Fluoroscopic guided injections articles -Abstracts

Pain Physician 2000, 3 (3): 305-312

Caudal Epidural Steroid Injections

Review Article

Bentley A. Ogoke, MD

Pioneer Valley Pain Management & Palliative Medicine Center, Inc., Springfield, Massachusetts.

The caudal approach to the epidural space was first reported in 1901. Injection of steroids to treat low back pain was introduced in 1952. Caudal epidural steroid injection is a safe, effective technique when performed with appropriate care under fluoroscopic visualization. Caudal epidural injections are associated with inaccurate needle placement when performed blindly in a substantial number of patients, resulting in intravascular injections as well as other complications.

This review will discuss anatomic and technical considerations of caudal epidural injections, along with advantages, disadvantages, complications, and indications.

Keywords: Caudal epidural steroids, sacral hiatus, fluoroscopy, complications


Epidural Steroids for Treating "Failed Back Surgery Syndrome": Is Fluoroscopy Really Necessary?

Brian Fredman, MB BCh, Meir Ben Nun, MD, Edna Zohar, MD, Ghusan Iraqi, MD, Myra Shapiro, MBChB, Reuven Gepstein, MD, and Robert Jedeikin, BSc, MBChB, FFA(SA)

Departments of Anesthesiology and Intensive Care, Radiology and Spine Surgery, Meir Hospital, Kfar Saba; and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Address correspondence and reprint requests to Robert Jedeikin, BSc, MB ChB, FFA(SA), Department of Anesthesiology and Intensive Care, Meir Hospital, Kfar Saba 44281, Israel.

Epidural steroids are commonly administered in the treatment of "failed back surgery syndrome." Because patient response is dependent on accurate steroid placement, fluoroscopic guidance has been advocated. However, because of ever-increasing medical expenditures, the cost-benefit of routine fluoroscopy should be critically evaluated. Therefore, 50 patients were enrolled into this institutional review board-approved, prospective, controlled, single-blinded study. At a predetermined intervertebral level, the epidural space was identified using an air loss of resistance technique. Thereafter, an epidural catheter was inserted 2 cm through the epidural needle. To determine the accuracy of the clinical placement, contrast medium was administered through the epidural catheter; antero-posterior and lateral lumbar spine radiographs were then obtained. The number of attempts required to successfully locate the epidural space, the reliability of the air loss of resistance technique in indicating successful epidural penetration in failed back surgery syndrome, the ability of the clinician to accurately predict the intervertebral space at which the epidural injection was performed, and the spread of contrast medium within the epidural space were recorded. A total of 48 epidurograms were performed. The number of attempts to successfully enter the epidural space was 2 ± 1. In 44 cases, the radiological studies confirmed the clinical impression that the epidural space had been successfully identified. In three patients, the epidural catheter was in the paravertebral tissue. One myelogram was recorded. In 25 patients, the epidural catheter did not pass through the predetermined intervertebral space. In 35 cases, the contrast medium did not reach the level of pathology.

Implications: The clinical sign of loss of resistance is a reliable indicator of epidural space penetration in most cases of "failed back surgery syndrome." However, surface anatomy is unreliable and may result in inaccurate steroid placement. Finally, despite accurate placement, the depot-steroid solution will spread to reach the level of pathology in only 26% of cases.



American Journal of Neuroradiology 20:697-705 (4 1999)
© 1999 American Society of Neuroradiology


Epidurography and Therapeutic Epidural Injections: Technical Considerations and Experience with 5334 Cases

Blake A. Johnson ,a, Kurt P. Schellhasa and Steven R. Polleia

a From the Center for Diagnostic Imaging, 5775 Wayzata Blvd, Suite 190, St Louis Park, MN 55416.



BACKGROUND AND PURPOSE: Even in experienced hands, blind epidural steroid injections result in inaccurate needle placement in up to 30% of cases. The use of fluoroscopy and radiologic contrast material provides confirmation of accurate needle placement within the epidural space. We describe our technique and experience with contrast epidurography and therapeutic epidural steroid injections, and review the frequency of systemic and neurologic complications.

