Fluoro-Flip: A Quick Reference Guide to Spinal and Peripheral Pain Procedures Rudy Garza III, Maxim S Eckmann, Rachel Yinfei Xu
INDEX
Page numbers followed by f refer to figure.
A
Abdomen 38
Accidental cerebrospinal fluid 17f
Acetabulum, incisura of 86f
Anterior inferior iliac spine 7, 85
Antibiotics, administer 32
Aorta 48f
anterolateral wall of 48f
Aortic penetration 45
Apixaban 9
Articular pillars 27f
target midpoint of 22f
target waist of 26f
Ashworth scale, modified 77
Aspiration 5
Aspirin 9
Atlantoaxial intra-articular injection 6, 24, 24f, 25f
Axial back pain 22, 25, 32, 40, 66, 68, 74
B
Baclofen 77
Betamethasone 12
Bilateral recurrent laryngeal nerves 35
Bisects vertebral body 72f
Bowel perforation 52
Brachial plexopathy 32
Bupivacaine 10, 15, 35, 77, 80, 8587
Bursa 5
C
Carbocaine 10
Cardiac surgery 44
Cardiovascular toxicity 11
C-arm 1, 2f
Caudal epidural steroid injection 64
Cefazolin 32
Celiac plexus 4, 7
block 45, 47, 47f, 48f
Central nervous system toxicity 10
Cephalad 1
Cephalic tilt 1
Cerebrospinal fluid aspiration 15
Cervical
epidural steroid injection 28
facet intra-articular injection 22, 22f, 23f
interlaminar epidural steroid injection 28f, 29f
lead placement 33
medial branch block 25, 26f, 27f
radiculopathy 28, 30, 32
spinal
cord stimulator trial 32f, 33f
stenosis 28, 30
spondylosis 22, 24, 25
sympathetic 4
transforaminal epidural steroid injection 6, 30, 30f
Chassaignac's tubercle 35
Chemoneurolysis 15, 27, 69
Chemoneurolytic ablation 25, 68
Chest wall pain 44
Christmas tree appearance 67f
Chronic regional pain syndrome 19, 82
Clonidine 77
Clopidogrel 9
Coccygeal nerve block 4, 7
Complex regional pain syndrome 32, 74
Contralateral oblique rotation 2
Craniofacial blocks 4
D
Dabigatran 9
Dallas discogram classification, modified 74f
Decadron 12
Depomedrol 12
Dexamethasone 15
acetate 12
Dextrose 25
Diarrhea 45
Discography 5
Dorsal rami 80
E
Eagle's syndrome 21
Endometriosis 50
Enoxaparin 9
Epidural
block 45
blood patch 4
spread 52
steroid injection 7, 38
External auditory meatus 21f
F
Facet
arthrosis 25, 40, 68
column 27f
injection 58
joint 24f, 38f, 67, 68f70f, 81f
intra-articular 5
radiofrequency ablation 5
Facial pain, treatment of 15
Failed back syndrome 74
Failed neck syndrome 32
Femoral nerve 7
articular branch blocks of 84, 86f
block 83
Fentanyl 77
Final needle position 71f
Fluoroscopic imaging chain, components of 1f
Fluoroscopy 1, 4, 5
Foramen
ovale 16, 16f, 17
posterior one-third of 59f
G
Gadolinium 13
Ganglion impar block 4, 52, 53f55f
Gasserian ganglion block 15, 15f17f
Genicular nerve 87
block 7, 88f
Genitourinary pain 50
Glenohumeral
intra-articular injection 36f
joint injection 6
shoulder intra-articular injection 35f
Glossopharyngeal
nerve block 6, 20, 21f
neuralgia 20
Glucocorticoids, selection of 11
H
Head 15
Headaches 19
cervicogenic 22, 24, 25
occipital 22, 24, 25
Hematomas 32, 43, 56, 58, 60, 62, 63
Heparin 9
Hip 56
arthroplasty 84
articular branches of 7
intra-articular injection 7
osteoarthritis 82, 84
pain 82, 84
Horner's syndrome 35
Humeral head, target superolateral portion of 36f
Hydromorphone 77
Hypotension 11, 45, 50
I
Iliac artery 50
Infection 35
Intercoccygeal joint approach 52
Intercostal nerve 4
block 6, 44, 44f
Interlaminar epidural steroid injections 4
Interventional pain procedures 9
Intradiscal injection 50
Intrathecal
block 45
bolus dose 77
injection 50
trial 7, 76
Intravascular injection 15, 44, 63
Ipsilateral rotation 45f, 47f, 61f, 62f, 64f, 65f, 68f, 72f
J
Joint 5
inferior portion of 79f
sacrococcygeal 52, 53f
target lateral one-third of 24f
K
Kambin's triangle 63
Knee
genicular nerve blocks 86
intra-articular injection 7, 87f
osteoarthritis 85, 86
pain 85, 86
Kuntz's fibers 35
L
Lateral branch block 80, 81f
Lead placement 33f
