Flouro Images of Lumbar Spine Injections

1. Flouro Images of Lumbar Spine Injections David F. Drake, MD Director, VCU PM&R Pain Fellowship David Berkower, MD 2003-4 Pain Fellow

2. Using Contrast Dye • The following views were obtained using an injection dummy and therefore no contrast dye was used. • We recommend, when available, the use of contract dye to confirm needle placement

3. Lumbar Median Branch Block (MBB) The flouro is placed in the oblique position at approx 30 degrees to view the “scotty dog”. The needle is directed at the eye of the “scotty dog” and advanced until bone is contacted. Needle

4. Lumbar Facet Injection A lumbar facet injection would be done in a similar fashion as a MBB, however the target is the facet joint (between the ear of the lower “scotty dog” and the front foot of the upper “scotty dog”).

5. Sacroiliac Injection The flouro is placed just off AP in order to align the inferior poles of the SIJ. The needle is advanced into the inferior poles until a loss of resistance is appreciated. Needle

6. AP View of Lateral Hip Injection The lateral hip approach avoids the nerves and vessels which may be encountered in the anterior approach. It’s wise to get a lateral flouro view to confirm needle placement.

7. AP View of Anterior Hip Injection When performing a hip injection from the anterior, the artery should be palpated at all times and gentle negative pressure (aspiration) in the syringe is important to avoid intravascular injection.

8. AP View of Anterior Hip Injection – Part 2 A different view

9. Oblique View of Lumbar Transforaminal Epidural Place the flouro in the oblique position (approx 30 deg). Focus the needle under the chin of the “scotty dog” [superior aspect of lateral foramen]. Needle

10. Lateral View of Lumbar Transforaminal Obtain a lateral view to confirm needle is w/in the foramen.

11. AP View of Lumbar Transforaminal Finally, obtain an AP view To confirm the needle is Medial enough and w/in the Epidural space. *Note: for a selective spinal nerve injection the needle should be more lateral and not w/in the epidural space.

12. Oblique View of Disc Injection The flouro is placed in the oblique position [approx 30 deg]. The needle is advanced into the disc space. A firm, fibrous sensation is often felt when entering the disc.

13. Lateral View of Disc Injection A lateral flouro view is obtained to confirm needle depth.

14. AP View of Disc Injection An AP view may be obtained to assess how medial the needle is.

15. Oblique Lumbar Sympathetic Block An oblique flouro view [approx 30 deg] is obtained. The needle is directed just anterior to the L-3 vertebral body. Needle