METHODS: Epidural steroid injections were performed in 5489 consecutive outpatients over a period of 5 years by three procedural neuroradiologists. In 155 cases (2.8%), the injections were done without contrast material owing to either confirmed or suspected allergy. The remaining 5334 injections were performed after epidurography through the same needle. Patients and referring clinicians were instructed to contact us first regarding complications or any problem potentially related to the injection. In addition, the referring clinicians' offices were instructed to contact us regarding any conceivable procedure-related complications.

RESULTS: Only 10 patients in the entire series required either oral (n = 5) or intravenous (n = 5) sedation. Four complications (0.07%) required either transport to an emergency room (n = 2) or hospitalization (n = 2). None of the complications required surgical intervention, and all were self-limited with regard to symptoms and imaging manifestations. Fluoroscopic needle placement and epidurography provided visual confirmation of accurate needle placement, distribution of the injectate, and depiction of epidural space disease.

CONCLUSION: Epidurography in conjunction with epidural steroid injections provides for safe and accurate therapeutic injection and is associated with an exceedingly low frequency of untoward sequelae. It can be performed safely on an outpatient basis and does not require sedation or special monitoring.



The use of epidural injections for the treatment of back and/or radicular pain was described by Evans in 1930 (1). The procedure has been traditionally performed using a blind technique without fluoroscopic guidance, as described by Barry and Kendal (2). The blind interlaminar technique introduces the potential for erroneous needle placement and subsequent injection of substances into undesired locations, such as the subarachnoid space. White and coworkers (3, 4) found that inaccurate needle placement occurred in 25% to 30% of injections, even in the hands of skilled and experienced proceduralists. The documentation of accurate delivery of therapeutic injectate is crucial with respect to the safety and efficacy of this procedure. The potential complications of intrathecal steroid injections, such as adhesive arachnoiditis, have been well described (5, 6). In addition, even with negative needle aspiration, a significant number of injections following blind needle placement have been shown to be intravascular (3, 7).

Because of the high rate of erroneous needle placement associated with blind techniques, there has been movement toward fluoroscopically guided injections and epidurography to document accurate needle placement and to evaluate the epidural space before the instillation of therapeutic substances (813). Injecting variable amounts of radiologic contrast material under direct fluoroscopic observation, with filming (epidurography), before therapeutic injection provides improved safety and efficacy as compared with blind techniques (7). The risk of unintended intrathecal injection and its consequences can be virtually eliminated. Moreover, the practice of second and third steroid injections as a routine series (to assess efficacy) becomes unnecessary. We recount our experience with 5334 procedures in which epidurography was used immediately before and after epidural steroid injection, describe the technique of this relatively painless procedure, and present the complications we encountered.  




We perform epidurography in conjunction with epidural steroid injections in all patients unless there is either a history or reasonable suspicion of allergy to iodinated contrast agents. These are safe outpatient procedures that can assure correct needle placement as well as demonstrate anatomic derangements (14). They require an adequate volume of contrast material to be diagnostically useful; we advocate the use of 5 to 6 mL of contrast material in order to adequately opacify the epidural space and exclude loculations, adhesions, or other barriers to injectate dispersal.

