What is the role of fluoroscopy in the performance of therapeutic injections for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Fluoroscopy has transformed interventional pain management, not only for more precise needle placement, but also for venturing into new treatment venues, especially within the spinal canal. Precise needle placement allows practitioners to address multiple spinal pain generators with injections that include placement of radiographic contrast, local anesthetics, and corticosteroids into the epidural space, intra-articular facet joints, sacroiliac joints, and intervertebral discs. Symptomatic facet joints can be identified by median branch nerve blocks and then ameliorated with radio-frequency neurotomy or chemical neurolysis. New technologies have evolved, such as the use of spinal cord stimulators and a host of intradiskal procedures, including electrothermal coagulation, percutaneous mechanical disk decompression, laser disc decompression and radiofrequency intradiskal/annular neurolysis.

Other new treatment methods include vertebroplasty and kyphoplasty for vertebral fractures. Fluoroscopy allows more precise localization of both stellate and lumbar paravertebral sympathetic blocks, visceral sympathetic blocks, celiac plexus and superior hypogastric plexus blocks, and neurolysis of the Impar ganglion.

Several studies have demonstrated the comparative accuracy of experienced injectors and anesthesiologists using fluoroscopy compared with previous blind injection techniques and have shown a superior success rate with imaged needle guidance. [10]

Manchikanti et al advocate fluoroscopy as medically necessary for the performance of epidural corticosteroid injections. [11] Dye injection may reveal incorrect needle placement or inadequate penetration of the injectate to the level of pathology. Fluoroscopy eliminates the question of incorrect or suboptimal needle placement as compared with blind injections and can provide evidence of accurate needle positioning. Documentation of dye spread often mimics the probable flow of corticosteroids and other active medications, and therefore may correlate with the patient's response to treatment. Unintentional intravascular injection may occur during procedures despite negative aspiration through the needle. Vascular locations can be suspected when the contrast dye seems to wash away from the site of the needle tip after it is injected. Limited reasons for not using fluoroscopy include the avoidance of radiation, the cost of fluoroscopy, or allergy to contrast agents.

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