens; and 50,000 mrem to
the extremities. This does not include the amount of radiation calculated for natural exposure
associated with everyday living as well as routine dental examinations.
In 1994, the Center for Devices and Radiological Health of the U.S. Food and Drug Admin-
istration (FDA) issued an advisory3 cautioning physicians to be aware of the potential for adverse
effects to patients who have been exposed to prolonged periods of fluoroscopy. As the skin entry
site of the beam is the most susceptible to injury, the advisory stated that skin injury may result
after less than 1 h of fluoroscopy, even at typical dose rates. This is far in excess of the fluoroscopic
time used for even the most challenging pain procedures. The effects described may not be seen
for weeks after radiation exposure. The radiation safety officer of the hospital is a valuable resource
for more information on this subject.
While performing procedures under fluoroscopy, the goal is to minimize the absorbed dose to
the skin and to reduce radiation scatter from the patient to the physician and the staff. Typically,
the skin absorbs radiation at a rate of 2 to 5 rad/min. Radiation injury to the skin occurs at the
following approximate thresholds4:
3 Gy (300 rad): temporary epilation (hair removal by the roots)

6 Gy (600 rad): erythema
15 to 20 Gy (1500 to 2000 rad): desquamation, dermal necrosis, and ulceration
Most fluoroscopically guided spinal injections performed by pain physicians are done using a
C-arm (Figure 3.1). This provides the benefit of rotating the image to oblique views without having
to reposition the patient once the needle is in place. The beam is generated in the x-ray tube, passes
through the patient, where it is detected in the image intensifier, and results in a two-dimensional
image displayed on the monitor screen. The image intensifier converts the x-ray beams to light
energy, producing a clearer image. A lateral view is needed in order to determine the needle depth
in addition to the A/P angle view for accurate needle placement. Note that the A/P view is with
respect to the patient, not to the procedure table. This is particularly relevant when an A/P view is
needed in a patient with scoliosis. This will be discussed in more detail in future chapters.
FIGURE 3.1
Diagram of the C-arm and its components. The arrow pointing from the tube represents the emitting beam of x-rays going
through the patient. Note that the image intensifier (above the patient) is as close to the patient as possible. (1) Image
intensifier, (2) x-ray tube, (3) prone patient.
Steps to Minimize Radiation Exposure

There are steps that pain practitioners can take to minimize radiation exposure to the patient and
to the staff:
1. Use the last image hold to keep the last image seen on the screen and allow the physician to determine
the next needle adjustment based on that image.
2. Use the pulsed mode to greatly decrease exposure to the patient. Pulsed mode allows for the emission
of short pulses of the beam, resulting in fewer frames per second, which substantially reduces the
Radiation Safety 33
emitted dose when compared to nonpulsed fluoroscopy. In some instances, the radiation exposure
may be reduced up to 75%.5 This may take some time to get accustomed to initially, as the image
appears somewhat fractionated and is less clear, but the benefits in exposure reduction are substantial.
3. Keep the image within the patient’s body limits. Whenever possible, do not include areas outside of
the body habitus when imaging the spine.
4. Use collimation to reduce the size of the x-ray field. This often sharpens the image while reducing
scatter. It also helps to keep the main focus of the image in the center of the field; laser markers are
also helpful in accomplishing this goal. It is best to keep collimation as tightly around the field of
interest as possible to avoid scatter. Remember, scatter from the patient is a major source of exposure
to the pain physician. Collimation assists in keeping the image completely within the body habitus
of the patient. Note that there are two types of collimation:
a. Leaf (linear) collimation (Figure 3.2): This is actually not collimation but a filter. This is helpful
in cervical procedures, as it keeps the beam within the patient’s body mass. This is particularly
helpful for patients with slender necks.
b. Iris (circumferential) collimation (Figure 3.2): This cones down the image to the center of the
screen. (See Figure 3.4 for an example of an image taken without collimation.)
FIGURE 3.2
Leaf (linear) collimation.
FIGURE 3.3
Iris (circumferential) collimation.
Radiation Safety 35
FIGURE 3.4
No collimation was used with this image. Note the bright areas where the beam extends outside the patient’s frame.
5. Whenever possible, intermittent fluoroscopy should be used to minimize exposure time, as radiation
dose is directly related to exposure time. Avoid using continuous fluoroscopy, e.g., in obtaining an
oblique view of the spine. There is a direct relationship between the amount of radiation exposure
(time) and the dose received by the patient and the scatter exposure to the physician.3 This is the
aspect of fluoroscopy that is most easily controlled by the physician.
6. As the radiation comes from the x-ray tube, it is best to have the image intensifier as close to the
patient as possible. The closer the beam is to the patient, the greater the exposure to the patient.
Realize that the exposure decreases with the square of the distance from the beam. Thus, being twice
as far away from the source decreases the exposure by a factor of four. The physician should avoid
placing any part of his or her body between the x-ray tube (or beam) and the patient.
7. From this principle, it also stands that the farther away from the beam the physician or health care
worker is, the lower the exposure. When positioned to perform the block, it is best to be closer to
the image intensifier than to the x-ray tube. This becomes difficult with the lateral view in both
cervical and lumbar procedures, and special attention should be paid to the position of the physician
with regard to the x-ray tube. Realize that the greatest radiation exposure to the physician is due to
scatter that is reflected off the patient to the physician.
a. Inject contrast via extension tubing and under collimation to keep the physician’s hands out of
the beam. If guiding of the needle needs to be done under “live fluoroscopy,” consider placing
the needle with the aid of a surgical clamp.
b. Recognize the increased risk of exposure to the physician when obtaining lateral views under
fluoroscopy,6 especially when injecting dye under lateral fluoroscopy, as the beam is often very
close to the physician. This is an issue with lumbar discography, as injections of dye are often
performed in the lateral view to visualize dye spread into the nucleus. It is prudent to inject from
the side of the image intensifier or to have the technician operate the beam during that time so
that the physician may stand at a distance from the beam.
8. Limit the use of magnification. The magnification function permits a magnified view of the image to
appear on the screen, which may enhance the ability to accurately view the needle position. However,
this comes at the expense of increased radiation exposure. If magnification must be used, limit its
use to the lowest magnification setting possible. Placing the patient closer to the beam will magnify
the image but at the expense of increased radiation exposure. One method for obtaining a magnified
view is to use the “zoom” feature on the machine. This is a feature of the machine that when selected
magnifies or “zooms in” to the center of the last image held. It simply magnifies the picture seen on
the screen, but it does so without additional radiation exposure.
9. Limit the use of high-level fluoroscopy (HLF) imaging. This function of the fluoroscopy machine
increases the current (mA) in order to improve the image quality.8 This function is activated when
the “+” sign is pressed on the x-ray switch or foot pedal. Use this function sparingly in order to limit
excessive radiation exposure. Avoid continuous fluoroscopy using HLF imaging. HLF is most often
used to obtain an image that may then be saved for documentation of the final needle position.
10. Limit personnel in the procedure room to those directly involved with that patient’s care.
11. Most C-arms will automatically adjust to a high voltage (kV) while keeping the current (mA) low.
If the setting is placed at “low dose,” then the current decreases by approximately two thirds. This
results in a higher voltage per current going through the patient, which is more desirable for both
the patient and the pain physician (see Figure 3.5, Figure 3.6A, and Figure 3.6B).
12. With each exposure, there will often be a number expressed in terms of radcm2. This is a calculated
measure of radiation emitted by the machine with respect to the patient’s body surface area, known
as the dose area product (DAP). While this value has limitations in its interpretation, it is useful as
a relative value to try to minimze the DAP exposure for each patient.
13. Obese patients present a challenge, both in needle placement and visualization of the anatomy under
fluoroscopy. The use of low-dose settings in these patients results in a reduction in the image clarity;
thus, a higher current (mA) is often required to obtain a discernable image. Also, magnification is
more often used for these patients in order to get a clearer image.
14. Lastly, the equipment should be well maintained and regularly serviced to ensure good working order
(Figure 3.5).
Radiation Safety 37
LOW
PULSE FILM
DOSE
GENERATOR
FIGURE 3.5
Areas on the control panel of the C-arm where pulse and low dose imaging settings may be applied.
A needle placed in the foramen
(A)
A needle placed in the foramen
(B)
FIGURE 3.6
(A) This image was collimated both longitudinally (vertically) and circumferentially. The image was taken under pulsed
fluoroscopy on the “low dose” setting. There is some decrease in resolution, but the needle is still well visualized. (B) The
same image without pulsed fluoroscopy. Note the improved resolution.
Radiation Safety 39
Shielding
The use of shields may help to decrease exposure to the physician and staff due to scatter from
the patient. Below are the most common types of shields in use:
1. Lead aprons decrease exposure to the physicians’ organs by >90%. These aprons should contain a
thickness of at least 0.25 mm lead — >0.5 mm thickness provides more protection.6 They should be
routinely checked to ensure that they continue to act as effective barriers, and they should not be
folded.
2. Thyroid shields protect the thyroid gland from radiation, which may cause thyroid cancer.
3. Protective lead eyewear decreases exposure to the eyes by 90%. Although high doses are required
to produce radiation-induced cataracts, the risk also increases with age and the number of years of
radiation exposure. The protective eyewear should also be equipped with lateral shields to protect
scatter coming from the side.
4. Leaded gloves may be of use. There are some who are opposed to leaded gloves due to the false
sense of security that they may confer. The use of leaded gloves, while helpful in reducing scatter
to the hands, is not a sustitute for adhering to the above radiation safety principles. If the physician’s
hand is left under the beam and he or she is wearing leaded gloves, the fluoroscopy machine, which
has automatic brightness control, increases the radiation output in order to get a better image of the
practitioner’s hand, thus negating the benefit of the leaded gloves. There is also often a trade-off, as
the leaded gloves may decrease the manual dexterity of the physician.
5. Protective mobile barriers are leaded panels that may be placed between the practitioner and the
patient.
Radiation exposure is cumulative. Radiation badges should be worn with each exposure and
returned for monitoring at monthly or bimonthly intervals. There are different types of monitoring
equipment:
1. External exposure: This badge is often worn around the collar.

2. Organ exposure: This badge is worn underneath the lead.
3. Extremity/hand exposure: This is a finger ring — the label should be on the side that is exposed to
radiation.
In conclusion, fluoroscopy is a tool that the pain practitioner uses to guide him or her in
accurately placing medications around the spinal column, decreasing the volume of injectate
necessary to achieve a positive result. Basic knowledge of the risks and possible complications of
fluoroscopy is a vital part of performing these procedures.
Bibliography
1. Manchikanti, L., Cash, K., Moss, T.L., and Pampati V., Radiation exposure to the physician in inter-
ventional pain management, Pain Physician, 5(4), 385–393, 2002.
2. Manchikanti, L., Cash, K.A., Moss, T.L., Rivera, J., and Pampati, V., Risk of whole body radiation
exposure and protective measures in fluoroscopically guided interventional techniques: a prospective
evaluation, BMC Anesthesiology, 3, 2, 2003.
3. Brateman, L., The AAPM/RSNA Physics Tutorial for Residents, Imaging & Therapeutic Technology, 19(4).
4. FDA Public Health Advisory, Avoidance of Serious X-Ray Induced Skin Injuries to Patients during
Fluoroscopically Guided Procedures, Food and Drug Administration, Rockville, MD, September 9, 1994.
5. Hernandez, R.J. and Goodsitt, M.M., Reduction of radiation dose in pediatric patients using pulsed
fluoroscopy, American Journal of Roentgenology, 167, 1247–1253, 1996.
6. Fishman, S.M. et al., Radiation safety in pain medicine, Regional Anesthesia and Pain Medicine, 27(3),
296–305, 2002.
7. Mahesh, M., Fluoroscopy: patient radiation exposure issues. Radiographic, 21(4), 1033, 2001.
8. OEC Workstation Operator Manual 1998–2001.
9. Archer, B.R. and Wagner, L.K. Protecting patients by training physicians in fluoroscopic radiation
management. Am. Coll. Med. Phys., 1(1), 32–37, 2000.
Chapter
Basic Steps for Spinal Injections 4
41
Prior to any spinal injection, there is some basic preparation that needs to take place. All of the
necessary supplies and equipment for planned procedures should be available before the case is
started. General recommendations will be given for equipment and supplies, and specifics will not
be outlined, as different institutions have varying preferences.
There are six basic steps for every spinal injection. We will describe all procedures by following
these steps:
Step 1: Identify the target area or location of the spine that is to be injected, and determine the desired
needle pathway.
Step 2: Position the patient appropriately for the injection.
Step 3: Use fluoroscopy to identify the target area along the patient’s spine.
Step 4: Insert the needle into the target point or area of the spine using fluoroscopy as a guide.
Step 5: Confirm the needle placement under fluoroscopy.
Step 6: Inject the desired medication in the target area.
Step 1: Identify the Target Area or Location of the Spine to Be Injected

(Figure 4.1)
We often have a spine model in our procedure room for reference. In order to determine the needle
path (Figure 4.2), we must determine how to insert the needle from the site to reach the target area
or point of the spine.
FIGURE 4.1
Identify the target area or location of the spine.
FIGURE 4.2
Determine how to insert the needle from the site to reach the target area or point of the spine.
Step 2: Position the Patient for the Injection
Figure 4.3 demonstrates that a patient is placed in the prone position.
FIGURE 4.3
Denotes that a patient is placed in the prone position.
Step 3: Use Fluoroscopy to Identify the Target Area Along

the Patient’s Spine
This step includes placing the target area of the spine in the center of the TV screen (Figure 4.4
through Figure 4.9), orienting the images of the spine (Figure 4.10), confirming the target level of
the spine image (Figure 4.11), and rotating the C-arm to get the desired spinal images for the initial
needle insertion (Figure 4.12).
111111
1111
111
111111
111111
FIGURE 4.4
The fluoroscopic photo is displayed in the center of this TV screen.
111111
1111
111
111111
111111
FIGURE 4.5
The object is displayed on the left side of TV screen. The C-arm should be moved toward the spine.
111111
1111
111
111111
111111
FIGURE 4.6
The object is displayed on the right side of TV screen. The C-arm should be moved away from the spine.
1111 1
1
C-arm 1111
111
111111
111111
FIGURE 4.7
The axis of the C-arm should be perpendicular to the axis of a patient’s spine in order to display a perpendicular image on
the screen.
11111
1
1111 1
1 1111
1111 111
111
111111
111111
111111
111111
FIGURE 4.8
Images are rotated on screen when the C-arm’s axis is not perpendicular to the axis of patient’s spine.
Spine film
Spine film Displaying on TV screen
Patient’s left side

Left Right
FIGURE 4.9
The C-arm displays an image of the lumbar spine of the prone patient on the TV screen.
T12
L5
Rib
Ri
Left Sacrum Left
FIGURE 4.10
An image of the sacrum and an image of T12 help confirm levels of the vertebral image.
L4
FIGURE 4.11
Rotating the C-arm to the patient’s right side to get a right-sided oblique view of the image of the lumbar spine.
Step 4: Insert and Advance the Needle to the Target Point or Area of
the Spine under C-arm Fluoroscopy (Figure 4.12)
A needle
FIGURE 4.12
Demonstration of inserting a needle.
Step 5: Confirm the Needle Placement
In this case (Figure 4.13 through Figure 4.16), we demonstrate a right-sided lumbar transforaminal
epidural steroid injection. Contrast solution is injected to outline the target area in the spine to
reconfirm the relationship between the needle tip and the target area — the contrast material outlines
an epidural space and a spinal nerve root (Figure 4.16 and Figure 4.17).
The initial needle placement
FIGURE 4.13
A needle
FIGURE 4.14
The depth of the needle placement on a lateral view.
A needle
FIGURE 4.15
The relationship between the needle tip and the target area of the lumbar spine is rechecked on an anterior–posterior (A/P)
view.
Contrast
material
spreads into
Needle the epidural
space
FIGURE 4.16
Lateral view of the lumbar spine.
Needle
Contrast material spreads into

the epidural space and outlines
a spinal nerve root
FIGURE 4.17
A/P view of the lumbar spine.
Step 6: Inject the Medication (e.g., local anesthetic and steroid)
As the doses of local anesthetic and steroid vary with the individual, we will not be specific in our
recommendations.
Bibliography
Finton, D.S. and Czervionke, L.F., Eds., Image-Guided Spine Intervention, W.B. Saunders, Philadelphia, 2003.
Chapter
Fluoroscopic Images
of the Lumbar Spine
5
55
Fluoroscopic Images of the Lumbar Spine 57
Positioning the Patient

The prone position is the most frequently utilized position for all lumbar spinal injections (Figure
5.1). A typical fluoroscopic image of the anterior/posterior (A/P) view of the lumbar spine is shown
in Figure 5.2.
FIGURE 5.1
Prone position commonly used for lumbar spinal injections.
Anterior/Posterior View of the Lumbar Spine
4
1
2 5
6
FIGURE 5.2
Left: A/P view of the lumbar vertebrae. (1) Pedicle, (2) lamina, (3) spinous process, (4) superior articular process, (5) inferior
articular process, and (6) transverse process. Right: Photograph of the posterior aspect of a lumbar vertebra.
Figure 5.3 shows two images of A/P view of patients’ lumbar spines. Often, these images are
difficult to interpret.
FIGURE 5.3
A/P views of lumbar spines.
Obtaining an Oblique View of the Lumbar Spine

Figure 5.4 shows a typical fluoroscopic image of the right oblique view of the lumbar spine. The
C-arm is rotated to the patient’s right side. The image of the “Scottie dog” helps us to identify the
structures of the lumbar vertebrae. The “neck” of the dog represents the connection between the
pedicle and the lamina. The “ear” is the superior articular process. The “eye” is formed by the pedicle.
And, the ipsilateral transverse process forms the “nose” of the dog.
4
6
1
2
3
5
3 5
The “Scottie Dog” image
FIGURE 5.4
Image of the right oblique view of the lumbar spine. (1) Pedicle (the eye of the dog), (2) lamina, (3) spinous process,
(4) superior articular process (the ear of the dog), (5) inferior articular process (the front leg of the dog), and (6) transverse
process (the nose of the dog).
Figure 5.5 demonstrates how an image of the lumbar spine is changed from an A/P view to
an oblique view. The more the C-arm is rotated to the patient’s right, the greater is the distance
between the right-sided lateral margin of the vertebral body and the tip of the spinous process.
Margin of the vertebral body
Tip of the spinous process
FIGURE 5.5
Change of view of lumbar spine from A/P to oblique.
Figure 5.6 shows several images of the oblique view of the lumbar spine. The key difference in
these images is the relationship between the axis of the superior articular process and the axis of
the pedicle shadow. We can get different images of the oblique view (the “Scottie dog” images) of
the lumbar spine by rotating the C-arm to the patient’s side with slightly different angles based on
the procedures. For example, we may choose Image A for the lumbar medial branch injections.
(See the section on lumbar facet injections in Chapter 6 for details.) We may choose Image F for
the lumbar discography. (See the section on lumbar discography in Chapter 6 for details.)
FIGURE 5.6
Different images of oblique views of the lumbar spine.
Obtaining an Lateral View of the Lumbar Spine

Figure 5.7 is a typical fluoroscopic image of the lateral view of the lumbar spine. We usually use
a lateral view image to confirm needle depth. Figure 5.8 demonstrates that it may be very difficult
to determine which image is a true lateral view of the lumbar spine. We obtained these three images
by slightly rotating the C-arm without changing needle position (neither advancing the needle nor
retracting the needle).
5 7
2
6
3
FIGURE 5.7
(1) Pedicle, (2) spinous process, (3) superior articular process, (4) inferior articular process, (5) transverse process, (6)
vertebral body, and (7) intervertebral foramen.
FIGURE 5.8
Three-images of lumbar spine (lateral view).
Figure 5.9 illustrates a lateral view of the lumbar spine in a prone position. The shape of the
vertebral body is like a cylinder; the transverse processes on the sides, the lamina, and the spinous
process form a pie. Two small cylinders (two pedicles) connect “the cylinder” and “the pie.”
Tip of the transverse

process
Pedicles
Tip of transverse process

Vertebral body
FIGURE 5.9
Lateral view of lumbar spine in prone position.
We can easily view a clear lateral vertebral body (the cylinder) with pedicles by having the
x-ray beam pass through a diameter of the cylinder (Figure 5.10A). However, it may be difficult
to determine a true lateral view of the vertebral body, because the cylinder has many diameters
(Figure 5.10B). Therefore, it is not easy to determine needle depth by using images of the lateral
view only (Figure 5.11).
A B
FIGURE 5.10
Figure 5.11 illustrates different images of the lateral view of the lumbar spine without moving
needles. Rotating the C-arm at slightly different angles can change the distances between the tip
of the needle and the anterior margin of the vertebral body.
FIGURE 5.11
Lateral views of the lumbar spine.
Other structures in the lateral view of the lumbar spine, including the transverse process, the
superior articular process, the interior process, and the spinous process, do not provide additional
information for determining a true lateral view of the lumbar spine (Figure 5.12A). A two-
dimensional image of the lumbar spine can be illustrated as in Figure 5.12B. We are able to easily
identify the vertebral body, the pedicle, and the intervertebral foramen.
Vertebral body
Vertebral body
Intervertebral
foramen
Intervertebral
foramen
Pedicle
Pedicle
A B
FIGURE 5.12
Suggestions on How to Check the Needle Depth