Based on the high rate of erroneous needle placement described in the literature for blinded techniques and the potentially devastating effects of intrathecal steroid injection, we believe it is advisable to perform epidurography before therapeutic injection(s) into the epidural space. Logically, this argument also holds true for the placement of epidural catheters and other devices (13, 15). It is not always possible to confirm needle placement within the epidural compartment on the basis of low resistance with injection. In some patients, the infrafascial compartment provides little resistance to injection. Although a soft-tissue injection is not harmful, it will likely be of no therapeutic value and will provide a false-negative response to the procedure. Likewise, a venous injection of a low dose of steroid is unlikely to cause significant sequelae, but it is not desirable and it is unlikely to be effective. Negative aspiration for blood is insufficient to exclude intravascular needle placement (3, 7). While CSF will generally return with aspiration after intrathecal needle placement, a needle tip that has punctured the dura and is partially subarachnoid may not return CSF upon aspiration. The subsequent injection, however, could result in intrathecal delivery of the steroid agent. Intrathecal delivery of a significant dose of anesthetic may result in profound systemic hypotension, as well as undesired spinal anesthesia. Even more severe complications may result from intrathecal steroid administration: arachnoiditis and adhesions are potential consequences of intrathecal injection of steroid agent, especially with multiple injections (16). This can lead to profound and irreversible clinical sequelae. In skilled hands, our procedure ensures delivery of the therapeutic materials into the epidural space and prevents complications due to intrathecal or intravascular injections.

In addition to enhancing the safety of the procedure, the efficacy of this technique merits discussion. As discussed above, the blind technique does not reliably deliver the injectate into the epidural space. It is therefore a common practice to routinely perform three consecutive epidural injections even if there is no initial response to the first injection. In our practice, if there is no response to the initial injection (and injectate delivery was shown to be accurate with epidurography), second or third injections are not performed. Since we are certain of injection accuracy, arbitrary follow-up epidural injections become unnecessary for nonresponders. Furthermore, targeting and documenting the distribution of injectate to the epidural space relative to the site of a known disorder on the basis of results of advanced imaging studies and pain diagrams increase the chance of a therapeutic response. Documenting the distribution of injected materials may also explain a patient's response if a unilateral or limited epidural block is encountered (17, 18). On the other hand, if the injectate does not descend below a surgical site because of epidural adhesions, a subsequent injection at a more caudal location may prove effective.

We observed substantially greater delivery (and dispersal) of contrast agent and injected therapeutic substances in the lumbar region after either interlaminar or transforaminal injections at L2 to S1 as compared with caudal or sacral hiatus injections (Figs 46 ). In many caudal epidurograms and therapeutic injections, a significant volume remains in the sacral region, often well below the targeted abnormality in the lumbar region. We attempt to perform our injections either directly at or as near as is possible to the segmental disease exhibited on prior imaging studies and as determined by pain diagrams in order to maximize the volume of steroid (and local anesthetic) that reaches the target anatomy (Figs 4 and 5). The posttherapeutic injection epidurogram details the full extent of spread of injected materials. In addition, we select the type of injection technique (interlaminar versus transforaminal) on the basis of both observed structural disease and the patient's pain distribution. For patients with bilateral pain, we prefer to use an interlaminar technique, if possible, to ensure widespread, bilateral dispersal of the injectate (Fig 2). If pain is unilateral, we typically use a transforaminal technique (if anatomy permits) to maximize delivery of therapeutic substances to the foramen and epidural space nearest the observed target disorder and/or suspected origin of radicular symptoms (Figs 4 and 5).

We advocate that the proceduralist take direct responsibility for follow-up care during the 5 to 7 days after injection. This requires familiarity with the side effects and complications that might develop in relation to steroid treatment. The proceduralist is in a much more informed position to address procedure-related calls than is the referring clinician or an emergency physician in most circumstances. Maintaining direct responsibility for and communication with patients eliminates unnecessary visits to emergency rooms and helps the proceduralist develop a knowledge of common side effects, complaints, questions, and possible significant complications. We also contact patients between 3 and 7 days after their epidural injection to assess therapeutic response and status with respect to untoward sequelae. If there are any unusual complaints or circumstances, additional follow-up is then provided.

We have reviewed the efficacy of epidural steroid injections in our exclusively referral practice and have confirmed a high rate of success (19). Clinicians who specialize in spinal disorders identify the specific abnormality and indications for epidural steroid injections and refer these patients without economic incentive, thus eliminating the motivation for self-referral (for spine injection procedures).