Leg weakness 85
Lidocaine 10
Local anesthetic 10
complications 10
pharmacology 10
Longus colli muscle 34f
Lordosis 2
of spine, degree of 56f
Lumbar
discography 7, 72f, 74f
facet
intra-articular injection 68f, 69f
joint injection 7
interlaminar epidural steroid injection 56, 56f
intra-articular facet joint injection 66
medial branch block 7, 68, 70f, 71f
radiculopathy 56, 58, 60, 62, 63
spinal stenosis 56, 60, 62, 63
spine 56
spondylosis 66, 68
stenosis, severe 64
sympathetic block 4, 7, 82, 83f, 84f
transforaminal epidural steroid injection 58, 59f, 60, 62, 63
M
Magnetic resonance imaging 74
Mastoid air cells 16f
Maxillary
and mandibular nerve block 6, 18, 18f
sinus 18f
posterior wall of 16f
teeth 19
Medial branch block 5, 25, 26f, 27, 40, 68, 69
Mepivacaine 10
Methylene blue 25
Methylprednisolone 12, 35, 57, 85, 86, 87
Mid axial back pain 38
Morphine 77
Multiple steroid injections 35, 86
N
Nasal mucosa, superior-lateral margin of 20f
Nausea 15
Neck pain 28, 30
Needle placement, location of 26f
Needle-in-needle technique 71
Nerve injury 32, 43, 56, 58, 60, 62, 63
Neurovascular injection 35, 83, 85, 86
North American Spine Society 11
O
Obturator nerves 7
articular branch blocks of 84, 86f
Opioids 77
Osteonecrosis 35, 86
Osteoporosis 35, 86
P
Pain 20
abdominal 44
colorectal 50
exacerbation of 67
neuropathic 34
Painful peripheral neuropathies 32, 74
Paresthesia 63
Pelvic
pain, chronic 50
viscera 52
Pelvis 50
Periarticular injection 83
Perineum 50
Peripheral nerve 4
blocks 4
Petrous bone 17f
Phantom limb pain 34
Phenol 25
Phrenic nerves 35
Pneumothorax 44, 45, 45f
Post-dural puncture headache 19, 43, 56
Posterior joint margin 25f
Post-herpetic neuralgia
pain 44
prevention of 28
Postlaminectomy syndrome 64
Preservative free normal saline 28, 57
Procedural kit 3f
Proctalgia fugax 50
Provocative lumbar discography 71
Pterygomaxillary fissure 18f, 20
Pterygopalatine fossa 18f, 19f
Pudendal nerve block 4, 7, 54, 55f
R
Radiation enteritis 50
Radiofrequency ablation 7, 25, 25f, 27, 27f, 40, 41f, 42, 68, 69
Rectal tenesmus 50
Rectum 50
Respiratory failure 35
Rib fractures 44
Rivaroxaban 9
Ropivacaine 10
S
Sacral hiatus 66f
Sacroiliac joint 79f
injection 7, 78, 79f, 80f
Sacrum, sacral promontory point of 51f
Scoliosis 2
Shoulder
osteoarthritis 35
pain 35
Sphenopalatine ganglion 4
block 6, 19, 19f, 20f
Spinal cord 24f
infarct 32, 43, 56, 58, 60, 62, 63
injury 43
stimulator 7, 33f
trial 5, 32, 73, 75f, 76f
Spinal needle 4f
advance 17, 55, 63, 66, 69, 79
Spinous tubercles 81f
Splanchnic nerve block 4, 45, 45f, 46f
Standard epidural steroid injection 28, 56, 58, 60
Stellate ganglion 4, 6
block 34
Steroid 11, 35
sparing 32, 84, 87
Stocker's formula 3
Sufentanil 77
Superior articular process 25, 29, 39, 42, 51, 58
Superior hypogastric plexus 4
block 7, 50, 51f, 52f
T
Tachycardia 11
Target anterior inferior iliac spine 86f
Temporomandibular joint injection 6
Testicular cancer pain 50
Third occipital nerve 7, 24, 26f, 27
block 27
Thoracic
epidural steroid injection 6, 42
facet intra-articular injection 6, 38f, 39f
interlaminar epidural steroid injection 42f, 43f
intra-articular facet injection 38
medial branch
anatomic location of 41f
block 40, 40f, 41
neuropathic pain 44
spondylosis 38, 40
Ticagrelor 9
Total spinal block 15
Transcrural technique 7, 47
Transforaminal epidural steroid injection 4, 7, 11
Trapezoids, midpoint of 27f
Triamcinolone acetonide 12
Trigeminal nerve 4, 18
distribution 15
Trigeminal neuralgia 15
Tuohy needle, advance 58
U
Upper neck pain 24
V
Ventral laminar margin 29f
Vertebral
artery 24f
body 27, 29, 39
anterior portion of 83f
margin, anterolateral margin of 47f
W
Worsening
headache 15
pain 32, 43, 56, 58, 60, 62, 63
X
X-ray
generator 1
tube 1
Xylocaine 10
Z
Ziconotide 77
×
Chapter Notes