When imaging the lumbar spine, it is difficult to check the needle depth by realigning the images
of the lateral view alone (Figure 5.11). In contrast, it is easy to get a true A/P view of the lumbar
spine if an x-ray beam goes through the diameter of “the cylinder” and is perpendicular to “the
pie” (Figure 5.13). Therefore, we recommend using images of both the lateral view and the A/P
view of the lumbar spine together to confirm needle depth (Figure 5.14).
The perpendicular
Tip of the
transverse
Pedicles
Tip of transverse process

Vertebral body
The diameter
A B
FIGURE 5.13
Fluoroscopic images of A/P views of the lumbar spine. The spinous process (A) is located at the midline of the vertebral
body, and the vertebral body (B) is squared (commonly used terminology).
FIGURE 5.14
Images of the lateral view and the A/P view should also be used to check the needle depth. (A) Lateral view. The tip of
this needle is located slightly posterior to the anterior margin of the vertebral body. (B) A/P view. The tip of the needle is
located in the center of the pedicle shadow.
Bibliography
Bontrager, K.L. and Anthony, B.T., Eds., Textbook of Radiographic Positioning and Related Anatomy, 2nd
ed., C.V. Mosby Company, St. Louis, MO, 1990.
Netter, F.H., Ed., Atlas of Human Anatomy, Ciba Geigy Corporation, Tarrytown, 1989.
Waldman, S.D., Atlas of Interventional Pain Management, 2nd ed., W.B. Saunders, Philadelphia, 2004.
Chapter
Lumbar Spinal Injections 6
71
Lumbar Spinal Injections

This chapter addresses injections in and around the lumbar spine. We start off with the simplest to
perform, the lumbar medial branch block, and advance to the more technically challenging lumbar
discogram. The pain physician should be skilled in the performance of lumbar spinal injections
prior to attempting to perform injections within the thoracic or cervical regions.
Patient preparation: We ask the patients not to ingest any solid foods for a minimum of 6 hours
prior to the procedure. We recommend that the patients have another individual available to transport
them home following the procedure. Heart rate, blood pressure, and oxygen saturation may be moni-
tored. Pregnancy is a contraindication to the performance of all spinal injections under fluoroscopy.
Equipment/Materials:
• A 22- or 25-gauge 3½ in. spinal needle with or without a distal curved tip in the direction of the bevel.
• Water-soluble nonionic contrast.
• Local anesthetic (e.g., 0.25 to 0.5% bupivacaine or 2% lidocaine) and steroid. The volume of injected
material will vary depending on the injection performed. Diagnostic injections are performed with
a low volume (<1 ml), while therapeutic injections may be performed with a slightly larger volume.
Note that the local anesthetic and the steroid may be injected together as a solution or separately.
• Steroids are not necessary for medial branch injections.
• A syringe (or syringes) for injecting the local anesthetic and steroid. A 3 ml or 5 ml syringe is
recommended.
• Connection tubing to allow for dye injection without radiation exposure to the hands. This also
facilitates an immobile needle.
• Lidocaine (0.5 to 2%) and a thin (25- to 27-gauge) needle for local infiltration. When using 25-gauge
spinal needles in the lumbar region and the patient’s anatomy is easily visualized, local anesthetic
skin infiltration is often not necessary.
Sedation: Light sedation is recommended, e.g., with midazolam 1 to 2 mg intravenously.
Lumbar Medial Branch Block

The lumbar medial branch block is one of the most commonly performed spinal injections in our
practice; it is also among the easiest to perform. We thus recommend using this block to teach
beginner pain physicians the technique of basic spinal injections. Lumbar medial branch injections
are often performed as diagnostic injections for pain arising from the lumbar facets.1,2 Their use
as therapeutic injections was also reported.1
Indications:
Axial low back pain that does not radiate distal to the knee
Low back pain without radicular symptoms
Mechanical low back pain
Contraindications:
Patient refusal
Systemic anticoagulation or coagulopathy
Systemic or localized infection at the site
Step 1: Identify the Target Area on the Lumbar Spine
The target area is the area or small groove where the superior articular process joins the base of
the transverse process of the lumbar vertebra. The lumbar medial branch lies against the bone in
this region (Figure 6.1).
A The target area B
Medial
branches
FIGURE 6.1
(A) Photograph of a right-sided oblique view of the lumbar vertebrae. The dot indicates the target area of the lumbar
vertebra for a medial branch injection. (B) Location of lumbar medial branches.
The lumbar medial branch is the medial branch of the dorsal primary ramus of the spinal nerve
root (Figure 6.2). The needle is advanced toward the target area posteriolaterally (Figure 6.3).
Lumbar Spinal nerve

root
Lumbar medial
branch
Dorsal primary
ramus
FIGURE 6.2
Origin of the lumbar medial branch in a right-sided oblique view of the lumbar vertebrae.
A
B
FIGURE 6.3
(A) Needle placements in a posterior view. (B) Needle placements in an oblique view.
Step 2: Position the Patient

The patient is in a prone position, and the C-arm comes in from the patient’s side (Figure 6.4).
FIGURE 6.4
Patient in prone position; C-arm at patient’s side.
Step 3: Use the Fluoroscopy to Identify the Target Area

To get a true lumbar A/P image (Figure 6.5), we must identify the target levels and orient the
images.The C-arm is rotated and tilted to get an anterior–posterior (A/P) image of the target lumbar
vertebra.
The L1 spinal nerve root, for example, exits from the spine via the intervertebral foramen
between L1 and L2. The L1 posterior ramus and its medial branch lie against the bone at the
junction between the superior articular process and the transverse process of L2 (not L1). This
means that the L1 medial branch is injected at the level of the L2 transverse process; the L2 medial
branch is located at the level of the L3 transverse process; the L3 medial branch is located at the
level of the L4 transverse process; the L4 medial branch is located at the level of the L5 transverse
process; the L5 dorsal ramus is located just lateral to the S1 superior articular process (Figure 6.6).
In order to count levels of lumbar medial branches, we must understand how to number the spinal
nerve roots, because lumbar medial branches are the terminal branches of the spinal nerve roots.
Each spinal nerve root comes from the vertebral column via an intervertebral foramen.
Right
Rib
L2
Tip of a metal
pointer
FIGURE 6.5
T12
A B T12
T12 MB
L1
L1
L1 MB
L2
L2
L2 MB
L3
L3
L3 MB
L4
L4
L4 MB
L5 L5
L5 Dorsal
Ramus
Sacrum
FIGURE 6.6
Step 4: Insert the Needle into the Target Area
It is important to understand how to choose fluoroscopic images of the target lumbar vertebra for
the initial needle insertion.
The A/P View

The location of a lumbar medial branch is demonstrated in Figure 6.7. The target point is located
medially and inferiorly to the junction point between the lateral margin of the superior articular
process and the superior margin of the transverse process.
A B
Junction point between lateral

Medial branch margin of the superior articular
process and the superior margin of
the transverse process
FIGURE 6.7
(A) A/P viewed lumbar vertebrae (B) Location of the medial branch (the white dot line outlines the lateral margin of the
superior articular process and the superior margin of the transverse process). (C) White dots are possible target points for
the medial branch injection.
Correct needle insertion in the A/P view may be difficult to determine, because it is very
difficult to outline the entire lateral margin of the superior articular process (Figure 6.7), and the
distal portion of the lumbar medial branch varies. We recommend using the lateral view to recheck
needle placement (Figure 6.8).
Needle
B
Medial br anch
Needle
D
FIGURE 6.8
(A) Laterally viewed photograph of a lumbar vertebra with correct needle placement for the medial branch block. (B)
Laterally viewed fluoroscopic image of the lumbar vertebra with correct needle placement. (C) Laterally viewed photograph
with a needle tip contacting the posterior margin of the superior articular process. (D) Laterally viewed fluoroscopic image
with a needle contacting the posterior margin of the superior articular process.
We recommend using an obliquely viewed fluoroscopic image of the lumbar vertebra to guide
needle placement for the lumbar medial branch injection (Figure 6.9).
A target
point
A B
Medial branch
An ideal target
point for the
lumbar medial
branch
FIGURE 6.9
(A) Right-sided obliquely viewed photograph of a lumbar vertebra. (B) Right-sided obliquely viewed fluoroscopic image
of a lumbar vertebra. (C) Target point for needle insertion.
The reasons for using the oblique image for the lumbar medial branch injection include that
we can block the proximal portion of the medial branch (Figure 6.10A through Figure 6.10D), and
it is easy to identify the lateral margin of the superior articular process (Figure 6.10D).
Distal portion of the medial branch
C D
Proximal
portion of
the
medial
branch
Distal portion of the medial branch
FIGURE 6.10
The obliquely viewed fluoroscopic image is better for guiding the lumbar medial branch injection.
Using a variety of oblique images of the lumbar vertebra may not significantly affect needle
placement for the lumbar medial branch. However, the needle tip must contact the area below the
junction between the lateral margin of the superior articular process and the superior margin of the
transverse process (Figure 6.11).
A B C
FIGURE 6.11
Series of right-sided obliquely viewed photographs of a lumbar vertebra. A through C demonstrate that the more the vertebra
is rotated, the better the proximal portion of the medial branch can be visualized.
We suggest rotating the C-arm only enough to clearly identify the lateral margin of the superior
articular process (Figure 6.12). The lateral margin of the pedicle shadow usually overlies the junction
between this lateral margin and the superior margin of the transverse process. On the other hand,
the target point is at about the one o’clock or two o’clock position on the pedicle shadow (Figure
6.12B).
A B
Target
point
FIGURE 6.12
(A) Right-sided obliquely viewed lumbar vertebra. (B) Target point for the needle placement of the lumbar medial branch
injection. The white dotted line outlines the lateral margin of the superior articular process shadow and the superior margin
of the transverse process.
After choosing the ideal fluoroscopic image, a needle is inserted and advanced under fluoro-
scopic guidance until the needle tip contacts the target point.
Special Considerations for the L5 Dorsal Ramus Injection

The L5 “medial branch” is not the medial branch of L5 but rather the dorsal primary ramus of the
L5 (Figure 6.13) spinal nerve. The L5 dorsal primary ramus lies against the bony groove formed
by the sacral ala and the superior articular process of S1.
A B
L5 dorsal ramus Right-sided L5 dorsal ramus
L5
Right-sided
L5 dorsal ramus
Sacral ala
Posterior of
the sacrum Anterior surface
of the sacrum
C
FIGURE 6.13
(A) Photograph of the posterior view of the lower portion of the lumbar spine. (B) Right oblique view of the lower portion
of the lumbar spine. (C) Right-sided lateral-superior view of the L5 and the sacrum.
The needle insertion for the L5 dorsal ramus injection includes a posterior approach and an
oblique approach:
1. The posterior approach is achieved using an A/P-viewed fluoroscopic image of L5 as a guided image
for the initial needle placement. The target zone is the area that is slightly inferior to the junction
point between the base of the superior articular process of S1 and the sacral ala (Figure 6.14).
Sacral ala
S1 superior
articular process B
L5
L5 medial branch
Right-sided L5 medial
branch target point
(white dot)
FIGURE 6.14
(A) Fluoroscopic image of an A/P view of the L5 and the top portion of the sacrum. The white dot shows the target point
of the right-sided L5 medial branch injection. (B) Photograph of the posteriorly viewed area between L5 and the sacral ala
that illustrates the location of the right-sided L5 medial branch.
2. An oblique approach is employed using an obliquely viewed fluoroscopic image as a guided image
for the initial needle placement. The C-arm is slightly rotated to the affected side about 10 to 20˚
(Figure 6.15).
A B
The
target
point
for L5
dorsal
The target point for the ramus
right-sided L5 dorsal Right-sided L5
ramus injection dorsal ramus
FIGURE 6.15
(A) Right-sided obliquely viewed L5 image. (B) Photograph of the right-sided obliquely viewed area between L5 and the
sacral ala.
We emphasize the importance of identifying the S1 articular process and the sacral ala for the
L5 dorsal ramus block regardless of the approach.
The needle placement for the lumbar medial branch block at all levels can be rechecked in a lateral
view of the lumbar spine (Figure 6.16).
The needle tip is located below the

A lower margin of the intervertebral
foramen and advanced not beyond
the posterior margin of the
intervertebral foramen.
FIGURE 6.16
Correct needle placement for the lumbar medial branch block in the lateral view. (A) Photograph of the lateral view of the
lumbar spine with a placed needle of the lumbar medial branch block. (B) Fluoroscopic image of the lumbar spine with a
placed needle
We may also need to use an A/P view and a lateral view of L5 together to recheck the needle
placement for an L5 medial branch block. If we put the C-arm back to the neutral position (Figure
6.17), the needle tip will aim significantly caudally in the A/P view (Figure 6.18).
FIGURE 6.17
(A) The C-arm is in a neutral position. (B) The x-ray beam does not align with the L5/S1 disc.
A
B
C D
FIGURE 6.18
Needle placement for the right-sided L5 dorsal ramus block in the A/P view. (A) Posteriorly viewed photography with a
placed needle for the right-sided L5 dorsal ramus block. (B) A/P image of the right-sided L5 dorsal ramus block. (C, D)
The needle directions may look different if the angles of the view are different.
Rechecking the needle placement in the lateral view should follow the same criteria as described
previously — the needle tip should be located below the lower margin and behind the posterior
margin of the L5/S1 intervertebral foramen (Figure 6.19).
The iliac
crest
shadow
L5/S1
intervertebral
foramen
B1 B2
The needle tip is located below the lower

margin of the intervertebral foramen and
posterior to the posterior margin of the
intervertebral foramen.
FIGURE 6.19
Illustration of how to recheck the needle placement for the L5 dorsal ramus block in the lateral view. (A) Photograph of
the lateral view of the lower portion of the lumbar spine and the iliac crest. The iliac crest covers the needle tip. (B1)
Laterally viewed fluoroscopic image of the needle placement for the L5 dorsal ramus block. (B2) The same image as B1
with labels.
Step 6: Inject the Medication
Lumbar Medial Branch Denervation
Indications: If the patient receives temporary but significant (>70%) pain relief from diagnostic
lumbar medial branch injections, he or she is a good candidate for the lumbar medial branch
denervation.
We follow the same step to get a slightly obliquely viewed image of the target vertebra (Figure
6.20). We usually choose the initial radiofrequency needle entry point at the lower margin of the
transverse process and slightly lateral to the lateral margin of the pedicle shadow (Figure 6.21A).
The needle is then advanced slightly medially and cephalically. The end point of the process is when
the needle tip contacts the junction point between the superior articular process and the transverse
process, as we described in the above section on the lumbar medial branch block (Figure 6.21B).
A B
FIGURE 6.20
(A) Right-sided oblique view of the lumbar vertebra above L5. (B) Right-sided oblique view of the L5 vertebra.
The initial needle entry

point
(A) (B)
FIGURE 6.21
(A) Initial entry point and (B) target area.
Needle placement should be rechecked at the lateral view, as described in the lumbar medial
branch block section, above.

Step 1: Identify the Target Area
Needle entry is via an intervertebral foramen posteriolaterally (Figure 6.22A and Figure 6.22B).
A
B
FIGURE 6.22
(A) Photograph of a posterior view of the lumbar spine with a needle approaching the foramen. (B) Photograph of the
lumbar spine with a needle approaching in the oblique view.
The patient is in a prone position, and the C-arm comes in from the patient’s side (Figure 6.23).
FIGURE 6.23
C-arm at side of patient in prone position.
Step 3: Use Fluoroscopy to Identify the Target Area
The C-arm is rotated and tilted to get an A/P image of the target lumbar vertebra (Figure 6.24A
through Figure 6.24C). The C-arm is then rotated toward the affected side to get an oblique
fluoroscopic image of the target lumbar vertebra (Figure 6.25A and Figure 6.25B).
T12
L5
Left
Right
Rib
A shadow
of a metal
pointer
Sacrum
A B
A shadow of a
metal pointer
FIGURE 6.24
(A, B) Orientation of the image; the levels may be counted from T12 to ensure that there are five lumbar vertebrae. (C)
A/P view of the first to third lumbar vertebrae. Their spinous processes are at the midline of the vertebral bodies, but only
the L1 and L2 vertebral bodies are squared.
A B
FIGURE 6.25
(A) Photograph of the lumbar spine, right oblique view. (B) Fluoroscopic image of the lumbar spine, right oblique view.
In general, the best oblique view of the lumbar spine for a lumbar transforaminal epidural
steroid injection is obtained when the superior articular process at the target level intersects the
center of pedicle shadow that is located immediately above (Figure 6.26).
Tip of superior articular

process points up to the
center of the pedicle above.
Target vertebra
FIGURE 6.26
Correct right oblique view of lumbar vertebrae for lumbar transforaminal epidural steroid injection.
Step 4: Insert the Needle to the Target Area
When performing a lumbar transforaminal injection, the entry (Figure 6.27A) is located as follows:
At the inferior margin of the transverse process at the target vertebra

Superior to the tip of the superior articular process at the level below the target vertebra
Lateral to the lateral margin of the inferior articular process at the level below the target vertebra
Figure 6.27B shows the initial needle placement.

Target vertebra
Inferior margin of
transverse process
Lateral margin of
inferior articular
process
Tip of superior
articular process
Needle
FIGURE 6.27
(A) Zone of initial needle placement. (B) Fluoroscopic image of the initial needle placement for right-sided lumbar
transforaminal epidural steroid injection.
The depth of the needle should be checked with lateral views. The final depth of the needle in the
lateral view is located between the middle and the posterior one third of the intervertebral foramen
(Figure 6.28A). In the A/P view, the needle tip should be located underneath the pedicle shadow,
with the area between the medial margin and the center of the pedicle shadow at the target level
(Figure 6.28B). If the patient experiences severe paresthesias, regardless of the needle position, the
needle must be repositioned.
A B
The needle tip is located The needle tip is located

at the midway and upper underneath of the pedicle and
one third of between the medial margin and
intervertebral foramen center of the pedicle
FIGURE 6.28
A lateral image and an A/P fluoroscopic image of epidurogram, which may include a nerve-
gram, should be obtained. Vertical epidural spread of the contrast agent is visualized within the
posterior aspect of the intervertebral foramen in the lateral view (Figure 6.29A). In the A/P view,
the contrast agent spreads underneath and medial to the pedicle shadow and outlines the target
spinal nerve exiting the foramen (Figure 6.29B).
(A) (B)
FIGURE 6.29
Step 6: Inject the Medication
We recommend injecting 1 to 2 ml of 0.25% of bupivacaine and 10 to 40 mg (0.2 to 1 ml) of steroid.
Special Considerations of Oblique Views
It is important not to under- or overrotate the C-arm in obtaining an ideal fluoroscopic image (Figure
6.30). Learning how to get the correct oblique image of the lumbar spine is important for performing
lumbar transforaminal epidural steroid injections. The following figures demonstrate oblique images
of the lumbar vertebra that can interfere with accurate needle placement (Figure 6.30A through Figure
6.30C).
A B C
FIGURE 6.30
(A) C-arm in a neutral position. (B, C) The C-arm when it is rotated to the patient’s right side at varying angles.
Rules for Getting Oblique Views of the Lumbar Spine