A final justification for using these techniques is provided by the patients. Hundreds of our patients have commented on the relatively painless nature of the procedure as compared with their prior experience with a blind injection technique. This is an important point with respect to patient sedation and monitoring. We intravenously sedated (conscious sedation with monitoring) only five patients in this series of over 5400 patients, and these were done because of severe anxiety before the procedure. Every patient who required sedation had previously undergone blind epidural injection(s) elsewhere with a most unfavorable experience. Because fluoroscopically guided epidural injection performed after epidurography is extremely safe and causes minimal patient discomfort, intravenous (IV) sedation and monitoring are only rarely necessary. Because IV sedation is not used, hospitalization and cardiac monitoring are not required for epidural steroid injections when performed under these circumstances, making the procedure ideally suited to outpatient settings. A recent report by Hodges et al (20) further underscores our conviction that IV sedation is not necessary, and in fact may be contraindicated. These authors reported two serious and permanent complications that occurred in sedated patients undergoing cervical epidural steroid injection. Heavily sedated patients are unable to respond with the expected pain and paresthesias due to spinal cord irritation in the event of errant needle placement. Not only were these patients deeply sedated but contrast material was not injected before steroid injection to confirm needle placement within the dorsal epidural space. Performing epidurography in an awake and fully alert patient before steroid injection virtually eliminates the potential for serious complications when done by skilled and experienced proceduralists.


Transforaminal Lumbar Epidural Steroid Injections

Original Article



Laxmaiah Manchikanti, MD

Pain Management Center of Paducah, Paducah, Kentucky.

Low back pain is an important medical, social, and economic problem involving approximately 15% to 39% of the population. Of the numerous therapeutic interventions available for treatment of chronic low back pain, including surgery, epidural administration of corticosteroids is one such intervention commonly used. Several approaches available to access the lumbar epidural space are the caudal, interlaminar, and transforaminal, also known as nerve root or selective epidural injection. The objective of an epidural steroid injection is to deliver corticosteroid close to the site of pathology, presumably onto an inflamed nerve root. This objective can be achieved by the transforaminal route rather than the caudal or interlaminar routes.

Reports of the effectiveness of epidural corticosteroids have varied from 18% to 90%. However, reports of the effectiveness of transforaminal epidural steroids have shown it to be superior, with outcome data indicating cost effectiveness as well as safety.

This review describes various aspects of transforaminal epidural steroid injections in managing chronic low back pain.

KEYWORDS: Epidural steroid injections, caudal epidural, interlaminar epidural, transforaminal epidural, chronic low back pain, corticosteroids

The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns.

Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN.

Interventional Pain Program, MGH Pain Center, Department of Anesthesia and Critical Care, MA General Hospital and Harvard Medical School, Boston, Massachusetts, USA. mstojanovic@partners.org

STUDY DESIGN: A multicenter, retrospective analysis of cervical epidurograms. OBJECTIVES: To determine the effectiveness of the loss of resistance (LOR) technique in identifying the cervical epidural space. To delineate the pattern of epidural contrast spread during cervical epidural steroid injections. BACKGROUND: Previous studies have shown that if performed without fluoroscopy, the LOR technique can result in inaccurate needle placement in up to 30% of lumbar epidural steroid injections. To date, no study has examined accuracy of LOR technique and pattern of radiographic contrast spread in cervical epidural levels. METHODS: Epidurograms of 38 cervical epidural steroid injections in 31 patients were reviewed. The number of LOR attempts and pattern of contrast spread was analyzed. The effects of age, gender, MRI results, previous cervical laminectomy, and the physician's level of training were correlated with results. RESULTS: The authors found a 53% rate of false LOR during the first attempt to enter the epidural space. Unilateral epidural contrast spread was found in 51% and ventral epidural spread was found in 28% of cases. The average number of cervical vertebral levels covered with 2 mL of contrast was 3.14, with significantly wider spread noted in those patients who had not undergone previous cervical laminectomy. Other variables did not influence the accuracy of needle placement and pattern of epidural contrast spread. CONCLUSIONS: The loss of resistance technique may not be an adequate method for ensuring accurate needle placement in blindly performed cervical epidural injections. The use of epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of pathology.



