Thomas S. Lee

Injectate volumes needed to reach specific landmarks in lumbar transforaminal epidural injections.

To identify the volumes of contrast material needed to reach specific landmarks during lumbar transforaminal epidural injections (L‐TFEIs).

Injectate Volumes Needed to Reach Specific Landmarks in S1 Transforaminal Epidural Injections

OBJECTIVES   We identify the contrast volumes needed to reach specific landmarks during S1 transforaminal epidural injections (S1-TFEIs). DESIGN   Prospective, nonrandomized, observational human study. Setting.  Academic/private pain management practice. Subjects.  Forty-two patients undergoing S1-TFEIs were investigated. Thirty-seven patients were included in this study. Interventions.  S1-TFEIs were performed using contrast-enhanced fluoroscopic visualization. MAIN OUTCOME MEASUREMENTS   After confirming appropriate spinal needle position, up to 5 mL of nonionic contrast was slowly injected. Under biplanar fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: the ipsilateral S1 pedicle, the superior aspect of the L5-S1 disc space, and across the midline of the spinous process. RESULTS   After injecting 2 mL of contrast, 100% of S1-TFEIs spread to the medial aspect of the ipsilateral superior pedicle of S1. After injecting 3.0 mL of contrast, 92% of S1-TFEIs spread to the superior aspect of the L5-S1 intervertebral disc. After injecting 4 mL of contrast, 27% of S1-TFEIs spread beyond the midline of the spinous process, but by only a few millimeters. CONCLUSIONS   This study demonstrates injectate volumes needed to reach specific anatomic landmarks in S1-TFEIs. A volume of 3.0 mL of contrast reaches the superior aspect of the L5-S1 intervertebral disc 92% of the time.

L5-S1 Disc Access

This chapter describes strategies to enter the L5-S1 disc, which requires a modified technique, and delineates the “tricks” to approach the L5-S1 disc when the posterior iliac crest makes access more challenging. Initially, we present a direct trajectory that is similar to that described in Chapter 17A. For patients with high iliac crests or other technical limitations, additional options are presented. The “tricks” described here optimize the L5-S1 disc access, including the “over-tilt” and curved needle techniques. If only one “trick” is to be used, the “over-tilt” will often be sufficient.

Chapter 17A – Lumbar Provocation Discography/Disc Access: Standard Fluoroscopic Techniques

This chapter describes and demonstrates strategies to utilize anteroposterior (AP) and lateral imaging to optimally drive the needle tip to a lumbar disc’s central target. It also includes additional information about discographic image interpretation.

Lumbar Zygapophysial Intraarticular Joint Injection—Posterior Approach: Fluoroscopic Guidance

In this chapter, the approach described for zygapophysial joint injection involves the use of a trajectory view in an oblique orientation and advancement involving the use of a minimum of two views: anteroposterior and oblique. The use of a lateral view is also recommended for final confirmation, especially when the superior recess needs to be accessed. Inferior recess access will also be described.