Isaac Cohen

Cervical Transforaminal Epidural Steroid Injection

What causes pain in the epidural space? The cervical area of the spine has seven bones, called vertebrae. Soft discs found between these vertebrae cushion them, hold them together, and control motion. If a disc tears, chemicals inside may leak out. This can inflame nerve roots or the dura, and cause pain. A large disc tear may cause a disc to bulge, inflaming nerve roots or the dura, and cause pain. Bone spurs, called osteophytes, can also press against nerve roots and cause pain.

Chapter 3 – Introduction to Fluoroscopic Techniques: Anatomy, Setup, and Procedural Pearls

This chapter describes basic and advanced fluoroscopy techniques to achieve optimal C-arm setups. These include an understanding of the C-arm operation, fluoroscopic anatomy, basic projections, optimal views, and parallax. n nThe first step to a successful procedure includes setting up the C-arm according to the anatomy of the specific targeted segment. The C-arm setup determines the trajectory that the needle will take to reach its target, provided that the operator uses “down the beam” technique. It should be evident that a safe, efficient, and effective procedure is dependent on an optimal C-arm setup. n nThe authors would like to emphasize that the setup should be specifically focused on the target segment. Visual recognition of bony landmarks, rather than specific measurements or angles, is emphasized, given that the morphology and orientation of each anatomic segment can differ. n nThe challenge for an interventionalist is to reconcile the two-dimensional configuration of the fluoroscopic image with the three-dimensional anatomy of the patient. Such an understanding requires time, practice, and knowledge of spinal anatomy and fluoroscopy. n nIn the latter half of the chapter, these more “advanced” fluoroscopic techniques will help the reader obtain the skills needed to troubleshoot any nonoptimal image, and therefore provide the safest and most efficient procedure for the patient. n nThe following fluoroscopic techniques will help to optimize the visualization of key bony landmarks when positioning the needle to reach a specific target.

Cervical Zygapophysial Joint Intraarticular Injection, Posterior Approach: Fluoroscopic Guidance

In this chapter, the posterior approach for injecting the zygapophysial joints (Z-joints) is described. Compared with the lateral approach, the posterior approach allows for access to multiple joint levels on both sides of the spine, thereby negating the need to reposition the patient or C-arm when performing bilateral injections. This approach is often required for injecting the more inferior Z-joints, where a lateral approach may involve the risk of contacting the lung apex or the inferior neurovascular structures. With this approach, the trajectory view is an anteroposterior view with a caudad tilt (i.e., a pillar view), which also serves as the anteroposterior view with multiplanar imaging. Because the lateral view is used to assess depth, one need not step off of the inferior or superior articulation of the joint before penetrating the joint capsule, as is often recommended. A contralateral oblique (CLO) view is an additional multiplanar view and can be used as a relative depth view. Typically a 22- or 25-G needle is used to inject a maximum volume of 1 ml of a steroid and anesthetic mixture into each joint.