Figure 6.31 demonstrates that the needle cannot be inserted into the intervertebral foramen if it is
inserted perpendicularly to the vertebral body, posterior–anterior from above the tip of the superior
articular process. For this reason, we do not use the A/P view of the lumbar spine to guide the
initial needle insertion.
Vertebral body
Needle Transverse process
Pedicle Spinal nerve root
Spinal cord
Tip of superior articular
Spinous process
lamina
FIGURE 6.31
(A) Photograph of the lumbar spine with a needle in the posterior view (B) A/P fluoroscopic image of the lumbar spine.
(C) Diagram showing the difficulty encountered when the needle is inserted from the skin perpendicularly to the vertebral
body from above the tip of the superior articular process.
Figure 6.32 shows the difficulty in accurately placing the needle into the intervertebral foramen
when there is underrotation of the image of the lumbar vertebra by C-arm.
Tip of superior
articular process
points up to the
lateral margin of the
pedicle at the level
above
A B
FIGURE 6.32
(A) Photograph of under-rotated lumbar vertebrae with a needle entry from right oblique view. (B) Fluoroscopic image of
the lumbar spine showing the right oblique view, under-rotated. The tip of the superior articular process points up to the
lateral margin of the pedicle shadow above. (C) Example of how an under-rotated vertebra makes the needle placement
more difficult.
Proper rotation of the C-arm with respect to the lumbar vertebrae allows the needle tip to pass
easily into the intervertebral foramen (Figure 6.33).
Tip of superior
articular process
points up to the
center of the
pedicle at the level
above
A B
Needle
FIGURE 6.33
(A) Photo of properly rotated vertebrae to the right. (B) Fluoroscopic image of the lumbar spine, right proper oblique view.
The tip of the superior articular process points up to the center of the pedicle shadow at the level above. (C) Proper rotation
of the lumbar vertebra and the proper needle placement. The needle is able to be inserted into the intervertebral foramen.
Figure 6.34 demonstrates that overrotation of the C-arm also increases the difficulty of per-
forming accurate needle placement.
The tip of superior

articular process is
located at the center
of the disc space
A B
Needle
FIGURE 6.34
(A) Lumbar vertebrae over-rotated to the right. (B) Fluoroscopic image of lumbar vertebrae over-rotated to the right because
the tip of the superior articular process is at the midway of the disc space between two vertebrae. (C) Improper needle
placement.
The following images (Figure 6.35) illustrate a left transforaminal epidural steroid injection
at the level of L4/L5. We changed C-arm rotations to correct the initial inaccurate needle positions.
A B C
D E
Tip of superior Tip of superior articular
articular process process points up to the
points up to the center of pedicle at the
lateral margin of level above
pedicle at level
above
F G H
FIGURE 6.35
(A) Initial needle insertion in the left oblique view. (B) A false “proper needle location” at the lateral view (needle tip at
the upper one third and at the midway of the intervertebral foramen). (C) Needle tip away from the spine in the A/P view.
(D) A second oblique view obtained by rotating the C-arm to the left. The initial needle entry in (A) was medial to the
superior articular process. (E–H) In order to obtain the proper needle placement it was necessary to check the oblique,
lateral, and A/P views. (I) A correct segmental epidurogram with a nervegram.
The images shown in Figure 6.36A through Figure 6.36H demonstrate how overrotating the
C-arm also results in improper needle placement. Figure 6.36A shows the superior articular process
of L2 pointing up to the medial margin of the pedicle shadow at the level above. Figure 6.36B
through Figure 6.36D show the needle placement when this overrotated oblique view is used. Figure
6.36E and Figure 6.36F show “proper” needle placement in the A/P view and in the lateral view.
However, Figure 6.36F shows improper spread of contrast agent. Figure 6.36H confirmed that it
is not an epidurogram.
A B C D
E
F G
Improper spread of contrast agent

H
This contrast image is

not an epidurogram
FIGURE 6.36
Improper spread of contrast agent.
Sometimes getting an ideal oblique image of the lumbar vertebrae for lumbar epidural steroid
injections is difficult, because the shapes of patients’ lumbar vertebrae vary. This means that we
cannot always use the relationship between the tip of the superior articular process and the pedicle
shadow at the level above on the oblique view (Figure 6.37A through Figure 6.37D) to decide a
proper C-arm oblique rotation.
Tip of superior
articular process points
up to the center of the
Target vertebra pedicule above
FIGURE 6.37
In Figure 6.38A through Figure 6.38D, the relationship between the tip of a superior articular
process could not be used as a guide for the lumbar transforaminal epidural steroid injection. Figure
6.38A looks like an overrotated oblique view lumbar spine image, because the tips of the superior
articular processes at each level from L2 to L4 point up to the medial margin of the pedicle shadow
above. In Figure 6.38B, the needle is inserted between L1 and L2. Figure 6.38C shows an A/P
view of proper needle placement, as the needle tip is located below the pedicle shadow and also
medial to the medial margin of the pedicle shadow. Figure 6.38D shows a correct epidurogram and
nervegram.
A B
Needle Needle
C D
FIGURE 6.38
We believe that the angle between the transverse process and the superior process (Figure 6.39)
is one of the factors that accounts for varying appearances of the lumbar vertebrae in the oblique
view.
Angle between transverse process and

superior articular process
FIGURE 6.39
The arrow shows the angle between the transverse process and the superior articular process.
We can use the relationship between the tip of the superior articular process and the upper
margin of the vertebral body as a guide to confirm the correct oblique view if the angle is close to
90° (Figure 6.40). This does not hold true if this angle is much bigger than 90˚ (Figure 6.41).
An almost 90° angle
FIGURE 6.40
The angle in this example is sharp.
Angle much bigger than 90 degrees
FIGURE 6.41
The angle pictured here is greater than 90°.
This angle is less than

90 degrees.
FIGURE 6.42
We have not observed an angle between the transverse process and the superior articular process that is less than 90°.
Therefore, we recommend using at least two rules together to check for optimal oblique images
for lumbar epidural steroid injections:
Rule 1: The tip of the superior articular process bisects the center of the pedicle shadow at the level
above (Figure 6.43 A).
Rule 2: The tip of the superior articular process is located at one third of the disc space (Figure 6.43B).
Tip of
superior
articular
process
bisects the
pedicle
shadow
above
(a)
1/3
1/3
1/3
(b)
FIGURE 6.43
We consider Rule 2 to be more important than Rule 1 to determine a proper C-arm position for
obtaining a correct oblique image of lumbar spine.
We also recommend always using both lateral and A/P images to guide and check needle depth
and direction.
Figure 6.44A, an oblique view, shows that a needle is inserted below the transverse process
(below the pedicle in the fluoroscopic image), lateral to the inferior articular process, and above the
superior articular process. Image B, a lateral view, shows that the needle tip is located in the upper
one third of the intervertebral foramen. Image C, an A/P view, shows that the needle tip is underneath
the pedicle. Figure 6.44 illustrates proper needle placement in oblique, lateral, and A/P views. If we
use only a lateral image to check the needle depth, we may not be able to identify improper needle
placement. Figure 6.45 demonstrates that three needle placements can give similar lateral photographs.
FIGURE 6.44
Proper needle placements in oblique view (A), lateral view (B), and A/P view (C).
FIGURE 6.45
The above pictures show that three different needle entrance sites in the A/P views can result in the same needle position
in the lateral view.
Figure 6.46 illustrates that needles are inserted in different directions to the lumbar spine,
proven by A/P views (images A and B). However, lateral images (images C and D) show that these
two needle depths are similar.
A C
B D
FIGURE 6.46
A/P views of needles inserted from different directions (A and B). Lateral images showing similar needle depths (C and D).
The following two cases show how to confirm needle placements:
Case 1 (Figure 6.47): Correct needle placement at a level between L4 and L5 on the right side.
Use Rule #1 and #2 to Use lateral view and A/P view to confirm the
choose an oblique for needle depth and needle driving direction
the initial needle
Lateral A/P epidurogram

epidurogram
FIGURE 6.47
Proper needle placement between L4 and L5 on right side.
Case 2 (Figure 6.48): Another correct needle placement at a level between L4 and L5 on the right side.
Use Rule # 1 and #2 to

choose an oblique for
Use lateral view and A/P view to confirm the
the initial needle
needle depth and needle driving direction
Lateral epidurogram A/P epidurogram
FIGURE 6.48
Another proper needle placement between L4 and L5 on right side.

at the Level of L5/S1
The needle is inserted into the intervertebral foramen between L5 and the first sacral segment (ala or
wing of the sacrum) (Figure 6.49).
Ala or sacral wing
FIGURE 6.49
Insertion of needle into intervertebral foramen between L5 and first sacral segment.
The patient is in the prone position, as they would be for any other lumbar procedure (Figure 6.50).
FIGURE 6.50
Patient in prone position.
Step 3: Use C-Arm to Identify the Target Area
Obtaining appropriate fluoroscopic images for L5/S1 transforaminal epidural steroid injections is
different than obtaining those for the upper lumbar levels, although the same principles and rules
described above apply. There are several special considerations at this level. These include the lumbar
lordosis (Figure 6.51A and Figure 6.51B), the sacral promontory (Figure 6.51C), and the concave
shape of the sacrum (Figure 6.51B).
The vertebral column forms a series of anteroposterior curves. A lordosis is defined as any
convex forward curve. The curvature of an adult’s lumbar spine (Figure 6.51) is a convex forward
curve.
A
Lumbar lordosis (convex forward curve)
Sacral curvature (concave

forward)
B C
Lumbar lordosis Sacral promontory
FIGURE 6.51
Curvature of adult lumbar spine.
In order to square the L5 vertebral body or to open the disc space between L5 and S1 in the
A/P view, the C-arm needs to have a significant cephalic tilt (Figure 6.52). This tilt varies among
patients based on their degrees of lumbar lordosis, the severity of the sacral promontory, and the
degrees of sacral curvature (Figure 6.53).
FIGURE 6.52
FIGURE 6.53
If the fluoroscopic beam does not align with the disc between L5 and S1 (Figure 6.54A), the
tip of the spinous process of L5 will be located above or on the posterior lower margin of the L5
vertebral body (Figure 6.55B and Figure 6.55C). When the C-arm is tilted in a cephalic direction, it
allows the fluoroscopic beam to align with the L5/S1 disc (Figure 6.55A). The tip of the spinous process
of L5 will be located below the posterior inferior margin of the L5 vertebral body (Figure 6.55B
and Figure 6.55C). The C-arm is then rotated to the affected side (Figure 6.56) to get an oblique-
viewed L5 (Figure 6.57A). We still follow Rule 1 as we described above to have the tip of the S1
superior articular process bisecting the pedicle shadow of L5 (Figure 6.57B).
X-tube
Tip of spinous process is located above

the posterior lower margin of L5
vertebral body
Lower margin of L5 lamina
B c
Posterior margin
of sacrum body
Posterior lower margin of L5 vertebral body

FIGURE 6.54
In (B) and (C) the fluoroscopic beam is not aligned with the disc between L5 and S1. (B) Posterior view of L5 and the
disc space between L5 and S1 when the fluoroscopic beam is not aligned with the disc. (C) A/P image of an L5 body
whose image is not squared.
The tip of the spinous process is located below

the posterior inferior margin of the L5 vertebral
body.
X tube
The posterior lower margin of the C

L5 vertebral body
FIGURE 6.55
The fluoroscopic beam is aligned with the L5/S1 disc. (B) The appearance of the L5 vertebral body and the disc space
between L5 and S1 when the fluoroscopic beam aligns with the disc. (C) A/P viewed image of a squared L5 body.
FIGURE 6.56
Tip of S1
superior
articular
process
bisects L5
A B
FIGURE 6.57
(A) Photograph of L5, left oblique view. (B) Fluoroscopic image of L5, left oblique view; the tip of the left superior articular
process bisects the pedicle shadow at L5.
A triangular-shaped needle entry zone is formed by the iliac crest (lateral), the lateral margin
of the S1 superior articular process (medial), and the inferior margin of the transverse process
(superior) (Figure 6.58). The needle should be inserted above the tip of the S1 superior articular
process (Figure 6.59).
L5 transverse process
S1 superior articular
process
Iliac crest
FIGURE 6.58
Needle insertion
point
FIGURE 6.59
However, we observed that the needle entry zone as described above varies among patients
due to the differences in the appearance of the iliac crest (Figure 6.60). These differences sometimes
make needle insertion very difficult, because a high iliac crest line may cover the needle entry zone
in the oblique view (Figure 6.61).
L5 L5
B
A
L5
CC
FIGURE 6.60
Different appearances of the iliac crest. A is higher than B. C is lower than A and B.
L5
L5
Iliac crest line
Iliac crest
L5
L5
Iliac crest line
B Iliac crest
L5
L5
Iliac crest line
C
Iliac crest
FIGURE 6.61
Different appearances of the iliac crest in a left oblique view.
We recommend always trying to rotate the C-arm to the affected side until the superior articular
process of S1 bisects the L4 pedicle shadow in order to get an initial needle entry point if the iliac
crest line is low in this view (Figure 6.62).
Needle
FIGURE 6.62
Initial needle placement for left-side L5/S1 transforaminal epidural steroid injection.
However, if the iliac crest covers the needle entry zone in an oblique view, we recommend rotating
the C-arm until this needle entry zone is maximally open. The needle entry will then be chosen at
a position lateral to the tip of the S1 superior articular process (Figure 6.63). The needle is then
advanced in this oblique view until it contacts either the upper portion of the lateral margin of the
S1 superior articular process or the inferior portion of the lateral margin of the L5 inferior articular
process (Figure 6.64).
L
Initial needle entry point Iliac crest line
A B
FIGURE 6.63
(A) Marked needle entry point in an oblique view. (B) Initial needle placement.
A B
The needle tip contacts the lateral side

of the S1 superior articular process
FIGURE 6.64
(A) The needle contacts the lateral margin of the S1 superior articular process. (B) The needle tip contacts the upper portion
of the lateral margin of the S1 superior articular process.
The needle tip behind S1 superior articular process
FIGURE 6.65
The needle tip is behind the S1 superior articular process.

The depth of the needle placement should be checked in a lateral view (Figure 6.66A) and an A/P
view as described before (Figure 6.66B).
A B
FIGURE 6.66
Lateral view of needle placement (A). A/P view of needle placement (B).
A B
FIGURE 6.67
(A) Left-sided L5/S1 epidurogram, including the L5 nervegram and S1 nervegram in an A/P view. (B) L5/S1 epidurogram
in a lateral view.
Lumbar Discography
Introduction
Lumbar discography is a diagnostic test that seeks to provide clinically relevant information about
the source of a patient’s low back pain, with or without radiation to the lower extremity, that is not
provided by other imaging techniques, such as magnetic resonance imaging (MRI). Radiographi-
cally, abnormal lumbar discs may or may not be associated with the patient’s symptoms.2 The outer
annulus is richly innervated.3,4
Injection of dye within the substance of the pain-generating disc often reproduces the patient’s
pain symptoms. This is particularly significant if the concordant pain is reproduced at low injection
H IZ
FIGURE 6.68
On the posterior aspect of the L23 and L45 disc is a bright spot known as a high intensity zone (HIZ).
pressures.5 The disc is comprised of three main regions: the nucleus pulposus, the annulus fibrosus,
and the cartilaginous end plates. Mechanical stress is mostly distributed to the lumbar vertebral end
plate, which is the disc’s source of nutritional supply. Disc degeneration is thought to be the result
of repetitive mechanical stress to the disc, although this is not necessarily associated with direct trauma.
Discogenic pain, i.e., pain emanating from within the disc, is often axial low back pain and is
frequently aggravated by the assumption of certain body positions (e.g., prolonged sitting and
valsalva). Patients with discogenic pain often have annular tears or fissures within the disc that
contribute to their pain symptoms. Radiographically, these fissures may appear on the MRI as a
“high-intensity zone” (HIZ) (Figure 6.68) on the T2 weighted image. This HIZ on the MRI
represents a “radial” or “type II” annular tear. Radial tears are concentric fissures in the annular
fibers. In the past, a HIZ was described as a reliable marker of painful disc disruption, but that
concept has since been disputed.6–8 The presence of HIZs was noted in asymptomatic as well as
symptomatic individuals.6 While MRIs give useful information on disc morphology, they are limited
in their clinical application, as HIZs or other disc abnormalities are not always pain generators in
an individual patient. The MRI cannot identify which disc is causing the patient’s pain. Performing
a provocative discogram that recreates the patient’s exact (concordant) pain symptoms seeks to
establish the pain-generating lumbar disc.
Prior to performing discography, other sources of pain and spinal pathology should be ruled
out with radiographic studies. Once these have been ruled out and a discogram is performed at
least two discs must be evaluated. In order to have a valid provocative discogram, it is important
to establish that there is a nonpainful (control) disc.9 A painful discogram at a single level without
a nonpainful control discogram is a meaningless diagnostic test. Thus dicograms need to be
performed at both the suspected pain generating disc and at a control disc. While there may be
back discomfort as a result of intradiscal injection of contrast into a normal disc, an injection into
a normal disc usually does not produce concordant pain symptoms.
There are two types of information that may be obtained from lumbar discography:
1. The presence or absence of concordant pain in response to the injection of contrast (provocative
discography)
2. Information regarding the disc morphology based on the way in which the contrast spreads.
Provocative discography is the only means that we have to distinguish painful or symptomatic
discs from those that are not sources of pain. There is a risk of false-positive results, and thus,
patient selection is very important.10 Disc morphology can be further evaluated with a postdiscog-
raphy computed tomography (CT), where contrast can be seen within the annular tears. The CT
should ideally be performed within a few hours of the discogram to ensure adequate visualization
of the contrast. Discography is not for everyone; discography on asymptomatic volunteers and
patients with somatization disorder has reported high false-positive rates.10 Patients who report pain
during a discogram performed on a nondisrupted disc are more likely to have elevated hypochondriasis,
hysteria, and depression scores on the Minnesota Multiphasic Personality Inventory (MMPI).11
Indications:
1. Failure of all other diagnostic tests to provide the source of back pain
2. Diagnosis of the source of back pain in patients who are surgical candidates or are candidates for
intradiscal procedures
3. Evaluation of the level above or below the level of a fusion
4. Determination of symptomatic levels in a patient with multilevel disc disease
Contraindications:
1. Patient refusal
2. Systemic infection
3. Systemic anticoagulation
4. Pregnancy
5. Severe allergy to nonionic dye
6. Severe spinal stenosis
Complications:
1. Back pain
2. Discitis
3. Arachnoiditis
4. Damage to the disc
5. Postdural puncture headache
6. Meningitis
1. See the equipment and materials section at the beginning of this chapter — those listed below are
in addition to those listed at the chapter’s beginning.
2. With the exception of very thin patients, discography requires a longer needle than the 3½ in. spinal
needle used for most other spinal injections. A 25-gauge 4 11/16 in. or 5 in. needle may be used in
the average-sized patient.
3. A 25-gauge discography needle with an introducer may be used. These are especially helpful in
performing L5/S1 discograms.
4. Alternatively, a long (7 in., 22-gauge) spinal needle may also be used for obese patients. Curving
the needle at the distal tip in the direction of the needle bevel allows for easy navigation of the needle,
particularly when attempting to enter the L5/S1 disc.
5. Strict sterile technique is applied at all times; the needle should be kept within its sheath until the
time of use. Avoid handling the needle tip prior to the insertion of the needle.
6. A manometer is helpful when quantifying intradiscal pressures. It is also helpful when creating a
chart to document intradiscal pressures.
7. Prophylactic intravenous antibiotics, to be administered within 30 min of the procedure.
8. Water-soluble, nonionic contrast dye. Although there is no literature showing added benefit, we also
give patients both intradiscal antibiotics. The intradiscal antibiotics are given in combination with
the injected contrast (e.g., 1 to 10 mg/ml cefazolin). Generally, no more than 3 ml of dye is injected
into each disc.
9. The patient should be given instructions on post-procedure expectations and possible complications.
Manometry
Derby described using pressure-controlled discography to predict outcome. It provides a more
quantitative description of the discography results.12 The opening pressure is that pressure at which
dye was first observed within the disk space.5 A chemically sensitive disc is one that reproduces
concordant pain at low disc pressures (<15 psi above opening pressure). A mechanically sensitive
disc is one that reproduces concordant pain between 15 and 50 psi above opening pressure.5 Many
practitioners use a 3 ml syringe and use tactile feedback to assess the injection pressure of dye into
the disc as “low,” “intermediate or moderate,” or “high.” However, there are reports of discography
resulting in the production of pain in asymptomatic volunteers. Manometry may help to prevent the
injection of dye at very high pressures and the creation of a false-positive response (Figure 6.69).10
FIGURE 6.69
Examples of syringes used for manometry while performing discography.
Patient Preparation
Intravenous cefazolin (Ancef) 1 g is administered within 30 min of the procedure. If the patient is
allergic to cephazolin, clindamycin 900 mg intravenously may be used instead. Strict aseptic
technique is used, with sterile preparation and drape of the patient’s back.
Sedation
Discography is best performed with little to no sedation. A small amount of opioid once the
procedure is finished is acceptable to alleviate discomfort secondary to the procedure. It is important
to have the patient alert so that he or she may determine whether or not the discomfort that they
feel is an exact reproduction of his or her usual pain symptoms. If there is concern about further
documentation, then the pain physician may videotape the procedure, particularly the patient’s
facial response to the injection.
Preparation for Needle Placement

1. Which side is best to perform discography? Generally, the needle entry site is on the side contralateral
to the pain. This will avoid conflicting responses from the needle trauma in determining concordant pain.
2. Which levels should be performed? The suspected pain generator disc should be studied; however,
a nonpainful/normal control disc should always be studied as well. If all discs studied are painful,
and there are no nonpainful discs, the study is less meaningful and more difficult to interpret.
3. On which side should the C-arm be positioned? The C-arm should be on the same side as needle
entry, due to the exaggerated oblique angle that is often required for discography. This angle may
be more than the C-arm is able to perform from the contralateral side.
4. Using fluoroscopy in the A/P view, count the vertebrae from T12 to ensure that you are injecting the
correct disc. If there are more than five lumbar vertebrae, ensure that the intervertebral disc that you
are studying is the same disc that you were asked to study.
Patient Position
The patient is placed in the prone position on the procedure table (Figure 6.70A).
(A)
(B) (C)
FIGURE 6.70
(A) The patient should be in the prone position on the procedure table with a lumbar support placed under the lower
abdomen to reduce the natural lumbar lordosis. (B) Photographs of the lateral view of the oblique spine showing the needle
insertion of the lumbar discography. (C) Magnified version of B.
C-Arm Position
1. The C-arm is positioned on the same side as the needle entry. Square off the vertebral end plates in
the A/P view. If both the superior and inferior vertebral end plates cannot be squared off, then the
superior end plate below must be square (Figure 6.70D).
(D)
FIGURE 6.70 (continued).