Lutz GE; Vad VB; Wisneski RJ

Department of Physical Medicine and Rehabilitation, Hospital for Special Surgery, New York, NY 10021, USA.

Arch Phys Med Rehabil 1998 Nov;79(11):1362-6

PMID: 9821894 UI: 99037656

OBJECTIVES: To determine the therapeutic value and long-term effects of fluoroscopic transforaminal epidural steroid injections in patients with refractory radicular leg pain. BACKGROUND DATA: Although numerous studies have evaluated the efficacy of traditional transsacral (caudal) or translaminar (lumbar) administration of epidural steroids, to our knowledge no studies have assessed specifically the therapeutic value of fluoroscopic transforaminal epidural steroids. STUDY DESIGN: A prospective case series that investigated the outcome of patients with lumbar herniated nucleus pulposus and radiculopathy who received fluoroscopic transforaminal epidural steroid injections. METHODS: Patients who met our inclusion criteria received fluoroscopically guided, contrast-enhanced transforaminal epidural administration of anesthetic and steroid directly at the level and side of their documented pathology. Patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, activity level, and patient satisfaction. RESULTS: Sixty-nine patients met our inclusion criteria and were followed for an average period of 80 weeks (range, 28 to 144 weeks); 75.4% of patients had a successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, as well as an ability to return to or near their previous levels of functioning after only 1.8 injections per patient (range, 1 to 4 injections). Of our patients, 78.3% were satisfied with their final outcomes. CONCLUSIONS: Fluoroscopic transforminal epidural steroids are an effective nonsurgical treatment option for patients with lumbar herniated nucleus pulposus and radiculopathy in whom more conservative treatments are not effective and should be considered before surgical intervention.

Selective Spinal Injections

by Donald R. Johnson II, M. D,* & Steven C. Poletti, M. D.

Historically, epidural steroid injections have provided anesthetic relief for surgical procedures and childbirth. More than 60 years ago, it was recognized that the therapeutic benefits of such injections could be extended to the treatment of patients with low back pain. However, there is growing evidence that these anesthetic techniques are not directly applicable to the patient with low back pain. In this paper, we will discuss the indications, techniques of administration, and diagnostic and therapeutic benefits of spinal injections for low back pain.

Indications For Selective Spinal Injection
The typical epidural steroid injection can bathe several intervertebral levels, thereby resulting in a comprehensive anesthetizing effect on the spine. However, for patients with low back pain, a more localized injection is often helpful in determining the etiology of the patientís pain, and thus clarifying the diagnosis. Just as internal derangement of the knee is no longer considered an acceptable diagnosis for patients with knee pain, lumbago should no longer be acceptable as a diagnosis for low back pain. Back pain may emanate from many anatomic structures, such as facet joints, sacroiliac joints, hip joints, discs, or the nerve roots.1

To address the problem of pain localization, as well as to insure that injections are in the desired location, spinal injections should be done under fluoroscopy. Fluoroscopy allows accurate placement of the injection into any anatomic structure suspected to be the source of the patient's pain. White et al.2 have demonstrated that experienced anesthesiologists missed the epidural space 25 percent of the time when they performed epidural injections without the benefit of fluoroscopy. The reasons for this may include decreased interlaminar space, as commonly seen with spinal stenosis, postoperative scarring, obesity, and previous spinal fusions.

