Category Archives: Spinal Injection

Spinal pain, especially low back pain (5% incidence and 60% to 80% lifetime prevalence in the United States), is very common (1). Low back pain is the leading cause of disability in people younger than 45 years. Although spinal pain often improves and resolves, a significant proportion of patients have ongoing symptoms and pain recurrence. Low back pain is a costly disorder with an annual cost approaching $50 billion (1). Therefore, a comprehensive rehabilitation approach that improves outcomes for patients with spinal pain can have a significant positive medical and economic impact. Adequate pain control can minimize disability, maximize function, improve quality of life, and potentially improve long-term outcomes by preventing the development of chronic pain syndromes. Spinal injection procedures have become an integral part of comprehensive rehabilitative management for individuals with spinal pain. Judicious use of these interventional procedures on carefully selected patients can provide optimal pain control, reduce disability, and improve functional outcome. This chapter is intended to discuss common spinal interventional procedures in an evidence-based manner and provide some instruction on performance of these procedures.

Coccyx Injections

Coccyx pain (coccydynia) apparently occurs far less commonly than lumbosacral pain. Coccydynia can be a severe and persistent pain, causing significant suffering, frustration, and functional limitations (199). These patients often have a history of coccyx trauma (e.g., from a fall or childbirth) resulting in contusions, fractures, dislocations, or other injuries. However, other cases are idiopathic. […]

Discography (Diagnostic Disc Injection)

Discography (Diagnostic Disc Injection)

Although still controversial, discography (diagnostic intervertebral disc injection) is both an imaging study and a provocative physiologic study for determining whether an intervertebral disc is in fact a pain generator in a given patient (Table 68-7). Inserting a spinal needle into the center of the intervertebral disc and injecting contrast dye provides both physiologic information […]

Sacroiliac Joint Injection

The sacroiliac (SI) joint can be a significant source of low back pain (141–143). Etiologies of SI pain include spondylo arthropathy, crystal arthropathy, septic arthritis, trauma, and pregnancy diasthesis (144). In addition, SI joint dysfunction (pain from a biomechanical disorder without a demonstrable lesion) has been proposed as a possible etiology of SI pain (145). […]

Radiofrequency Neurotomy for Z-joint Pain

Radiofrequency neurotomy interrupts the nociceptive afferent from the Z-joint by thermally coagulating the two medial branches that innervate a given Z-joint. The exposed terminal portion of radiofrequency probe delivers heat at 80°C. For each Z-joint (except the C2-3 joint, which is innervated by the third occipital nerve), two medial branches need to be ablated. Indications […]

Zygapophyseal Joint Injection

Introduction The prevalence of lumbar zygapophyseal joint (Z-joint) pain has been reported to be approximately 6% in a primary care setting (94). However, in a tertiary spine center, lumbar Z-joint pain has been reported to range from 15% in younger individuals (96) to 40% in older populations (98) with chronic low back pain. In individuals […]

Selective Nerve Root Block

Diagnostic Nerve Root Block Because of the overlap pattern of dermatomal innervation and the anatomic variants of spinal nerves, clinical history and physical examination alone are often not sufficient to accurately diagnose the segmental level of a spinal nerve lesion. In addition, current imaging studies and electrodiagnostic tests have limited sensitivity and specificity in reaching […]

Fluoroscopic Guidance and Contrast

Fluoroscopic guidance and contrast enhancement are essential for accuracy when performing epidural injections (43). Published data show that even in experienced hands, epidural injections without fluoroscopic and contrast-enhanced guidance (i.e., “blind injections”) often result in inaccurate placement (Table 68-3) (43). These misplacements include the needle being inadvertently positioned into the subarachnoid, intravascular (Table 68-4), or […]

Caudal Lumbar Epidural Injections

Caudal lumbar epidural injections are performed by inserting a needle through the sacral hiatus into the epidural space at the sacral canal (Figs. 68-9 and 68-10). The patient is placed in a prone position. The legs are slightly abducted and feet turned inward to separate the gluteal fold to facilitate palpation of the sacral cornu. […]

Transforaminal Epidural Injection

Comment In one systematic review comparing transforaminal, interlaminar, and caudal ESIs, the authors concluded that there was moderate evidence for long-term (>6 weeks) relief of lumbar radicular pain using the transforaminal and caudal approaches, but limited evidence using the interlaminar approach (30). The authors also concluded that there was moderate evidence for relief of cervical […]

Interlaminar Epidural Injection

Technique The patient is placed in a prone position, ideally with a pillow or abdominal roll under the abdomen to help open up the lumbar interlaminar space by reversing the lumbar lordosis. The skin is then prepped and draped in a sterile manner. The targeted interlaminar space is identified using an anteroposterior (AP) fluoroscopic view, […]