(D) The vertebral endplates are squared in the AP view.
2. Once the vertebral end plates are squared, the C-arm may be moved into the oblique view to prepare
for needle entry.
3. Move the C-arm laterally around the patient until the superior articular process (SAP) is in the center
of the vertebral end plate. This usually creates a more oblique angle of the C-arm than would normally
be used for an intra-articular facet joint or transforaminal injection. The marker in Figure 6.71 shows
the needle entry site.
FIGURE 6.71
(A) Photograph of the oblique view of the target lumbar vertebra. (B) The tip of the pointer shows the needle entry point.
Note that the vertebral bodies are squared off and the superior articular process bisects the line created by the vertebral
endplates.
4. Sometimes moving the patient closer to the C-arm helps to facilitate this view.
Needle Placement
1. The needle is inserted into the lumbar disc via the groove located lateral to the lower portion of the
SAP (Figure 6.70B, Figure 6.70C, and Figure 6.71).
2. Needle entry is in the oblique view just lateral to the SAP. If the needle remains lateral to the SAP,
then far medial (intrathecal) needle placement will be avoided (Figure 6.72A).
Needle
(A)
FIGURE 6.72
(A) The needle entry is just lateral to the superior articular process (SAP).
3. The use of a curved-tip needle for enhanced control of the steering of the needle is recommended.
Once the SAP is contacted, the needle tip may be rotated laterally, then advanced around the SAP,
and guided into the center of the disc (Figure 6.72B).
(B)

((B) The needle is just past the SAP and is about to enter the disc in the lateral view.
4. There will be a change in resistance to advancement (like that of entering an eraser) once the annulus
is pierced, which may result in transient back pain for the patient (Figure 6.73A).
(A)
FIGURE 6.73
(A) The needle has just entered the disc. The AP view will look something like the above image with the needle in the
lateral aspect of the disc, still in the annulus. If you inject dye at this point, you will get an annulogram and not a discogram.
5. Once the disc is contacted, the C-arm is rotated from the A/P position to the lateral view. In order
to avoid the needle piercing the anterior margin of the disc, we recommend advancing the needle in
the lateral view.
6. Early in the needle advancement, the A/P view of the needle in the disc may appear as shown in
Figure 6.73B.
(B)

(B) In general you must advance the needle at least past the pedicle shadow to enter the nucleus in the AP view. If the
needle is in the center of the disc in the lateral view but has this appearance on the AP view, then the needle is too anterior
and lateral and must be redirected posteriorly and medially to access the center of the nucleus.
7. As we will discuss later in this chapter, it is possible to have excellent needle position in one view
and discover that the needle is not within the nucleus. Thus, once the needle appears to be within
the central aspect of the disc in the lateral view, an A/P view is repeated in order to verify that the
needle is within the center of the disc in both views (Figure 6.74).
8. Once you are satisfied that the needle is within the nucleus, then contrast is injected.
Potential Difficulties with Needle Placement

(Annular Placement of the Needle)
1. There are times when the needle appears to be in good position in one view, and upon viewing the
needle position from another angle, it is apparent that the needle is in the annulus (the periphery of
the disc) and not within the nucleus.
2. If the needle is in the center of the disc in the lateral view but is not in the center of the disc in the
A/P view, then the needle is too lateral and must be redirected posteriorly and medially in order to
access the center of the nucleus.
3. When advancing the needle, it is often easier to get the needle into the center of the disc if the needle
is angled slightly posteriorly so that the needle will advance medially into the disc. If the needle is
initially advanced at an acute angle, the result will be an annular placement and injection of dye.
Both views need to be checked, as the needle may appear to be in good position in, e.g., the lateral
view, but it may be too lateral in the A/P view, or vice versa. In both of those instances, the needle
needs to be repositioned to avoid an annular injection. (See Figure 6.73C through Figure 6.73E.)
The facetal column
(C)
The line of the medial margin of the
facetal column
Posterior Anterior
(D)
Anterior
(E)
Posterior

(C) Illustrates a needle that has not passed the facetal column in the AP view and thus has not entered the nucleus. (D and
E) Demonstrate a needle that is placed too laterally within the disc and ends up in the anterior-lateral annulus. (D) Shows
how the needle might appear in good position if seen via the lateral view. (E) Shows that when the same needle is visualized
from the AP view it is seen to be too lateral within the disc space.
What does an annulogram look like under fluoroscopy? There is a characteristic angular
appearance to an annulogram. The opening injection pressure is often greater than is seen with a
discogram (Figure 6.74A through Figure 6.74C).
(A)
(B)
FIGURE 6.74
(A) Lateral view of an annulogram. Note the box like appearance of the contrast in this lateral image. (B) AP view of an
annulogram.
(C)

(C) Image of an initial annulogram where the needle was repositioned and initial injection of contrast spread across the
midline.
Contrast Injection within the Disc Space
1. The needle is in good position; verified in both A/P and lateral views (Figure 6.75A through Figure
6.75D).
(A)
(B)
FIGURE 6.75
(A) The needle is within the nucleus in the A/P view. (B) The lateral view of the 25-gauge needle within the nucleus.
The end plates are not

squared.
(C)
(D)

(C) This lateral image is not squared; it is a parallax view and it is difficult to tell whether the needle is in good position.
(D) Two needles advanced into the disc in the lateral view.
2. Aspirate the contrast containing antibiotic into the manometer syringe (if manometry is to be used).
Check to ensure that it is set to psi (not atm); note how many milliliters of antibiotic containing
contrast are contained within the syringe prior to starting. Turn the syringe handle, and note the
pressure reading when dye first comes out of the needle. This is the opening pressure.
3. Continue to inject dye into the disc, and watch for adequate spread of dye. Monitor the volume
injected, the injection pressure, and the patient’s response. We recommend not injecting more than
3 ml of dye within the disc (Figure 6.76A, Figure 6.76B, and Figure 6.77).
(A)
(B)
FIGURE 6.76
(A) AP view of a normal discogram. (B) Lateral view of a normal discogram.
FIGURE 6.77
AP view of a discogram at L3/L4.
4. Record the pressure at which the patient reports pain. Also record the pain intensity and character
using a verbal analog scale (0 to 10). Record how similar the pain is to the patient’s usual and
customary pain (concordance).
5. Record the morphology of the disc — whether it is normal or whether fissures are seen, or whether
there is epidural spread. Epidural spread is best seen in the lateral view (Figure 6.78A and Figure 6.78B).
(A)
(B)
FIGURE 6.78
(A) Lateral view of contrast within the L3/4, L4/5 and L5/S1 discs. The arrow is pointing to the epidural extravasation of
the contrast from the L3/4 disc space. (B) AP view of a discogram at L5/S1 with contrast spread across the disc.
6. A normal disc will generally not hold more than 3 ml. After the provocative discography, an analgesic
response may be observed after the intradiscal injection of a small quantity of local anesthetic.
Intradiscal steroids have also been used with varying results.
7. The patient’s pain response: The key to pain assessment in provocative discography is determining
whether the patient’s usual pain symptoms are reproduced during discography. Thus, particular
attention must be paid to the patient’s pain response:
a. Does the patient have concordant pain? That is, were the character and location of the patient’s
pain reproduced with the discography exactly like the patient’s usual pain? Is the intensity of
the pain produced by discography similar, less than, or greater than the patient’s usual pain? Rate
both the pain intensity and concordance, e.g., 8/10 intensity and 10/10 concordance.
b. Does the patient have discordant pain? That is, the character and location of the pain are not
exactly like the patient’s usual pain, or the intensity is dissimilar to the patient’s typical pain. If
the level to be studied produces discordant pain, then the discogram at this level is described as
“indeterminate.” An example of how this is described is that the pain intensity was 8/10, and the
concordance was 3/10.
c. Is the injection painless? If so, then this is the control level. If all the levels injected are painless,
then the discogram is negative.
Mechanically vs. Chemically Sensitive Discs
Chemically sensitive discs are described as those discs producing concordant pain at less than 15 psi
above the opening pressure. Pain reproduction at low injection pressures indicates a very sensitive
annulus and is thought to be due to chemically sensitized nociceptors in the outer annulus.5
Mechanically sensitive discs produce concordant pain at 15 to 50 psi above opening pressure.
Discography at L5/S1
Discography at the L5/S1 level is more technically challenging than its more cephalad counterparts.
This is especially true in male patients, as the male iliac crest tends to angle closer to the spine,
making it more difficult to pass the needle into the L5/S1 disc space while avoiding the L5 nerve
root. A more detailed description of the anatomy and its consequences is detailed in the section on
L5/S1 transforaminal epidural steroid injections (Figure 6.62 and Figure 6.63). The likelihood of
encountering the exiting nerve root is greater, and a curved needle is helpful to avoid paresthesias.
The needle should be bent so that the bevel is cut in the same direction as the bend that you made
in the needle. Some pain physicians use an intrathecal approach to access the L5/S1 disc if the
oblique approach to the L5/S1 disc is technically impossible.
The C-arm position is different than is seen for the levels above L5/S1. The cephalad to caudal
tilt of the C-arm is such that the image intensifier is often very close to the patient’s torso (Figure 6.79).
Positioning C-Arm Fluoroscopy

The L5/S1 vertebral end plates are squared in the A/P view by positioning the C-arm as is depicted
in Figure 6.79.
FIGURE 6.79
The C-arm is tilted toward the patient’s head so that the L5/S1 vertebral end plates are squared in the AP view.
Inserting a Needle
The needle entry is performed in the oblique view. The C-arm should be rotated laterally until, if
possible, a “triangle” is obtained (Figure 6.80). The borders of this triangle are outlined as follows:
FIGURE 6.80
Entry site for an L5/S1 discogram.
1. Superiorly by the inferior border of the L5 vertebral body

2. Medially by the lateral aspect of the SAP of S1
3. Laterally by the medial aspect of the posterior superior iliac crest
The needle is then advanced via the opening provided by the triangular borders described above,
cautiously avoiding the exiting L5 nerve root. The angle at which the needle is placed is from
cephalad to caudad (Figure 6.81).
FIGURE 6.81
Lateral view of dye spread within disc.
Once the needle is past the SAP of S1, the C-arm is rotated to the lateral view to allow for entry
of the needle into the disc (Figure 6.82).
FIGURE 6.82
Lateral view of the needle in position for an L5/S1 discogram.
Confirming the Needle Placement

As with the levels above L5/S1, verify with an A/P view that the needle is within the nucleus
(Figure 6.83).
FIGURE 6.83
The needle is in the center of the L5/S1 disc. There is contrast seen in the L4/L5 disc above.
Injecting Contrast
Inject contrast via the needle as was described for the other lumbar levels. Record the patient’s
pain response and disc morphology as before. (See Figure 6.84 through Figure 6.86 for more detail.)
FIGURE 6.84
A discogram of a mature disc at L5/S1.
FIGURE 6.85
A circumferential annular tear is seen in this discogram.
FIGURE 6.86
A lateral view of an L4/L5 and L5/S1 discogram.
When the disc height is reduced, discography at this level is more difficult, and the area through
which the needle must traverse and avoid the nerve root is smaller. This is also compounded by
the fact that the iliac crests in men are at a more acute angle, making the angle required to enter
into the disc space steeper than that for women. This sometimes requires a greater bend of the
needle; there are some practitioners that place two small bends in the needle to facilitate the more
acute angle seen at this level. Sometimes the needle needs to enter the disc from a more lateral approach
in order to be placed in the center of the disc. This may be done either by having a more lateral
entrance to the “triangle” described above or by directing the needle more laterally once it is past the
iliac crest and then redirecting medially toward the disc space. Finally, in patients with particularly
difficult anatomy, there is the option of advancing the needle through the intrathecal space directly
into the disc. The needle should be advanced into the center of the disc in the lateral view as before.
When checking the A/P view, the bodies should be square (Figure 6.16A and Figure 6.16B),
recalling that the C-arm tilt needed for needle entry was much greater than that needed for the
more cephalad levels.
Post-Procedure
It is prudent to supply the patient with post-procedure information cautioning them to avoid
activities that increase disc pressure for the hours following discography (e.g., avoid straining).
They should be cautioned on warning signs of discitis (e.g., fever, increased back/leg pain that is
not their usual pain) or cauda equina syndrome. They should be warned that some back discomfort
is normal, but a marked increase in back pain that is different from their usual pain, especially in
the presence of fever, warrants further investigation.
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13. Dreyfuss, P., Schwarzer, A.C., Lau, P., and Bogduk, N. Specificity of lumbar medial branch and L5
dorsal ramus blocks: a computed tomographic study. Spine 22, 895–902, 1997.
14. van Kleef, M., Barendse, G.A.M., Kessels, A., Voets, H.M., Weber, W.E.J, and de Lange, S. Randomized
trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 24 (18), 1937–1942,
1999.
15. Bogduk, N. and Long, D.M. The anatomy of the so-called “articular nerves” and their relationship to
facet denervation in the treatment of low-back pain. Journal of Neurosurgery 51, 172–177, 1999.
16. Lutz, G.E., Vad, V.B., and Wisneski, R.J. Fluoroscopic transforaminal epidural steroid injections: an
outcome study. Arch Phys Med Rehab 79, 1362–1366, 1998.
17. Weiner, B.K. and Fraser, R.D. Foraminal injection for lateral lumbar disc herniation. J Bone Joint Surg
79B, 804–807, 1997.
18. Hopwood, M.B. and Abram, S.E. Factors associated with failure of lumbar epidural steroids. Regional
Anesthesia 18, 238–243, 1993.
19. Hogan, Q.H. Lumbar epidural anatomy, A new look by cryomicrotome section. Anesthesiology 75,
767–775, 1991.
20. Guyer, R.D. and Ohnmeiss, D.D. Lumbar discography. Spine (3 suppl), 11S–27S, 2003
21. Bogduk, N. Lumbar discography. Spine 21(3), 402–404. Feb 1996.
22. Coppes, M.H., Marani, E., Thomeer, R.T.W.M., and Groen, G.J. Innervation of “painful” lumbar discs.
Spine 22(20), 2342–2350, 1997.
23. Fagan, A., Moor, R., Roberts, B.V., Blumbergs, P., and Fraser, R. ISSLS Prize Winner: The Innervation
of the Intervertebral Disc: A Quantitative Analysis. Spine 28(23), 2570–2576, 2003.
24. Recommendations for Lumbar Discography. ISIS Newsletter, December 1997, pp. 80–91.
25. Jensen, M.C., Brant-Zawadzki, M.N., Obuchowski, N., Modic, M.T., Malkasian, D., and Ross, J.S.
Magnetic Resonance imaging of the lumbar spine in people without back pain. The New England
Journal of Medicine 331, 69–73, 1994.
Chapter
Fluoroscopic Images
of the Cervical Spine
7
151
Fluoroscopic Images of the Cervical Spine 153
Positioning the Patient

Cervical spinal injections can be done in either the supine (Figure 7.1A), prone (Figure 7.1B), or
lateral positions (Figure 7.1C).
FIGURE 7.1
Cervical spine injection positions. (A) Supine position. (B) Prone position. (c) Lateral position.
Positioning the C-Arm

The C-arm can be positioned in many ways for cervical spinal injections (Figure 7.2). For example,
the C-arm can be positioned from the patient’s side, as when performing lumbar procedures (Figure
7.2A). The C-arm can also be positioned from behind the patient’s head (Figure 7.2B). The C-arm
can be positioned to get a lateral view of the cervical spine as seen in Figure 7.2C and Figure 7.2D.
FIGURE 7.2
C-arm positions. (A) At side. (B) At patient’s head. (C) and (D) Positioned for lateral view of cervical spine.
A/P (P/A) View and Lateral View of the Cervical Spine

Images of both the anterior–posterior (A/P) view in the prone position, the posterior–anterior (P/A)
view in the supine position and the lateral view of the cervical spine, look quite different from
images of the A/P and lateral view of the lumbar spine (Figure 7.3). This is due to the unique
shapes of the cervical vertebrae.
A B
C D
Mandible
FIGURE 7.3
The cervical and the lumbar spine. (A) P/A view of the cervical spine. (B) A/P view of the lumbar spine. (C) Lateral view
of the cervical spine. (D) Lateral view of the lumbar spine.
Comparison of Cervical Vertebrae and Lumbar Vertebrae

Like a lumbar vertebra (Figure 7.4B), a cervical vertebra (Figure 7.4A) consists of the vertebral
body, two transverse processes, two pedicles, lamina, two superior articular processes, two inferior
articular processes, and a spinous process. However, the cervical vertebra differs from the lumbar
vertebra. Their differences are summarized in Table 7.1. Figure 7.5 is a P/A view image of the
cervical spine.
FIGURE 7.4
(A) Cervical vertebra (superior view). (B) Lumbar vertebra (superior view). (C) Lateral view of the cervical spine from C4
to C7. (D) Lateral view of the lumbar vertebra.
TABLE 7.1
Comparison of Cervical Vertebrae and Lumbar Vertebrae
Cervical Vertebra Lumbar Vertebra
Vertebral body Small Large
Transverse process Quite small Large
Connects to lateral surface of vertebral body Connects to posterior surface of vertebral body
Anterior to the pedicle Posterior to the pedicle
Has transverse foramen Lateral to the superior articular process
Anterior to the superior articular process
Pedicle Short Long
Connects to posterior surface of transverse Connects to posterior surface of lumbar
process vertebral body
Spinous process Varies in length Long
Ends in two tips (called bifid tips) Ends in only one tip
Superior articular Connects to pedicle only Connects to pedicle and transverse process
process
Inferior articular Articular pillar connects the superior and Pars interarticularis (part of lamina) connects to
process inferior articular processes superior and inferior articular processes
FIGURE 7.5
Fluoroscopic image of the P/A view of the cervical spine. (1) Spinous process, (2) transverse process with transverse
foramen, (3) articular pillar, (4) vertebral body.
Lateral and Oblique Views of the Cervical Spine

Figure 7.6 is a lateral fluoroscopic image of the cervical spine. We usually rotate the fluoroscopic
image horizontally if the patient is in a supine position (Figure 7.7).
Mandible
3
6
2
4
7
FIGURE 7.6
Fluoroscopic image of the lateral view of the cervical spine. (1) Spinous process, (2) articular pillar, (3) superior articular
process, (4) inferior articular process, (5) vertebral body, (6) pedicle, (7) transverse process with transverse foramen.
Mandible
6
5
3 1 4
FIGURE 7.7
Fluoroscopic image of the lateral view of the cervical spine (rotation of fluoroscopic image in Figure 7.6). (1) Spinous
process, (2) articular pillar, (3) superior articular process, (4) inferior articular process, (5) vertebral body, (6) transverse
process with transverse image of the foramen.
In true lateral images of the cervical spine (Figure 7.8), the vertebral body is squared, the
articular pillar is a trapezoid shape, the facet joint space is open, the transverse process with
transverse foramen cover the posterior–superior portion of the vertebral body, and the spinous
process has sharp superior–posterior and inferior margins.
Mandible
Transverse processes with transverse foramina cover posterior–superior

portion of vertebral body
Vertebral body is squared off
Vertebral body
Transverse process with

transverse foramen
Articular pillar
Spinous
process
Facet space is open

A trapezoid Spinous process
shape of has sharp
Articular pillar margins
FIGURE 7.8
Lateral images of cervical spine.
Figure 7.9 illustrates the comparison between the true lateral view and the false lateral view
of the cervical spine images. The left column illustrates true lateral view images. The right column
illustrates the false lateral images.
A B
Mandible
C D
E F
FIGURE 7.9
(A) True lateral image. (B–F) False lateral images.
It is very difficult to identify intervertebral foramina on the lateral image of the cervical spine
compared with the lateral image of the lumbar spine (Figure 7.10). This is because the cervical
transverse processes complex opacifies the image of intervertebral foramen. However, if we view
the cervical spine obliquely and inferiorly (Figure 7.11), we can visualize the intervertebral foramina
easily.
Mandible
Transverse processes cover intervertebral

foramens
Intervertebral
foramens B
FIGURE 7.10
(A, B) Lateral images of the cervical spine. (C) Lateral image of the lumbar spine.
FIGURE 7.11
(A) Photo of inferior and oblique views of the cervical spine. (B) Photo of the lateral view of cervical spine.
A unique oblique image of the cervical spine (Figure 7.12) can be obtained by tilting the C-arm
to the injecting side about 45˚ and rotating caudally about 20 to 30˚ (Figure 7.13).
Mandible
FIGURE 7.12
Right-sided obliquely viewed fluoroscopic image of the cervical spine.
FIGURE 7.13
The C-arm positions required to obtain a fluoroscopic image of the cervical spine shown in Figure 7.12.
Cervical Intervetrebral Foramina and the Cervical Spinal