Techniques Of Administration And Diagnostic Benefits
Since January of 1991, the Carolina Spine Institute has performed over 4,000 selective fluoroscopically-guided spinal injections.3 All injections are done in a spinal injection suite specifically designed for the use of fluoroscopy and equipped with a digital C-arm fluoroscope which provides high image magnification in detail. Prior to patient injection, an examination by a physician, and often a spinal physical therapist, is made to assess the most likely sources of pain. The clinical assessment is correlated with a review of electrodiagnostic information and any pertinent imaging studies, particularly CAT scans and MRI scans, to make a presumptive diagnosis of the patient's pain generator. The patient is then taken under fluoroscopy. The skin is anesthetized with 1% Xylocaine and injections are made into the presumed pain generators. Needle placement is usually verified by the injection of omnipaque 240 contrast dye, followed by an injection of 1% Xylocaine in a steroid solution, usually Depo Medrol. The patient is then taken from the fluoroscopic table to an adjoining waiting room, where a post-block examination is done to assess the immediate effect of the injection. The patient is asked to reproduce his typical discomfort, usually through a series of movements such as bending, twisting, walking, or sitting. Changes in the patient's discomfort provide immediate feedback to both the patient and therapist and helps to identify the etiology of the patient's low back pain. After being monitored for 15-30 minutes, the patient is discharged home.

Selective spinal injections can be placed into the sacroiliac joints, facet joints, epidural space, nerve roots, discs, or congenital bony anomalies. One of the more common spinal injections is the selective nerve root injection. To perform this injection, the patient is placed in a prone position under fluoroscopy. The nerve root exits the spime below its adjacent transverse process and lateral to its adjacent pedicle. After the skin is anesthetized, an 18-gauge needle is placed just inferior to the base of the transverse process, slightly lateral to the pedicle and just deep in the coronal plane to the intertransverse membrane. A 22-gauge spinal needle is then threaded through the 18-gauge needle into the exit zone of the neural foramen. Contrast dye is injected and a radiculogram is reproduced under fluoroscopy. For example, a patient with a right L5 radiculopathy secondary to a disc herniation would undergo a right L5 selective nerve root injection. When contrast is injected over this nerve root, the patient's typical pain is immediately reproduced. Then one to three cc's of 1% Xylocaine, as well as 60-80 mgs of Depo Medrol are injected. Within seconds, the patient's discomfort is diminished as the anesthetic solution is absorbed. An assessment of the injection's efficacy is made within 5 to 15 minutes, as described above. If the patient's pain is largely resolved, then we can be reasonably certain that irritation of the L5 nerve root is the source of the pain.

Derby4 has shown that patients who receive immediate pain relief with selective nerve root injections, often benefit from surgical decompression of the root. Conversely, patients for whom there is no relief of pain after selective nerve root injections have poor surgical outcome. Selective nerve root injections can also be given to patients with a history of previous spinal surgery. For this group of patients, epidural injections are often impossible because of the large amount of epidural fibrosis and bony mass from fusions. However, selective nerve root injections may be very helpful. We have found this technique to be extremely useful in postoperative patients and often is the only technique available to deliver medication to painful nerve roots.

In addition to the diagnostic benefits of these selective spinal injections, we believe these injections often have a substantial therapeutic benefit.5 We are currently reviewing a large group of patients with herniated discs and free fragments in the epidural space who have been treated conservatively with such injections and physical therapy rehabilitation exercises, and have made complete recoveries without surgery. However the utilization of these selective spinal injections should be placed in the continuum of care which includes thorough examinations, appropriate imaging, electrodiagnostics, arid active therapeutic rehabilitation, as well as education. While these injections in and of themselves are not a total medical treatment or cure for any back problem, they can be a very effective form of treatment. It has been proposed by others that maximal therapeutic benefits are obtained through a series of blocks, consisting of three to seven injections performed one week apart. However, there is no current medical literature to support such a proposal. In our experience, selective injections can dramatically reduce the number of injections required: only 50 percent of our patients require a second injection, and only five percent require a third injection. In conclusion, we feel that selective fluoroscopically-guided spinal injections are the current state of the art for epidural anesthetics and steroids delivery. When combined with other treatment modalities, they may be therapeutic, as well as diagnostic. By using these injection techniques, the need for many types of spinal surgeries can be avoided.