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Basics to FluoroscopyChapter 1

 
C-ARM
Components of the fluoroscopic imaging chain (Figs. 1.1 and 1.2):
X-ray generator: The X-ray generator delivers the electrical power to energize the X-ray tube and permits the selection of X-ray energy, X-ray quantity, and exposure time.
X-ray tube: It converts electrical energy from the X-ray generator to a X-ray beam. It is the source of radiation.
Collimator: It contains shutter blades that define the shape of the X-ray beam. Collimating the beam, or “coning down”, results in less scatter X-ray beams and therefore a sharper image. It also reduces the overall radiation dose.
Patient table and pad: It is usually made from a carbon fiber composite material to minimize X-ray attenuation. Thin foam pads are better than thick gel pads.
Image intensifier: It converts the X-ray spectrum transmitted through the patient into a highly visible image and amplifies image brightness.
 
C-arm Maneuvers
 
Tilt versus Oblique Rotation
  • All movements of the C-arm are in relation to the image intensifier.
    • Cephalad/cephalic tilt: >C-arm angled to the patient's head
    • Caudate/caudal tilt: >C-arm angled to the patient's feet
zoom view
Fig. 1.1: Components of the fluoroscopic imaging chain.1
2
zoom view
Fig. 1.2: The C-arm. The tube emits X-rays beams that penetrate the patient's body. The image intensifier converts the X-rays into a visible image that is then displayed on the image monitor. Distance, time, and shielding are the three most important basic guides for radiation safety. Radiation dose varies inversely to the square of the distance from the source. Always take a step back before you take a shot.
    • Ipsilateral oblique rotation: >C-arm rotated toward the side of the injection
    • Contralateral oblique rotation: >C-arm rotated toward the opposite side of the injection.
 
Anteroposterior versus Lateral
  • Anteroposterior (AP) view (different at each level based upon positioning, scoliosis, lordosis, etc.):
    • The spinous process is equidistant from both the pedicles
    • The vertebral body endplates are horizontal lines and not oval-shaped
    • AP versus PA (posteroanterior): Based upon X-ray tube. Using a C-arm, AP view are obtained when a patient is in the prone position (patient laying on the abdomen) versus PA view patients are supine (patient on their back).
    • Not necessarily at 0° from angulation.
  • Lateral view:
    • Oblique 90° from a true AP view.
 
STANDARD SET UP (FIG. 1.3)
  • Sterile gloves, mask, and scrub cap
  • One Prep tray
  • Four absorbent towel/fenestrated drape
  • Chlorhexidine gluconate (ChloraPrep) or isopropyl alcohol for preoperative skin prep
  • One 18–20 G × 3.5 inch Tuohy epidural needle or one 22 G 5-inch spinal needle
  • Two 4 inch × 4 inch gauze dressings
  • One 3 cc Luer lock syringes—contrast media
  • One 5 cc Luer lock syringe—steroid cocktail3
zoom view
Fig. 1.3: Procedural kit.
  • One 10 cc Luer lock syringe—local anesthetic transdermal infiltration
  • One 10 mL LOR syringe with Luer slip tip [if an interlaminar epidural steroid injection (ESI) is performed]
  • One 18 G × 1.5 inch needle—aspiration needle
  • One 25 G × 1.5 inch needle—transdermal infiltration needle
  • Extension tubing (minimizes needle movements and increases distance from radiation exposure)
  • One set of 10 medication labels
  • Band-aids.
 
