Jonathan S. Kirschner

Ultrasound Techniques and Procedural Pearls

This chapter provides a basic introduction to ultrasound and its use in interventional procedures. We will discuss several ways to improve image quality and optimize the features of ultrasound that make it an invaluable tool. Sonographic anatomy of the relevant spinal structures and landmarks will be reviewed. In this atlas, we will discuss “hybrid” techniques in which ultrasound and fluoroscopy are combined to enhance safety and precision, minimize discomfort, and reduce radiation exposure for interventional procedures.

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.

Chapter 2 – Needle Techniques

Many aspects are involved in a technically successful, efficient, and safe spinal injection procedure. These aspects are discussed in Box 2.1. This chapter focuses on item 4 from that list: directing or “driving” the needle tip into proper position.

Chapter 1 – Introduction: How to Use This Atlas

Interventional procedures play an integral role in the diagnosis and treatment of spinal pain. Injections can also be helpful in diagnosing or ruling out conditions that commonly masquerade as spinal pain, such as hip or shoulder pathology. Practitioners from multiple specialties perform these procedures with great variability in procedural technique and training. This atlas should function as a reference tool for providing a safe, structured approach to performing image-guided interventional procedures used to diagnose and treat symptoms emanating from the spine and/or structures that may masquerade as spinal conditions. This atlas is intended to be an adjunct to formal training in image-guided interventional pain care; it is not meant to be used in lieu of proper hands-on training with experienced mentors.

Stellate Ganglion Injection: Ultrasound Guidance

For ultrasound (US), a transverse in plane with long-axis confirmation technique at the level of the Chassaignac’s tubercle of C6 is described. By utilizing a hybrid fluoroscopic approach, US is used to carefully position the needle away from critical structures in the soft tissue of the anterolateral neck, guiding the safest injection possible. After US-guided (USG) needle placement, injected contrast under fluoroscopy (hybrid technique) verifies unilateral and nonvascular contrast flow. Vital structures identified and avoided under USG injection include the trachea, esophagus, thyroid, inferior thyroid artery, recurrent laryngeal nerve, common carotid artery, internal jugular vein, and vertebral artery.

A Billing and Coding Workshop for PM&R Residents

The complexity of medical billing, coding, and practice management has increased dramatically over the last 25 years. In 1992, the Current Procedural Terminology (CPT) Editorial Panel defined criteria to standardize the reporting of physician-patient encounters. The first version of the “Documentation Guidelines for Evaluation and Management Services” was introduced in 1995 and revised in 1997. The ninth version of the International Classification of Diseases (ICD9), first introduced in 1979 and comprising 13,000 codes, has now been supplanted by ICD-10 in October 2015 with approximately 68,000 codes. In 2011, the first phase of Meaningful Use was implemented, soon followed by phases 2 and 3. The Physician Quality Reporting System (PQRS) began applying negative payment systems in 2015 to those physicians and group practices that did not report data on quality measures [1]. Recognizing the importance of educating residents about the changing nature of health care delivery, in 1999 the ACGME defined six core competencies, one of which is “systemsbased practice,” defined as “actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value [2].”