Nerve Roots
There are eight cervical spinal nerve roots and only seven cervical vertebrae. There is no interver-
tebral foramen between C1 and C2. The first visualized cervical intervertebral foramen is between
C2 and C3. The C3 spinal nerve root travels via this foramen (Figure 7.14). The vertebral artery
goes via the transverse foramina, usually from the C6 foramen to the C1 foramen into the skull (Figure
7.15A and Figure 7.16A). The possible locations of the vertebral artery are demonstrated on the
laterally and obliquely viewed fluoroscopic images of the cervical spine (Figure 7.15B and Figure
7.16B).
Mandible
The foramen between C2 and C3
There is no foramen between C1 and C2
FIGURE 7.14
Method for counting intervertebral foramina and cervical spinal nerve roots.
Mandible
Vertebral artery
B
Vertebral artery
FIGURE 7.15
Location of the vertebral artery on the lateral view of the cervical spine.
Mandible
Vertebral artery
Vertebral artery
FIGURE 7.16
Location of the vertebral artery on the obliquely viewed cervical spine.
Bibliography
Brown, D.L., Ed., Atlas of Regional Anesthesia, 2nd ed., W.B Saunders, Philadelphia, 1999.
Chapter
Cervical Injections 8
169
In this chapter, we will discuss injections around the cervical spine for the relief of pain due to
headaches, neck pain, shoulder pain, and arm and hand pain. We will first begin with cervical facet
injections, both intra-articular and medial branch injections and radiofrequency denervation, and
we will then proceed to cervical epidural and nerve root injections. Both interlaminar and transfor-
aminal epidural steroid injections will be discussed.
The pain physician should be very familiar with lumbar injections prior to attempting any
injections in the neck. Familiarity with airway management is also recommended for physicians
who perform cervical spinal injections.
Preparation for the Performance of Cervical Injections

Patient preparation: We advise the patients to have no solid foods for a minimum of 6 h,
particularly prior to cervical injections. We recommend that the patients have another individual
available to transport them home following the procedure. Sterile preparation and drape are required;
preparation above and below the hairline may be required, particularly for the upper cervical
injections. Monitor the patient’s heart rate, blood pressure, and oxygen saturation. The American
Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines report no evidence of
additional risk for patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) who received
spinal or epidural analgesia.1 However, when performing cervical transforaminal injections, it is
the author’s practice, as a precaution, to ask the patients not to take aspirin for 7 to 10 d prior to
the procedure and not to take NSAIDs (with the exception of COX-2 inhibitors) the day of the
procedure.
• A 22- or 25-gauge 3½ in. spinal needle, with or without a distal curved tip in the direction of the
bevel, is used for most cervical procedures performed in the prone position. A 25-gauge, 2 in. spinal
needle is adequate for the vast majority of cervical foraminal and facet injections that are performed
with the patient in the supine position. It is very rare, even in obese patients, to require a 3½ in.
spinal needle for cervical transforaminal injections.
• Intravenous (IV) access for all cervical transforaminal injections as a safety precaution in the event
of intravascular injection.
• Oxygen delivered at low flows via nasal cannula is suggested.
• Water-soluble nonionic dye.
• Local anesthetic (e.g., 0.25 to 0.5% bupivacaine or 2% lidocaine) and steroid for a total of 1 ml or
less of injectate. Note that the local anesthetic and steroid may be injected together as a combined
solution or separately.
• We recommend using the least particulate steroid available for transforaminal epidural steroid or
selective nerve root injections. Steroids are not necessary for medial branch injections.
• A syringe (or syringes) for injecting the local anesthestic and steroid. A 3 ml or smaller is recom-
mended; a 10 ml syringe is too large and will generate too much pressure with aspiration and risk
inadvertent vascular injection.
• Connection tubing to allow for contrast injection without fluoroscopy exposure to the hands. This
also facilitates an immobile needle.
• Lidocaine (0.5 to 2%) and a 25- to 27-gauge needle for local infiltration. We do not recommend the
use of needles greater than 1 in. for skin infiltration for cervical procedures, particularly in thin
patients. We recommend very superficial, subcutaneous injections of local anesthetic to avoid intra-
vascular or brachial plexus injections.
Sedation: Light sedation is recommended, e.g., with midazolam 1 to 2 mg intravenously.

Cervical Facet Injections

Headaches and pain felt in the neck, shoulders, and upper back may originate in the upper, middle,
and lower cervical facets, respectively.2,3 Cervicogenic headaches differ from vascular headaches
both in their symptoms and in the origination of cervicogenic headache from the posterior superior
neck. These headaches may also be reproduced by palpation of the painful facet joint, with lateral
neck movement, and particularly with neck extension. Cervicogenic facet and radicular pain are
similar in character when originally from the upper cervical levels (C1–C4). The C2/C3 joint was
reported to be a source of headaches following whiplash injury. Excellent response has been reported
for relief of these headaches from lesions of the third occipital nerve, which innervates the C2/C3
facet joint.4 Below C4, cervical facet pain radiates to the shoulder and upper back; while cervical
radiculopathy involving the C5 root and below involves the shoulder then radiates distally to the
arm (Figure 8.1).
C1
(atlas)
C2
(axis)
C7
T1
FIGURE 8.1
The cervical spine, viewed from the lateral approach. The needles indicate the target areas for both medial branch and
intraarticular facet injections on the left side.
Intra-Articular Facet Injections

C1/C2 Joint Injection
The C1/C2 or atlantoaxial (AA) joint (Figure 8.2A) receives innervation from the C2 nerve root.
Pain, generally posterior headaches, that comes from the C1/C2 joint is generally localized to the
suboccipital region and may be exacerbated with neck rotation. Pain coming from the upper cervical
facets is more often manifested as headache rather than neck pain.5 The C-arm should be adjusted
in order to obtain the clearest view into the joint. The angulation of the C1/C2 joint is not as caudal
as it is in the lower cervical facets. The vertebral artery is just lateral to the C1/C2 joint; thus. the
needle should stay medial to the lateral border of the C1/C2 joint at all times. If the needle enters
medial to the junction of the lateral one third of the joint, the likelihood of an intrathecal injection
increases (Figure 8.2B).
(A)
Atlantoaxial (AA) joint
(B)
FIGURE 8.2
(A) Photograph of a spine model of the C1/C2 joint. (B) The spine with the C1/C2 joint marked.
Indications:
1. Neck pain with associated posterior headache
2. Upper neck pain exacerbated by neck movement
Contraindications:
1. Patient refusal
2. Systemic anticoagulation or coagulopathy
3. Systemic or localized infection at the site
4. Unstable cervical spine
Patient position: The patient is placed in the prone position; a pillow may be placed under
the chest to allow for slight neck flexion (Figure 8.3).
A pillow under the chest
FIGURE 8.3
The patient position for C1/C2 intraarticular injection.
C-arm position:
1. The C-arm is placed at the head of the bed in front of the patient (or, alternatively, it may be at the
patient’s side).
2. If the image intensifier is at the head, then it is rotated approximately 20˚ toward the head to get an
anterior–posterior (A/P) view of the joint. This is best accomplished with the patient’s mouth open.
Adjust the image intensifier angle until a sharp image of the AA joint is visualized.
3. We recommend saving copies of the A/P and lateral views showing the location of the needle tip
before and after the injection of contrast into the joint.
Procedure:
1. The patient’s posterior occipital region is prepped in a sterile fashion above and below the hairline
and then draped.
2. The C-arm is positioned as described above.
3. A 22- or 25-gauge, 3½ in. spinal needle is used. A slight curved tip often makes the needle easier
to steer and allows for “bevel control.”
4. It is easier to visualize the AA (C1/C2) joint if the patient’s mouth is open (Figure 8.4A and Figure 8.4B).
5. The needle is advanced from the caudal aspect of the AA joint and enters the joint at the junction
of the lateral one third and medial two thirds of the joint in the A/P view.
6. The needle depth is ascertained in the lateral view, and the needle tip position within the AA joint
is determined in the A/P view.
(A)
(B)
FIGURE 8.4
(A) C1/C2 view with mouth closed. The needle is seen entering the left C1/C2 joint. (B) C1/C2 view with mouth open to
make visualization easier. The needle is seen entering the left C1/C2 joint space.
7. Advancing in the A/P view increases the likelihood that the needle will stay in the correct location
within the joint space.
8. Verify the needle depth periodically with lateral views (Figure 8.5).
(A)
(B)
FIGURE 8.5
(A) Lateral view of the C1/C2 joint, with the needle approaching the joint. (B) The needle has advanced toward the C1/C2
(AA) joint in the lateral view.
(C)
(D)
FIGURE 8.5 (continued)

(C) The needle continues to advance into the C1/C2 joint in the lateral view. (D) Photograph of a cervical spine model
viewed from the lateral aspect.
9. After negative aspiration, <0.5 ml of nonionic contrast dye into the joint is recommended to verify
the correct needle position (Figure 8.6).
FIGURE 8.6
Examples of A/P views of dye within the left C1/C2 joint space.
10. The joint space is entered inferiorly and then walked in. The target is the junction between the lateral
one third and medial two thirds of the joint space. A small volume of local anesthetic and steroid is
injected into the joint space after negative aspiration.
11. After negative aspiration, the combination of local anesthetic and steroid is then injected carefully
into the joint.
Complications:
1. Injection into the vertebral artery, venous plexus, or cerebrospinal fluid (CSF) of air, local anesthetic,
or steroid
2. Injection into the foramen magnum or spinal cord
3. Laceration of the vertebral artery
4. Cerebellar hemorrhage or infarction
C2/C3 to C6/C7 Intra-Articular Joint Injections

Pain from the C2/C3 to C4/C5 facets is felt in the neck and upper shoulders.6,7 Below this level,
the pain spreads distally down the upper back and scapulae. The symptoms are increased with neck
extension and lateral bending and may be reproduced with palpation of the facet joints, particularly
when palpated from a slightly lateral direction.
Contraindications:
1. Patient refusal
Patient position: Intra-articular injections of the C2/C3 to C6/C7 facet joints may be performed
in the prone, lateral, or supine positions. In the supine and lateral positions, the lateral view is used;
in the prone position, the A/P view is used.
C-arm position:
1. From the supine position:
a. The C-arm may either be perpendicular to the patient’s head or in line with the patient when it
is positioned behind the patient’s head.
b. It is important to keep the patient’s head looking up toward the ceiling to keep the head in neutral
position.
c. Tilt the C-arm to get a lateral view showing clear joint lines without an overlapping shadow from
the contralateral joint (Figure 8.7).
(A)
(B)
FIGURE 8.7
(A) The patient is supine and the C-arm is aligned for a lateral image. (B) The patient is in the lateral position and the
C-arm is aligned for a lateral image.
d. It is important to get a true lateral view with even joint space margins when performing these
injections (see Chapter 7, Figure 7.9), otherwise, the needle may venture posteriorly and medially,
resulting in intrathecal injection or cord injury. The needle tip position should be verified in both
the A/P and lateral views, even if it “feels” as though it is in the joint.
2. From the prone position:
a. The prone position has advantages in the performance of bilateral intra-articular cervical facet
injections. When bilateral injections are performed in the supine position, the contralateral needle
may obscure visualization once contrast is injected. In the prone position, there is no overlapping
image from the contralateral side.
b. The cervical facets are slanted in a slightly caudad direction.
c. The C-arm is rotated forward so that the image intensifier is toward the feet, and the joint space
appears to be more open (Figure 8.8).
(A)
(B)
FIGURE 8.8
(A) Diagram of the patient in the prone position. (B) Diagram of the correct C-arm alignment with the patient in the prone
position.
d. The needle entry is from slightly caudal to the cervical facet joint.
e. It may sometimes be necessary to slightly rotate the patient’s neck to the contralateral side in
order to better visualize the joint space.
f. The needle entry is at the lateral one third of the joint.
g. Stop advancing the needle once change in resistance is felt and the joint space is entered.
h. In the prone position, the A/P view is used for the needle approach to the joint, and the lateral
view is used to check the needle depth (Figure 8.12).
Procedure:
1. From the supine position:
a. The lateral fluoroscopic view is used for needle entry.
b. Needle entry is at the inferior to middle aspect of the joint space and is advanced into the
radiolucent joint space, keeping the needle tip over the joint space at all times (Figure 8.9A).
c. Once the change in resistance is felt and the joint space is entered, stop advancing the needle.
(A)
FIGURE 8.9
(A) Needle entry site for cervical intraarticular injection. The needle is pointing to the C3/4 facet joint.
d. The needle tip position is verified in both the A/P and lateral views, even if it “feels” as though
it is in the joint (Figure 8.9B).
(B)

(B) The needle is in the correct location within the joint in the P/A view.
e. A small amount of nonionic dye injected into the joint space verifies the correct position of the
needle (Figure 8.10).
(A)
(B)
FIGURE 8.10
(A) The needle has entered the joint. Note that due to the tunnel vision, the needle is exactly in line with the beam of the
C-arm. (B) A small amount of dye has been injected into the joint and can be seen to spread within the joint space.
f. If the capsule is disrupted, there may be epidural spread (Figure 8.11).
(A)
(B)
FIGURE 8.11
(A) P/A view of an intraarticular facet injection with dye spread along the joint. (B) P/A view of an intraarticular facet
injection with dye spread in the joint and dispersing into the epidural space.
FIGURE 8.12
Intraarticular injection performed in a patient in the prone position, with dye spread along the joint space.
g. For injection, <1 ml of a solution of local anesthetic and steroid is recommended.

h. A small amount of nonionic contrast injected into the joint space verifies the position of the
needle.
i. If the capsule is disrupted, there may be epidural spread.
j. A solution of local anesthetic and steroid, <1 ml, is injected.
Cervical Medial Branch Injections
Cervical medial branch injections may be performed in either the prone or supine position, utilizing
A/P, lateral, or oblique approaches.8 The cervical facets may be anesthetized with a local anesthetic
blockade of the medial branches of the dorsal rami of the spinal nerves that supply each joint. The
typical location of the medial branches is in the center of the trapezoid formed by the lateral aspect
of the facet. This is most often seen at the C4 and the C5 medial branches that innervate the C4/C5
facet joint (Figure 8.13). Medial branch injections are performed as a diagnostic tool prior to the
performance of radiofrequency denervations of those nerves. The cervical facet joint is innervated
by the medial branches of the nerves above and below that joint. For example, the C4/C5 facet
joint is innervated by the medial branches of the C4 and C5 dorsal rami of the C4 and C5 spinal
nerves. Thus, in order to anesthetize the C4/C5 facet joint, two injections must be performed. When
using the oblique approach for medial branch injections or denervations, the needle entry is slightly
below (posterior to) the foramen in the oblique view. The target site is at the base of the superior
articular process in the oblique view and in the center of the waist of the vertebra in the posterior–
anterior (P/A) view. In the lateral view, it is in the center of the image that has the appearance of
a trapezoid. In the lateral view of the lower cervical facets, the medial branches have been described
to lie in the superior aspect of the waist of that trapezoid.
C1
C2
Cervical medial
branches
T1
(A)
FIGURE 8.13
(A) Model of the lateral cervical spine labeled with the positions of the cervical medial branches.
(B)
Cervical medial branch is located in the center of the trapezoid

(B) Diagram of the target point for cervical medial branches in the center of the trapezoid.
Contraindications:
1. Patient refusal
Patient position: This procedure may be performed with the patient in the supine, lateral
decubitus, or prone position. The supine position is commonly used for most of the cervical
procedures that we perform.
C-arm position: A more detailed description of C-arm positioning is found in Chapter 7. In all of the
injections described in this book, it is imperative that the image on the screen is a clear representation
of the target area. Refer to Chapter 7 for details on how to get a properly aligned fluoroscopic image of
the cervical spine in the lateral, P/A and A/P, and oblique views.
1. This procedure is easier to perform with the C-arm at the head of the patient and the patient in the
supine position. Unless otherwise specified, all of the descriptions below will refer to the patient in
the supine position.
2. The cervical medial branches may be approached from the lateral, prone, or oblique view.
3. Lateral approach:
a. The patient is in the supine position with the head facing the ceiling (Figure 8.7A).
b. Square off the cervical facet joints with the C-arm in the lateral view.
4. Oblique approach (Figure 8.14):
FIGURE 8.14
Diagram of the oblique C-arm position for cervical medial branch injections.
a. Square off the cervical end plates in the A/P view by moving the image intensifier approximately
20˚ toward the feet.
b. Then, move the C-arm between 45 and 50˚ until the contralateral transverse foramen are just
below the superior border of the vertebral bodies, and the ipsilateral transverse foramen appear
as dark ovals on the posterior aspect of the spine. This view is slightly different from the oblique
view used for cervical transforaminal injections. In this view, the contralateral transverse foramina
are more posterior to the border of the vertebral bodies than is seen in the view for the cervical
transforaminal injections.9
c. The cervical foramen should be easily visualized in this view.
5. Prone approach:
a. The head may be in the neutral position, facing down; the neck should not be extended.
b. The C-arm is rotated forward until the best view of the joints is seen.
c. The posterior approach must be used to access the C8 medial branch, and we recommend it for
C7 medial branch radiofrequency denervations as well.
Procedure:
1. Lateral approach (Figure 8.7A, Figure 8.13, Figure 8.15)):
FIGURE 8.15
Lateral view of a cervical medial branch injection.
a. The needle entry is at the center of the trapezoid seen in the lateral view. This is best seen with
the C4 and C5 levels.
b. The needle depth is checked in the A/P view, and the location of the needle tip with respect to
the facet is checked in the lateral view.
c. In the A/P view, the needle is seen in the lateral concavity of the cervical facetal column. The
needle should not be medial to this lateral border.
d. The medial branches of the C3, C6, and C7 dorsal rami lie more superiorly along the trapezoid.
e. The needle tip should be advanced on top of bone (the trapezoid) to avoid entry into the epidural
or intrathecal spaces.
2. Oblique approach:
a. Needle entry is slightly below the foramen and angled anteriorly.
b. The needle tip should be advanced on top of bone as much as possible. Posterior placement of
the needle during advancement increases the possibility of a medial (epidural or intrathecal)
needle position.
c. The needle is advanced until it hits bone.
d. The needle position may be checked in the lateral view.
e. The needle position is also verified in the A/P view to ensure that it is lateral to the cervical facet
shadow (Figure 8.16).
FIGURE 8.16
P/A view of a cervical medial branch injection. Note that the needle is in the waist of the cervical facet in this view.
3. Prone approach:
a. Target the depression or “waist” seen on the A/P view of the cervical facet that represents the
lateral aspect of the facetal column.
b. Once bone is contacted, rotate the C-arm to obtain a lateral view, and advance the needle to the
center of the trapezoid, staying close to bone at all times. A “true” lateral view is very important.
c. In patients with short necks, a lateral view may not be possible, as the shoulder obscures the view.
Needle depth is then difficult to assess. In those cases, the needle should remain on the postero-
lateral aspect of the facetal column. Ensure that the A/P view being used is aligned correctly.
d. A small volume (e.g., 0.3 ml) of local anesthetic is injected at each level after negative aspiration.
e. Consideration should be given to injecting a small amount of contrast prior to injection of local
anesthetic to avoid intravascular injection.
Cervical Medial Branch Radiofrequency Denervation