The Needle (FIG. 1.4)
  • Quincke type (cutting) needle
  • 22 G 5-inch spinal needle:
    • May require less frequent adjustment compared to a 25 G
    • 5 inch versus 3.5 inch:
      • Do not find yourself short. A 5-inch needle can be used for about 90% of the blocks. Body habitus (BMI >30), oblique angulation, and block selection will determine the required length of the needle.
      • Estimation of skin to the subarachnoid space depth (SSD) can be measured using Stocker's formula: SSD (mm) = 0.5 × weight (kg) + 182
  • Distance taken from mid spinal level:
    • The needle moves in the direction of the bevel or opposite to the notch.
      • Place a 5–10° bend away from the notch to improve steerability
      • Exception: The Tuohy needle—the notch is on the same side as the curvature of the needle.4
zoom view
Fig. 1.4: Spinal needle.
  • Needle driving:
    • Needle driving skills come with experience. When first starting off, identify your target and place the C-arm laser aimer (if available) at the center of your target. Then, “light at the center of the hub!” Place the X-ray laser marker over the hub. This technique helps keep the needle aligned to the target producing a “gun barrel” view.
 
PAIN PROCEDURE CURRENT PROCEDURE TERMINOLOGY CODES (2017)3
 
Craniofacial Blocks (Fluoroscopy is not Bundled)
  • Trigeminal nerve (any branch): 64400
  • Sphenopalatine ganglion: 64505
 
Sympathetic Blocks (Fluoroscopy is not Bundled)
  • Stellate ganglion (cervical sympathetic): 64510
  • Superior hypogastric plexus: 64517
  • Thoracic or lumbar paravertebral sympathetic [lumbar sympathetic block (LSB)] or ganglion impar block: 64520
  • Celiac plexus: 64530
  • Splanchnic nerve block: 64530
 
Peripheral Nerve Blocks (Fluoroscopy is not Bundled)
  • Other peripheral nerve: 64450
    • Destruction: 64640
  • Pudendal nerve block: 64430
  • Intercostal nerve (single): 64420
  • Intercostal nerve (multiple): 64421
  • Coccygeal nerve block: 64450
 
Interlaminar Epidural Steroid Injections (Fluoroscopy is Bundled)
  • Interlaminar—cervical or thoracic: 62321
  • Interlaminar—lumbar or sacral (caudal): 62323
  • Epidural blood patch: 62273
 
Transforaminal Epidural Steroid Injection (Fluoroscopy is Bundled)
  • Transforaminal—cervical or thoracic (first level): 64479
  • Transforaminal—cervical or thoracic (each additional level): 644805
  • Transforaminal—lumbar or sacral (first level): 64483
  • Transforaminal—lumbar or sacral (each additional level): 64484
 
Intra-articular Facet Joint or Medial Branch Block (Fluoroscopy is Bundled)
  • Intra-articular joint or medial branch block (MBB)—cervical or thoracic (first level): 64490
  • Intra-articular joint or MBB—cervical or thoracic (second level): 64491
  • Intra-articular joint or MBB—cervical or thoracic (third level): 64492
  • Intra-articular joint or MBB—lumbar or sacral (first level): 64493
  • Intra-articular joint or MBB—lumbar or sacral (second level): 64494
  • Intra-articular joint or MBB—lumbar or sacral (third level): 64495.
Note: Codes based upon spinal level/facet joint, not individual medial branches. Each facet joint is innervated by two different medial branch nerves. Hence, an L3-5 medial branch block, deinnervates the L4/5 and L5/S1 facet joint, therefore can only be billed as a first and second level procedure.
 
Facet Joint Radiofrequency Ablation (Fluoroscopy is not Bundled)
  • Medial branch cervical or thoracic (first joint): 64633
  • Medial branch cervical or thoracic (each additional joint): 64634
  • Medial branch lumbar or sacral (first joint): 64635
  • Radiofrequency ablation (RFA)—lumbar or sacral (each additional joint): 64636.
 
Spinal Cord Stimulator Trial—Cervical or Thoracolumbar (Fluoroscopy is Bundled)
  • Percutaneous lead placement: 63650—bill × 2 if trial required 2 leads
    • Includes 10-day global period.
 
Discogram/Discography (Fluoroscopy is Bundled)
  • Lumbar discogram/discography (each disk): 62290.
 
Intrathecal Trial (Fluoroscopy is not Bundled)
  • Injection of diagnostic substance (anesthetics, antispasmotics, opioids solutions) into the epidural or subarachnoid space: 62322.
 