1 Mooney V: Where is the pain coming from? Spine 12:754-59, 1987 back

2 White A. Derby R, Wynne G: Epidural injections for the diagnosis and treatment of low-back pain. Spine 5:78-86, 1980. back

3 Poletti S, Johnson D: The use of diagnostic injections in the cervical and lumbar spine. North and South Carolina Orthopedic Society, Charleston, SC. June 1992. back

4 Derby R: Diagnostic block procedures: use in pain localization. Spine: State of the An Reviews. 1:47-64. Sept. 1986. back

5 Stanley D, MeLaren MI, Euinton HA, Getty CJM: A prospective study of nerve root infiltration in the diagnosis of sciatica; a comparison with radiculography, computed tomography and operative findings.
Spine 15:540-43, 1990.

* Address correspondence to Dr. Johnson at the Carolina Spine Institute, 247 Calhoun Street, Char1eston, SC 29401.




Effectiveness of Transforaminal Epidural Steroid Injections in Low Back Pain: A One-Year Experience

Original Contribution

Samuel K. Rosenberg, MD, Andreas Grabinsky, MD, Christine Kooser, RN and Mark V. Boswell, MD, PhD

Anesthesia Pain Service, Department of Anesthesiology, University Hospitals of Cleveland, Cleveland, Ohio.


Transforaminal epidural steroid injections under fluoroscopy are an alternative treatment for lower back pain with radiculopathy. We followed 82 patients with a stand-ardized telephone questionnaire at 2, 6, and 12 months after the first injection, in order to assess their effectiveness.

Ninety-two patients with radiculopathic back pain due to spinal stenosis, herniated discs, spondylolisthesis, and degenerated discs, underwent transforaminal epidural steroid injections under fluoroscopy. Eighty-two patients were followed with a standardized telephone questionnaire. The population was divided into four groups: Group I, previous back surgery (16%); Group II, discogenic abnormalities: herniations, bulges, or degeneration, (42%); Group III, spinal stenosis (32%); Group IV, those without MRI (11%).

Age ranged between 24 to 99 years, mean 64.5. Forty-seven were female, 35 male. Thirteen patients (16%) underwent one procedure, 27 patients (33%) two, 37 patients (45%) three, and five patients (6%) four, an average 2.4 procedures per patient. The pain scores for all patients improved significantly at all three time points (2, 6 and 12 months) compared to the initial mean pain score of 7.3 to mean pain scores of 3.4, 4.5 and 3.9 respectively. After one year, 36 patients did not take any pain medications. Greater than 50% improvement after one year was seen in 23% of Group I; 59% in Group II; 35% in Group III and 67% in Group IV.

Transforaminal epidural steroid injections can offer significant pain reduction up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.

Pain Physician 2003, 6 (2): 155-158


Is Fluoroscopy Necessary for Sacroiliac Joint Injections?


An Original Contribution


Hans C. Hansen, MD


The Pain Relief Centers, PA, Conover, NC


The use of sacroiliac joint injection has been a steadily increasing for therapeutic and diagnostic purposes in the United States. Because of the conceivably easy accessibility of sacroiliac joint and reported low incidence of morbidity, the sacroiliac joint injection is felt to be a procedure that maybe performed easily in the office based setting. While this procedure may be common, the sacroiliac joint injection is not performed accurately without the aide of imaging.

Further complicating the issue of sacroiliac joint injections is the lack of specific and reliable diagnostic testing. Clinical evaluation and imaging studies are often unreliable and practitioners often mistakenly assume that pain over the posterior superior iliac spine is pathognomonic for sacral joint pain. In addition, referral patterns are unreliable and bedside testing is often non-diagnostic.

Sixty patients undergoing sacroiliac joint injections were studied. Sacroiliac joint injections were placed blindly then examined under fluoroscopy for accurate needle placement. The needle was placed by a single experienced spinal injectionist.

Results of blind needle placement revealed that only 5 of 60 patients were felt to have needle placement approximating a therapeutic point of contact with the sacroiliac joint. Furthermore, the posterior superior iliac spine, was found to be a poor indicator of sacroiliac joint anatomic access.

The results of this study show that accurate placement of sacroiliac joint injections is successful without fluoroscopy in only 12% of the patients, even in experienced hands.