Significant pain relief lasting 6 to 15 months has been observed with radiofrequency denervation
of the medial branches of the cervical dorsal rami supplying the facet joints.7 If the patient receives
significant (>70%) pain relief from diagnostic facet injections, they are good candidates for radio-
frequency denervation.10–13 Again, at least two levels need to be lesioned in order to denervate a
single joint, i.e., lesions need to be performed at both the C3 and C4 medial branches in order to
denervate, e.g., the C3/C4 joint. The superficial branch to the C2/C3 joint, the third occipital nerve, is
larger than the other medial branches and, thus, requires multiple lesions to adequately denervate.10–12,14
Radiofrequency Denervation: (C3 to C8) Medial Branches
The needle placement for radiofrequency denervation differs from that of facet injections in that the
goal is to maximize the lesion size and efficacy. There are two kinds of radiofrequency lesions: heat
(destructive) lesions and pulsed (nondestructive) lesions. Both may be used in the cervical spine.
Equipment/Materials: The equipment and materials for radiofrequency denervation are different than
those for other cervical injections.
1. A 5 cm radiofrequency needle with 5 mm or smaller active tip; curved or straight needle tip. A
radiofrequency generator, a dispersive pad placed on the patient’s lower extremity, and a radiofre-
quency electrode. In some rare instances, there may be a patient with a very thick neck, where a 5
cm needle is not long enough and a 10 cm needle may be used, preferably with a 5 mm active tip.
2. Oxygen delivered at low flows via nasal cannula.
3. Local anesthetic (e.g., 0.5% bupivacaine or 2% lidocaine).
4. A 3 ml syringe.
5. Lidocaine (1%) and short (<1 in. needle) 25- or 26-gauge needle for superficial local infiltration in
order to avoid intravascular or brachial plexus injection.
6. IV access is obtained to provide mild sedation, as the needles for these procedures are larger than
those used for diagnostic injections.
Contraindications:
1. Patient refusal
Procedure:
1. Lateral approach (Figure 8.7A):

a. The needle entry is at the center of the trapezoid shape created by the lateral image of the cervical
facet. This is best seen at the C4 and C5 levels.
b. The needle depth is checked in the A/P view, and the location of the needle tip with respect to
the facet is checked via the lateral view.
c. In the A/P view, the needle is seen in the lateral concavity of the cervical facet. It should not be
medial to this shadow.
d. The medial branches of the C3, C6, and C7 dorsal rami lie more superiorly along the trapezoid
of the articular pillar. There is both a superficial branch and a deep branch of the C3 medial
branches. The deep medial branch innervates the C3/C4 facet, and the large superficial medial branch
(the third occipital nerve) innervates the C2/C3 facet.3,13,15
e. The needle tip should be advanced on top of bone (the trapezoid) to decrease the likelihood of
epidural or intrathecal needle position (Figure 8.17).
(A)
(B)
FIGURE 8.17
(A) The radiofrequency needles are approaching the cervical facets from the lateral view. (B) The radiofrequency needles
are in place.
2. Oblique approach: The approach is the same as that for cervical medial branch injections. The needle
should be at the posterior inferior aspect of the foramen (Figure 8.18).
FIGURE 8.18
The needles are placed in the oblique view.
3. As with medial branch blocks, lesions of the C7 medial branch are easily performed in the prone
position. The C7 medial branch courses posteriorly around the C7 superior articular process, so it
may be accessed posteriorly (Figure 8.19A and Figure 8.19B).
(A)
(B)
FIGURE 8.19
(A) A radiofrequency lesion at the C7 medial branch, A/P view. (B) The needle location is confirmed in the lateral view.
4. Sensory and motor stimulation are performed and recorded:

a. Sensory stimulation is performed at 50 Hz up to 1 V. We suggest recording the lowest voltage
at which the patient feels sensation. The patient should not feel any sensation to their upper
extremities or chest.
b. Motor stimulation is then performed at 2 Hz up to 2 V. Stimulation should produce movement
only in the neck, with no corresponding movement in the upper extremities or diaphragm. Again,
we also suggest noting the lowest voltage at which the patient experiences motor stimulation.
c. After sensory and motor stimulations are performed and you are satisfied that the needle is in
good position, the lesion may be performed.
5. For lesioning, this author usually performs two radiofrequency lesions per level in the cervical region.
The first lesion is performed under pulsed radiofrequency, followed by a more posterior heat lesion
after the needle is withdrawn slightly. Performing the pulsed lesion prior to the heat lesion allows
for sensory and motor stimulation of the second lesion, as no local anesthetic is required for the
pulsed lesion.
a. Heat lesion: A small amount (e.g., 0.3 ml) of lidocaine is injected into the needle 1 to 2 min
prior to the lesion. A lesion at 80˚C for 60 to 90 sec is then performed after satisfactory sensory
and motor stimulation, as above.
b. Pulsed lesion: No local anesthetic is needed prior to performing this lesion, as this procedure is
not painful to the patient. The voltage setting is generally 45 V, and the temperature is no greater
than 42˚C. Temperatures above 45˚C are considered destructive.
c. Note that it is thought that the needle position should differ for heat vs. pulsed lesioning:
i. Heat lesion: The needle is placed as parallel as possible to the medial branch of the dorsal
ramus.
ii. Pulsed lesion: The needle should be placed as close as possible to the “tunnel vision” view,
i.e., more perpendicular to the facetal column or trapezoid.
Cervical Epidural and Selective Nerve Root Injections

There are two basic techniques for the performance of cervical epidural injections under fluoroscopy —
the interlaminar and the transforaminal approaches. These techniques vary in both needle tip
location and patient positioning.
Cervical Transforaminal Injections
The transforaminal approach may be used from the C1/C2 to the C7/T1 foramina. Transforaminal
injections are most often performed in the supine position, but the lateral decubitus position with
the neck in neutral position has also been used. The technique described below utilizes the supine
position. This is more comfortable for the patient and allows for more control of the position of
the patient’s head. It is difficult to visualize the needle tip and to avoid pneumothorax with the
transforaminal approach using the oblique view below the level of C7/T1. Transforaminal epidural
steroid injections and selective nerve root injections differ in the volume of solution injected and
the location of the contrast spread. The selective nerve root injection, considered a diagnostic block,
attempts to place the solution selectively along the nerve root while avoiding the epidural space.
It is performed by injecting a small amount of contrast by the foramen, allowing for spread along
the nerve root. This is followed by injecting a similar volume of local anesthetic through the needle.
Extreme caution should be observed when performing procedures within the cervical spine.
If during the procedure the patient experiences severe paresthesia, no matter how perfect the needle
position appears to be on fluoroscopy, reposition the needle. There are vascular structures that are
to be avoided, most notably, the vertebral artery and the cervical radicular arteries (Figure 7.16).
The absence of blood aspiration from the needle offers no guarantee that an intravascular injection will
not ensue. A prospective study involving 504 cervical transforaminal injections found that observed
blood in the needle was 97% specific but only 45.9% sensitive.16 The consequences of intra-arterial
injection of particulate material (steroid) are disastrous.17 For these reasons, contrast injection prior
to the injection of local anesthetic and steroid is strongly recommended. The patient should be
awake enough to converse with the physician, and thus, light sedation is advised (Figure 8.20).18
FIGURE 8.20
Model of the cervical spine.
C2 Dorsal Root Ganglion Injection
The C2 nerve root supplies the C1/C2 joint. Patients with occipital neuralgia may benefit from a
C1/C2 intra-articular facet injection, a peripheral occipital nerve block, or a C2 selective nerve
root/dorsal root ganglion injection.
Patient position: Place the patient in the supine position, with the patient’s head in the neutral
position, facing the ceiling. The patient may have to be reminded to maintain this position so that
the image seen on the fluoroscopy screen remains constant.
C-arm position:
1. The C-arm is adjusted to obtain a lateral view (Figure 8.7A). Note that the C1/C2 transforaminal
injection is the only cervical transforaminal injection that is performed with a lateral image from the
C-arm. C2/C3 to C7/T1 transforaminal injections are performed with the oblique view of the C-arm.
2. The C1 ring closely resembles a vertical line if the x-ray beam is projecting in a lateral view and
the patient is supine. There should be minimal to no double lines on the upper cervical facets or on
the mandible. The facet joints of C2/C3 and C3/C4 should be in focus in this lateral image.
3. The needle depth is ascertained in the P/A view; the needle tip position within the space is determined
in the lateral view. The space between C1/C2 is not truly a foramen. The first cervical foramen is
located at C2/C3 (Figure 7.14).
4. Tunnel vision describes inserting and guiding the needle in the same direction as the C-arm beam.
The needle in this instance appears as little more than a dot on the image.
5. We recommend saving copies of P/A and lateral views showing the needle tip before and after contrast
injection.
Procedure:
1. Perform sterile preparation and drape to the lateral neck from the hairline to the clavicle.
2. Ensure that the borders are aligned and that the lateral image is truly a lateral image of the patient’s
neck.
3. Use the 25-gauge, 2 in. spinal needle to enter the foramen in the lateral view a few millimeters
posterior to the AA or C1/C2 joint in the lateral view. The vertebral artery is anterior to the foramen
in the lateral view (Figure 7.15, Figure 8.21).
FIGURE 8.21
C2 nerve root injection, lateral view. Note that the needle is posterior to the anterior aspect of the thumb-shaped foramen,
but caution is taken not to traverse the vertebral artery.
4. Note that a tunnel vision view may be used.

5. See that in the P/A view, the needle is lateral to the intersection of the middle and lateral one third
of the AA joint (Figure 8.22).
FIGURE 8.22
C2 nerve root injection, A/P view. The needle is seen no more medial than the lateral one-third of the AA joint.
6. At this time, connect the contrast-containing syringe that is attached to connection tubing (an
immobile needle) and verify under fluoroscopy that the needle has not changed position. The immobile
needle technique is especially important with these injections. It helps to keep the needle in the same
position after both contrast and epidural steroid injections occurred. Short connection tubing (ap-
proximately 0.3 ml capacity) that connects the injection needle to the syringe is recommended.
7. Inject a small amount (we suggest <0.5 ml) of nonionic contrast to verify the correct needle position
(Figure 8.23).
FIGURE 8.23
C2 nerve root injection with dye spread along the nerve root.
8. Disconnect the syringe containing contrast, and attach the syringe containing lidocaine.
9. Verify that the needle position has not changed within the foramen.
10. It is this author’s practice to inject approximately 0.5 ml of lidocaine, after negative aspiration, and
wait approximately 30 to 60 sec.
11. If the 30 to 60 sec interval is uneventful, this author then removes the lidocaine-containing syringe
and replaces it with the syringe that contains the steroid. The needle position is again verified. During
these syringe changes, the connection tubing remains in place.
12. We recommend that 1 ml or less of solution (steroid with or without local anesthetic) be injected
after negative aspiration.
C3 to C7 Transforaminal Injections
Cervical transforaminal injections below the level of the C1/C2 foramen are performed in the
oblique view under fluoroscopy. The term “selective nerve root” injection is somewhat of a mis-
nomer, as there is no way to ensure the absence of epidural spread with these injections. However,
it is possible to minimize epidural spread by limiting the volume of local anesthetic and steroid
injected to the volume of contrast that does not result in epidural spread.
Patient position: Place the patient in the supine position as was described in Chapter 7 (Figure
7.13). Ensure that the patient’s head is in the neutral position with the patient looking up at the
ceiling. This is very important, as a rotated cervical spine makes accurate needle placement more
difficult. The C-arm should be superior to the patient’s head in line with the patient (Figure 8.14).
This allows for easy access to the oblique view of the cervical spine. The fluoroscopy table should
allow for easy manipulation of the C-arm from the A/P to the oblique views.
C-arm positioning: When performing intraspinal injections, it is important to know which nerve root is
exiting out of the foramen through which the physician plans to inject medications. In the cervical spine,
the exiting nerve root is named after the inferior vertebral body; a disc herniation also affects the nerve
root at the same level. Thus, the C4 nerve root exits the C3/C4 foramen, and a disc herniation at C3/C4
will also cause most of the symptoms in the distribution of the C4 nerve root. There are a few options
for C-arm positioning for transforaminal injections. The steps described below are for procedures per-
formed in the oblique view of the C-arm. This description presumes that the patient is in the supine
position.
1. The patient’s head is aligned with the C-arm, and the C-arm is positioned directly behind the patient’s
head.
2. The first step in aligning the C-arm to the patient’s cervical column is to square off the vertebral end
plates in the P/A view. This is accomplished by rotating the image intensifier of the C-arm approx-
imately 20˚ forward toward the feet in the P/A view. Next, tilt the C-arm approximately 45˚ in the
oblique view until the foramen comes into view. The image intensifier in the final position is relatively
close to the patient’s chest (Figure 7.13).
3. Optimize the view of the circular foramen. The contralateral transverse is seen as a circular shadow
at the anterior aspect of the vertebral body.
4. Note that the most cephalad foramen seen in the oblique view is always the C2/C3 foramen, through
which the C3 nerve root exits.
5. These procedures are best performed on a specialized fluoroscopy table for pain procedures. In some
instances, it may improve visualization of the foramen if the patient is moved closer to the pain
physician on the procedure bed. The angle needed for the upper cervical foramen is often not the
same as it is for the lower cervical foramen due to the natural curvature of the cervical space and
the difference in the angulation of the foramen.
6. We recommend saving copies of P/A and oblique views showing the needle tip before and after dye
injection.
Procedure:
1. Sterile preparation and drape of the lateral neck.

2. The needle entry is in the oblique view, at, approximately, a 45˚ angle.
3. The needle is advanced judiciously in the oblique view, verifying the needle depth periodically with
a P/A view. It is better to start off with the needle tip a little too anterior and aim the needle posteriorly
than to start off a little too posterior in direction and have the needle deflected off the bone and end
up too anteriorly. The vertebral artery lies in the anterior aspect of the foramen and is to be avoided
(Figure 8.24).
FIGURE 8.24
The marker shows the target site for the needle in the posterior superior aspect of the foramen.
4. Check the needle depth in the P/A view (Figure 8.25).
FIGURE 8.25
The needle is approaching the foramen, and this P/A image shows that the needle is still some distance away. The
needle depth is too shallow.
5. Note that when you check the needle depth with the P/A view, the angle of the C-arm should be
noted so that you return to the same image to continue advancing the needle. If the angle increased,
then the image seen is more posterior in the foramen (Figure 8.26).
(A)
(B)
FIGURE 8.26
(A) The needle is placed in the foramen and the angle of the C-arm adjusted. This needle was placed with the C-arm
in the 45-degree oblique view, with the vertebral bodies first squared off in a 20-degree tilt. (B) The needle has not
been moved, but the angle of the C-arm has been moved to 55 degrees.
6. The direction of the needle should be established while the needle is relatively superficial. Once
tunnel vision or the desired direction is established, the needle may then be advanced to the target
spot. It is more likely that the needle will align in the desired direction if the bevel is pointed in the
direction of the target on skin entry. It is more desirable to insert the needle at an angle that is directed
slightly posterior, thus helping to avoid anterior placement of the needle tip in its final position.
7. The appearance of the needle tip should vary little during the oblique approach. We recommend
staying in the posterior and superior aspect of the foramen.
8. When checking the depth of the needle in the P/A view, ensure that the view is indeed an A/P view
and not slightly oblique, as it is imperative to know where the needle tip is in relation to the vertebral
column. Verify that the spinal processes are lined up in a straight line (Figure 8.27).
(A)
FIGURE 8.27
(A) This image is properly aligned; the spinous processes are facing forward. The vertebral endplates are also squared off.
(B)

(B) This image is off center, and needle depth cannot be adequately determined.
9. In most instances, the vertebral artery enters the cervical foramen at C6/C7. Avoidance of injection
of particulate material (e.g., steroid) into this artery is critical to avoiding a disastrous neurological
outcome. The artery is in the anteromedial aspect of the foramen. The nerve root exits via the distal
aspect of the foramen. Thus, the desired needle position is as close to tunnel vision as possible in
the postero-lateral aspect of the foramen. In addition, the needle should not venture medial to the
halfway point of the facetal column on the P/A view (Figure 8.25).
10. As with the C1/C2 transforaminal injections, it has been this author’s practice to give a “test dose”
with lidocaine prior to injection of the steroid:
a. Shortly after an uneventful injection of a small amount of nonionic contrast (e.g., 0.5 ml) showing
spread along the nerve root into the epidural space and not into the intravascular space, we
recommend aspirating again and injecting approximately 0.5 ml of lidocaine without epinephrine
(Figure 8.28). This author then waits approximately 30 to 60 sec to avoid intravascular or
intrathecal injection. If there is no evidence of either form of undesirable injection, the steroid
with or without additional local anesthetic is then injected after repeat negative aspiration, making
sure to keep the needle tip in the same position that it was in when the contrast was injected.
(A)
(B)
FIGURE 8.28
(A) The needle is at the midpoint of the facetal column. This is the most medial that the needle should be placed. (B) A
small amount of contrast is injected after negative aspiration. A repeat image should look identical to the original image.
(C)

(C) This is how the image may appear after the test dose of a short-acting local anesthetic has been administered following
adequate contrast spread.
b. The needle is kept immobile with connection tubing joining the needle and syringe with solution
to minimize needle movement after contrast confirmation takes place.
c. The syringe is aspirated periodically during the insertion of the solution.
11. We recommend obtaining a second fluoroscopic image shortly after contrast is injected to observe
that the contrast remained in place. If the needle and contrast are intravascular, the contrast will
disappear; the contrast disappears more quickly with intra-arterial vs. intravenous injection. Vertebral
artery spread is easily visualized as a quick vertical spread of contrast, which then disappears shortly
after injection; radicular artery spread results in a more horizontal spread if the injected contrast. We
recommend that consideration be given to cancellation of the procedure of arterial spread of dye is
visualized (Figure 8.29).
FIGURE 8.29
Examples of an intravascular injection.
12. We recommend saving images of the needle taken in two views with and without contrast, e.g., P/A
and oblique, as a record of the procedure.
Selective Nerve Root Injection or Epidural Steroid Injection
There are times when a selective nerve root injection is performed to try to isolate the level of
symptoms in the patient. A selective nerve root injection attempts to inject local anesthetic (with
or without steroids) just along the nerve root without involving the epidural space. It is very difficult
to ensure that the solultion will not traverse into the epidural space. For selective nerve root
injections, the needle tip is placed in the more lateral aspect of the foramen (Figure 8.30).
FIGURE 8.30
The needle tip is laterally placed within the foramen to avoid epidural spread.
A small amount of contrast is injected, and if it spreads along the nerve root and not into the
epidural space, the injection is ceased, and the volume injected is noted. The same quantity of local
anesthetic is then injected for a “selective” nerve root injection (Figure 8.31 to 8.33).
FIGURE 8.31
A small amount of contrast is injected.
FIGURE 8.32
This is the appearance after the local anesthetic is injected and the nerve root is seen outlined by the washout of the dye.
FIGURE 8.33
Oblique view of a nerve root injection. There is no detectable epidural spread.
FIGURE 8.34
Oblique views of a transforaminal injection revealing epidural spread.

A/P views of contrast with epidural spread.
It is important not to confuse selective nerve root injections with intramuscular injections
(Figure 8.35).
FIGURE 8.35
Intramuscular injection and contrast spread.
Figure 8.36 shows an example where the needle was initially placed too laterally with respect
to the vertebral border — the injected contrast did not spread into the foramen. The needle was
then repositioned, and appropriate contrast spread was seen.
FIGURE 8.36
The initial needle placement in this image was outside the foramen as shown by the lateral contrast spread above the needle.
The needle was then repositioned, and contrast is seen spreading along the foramen into the epidural space.
Interlaminar Epidural Steroid Injections
Prior to the routine use of fluoroscopy for cervical interlaminar epidural injections, these injections
were traditionally performed in the sitting position with the patient’s head flexed. This sitting
technique may also be used when the injections are performed under fluoroscopy with the C-arm
encircling the patient. Today, interlaminar injections that are performed under fluoroscopy are
generally performed in the prone position with the neck slightly flexed. We recommend that the
interlaminar approach be limited to the C7/T1 interspace and below, as work with cadaver specimens
indicated that there is minimal posterior epidural space above the C7/T1 interspace.19 Examination
of human cadavers revealed midline gaps in the ligamentum flavum at the cervical and thoracic
levels. These gaps were frequently observed at the cervical (>50%) levels but were rare below the
T3/T4 level.20 Thus, a slightly paramedian approach may be more optimal.19 The solution may then
be delivered via the epidural needle or via a catheter threaded through the epidural needle. (This
latter technique attempts to mimic the selectivity of a cervical transforaminal injection.)
Patient preparation: We recommend obtaining a cervical MRI demonstrating the absence of
cervical stenosis at the level of injection. Refer to the beginning of this chapter for other aspects
of patient preparation for cervical procedures.
Equipment/Materials: We recommend a prepackaged interlaminar epidural kit containing a loss of
resistance glass or plastic syringe and a blunt-tipped curved epidural needle, generally 17 or 18 gauge,
with or without a radio-opaque catheter. The other materials are the same as for other cervical injections.
Patient position: The patient is placed prone on the procedure table. The patient’s head is
placed in a neutral, slightly flexed position facing the floor.
C-arm position: The C-arm is adjusted to the patient for an A/P image (Figure 8.8B). The image
intensifier is rotated slightly toward the feet to obtain an optimal view of the epidural space.
Procedure:
1. The patient’s posterior neck and upper back are prepared and draped in a sterile fashion. The skin
is infiltrated with lidocaine at the C7/T1 interspace. This interspace is generally prominent and easily
palpated and then verified with fluoroscopy.
2. The epidural needle is then advanced into the ligamentum flavum in the A/P view. Due to obstruction
of the lateral view by the patient’s shoulders, it is very important to be able to detect the sensation
of the ligamentum flavum with the epidural needle. Contacting the lamina prior to advancing the
needle into the ligamentum flavum is often helpful in assessing needle depth.
3. Loss of resistance with air or saline or a combination is performed. A small amount of nonionic
contrast (we recommend approximately 1 ml) is injected after negative aspiration to confirm needle
placement in the epidural space. This can be done via the epidural needle or via an epidural catheter.
We recommend checking both A/P and lateral views to verify appropriate contract spread (Figure
8.37, Figure 8.38).
FIGURE 8.37
Interlaminar needle placement with a catheter threaded and contrast lateralized to the left side. The needle was inserted at
the C7/T1 interspace.
FIGURE 8.38
Lateral view of interlaminar needle placement at C7/T1. Visualization is often difficult due to opacification by the shoulders.
However, you can see that the needle is not anterior to the epidural space.
4. We recommend that a low volume of a solution containing, for example, 1 ml of steroid and 2 ml
of local anesthetic be injected after a repeated negative aspiration. The steroid-containing solution
is then flushed with a small amount of local anesthetic or saline prior to withdrawal of the needle.
5. Once again, we recommend keeping a copy of images in two views, e.g., A/P and lateral views: one
with the needle tip without contrast and another with contrast spread. Sometimes contrast may be
injected, and it is clear that the needle tip is not in the epidural space. In that case, save the image
of the needle tip prior to the last contrast injection and try to have the needle tip visible in addition
to having an image with the correct contrast spread within the epidural space. Lateral images may
be difficult to visualize due to the shoulder shadow obscuring an optimal view.
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midline, Anesthesiology, 99, 1387–1390, 2003.
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neck and back pain: a systematic review within the framework of the Cochrane Collaboration Back
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in the general population: a population-based cohort study, Pain, 112, 267–273, 2004.
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facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions, BMC Musculoskeletal
Disorders, 5, 15–21, 2004.
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Chapter
Fluoroscopic Images of the
Sacrum and Pelvis
9
221
Fluoroscopic Images of the Sacrum and Pelvis 223
Posterior View of the Pelvis and the Sacrum

