without using x-ray guidance (fluoroscopy). Why is x-ray guidance now used whereas in the past it was not
required?
Answer: Our understanding of the anatomy, concerns regarding the safety of the patient, and improved
accuracy of injections have all driven the movement away from blind office injections. The American Pain
Society demonstrated in a normal patient during a blind sitting office epidural, the medication does not
reach the target area more than 1/3 of the time and is actually in the spinal sac (where the spinal fluid lives)
1-2% of the time. Injection of a steroid into the spinal sac can cause disasterous results (arachnoiditis) and
the injection of the steroid in this location is specifically contraindicated by the manufacturer. The person
giving the injections in the spinal sac was not even aware the tip of the needle was located there.
Furthermore, there are other studies demonstrating in patients with prior spine surgery, blind office epidural
injections only reach the proper location in 25% of the injections. Use of fluoroscopy can increase this to
100%. The injections are expensive and in the office sitting on a table, may be very painful, especially if
there had been prior back surgery. Would you have surgery by a surgeon who's success rate was only 25%
because he did not open his eyes? I think not. Also, insurance often limits the number of injections over a
given time period and if there is an inaccurate injection given because of the lack of fluoroscopy, then that
reduces your chances of success, and becomes an expensive waste of time and money.
Fluoroscopic or CT guided injections are now the standard of care as defined by several national pain
management organizations including ISIS and ASIPP. Anything less than fluoroscopy or CT use for spinal
injections is a substandard injection that is potentially dangerous.
2. Question: I had one epidural steroid injection sitting in the operating room and it worked well. The next
two injections did nothing for my pain. Why is that?
Answer: Blind epidural steroid injections are like blasting the spine with a shotgun loaded with steroids.
Sometimes they work and sometimes they don't, but they are often inconsistent in their results due to the lack
of accurate placement (the injection may not even be at the correct spine level since it is not possible to
accurately determine levels without fluoroscopy). Also, the steroid is injected in a larger volume to
promote the spread of the steroid to the appropriate level of pathology, but this has the effect of diluting out
the steroid which actually delivers very little steroid to the site of pathology. Use of a smaller volume
results in an injection of concentrated steroid into the epidural fat where it is absorbed, and doesn't reach
the site of the pathology.
3. Question: I understand the transforaminal approach is often being used now instead of the sitting office
epidural. What is the difference and why is transforaminal better?
Answer: The transforaminal approach (traditional) places the steroid on the nerve root and the steroid
tracks up to the level of the disc herniation. The lateral recess block with a blunt needle (first invented at
Advanced Pain Management) is our preferred approach, and places the steroid directly onto the disc
herniation at the site of the nerve inflammation. Because the placement is so accurate, it is possible to
lower the amount of steroid given, thus reducing the side effects. Also, not dependent on diffusion or
tracking of the steroid into the spine takes away one of the variables resulting in a better injection result.
The lateral recess block or transforaminal block does not have the potential for injection of the steroid into
the fat of the back of the spine where it would not be effective.
4. Question: X-ray guided blocks expose the patient to the dangers of radiation. Is there a risk of
developing problems later from the x-ray exposure?
Answer: Because of the accuracy of the block placement, the experience of the pain management
physicians at APM, and the low dose fluoroscopy used, there is usually less radiation than with a chest
xray, and only a small fraction of that from a CT scan. Therefore, the risk of radiation dangers is felt to be
minimal, and worth the effort to deliver the medications accurately.
5. Question: My doctors also used to give facet injections, sacroiliac injections, and caudal injections
without x-ray guidance. What were the accuracies of these injections?
Answer: One study found 100% of the time it is not possible to get into the sacroiliac joints without
fluoroscopy. The facet joints are so small that it is also impossible to get into the joints without x-ray
guidance. Finally, one study found nearly a 20% rate of incorrectly placed needles during caudal blocks
performed without x-ray guidance.