Spinal injections that are performed in the sacral and pelvic area (Figure 9.1) may include sacroiliac
joint injection, lumbar L5 medial branch block (MBB) and radiofrequency (RF) ablation, and caudal
epidural steroid injection.
L5 MBB and RF
Sacroiliac joint
injection
Caudal epidural steroid injection
FIGURE 9.1
Several spinal injections in the sacral and pelvic areas, posterior view of the pelvis and the sacrum.
The sacrum is shaped like a shovel, with the apex, the most inferior portion. An anterior–posterior
(A/P) fluoroscopic image of the sacrum is shown in Figure 9.2. The anterior sacral foramina do
not align with the posterior foramina because of the curvature of the sacrum.
A/P View of Fluoroscopic Image of the Sacrum
Anterior
Posterior
sacral
B sacral
foramina
foramina
Anterior sacral Posterior

foramen sacral
foramen
FIGURE 9.2
(A) The spine is in the prone position. The fluoroscopic beam is perpendicular to the table. (B) Photograph of a sacrum
from the anterior aspect. (C) The fluoroscopic beam does not align with the anterior and posterior foramina. (D) A/P
fluoroscopic image of the sacrum.
If the x-ray beam aligns the anterior and posterior sacral foramina, we can get an A/P fluoro-
scopic image like that shown in Figure 9.3D.
Anterior
sacral
foramina
Posterior
sacral
foramina
A
FIGURE 9.3
(A,B) The spine is in the prone position. The fluoroscopic beam aligns the anterior and posterior sacral foramina. (C) A
photograph of a sacrum from the anterior aspect. The anterior and posterior foramina align. (D) A/P fluoroscopic image of
the sacrum with alignment of the anterior and the posterior foramina.
Sometimes, changing a fluoroscopic image to a regular x-ray image may help to identify sacral
foramina and the sacral hiatus (Figure 9.4). However, sacral foramina and sacral hiatus usually are
not easily identifiable due to the air in the rectum and the colon (Figure 9.5).
FIGURE 9.4
Fluoroscopic and x-ray images.
FIGURE 9.5
A/P view of the sacrum. It is difficult to identify the sacral foramina.
Identifying the posterior superior iliac spine (PSIS) (Figure 9.6) is also important for some
spinal injections, such as sacroiliac joint injection, because the needle is inserted below the PSIS.
Posterior superior iliac spine
Posterior and inferior portion of the

sacroiliac joint
A
FIGURE 9.6
(A) A/P fluoroscopic image of the sacrum. (B) A/P photographic image of the sacrum.
The sacral hiatus is an inferior opening of the spinal canal at the posterior aspect of the sacrum
(Figure 9.7A). The shape of the sacral hiatus is an inverted “U”. The two ends of the “U” are called
the sacral cornu (Figure 9.7A). Identifying sacral cornu on a lateral fluoroscopic image of the
sacrum may aid in performing the caudal epidural steroid injection (ESI) (Figure 9.7D).
Sacral hiatus
Sacral cornu
A
Sacral hiatus
Sacral cornu
FIGURE 9.7
(A) Photograph of a sacrum from the posterior aspect. (B) Photograph of a sacrum from the lateral aspect. (C) A/P
fluoroscopic image of the sacrum. (D) Lateral fluoroscopic image of the sacrum.
Bibliography
Chapter
Pelvic and Sacral Injections 10
229
Sacroiliac Joint Injection

Indications:
Low back pain without radiculopathy
Contraindications:
Patient refusal
The needle is inserted into the posterior–inferior opening of the sacroiliac joint below the posterior
superior iliac spine (PSIS) (Figure 10.1). The path of needle insertion has to follow the angle of
the posterior opening of the sacroiliac joint. Figure 10.2 is a photograph of the sacroiliac joint on the
right side as seen from the posterior aspect. The sacroiliac joint opens medially obliquely backward
at an angle, but the angle may vary from patient to patient. Figure 10.3 illustrates different angles
of the articular surface for the sacroiliac joint on the sacrum. These different angles create variations
for needle placement at the posterior opening of the sacroiliac joint (Figure 10.4). Awareness of
these differences is important, because the direction of needle insertion for the sacroiliac joint
injection has to be aligned with these angles.
PSIS
FIGURE 10.1
Needle is inserted below the posterior superior iliac spine (PSIS).
Illustration of the medial–

oblique angle of the
posterior opening of the
sacroiliac joint
FIGURE 10.2
Photograph of the posterior opening of the right sacroiliac joint.
FIGURE 10.3
Different angles of the articular surface on the sacrum for the sacroiliac joint.
FIGURE 10.4
Different angles of the posterior opening of the sacroiliac joint.
The patient is in the prone position.

The C-arm fluoroscopy comes in from the patient’s side (Figure 10.5A). The tunnel vision of the
posterior opening of the sacroiliac joint, the right-side sacroiliac joint, and the C-arm should be
tilted caudally (Figure 10.5B) and rotated to the patient’s left side (Figure 10.5C). The posterior
opening of the sacroiliac joint below the PSIS is identified in Figure 10.6. These figures illustrate
the tilting and rotating of the C-arm to get tunnel vision of the posterior opening of the sacroiliac
joint.
FIGURE 10.5
C-arm positions for right-sided sacroiliac joint injection.
PSIS
PSIS
A
Posterior
opening of
sacroiliac joint
PSIS
PSIS
Posterior
opening of
sacroiliac joint
Posterior
opening of
sacroiliac joint
FIGURE 10.6
Demonstration of how to align posterior opening of the sacroiliac joint.
Step 4 and Step 5: Insert the Needle and Confirm the Needle Placement
Proper needle insertion is shown in Figure 10.7. The needle should be inserted right below the PSIS
(Figure 10.7A and Figure 10.7B). Using an image of the anterior–posterior (A/P) view of the
sacrum (Figure 10.7E) helps not only to check needle depth but also to reconfirm proper needle
placement. The needle tip should be inserted below the PSIS and beyond the posterior margin of
the posterior joint opening (Figure 10.7D and Figure 10.7E). Contrast solution should spread
laterally to the needle tip, indicating correct needle placement (Figure 10.7C and Figure 10.7F).
A D
BB E
C F
FIGURE 10.7
Proper needle placement.
If the needle is inserted too low (Figure 10.8B and Figure 10.8E), the contrast solution can
leak out inferiorly (Figure 10.8C and Figure 10.8F). The patient may have lower extremity weakness
on the injected side after receiving local anesthetic, because the medication spreads to the sciatic
nerve that is located inferiorly to the lower portion of the sacroiliac joint.
A D
B E
C F
FIGURE 10.8
Improper needle placement. The needle is inserted too low.
Step 6: Inject Medications

We will not discuss the details in this handbook.
Caudal Epidural Steroid Injection

Indications:
Lumbar radiculopathy
Spinal stenosis
Contraindications:
Patient refusal
Needle placement for caudal epidural steroid injection is through the sacral hiatus into the sacral
epidural space (Figure 10.9).
FIGURE 10.9
Illustration of needle travel via the sacral hiatus.
The patient is in the prone position. The patient should have his or her legs abducted to about a
20° angle, with the toes rotated inward and the heels outward to relax the gluteal muscles (Figure
10.10).
FIGURE 10.10
Step 3: Use C-Arm to Identify the Target Areas
Sometimes it is difficult to identify the sacral hiatus by using the A/P fluoroscopic images because
of anatomic variants of the dorsal wall of the sacrum (Figure 10.11) and air in the rectum and
colon (Figure 10.10). We recommend also using a lateral view of the sacrum to help identify the
sacral hiatus (Figure 10.11C).
B C D E
FIGURE 10.11
(A) Photograph of the normal dorsal wall of the sacrum. (B) Normal dorsal wall of the sacrum with the normal invert U
or V sacral hiatus. (C) Small slit-like sacral hiatus. (D) Large sacral hiatus. (E) Large midline defects in the dorsal sacral
wall continuous with the sacral hiatus.
Skin entry should be 2 to 3 cm below the identified point in the sacral hiatus (Figure 10.12). The
needle is inserted at an angle of approximately 45° to the sacrum. The needle is then advanced
until it contacts the anterior wall of the sacrum between the sacral cornu (Figure 10.13A, Figure
10.14B, and Figure 10.14C). The needle is then withdrawn slightly and redirected at a decreased
angle toward the sacral hiatus (Figure 10.13B and Figure 10.14D through Figure 10.14F).
_ _
A B C
D _
E _ _
F
H I
FIGURE 10.12
Fluoroscopic A/P images of the sacrum and the sacral hiatus. Arrowheads in A through F may point to the sacral hiatus.
It is difficult to identify the sacral hiatus in G through I.
Sacral cornu
A
Sacral hiatus
Sacral
Sacral
hiatus cornu
FIGURE 10.13
(A,B) Photographs of the sacrum, lateral view. (C) Lateral view of a fluoroscopic image of the sacrum.
Sacral
cornu
FIGURE 10.14
Needle insertion into the sacral hiatus.
A B C
D E F
FIGURE 10.15
Fluoroscopic images of the lateral view of the sacrum. (A) Lateral view with the pointer tip. (B) Lateral view with a pointer
tip. (C) The needle contacts the anterior wall of the sacrum between the sacral cornu. (D–F) Redirecting the needle.
We found that loss of resistance is not always obtained when the needle enters the caudal
epidural space. Therefore, we recommend inserting an epidural catheter frequently while advancing
the needle.
Step 5: Confirm the Needle (Catheter) Placement
Proper catheter placement can be confirmed by checking that the catheter follows the curvature of
the sacrum (Figure 10.16A) and that the catheter stays at the midline (Figure 10.16B). Final
confirmation of proper position of the catheter within the caudal epidural space requires obtaining
a caudal epidurogram (Figure 10.16A and Figure 10.16B). The A/P view of the caudal epidurogram
shows that spread of the contrast agent looks like a picture of a Christmas tree (Figure 10.17).
Epidural needle
Epidural catheter
B
A
Epidural Epidural needle tip

catheter
FIGURE 10.16
(A) The lateral view image shows a properly placed epidural needle with a catheter that follows the curvature of the sacrum.
(B) The A/P view image shows that the epidural needle tip and epidural catheter stay at the midline.
A C
B
FIGURE 10.17
(A) Fluoroscopic lateral image of the caudal epidurogram. (B) Fluoroscopic A/P image of the caudal epidurogram. (C)
Photograph of the sacrum with sacral nerve, anterior aspect.
If the catheter is off the midline from the needle tip (Figure 10.18A), a lateral view is required
before the contrast agent is given. The catheter tip is usually off the dorsal wall of the sacrum on
the lateral view (Figure 10.18B). If the contrast agent is spread only on the one side (Figure 10.18C),
the lateral image usually indicates that the catheter is advanced subcutaneously (Figure 10.18D).
A B
C D
FIGURE 10.18
Demonstrates a catheter inserted subcutaneously. These images have a diagram of a subcutaneous catheter penciled in.
(A) An A/P fluoroscopic image of the sacrum demonstrates the catheter was located laterally to the midline. (B) A lateral
fluoroscopic image of the sacrum demonstrates the catheter was not in the caudal epidural space. (C, A/P view) and
(D, lateral view) demonstrate a contrast material spreading subcutaneously.
Step 6: Inject Medications
We recommend that the total volume of injection be 10 ml, including 5 ml of a local anesthetic,
such as 0.25% bupivacaine and 40 mg to a maximum of 80 mg of steroid diluted with normal saline.
Bibliography
Chapter
Sympathetic Blocks 11
T12
L2
L5
247
The sympathetic blocks that we will review include (a) the stellate ganglion block, (b) the lumbar
sympathetic block, and (c) the superior gastric plexus block (Figure 11.1).
C
1
T12
L2
C
7
T
1
L5
Stellate ganglion
block
Lumbar sympathetic
block
Anterior view of the spine
Superior hypogastric plexus

block
L
5
FIGURE 11.1
Sympathetic blocks.
Stellate Ganglion Block (Right Side)

Indications:
Upper extremity complex regional pain syndrome
Phantom limb pain
Contraindications:
Patient refusal
The target point is the anterior surface of the transverse process of C7 (Figure 11.2) since the
stellate ganglion is located opposite the seventh cervical and first thoracic vertebrae near the head
of the first rib.
C
C1 1
C6
C7
C
T1 7
The target point T
Anterior view of cervical 1
spine
FIGURE 11.2
The patient should be in the supine position, and the C-arm can be pushed in from the patient’s
head or the side (Figure 11.3 and and Figure 11.4).
FIGURE 11.3
C-arm at patient’s head.
FIGURE 11.4
C-arm at patient’s side.
Obtain a P/A view of cervical spine and identify the C7 vertebral body and the transverse process
(Figure 11.5).
C7
C
C7
C7 transverse process (right

side)
FIGURE 11.5
A P/A viewed C7–T1 vertebrae.
Step 4: Insert the Needle

Identify the target point on the image (Figure 11.6) and then insert a needle under the C-arm
(Figure 11.7).
FIGURE 11.6
A needle tip points to the target point on the image.
FIGURE 11.7
A needle tip contacts the anterior surface of the right-sided transverse process of C7.
After obtaining a negative aspiration, inject contrast to confirm the needle placement (Figure 11.8).
FIGURE 11.8
Contrast spreads cephalically and caudally.
Step 6: Inject Medication
Inject the recommended medication.
Lumbar Sympathetic Block

Indications: Lower extremity complex regional pain syndrome
Contraindications:
Patient refusal
The target points are the anterolateral surfaces of the lumbar vertebral bodies from L2 to L4
(Figure 11.9). The lumbar sympathetic chain (trunk) lies along the medial margin of the psoas
muscles (Figure 11.10).
T12
T12
L2
L2
L5 L5
Lumbar sympathetic Lumbar sympathetic

chains chains
(A) (B)
FIGURE 11.9
(A) Lateral view of the lumbar spine. (B) Anterior view of the lumbar spine.
Psoas muscle
FIGURE 11.10
A/P view of the lumbar spine with psoas muscles.
The needle is inserted postero–laterally toward the patient’s spine, bypassing the tip of the
transverse process (Figure 11.11).
FIGURE 11.11
The patient is in the prone position, and the C-arm is pushed in from the patient’s side (Figure 11.12).
FIGURE 11.12
Placement of C-arm at side of prone patient.

Obtain fluoroscopic images of the low thoracic and upper lumbar regions (Figure 11.13). Identify
the tip of the transverse process at the level of L2, L3, or L4 (Figure 11.14).
T12
Left
FIGURE 11.13
A/P view of the lumbar spine, including T12.
T12
Left
FIGURE 11.14
Rotate the C-arm to the injecting side until the tip of the transverse process matches the lateral
border of the vertebral body (Figure 11.15).
The tip of the

transverse process
FIGURE 11.15
Step 4 and Step 5: Insert the Needle and Confirm the Needle Placement
Choose the needle’s entry point (Figure 11.16). Insert and advance the needle under the C-arm
fluoroscopy until the needle tip contacts the vertebral body. Then the needle tip is “walked off” the
vertebral body (Figure 11.17). The needle depth is checked in the lateral view (Figure 11.18) and
in the A/P view (Figure 11.19).
Left
FIGURE 11.16
The tip of the pointer is the needle’s entry point.
Left
FIGURE 11.17
L3
FIGURE 11.18
Lateral view of the needle placement for the lumbar sympathetic block. The needle tip is slightly posterior to the anterior
border of the vertebral body.
L3
FIGURE 11.19
A/P view of needle placement for the lumbar sympathetic block. The needle tip is located in the center of the pedicle.
Figure 11.20 and Figure 11.21 show spread along the anterior-lateral margin of vertebra in
order to confirm the needle placement. If contrast outlines the psoas muscle (Figure 11.22), the
needle placement is too lateral to the vertebral body.
FIGURE 11.20
FIGURE 11.21
Psoas muscles
FIGURE 11.22
Step 6: Inject Medication(s)
No details will be discussed in this handbook.

Superior Hypogastric Plexus Block

Indications: Chronic pelvic pain
Contraindications:
Patient refusal
Step 1: Indentify the Target Area
The target area is the anterior surface of the lower portion of the L5 vertebral body, the disc between
L5 and the sacrum, and the anterior surface of the sacral promontory (Figure 11.23 to Figure 11.25).
The target
area
FIGURE 11.23
Superior hypogastric plexus

L5
Superior
L5 hypogastric
plexus
A B
FIGURE 11.24
(A) Anterior view of the superior hypogastric plexus. (B) Lateral view of the superior hypogastric plexus.
The patient is in a prone position, and the C-arm is pushed in from the patient’s side (Figure 11.25)
FIGURE 11.25
Step 3 through Step 6:
The needle is inserted from posterior laterally to the spine (Figure 11.26). We prefer not to go
through the disc between L5 and the sacrum.
Left Right
FIGURE 11.26
Get an A/P view of the lower portion of the lumbar spine including L5 and squaring the lower
margin of L5 or open the disc space between L5 and the sacrum (Figure 11.27).
L5/S1 disc space is open
FIGURE 11.27
The C-arm is rotated to the injecting side (e.g., to the right; Figure 11.28) until obtaining a
large triangle area that is formed by the iliac crest, the lower margin of transverse process, and the
lateral margin of the superior articular process of the sacrum.
Target needle entry site
FIGURE 11.28
Insert the needle at the junction between the iliac crest and the superior articular process
(Figure 11.29).
Target needle entry site
FIGURE 11.29
Initial needle placement for a left-sided superior hypogastric block.
Advance the needle in the lateral view until the needle tip reaches the anterior margin of L5
(Figure 11.30). Contrast is spread in the A/P view and the lateral view (Figure 11.31). Inject 5 cc
of appropriate local anesthetic.
FIGURE 11.30
FIGURE 11.31
Repeat Step 1 through Step 5 for another side injection. After verifying the needle placement,
inject another 5 cc of local anesthetic (Figure 11.32).
(a) (b)
FIGURE 11.32
A/P view of the needle placement of the right-sided superior hypogastric plexus block (A) without contrast and (B) with
contrast.
Bibliography
Brown, D.L., Ed., Atlas of Regional Anesthesia, 2nd ed., Saunders, Philadelphia, 1999.
Fenton, D.S. and Czervionke, l.F., Eds., Image-Guided Spine Intervention, Saunders, Philadelphia, 2003.
Netter, F.H., Ed., Atlas of Human Anatomy,, Ciba Geigy Corporation, Tarrytown, 1989.
Walkman, S.D., Ed., Atlas of Interventional Pain Management, 2nd ed., Saunders, Philadelphia, 2004.
Index
A patient position, 201, 216

patient preparation, 216
procedure, 202–209, 216–218
Annulogram, lumbar spinal injection, lateral view, 134–135 Caudal epidural steroid injection, 238–245
Axial skeleton, 8 contraindications to, 238
C-arm rotations, 9 dorsal wall, sacrum, 240
spine, anterior view, 10 fluoroscopic lateral view of, 244
indications, 238
lateral view, 244
B epidural needle, 244
sacral hiatus, 241
needle insertion into, 243
Bones, fluoroscopic view of, 18–26
needle travel via, 238
flat bones
sacrum, 241
patella, 18
lateral view, 242
rib, 18
lateral view of, 243
irregular lumbar bone
subcutaneous insertion, 245
facial bones, 19
Cervical epidural injection, 196–218
vertebra, 19
Cervical facet injection, 172–173
radius, 18
rib on top of patella, 19 lateral approach, 173
short bone, first phalange, 18 Cervical injection, 169–218
C2/C3 to C6/C7 intra-articular joint injection, 180–186
C-arm position, 180
contraindications to, 180
C patient position, 180
C2 dorsal root ganglion injection, 198
C-arm C-arm position, 198
components of, 32 patient position, 198–201
positioning of, 180, 188, 198, 216 (See also under procedure, 199–201
specific view) C3 to C7 transforaminal injection, 201–209
C2/C3 to C6/C7 intra-articular joint injection, 180–186 C-arm positioning, 202, 216
C-arm position, 180 equipment/materials, 216
contraindications to, 180 patient position, 201, 216
patient position, 180 patient preparation, 216
C2 root injection, 198 procedure, 202–209, 216–218
A/P view, 200 cervical epidural injection, 196–218
C-arm position, 198 cervical facet injection, 172–173
lateral view, 199 lateral approach, 173
patient position, 198–201 cervical medial branch injection, 186–191
procedure, 199–201 C-arm position, 188
C3 to C7 transforaminal injection, 201–209 contraindications to, 188
C-arm position, 216 patient position, 188
C-arm positioning, 202 cervical transforaminal injection, 196–198
equipment/materials, 216 complications of, 180
269
interlaminar epidural steroid injection, 216–218 rib on top of patella, 19

intra-articular facet injection, 174–180 short bone, 18
C-arm position, 175 vertebra, 19
C1/C2 intraarticular injection, patient position for, Contrast agent, lumbar spinal injection, improper spread
175 of, 100
C1/C2 joint Contrast injection within disc space, lumbar spinal,
lateral view, 177–178 136–141
spine model of, 174 Curvature, adult lumbar spine, injection, 113
C1/C2 joint injection, 174
C1/C2 joint space, dye within, A/P views, 179
mouth closed, C1/C2 view with, 176
patient position, 175 D
procedure, 175–179
nerve root injection, 196–218 Depth of needle placement, lateral view, 51
preparation for, 171
Discography, lumbar spinal injection, 124–127
A/P view of, 138
equipment/materials, 171
mature disc, A/P view, 139
sedation, 171
Dye spread within disc, lumbar spinal injection, lateral
radiofrequency denervation, 191–196
view, 143
C2 dorsal root ganglion injection, 198
C3 to C8 medial branches, 192
C3 to C7 transforaminal injection, 201–209
contraindications, 192
equipment/materials, 192–196
E
procedure, 192–196
Cervical medial branch injection, 186–191 Epidural steroid injection, 210–215
C-arm position, 188 lumbar transforaminal, 88–111
contraindications to, 188 Equipment/materials, 192–196, 216
patient position, 188
Cervical spinal nerve roots, counting of, 166
Cervical spine, 151–167
C-arm positions, 154, 165 F
cervical spinal nerve roots, counting of, 166
inferior view, 163 Facial bones, 19
injection positions, 153 First phalange, 18
intervertebral foramina, counting of, 166 Flat bones, 18
lateral view, 158–162 patella, 18
lumbar vertebrae, comparison, 156 rib, 18
model, 197–198 Fluoroscopic view of bones, 18–26
oblique view, 163 Foramen, needle approaching, posterior view, lumbar spinal
P/A view, 157 injection, 89
right-sided obliquely viewed view, 164
superior view, 156
vertebral artery
on lateral view of cervical spine, 167 H
on obliquely viewed cervical spine, 167
Cervical transforaminal injection, 196–198
High intensity zone, lumbar spinal injection, 125
Circumferential annular tear, lumbar spinal injection,
146
Circumferential collimation. See Iris collimation
Classification of bones, 18–26
facial bones, 19 I
first phalange, 18
flat bones, 18 Iliac crest, lumbar spinal injection, 120
irregular lumbar bone, 19 left oblique view, 121
long bone, 18 Injection, spinal, 41–53
patella, 18 axis of C-arm, 47
pedicles, 25–26 depth of needle placement, lateral view, 51
radius, fluoroscopic view, 18 fluoroscopic view, 44
rib, 18 initial needle placement, 51
Index 271
levels of vertebral view, 48 lack of alignment, with disc between fluoroscopic

location of spine, 43 beam, 116
lumbar spine lumbar transforaminal epidural steroid injection, 111–124
A/P view, 53 needle in center of, 145
lateral view, 52 needle in position for, 144
prone patient, 48 vertebral end plates squared in AP view, 142
needle insertion, 43 Lamina, 25
needle placement, 50 Lateral cervical spine labeled with positions of cervical
prone position, patient placement, 44 medial branches, 187–188
rotation, C-arm, 47, 49 Lateral view
target area identification, 43 cervical medial branch injection, 190
Interlaminar epidural steroid injection, 216–218 interlaminar needle placement at C7/T1, 217
Interlaminar needle placement with catheter threaded, dye Leaf collimation, 33
lateralized to left side, 217 Left oblique view, initial needle insertion in, 99
Intervertebral foramen, between L5, first sacral segment, Left-sided superior hypogastric block, 265
insertion of needle into, 112 Levels of vertebral view, 48
Intervertebral foramina, counting of, 166 Linear collimation. See Leaf collimation
Intra-articular facet injection, 174–180 Location of spine, 43
A/P views of dye within left C1/C2 joint space, 179 Long bone, 18
C-arm position, 175 Longitudinal, circumferential, collimation, 38
C1/C2 intraarticular injection, patient position for, 175 Low dose imaging setting application, C-arm control panel,
C1/C2 joint 37
dye within, A/P views, 179 Lower portion, posterior view of, 82
lateral view, 177–178 L5/S1, discography at, 141–147
with mouth closed, 176 L5/S1 injection, 142–147
spine model of, 174 Lumbar medial branch
C1/C2 joint, 174 block, lateral view, 84
lateral view of C1/C2 joint, with needle approaching denervation, 87–88
joint, 177–178 Lumbar spinal injection, 71–147
mouth closed, C1/C2 view with, 176 A/P view, 83
patient position, 175 target points on lumbar vertebra in, 77
procedure, 175–179 A/P viewed fluoroscopic view, target points on lumbar
spine model of C1/C2 joint, 174 vertebra in, 77
Intraarticular injection performed in patient in prone annular placement of needle, difficulties with, 132–135
position, with dye spread along joint space, annulogram, lateral view, 134–135
186 C-arm
Intramuscular injection, dye spread, 215 neutral position, 85
Intravascular injection, 209 position, 129
Iris collimation, 34 circumferential annular tear, 146
Irregular lumbar bone, 19 contrast agent, improper spread of, 100
facial bones, 19 contrast injection within disc space, 136–141
vertebra, 19 curvature, adult lumbar spine, 113
discogram
A/P view of, 138
mature disc, A/P view, 139
L dye spread within disc, lateral view, 143
L3/4, lateral view of contrast within, 140 foramen, needle approaching, posterior view, 89
L5 dorsal ramus injection, 82–84 high intensity zone, 125
L4/L5, right side, needle placement between, 110–111 iliac crest, 120
L5 left oblique view, 118 left oblique view, 121
L5 medial branch block, lateral view, needle position initial entry point, 88
recheck, 87 initial needle placement, 92
L5 right-sided obliquely viewed, 84 intervertebral foramen, between L5, first sacral
L5/S1 segment, insertion of needle into, 112
discogram, mature disc at, 146 L4, L5, right side, needle placement between, 110–111
entry site, 142 L5
epidurogram, left-sided, 125 left oblique view, 118
fluoroscopic beam aligned with, 117 right-sided obliquely viewed, 84
S1, lack of alignment, with disc between steps in, 88–92, 94–124
fluoroscopic beam, 116 superior articular process, needle entry lateral to,
L3/4, lateral view of contrast within, 140 130–131
L3/4 disc, lateral view of contrast within, 140 transforaminal epidural steroid injection, 91
L4/5 disc, lateral view of contrast within, 140 left-side L5/S1, needle placement, 122
L4/L5, right side, needle placement between, 110–111 transverse process, superior articular process, angle
L5 medial branch block, lateral view, needle position between, 103–104
recheck, 87 under-rotated lumbar vertebrae, 96
L5/S1 view orientation, 90
discogram, mature disc at, 146 Lumbar spine, 55–69
entry site, 142 A/P to oblique, 60
epidurogram, left-sided, 125 A/P view, 53, 57–58, 68
fluoroscopic beam aligned with, 117 in checking needle depth, 69
lack of alignment, with disc between fluoroscopic lateral view, 52, 63
beam, 116 in checking needle depth, 69
lateral view of contrast within, 140 needle depth unchanged, 67
needle in center of, 145 prone position, 63
needle in position for, 144
oblique view, 61
post-procedure, 147
pedicle, 62
vertebral end plates squared in AP view, 142
prone patient, 48
left oblique view, initial needle insertion in, 99
prone position, 57
left-sided L5/S1 epidurogram, 125
right oblique view, 59
lower portion, posterior view of, 82
Lumbar sympathetic block, 253–260
lumbar medial branch block, lateral view, 84
A/P view, 259
lumbar vertebra above L5, right-sided oblique view, 88
A/P view of lumbar spine, including T12, 256
manometry syringes, discography, 127
mechanically vs. chemically sensitive discs, 141 C-arm at side of prone patient, 255
medial branch block, 78 contraindications to, 253
needle entering disc, 131–133 indications, 253
needle entry point, oblique view, 122 lumber spine, lateral view of, 254
needle placement, 130–132 needle entry point, 257
lateral view of, 124 needle placement, lateral view, 258
needle placements, posterior view, 75 psoas muscles, lumbar spine with, A/P view of, 254
neutral position, C-arm in, 94 Lumbar vertebra above L5, right-sided oblique view, 88
nucleus in AP view, needle within, 136–137
oblique view
needle placements in, 107
target lumbar vertebra, 129 M
obliquely viewed fluoroscopic view, 80
over-rotated to right, 98 Manometry, 127–141
pain response, of patient, 141 Manometry syringes, discography, 127
patient position, 128 Marker shows target site for needle in posterior superior
patient preparation, 73, 127 aspect of foramen, 203
posterior annular tear, L5/S1 discogram, 147 Mechanically vs. chemically sensitive discs, 141
posterior view, needle in, 95 Medial branch block, 78
preparation for needle placement, 127–128 lumbar, 73–87
prone position
patient, 89
indications, 73
patient in, 75, 112, 128–129
properly rotated vertebrae, 97
right oblique view, needle entry from, 96
right-sided L5 medical branch block, A/P view, 86
right-sided oblique view, lumbar vertebrae, 74
N
origin of lumbar medial branch in, 74
right-sided obliquely viewed, 79, 81 Needle at midpoint of facetal column, 207–208
right-sided obliquely viewed view, 80 Needle entry site for cervical intraarticular injection, 183
S1 superior articular process, needle contacts lateral Needle insertion, 43
margin, 123 Needle placement, 50
sedation, 73, 127 Needle placements for spinal injection, axial view, 3–4
Index 273
Needle tip laterally placed within foramen to avoid epidural

spread, 210
R
Needles placed in oblique view, 194
Nerve root injection, 210–215 Radiation safety, 29–39
Nucleus in AP view, needle within, 136–137 C-arm, components of, 32
iris collimation, 34
longitudinal, circumferential, collimation, 38
low dose imaging setting application, C-arm control
O panel, 37
pulse, low dose imaging setting application, C-arm
control panel, 37
Oblique C-arm position for cervical medial branch quantification, radiation exposure, 31–32
injection, 189 shielding, 39
Oblique view Radiofrequency denervation, 191–196
needle placements in, 107 C2 dorsal root ganglion injection, 198
target lumbar vertebra, 129 C3 to C8 medial branches, 192
Oblique view of nerve root injection, 212 C3 to C7 transforaminal injection, 201–209
Oblique views of transforaminal injection revealing contraindications, 192
epidural spread, 213–214 equipment/materials, 192–196
Obliquely viewed fluoroscopic view, 80 procedure, 192–196
Radiofrequency denervation (C3 to C8) medial branches,
192
Radiofrequency lesion at C7 medial branch, A/P view, 195
P Radiofrequency needles approaching cervical facets from
lateral view, 193
P/A view of cervical medical branch injection, 191 Radiographic background
P/A view of intraarticular facet injection with dye spread axial skeleton, 8
along joint, 185 C-arm rotations, 9
Pain response, of patient, 141 spine, anterior view, 10
Patella, 18 classification of bones, pedicles, 25–26
rib on top of, 19 fluoroscopic view, 18–26
Patient in prone position, 182 flat bones, patella, 18
Patient position, 180, 188, 198–201, 216 irregular lumbar bone, vertebra, 19
Patient preparation, 216 radius, 18
Pedicles, 25–26, 62 rib on top of patella, 19
Pelvic girdle, 13–17 short bone, first phalange, 18
Pelvis, fluoroscopic view, 221–228 nerve root injection, 210–215
skeletal anatomy, 13–17
Phalange, first, 18
axial skeleton, 13–14
Posterior annular tear, L5/S1 discogram, 147
iliac spine
Posterior view, needle in, 95
lateral view, 17
Preparation for, 171
posterior superior, 17
lumbar vertebra, 15–16
anterior view, 16
sedation, 171
lateral view, 15
Preparation for needle placement, 127–128
oblique view, 16
Procedure, 192–196, 199–209, 216–218
posterior view, 16
Prone position
superior/oblique view, 15
lumbar spine, 63
pelvis, 17
patient in, 75, 89, 112, 128–129
posterior view, 17
patient placement, 44
sacrum, 17
Pulse, low dose imaging setting application, C-arm control
spine, fluoroscopic view, 10
panel, 37
vertebral column, 5–27
Radius, 18
Rib, 18
on top of patella, 19
Q Right-sided L5 medical branch block, A/P view, 86
Right-sided oblique view, lumbar vertebrae, 74
Quantification of radiation exposure, 31–32 origin of lumbar medial branch in, 74
Right-sided obliquely viewed, 79, 80, 81 posterior superior iliac spine, 17

Right-sided superior hypogastric plexus block, 267 sacrum, 17
Rotated view, 47 Small amount of dye injected, 211
Rotation of C-arm, 49 Spinal injection, 41–53
axis of C-arm, 47
depth of needle placement, lateral view, 51
fluoroscopic view, 44
S initial needle placement, 51
levels of vertebral view, 48
location of spine, 43
S1 superior articular process, needle contacts lateral
lumbar spine
margin, 123
A/P view, 53
Sacral hiatus, needle travel via, 238
lateral view, 52
Sacroiliac joint injection, 231–237
prone patient, 48
angles of posterior opening of, 233
needle insertion, 43
articular surface on sacrum for, 232
needle placement, 50
prone position, patient placement, 44
improper needle placement, 237
rotated view, 47
indications, 231
rotation of C-arm, 49
needle placement, 236
target area identification, 43
posterior, needle inserted below, 231
Spine, 10
posterior opening of, 235
Spinous process, 25
right, posterior opening of, 232
Stellate ganglion block, 250–253
right-sided injection, C-arm position for, 234 C-arm at patient's head, 250
Sacrum, fluoroscopic view, 221–228 C-arm at patient's side, 251
A/P view of sacrum, 227, 230 contrast spreads, cephalical, caudal, 253
fluoroscopic view, 226 needle tip, 252
posterior aspect, 228 P/A viewed C7-T1 vertebrae, 251
posterior view, 223 right side, 249–253
prone position, 224–225 Steps in, 32–39
sacrum from posterior aspect, 228 Superior articular process, needle entry lateral to,
spine in prone position, 224–225 130–131
x-ray view, 226 Superior hypogastric plexus block, 260–267
Safety with radiation, 29–39 anterior view of superior hypogastric plexus, 261
C-arm, components of, 32 contraindications to, 260
iris collimation, 34 indications, 260
leaf collimation, 33 Supine position, C-arm aligned for lateral view, 181
longitudinal, circumferential, collimation, 38 Sympathetic block
low dose imaging setting application, C-arm control lumbar, 253–260
panel, 37 A/P view, 259
pulse, low dose imaging setting application, C-arm A/P view of lumbar spine, including T12, 256
control panel, 37 C-arm at side of prone patient, 255
quantification, radiation exposure, 31–32 contraindications to, 253
shielding, 39 indications, 253
Sedation, 73, 127 lumber spine, lateral view of, 254
Shielding, 39 needle entry point, 257
Short bone, 18 needle placement, lateral view, 258
first phalange, 18 psoas muscles, lumbar spine with, A/P view of,
Skeletal anatomy, 13–17 254
axial skeleton, 13–14 superior hypogastric plexus block, 260–267
lumbar vertebra, 15–16 contraindications to, 260
anterior view, 16 indications, 260
lateral view, 15 Sympathetic blocks, 247–270
oblique view, 16 left-sided superior hypogastric block, 265
posterior view, 16 right-sided superior hypogastric plexus block, 267
superior/oblique view, 15 stellate ganglion block, 250–253
pelvis, 17 C-arm at patient's head, 250
lateral view, 17 C-arm at patient's side, 251
posterior view, 17 contrast spreads, cephalical, caudal, 253
Index 275
needle tip, 252

P/A viewed C7-T1 vertebrae, 251
U
right side, 249–253
superior hypogastric plexus block, 262–267 Under-rotated lumbar vertebrae, 96
anterior view of superior hypogastric plexus, 261
V
T
Vertebral artery
Target area identification, 43 on lateral view of cervical spine, 167
Transforaminal epidural steroid injection, 91 on obliquely viewed cervical spine, 167
left-side L5/S1, needle placement, 122 Vertebral column, 13–17
Transverse process, superior articular process, angle pelvic girdle, 13–17
between, 103–104 radiographic background of, 5–27

The Handbook of C-Arm Fluoroscopy-Guided Spinal Injections

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The Handbook of C-Arm Fluoroscopy-Guided Spinal Injections

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THE HANDBOOK OF

Linda hong wang

Boca Raton London New York

© 2006 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

International Standard Book Number-10: 0-8493-2254-5 (Hardcover)

Library of Congress Cataloging-in-Publication Data

Wang, Linda H. (Linda Hong)

Visit the Taylor & Francis Web site at

To our spouses, without whose love, support, and patience

Linda Hong Wang, M.D., Ph.D., graduated from Capital University of

Anne Marie McKenzie-Brown, M.D., graduated from Johns Hopkins

Chapter 1. An Introduction to Spinal Injections.....................................................1

Chapter 2. Basic Radiographic Background of the Vertebral Column ...................5

Chapter 3. Radiation Safety ................................................................................29

Chapter 4. Basic Steps for Spinal Injections .......................................................41

Chapter 5. Fluoroscopic Images of the Lumbar Spine ........................................55

Chapter 6. Lumbar Spinal Injections ...................................................................71

Chapter 7. Fluoroscopic Images of the Cervical Spine .....................................151

Chapter 8. Cervical Injections ...........................................................................169

Chapter 9. Fluoroscopic Images of the Sacrum and Pelvis...............................221

Chapter 11. Sympathetic Blocks.......................................................................247

Lumbar sympathetic block

Transforaminal epidural steroid injection

C-Arm Fluoroscopy and Images

Intensiﬁer Image display system

Footswitch X-ray tube

1. Identifying a target point in the area of the spine or the pelvis

Axial skeleton (total 80 pieces)

Anatomy of a Typical Lumbar Vertebra

Pelvic Girdle and Sacrum

Classiﬁcation of Bones and Typical Fluoroscopic Images

However, it is difﬁcult to identify anatomic structures on ﬂuoroscopic images of irregular bones

Inferior articular process

An x-ray beam penetrates a patient in a prone position. A typical anterior–posterior (A/P)

Patient in a prone A ﬂuoroscopic photo of anterior-posterior view

2-D image of pedicle shadow

2-D image of vertebral

A two-dimensional image of the vertebra is like a puzzle. A two-dimensional image of each

2-D image of spinous process

2-D image of vertebral body

An A/P ﬂuoroscopic image of a single lumbar vertebra or multiple vertebrae is illustrated in

Quantiﬁcation of Radiation Exposure

3 Gy (300 rad): temporary epilation (hair removal by the roots)

Steps to Minimize Radiation Exposure

A needle placed in the foramen

A needle placed in the foramen

1. External exposure: This badge is often worn around the collar.

Step 1: Identify the Target Area or Location of the Spine to Be Injected

Step 2: Position the Patient for the Injection

Figure 4.3 demonstrates that a patient is placed in the prone position.

Step 3: Use Fluoroscopy to Identify the Target Area Along

Spine ﬁlm Displaying on TV screen

Patient’s left side

Left Sacrum Left

Step 5: Conﬁrm the Needle Placement

The initial needle placement

Contrast material spreads into

Step 6: Inject the Medication (e.g., local anesthetic and steroid)

Positioning the Patient

Anterior/Posterior View of the Lumbar Spine

Obtaining an Oblique View of the Lumbar Spine

The “Scottie Dog” image

Margin of the vertebral body