Joints and Bursa—Injection or Aspiration (Fluoroscopy is not Bundled)
  • Major joint/bursa: 20610 (knee, hip, shoulder, trochanteric bursa, subacromial bursa, pes anserine bursa)
  • Intermediate joint/bursa: 20605 (temporomandibular, acromioclavicular, wrist, elbow, ankle, olecranon bursa)
  • Minor joint/bursa: 20600 [fingers proximal interphalangeal (PIP), distal interphalangeal (DIP), toes, carpometacarpal 20604]
  • Sacroiliac joint (SIJ) with fluoroscopy: 27096
  • Sacral (S1-S3) lateral branch blocks: 64450 × 3
    • Use 77003 instead of 77002
    • RFA of L5 dorsal primary ramus and S1-S3 lateral branches: 64640 × 4
  • Genicular nerve (knee) blocks: 64450 × 3 units
  • Genicular nerve RFA: 64640 × 3.6
 
Fluoroscopic Guidance (for Non-bundled Procedures)
  • Fluoroscopic guidance for non-spinal procedures: 77002
  • Fluoroscopic guidance for spinal procedures: 77003.
 
Modifiers
  • Applies only to an office visit with a procedure: 25
  • Bilateral procedures: 50
  • Incomplete procedure (patient did not tolerate procedure): 52
  • Aborted procedure (patient's well-being at risk, i.e. vasovagal): 53
  • Distinct procedural service: 59
    • It is used on claims to indicate that two procedures reported during the same encounter are separate and distinct from each other and eligible for separate and unreduced payment.
 
TARGET ANGLES
Target angles have been described in Table 1.1.
Table 1.1   Description of target angles.
Procedure
Angles (based upon the C-arm intensifier)
Gasserian block
  • Caudal tilt: 30–40°
  • Ipsilateral rotation: 15–20°
Mandibular and maxillary nerve block
  • Lateral view
Sphenopalatine ganglion block
  • Lateral view
Glossopharyngeal nerve block
  • Lateral view
Cervical facet joint injection
  • Caudal tilt: 25–35°
Atlantoaxial intra-articular injection
  • AP view (optional—caudal tilt: 5–10°)
Cervical medial branch/TON/RFA
  • Caudal tilt: 25–30°
  • Ipsilateral oblique versus 5–10°
Cervical ESI
  • Caudal tilt: 5–15°
  • Contralateral oblique 45–55° (52)—for needle advancement and confirmation
Cervical transforaminal ESI
  • Foraminal view: 40–50° (45)
Cervical spinal cord stimulation
  • See cervical ESI with access at T1/2 interspace
Stellate ganglion
  • C6; ipsilateral oblique 40–50° (45)
Glenohumeral joint injection
  • AP view
Temporomandibular joint injection
  • Lateral view
Thoracic facet joint injection
  • AP view
  • Contralateral oblique (45–50°) for needle advancement
Thoracic medial branch/RFA
  • AP view
  • Optional: Caudal tilt 5–10°, contralateral oblique 5–10°
Thoracic ESI
  • Caudal tilt: 25–35°
Intercostal nerve block
  • AP view
  • Optional: Caudal tilt 15–20°
Splanchnic
  • Anterolateral margin of the T11 or T12 vertebral body
  • Ipsilateral oblique 5–10°
7
Celiac plexus (transcrural technique)
  • Target: Anterolateral margin of the L1 vertebral body
  • Ipsilateral oblique 20–30° (TP aligns to the VB)
Superior hypogastric plexus block
  • Target: Anterolateral margin of the L5 vertebral body
  • Cephalad tilt: 20–30°
  • Ipsilateral oblique: 25–35°
Ganglion impar/bilateral S5 and coccygeal nerve block
  • AP view to confirm midline
  • Lateral view for needle advancement
Pudendal nerve block
  • Target: Ischial spine
  • Caudal tilt: 5–10°
  • Ipsilateral oblique: 5–10°
Lumbar ESI
  • Caudal tilt: 5–15°
Subpedicular TFESI
  • AP view (optional: ipsilateral oblique 5–10°)
Supraneural TFESI
  • Ipsilateral oblique: 15–20°
Retroneural TFESI
  • AP view (optional: ipsilateral oblique 5–10° until the lamina bisects the pedicle)
Infraneural TFESI
  • Ipsilateral rotation: 30–35°
Caudal ESI
  • AP view to determine midline
  • Lateral view for needle advancement
Lumbar facet joint injection
  • Ipsilateral oblique: 25–35°
Lumbar medial branch block (MBB)/RFA
  • L1-4 MBB:
    • Ipsilateral oblique: 15–20°
    • Caudal/cephalad tilt:15–20°
  • L1-4 MBRFA:
    • Ipsilateral oblique: 15–20°
    • Caudal tilt:15–20°
  • L5 DRB/RFA:
    • Ipsilateral oblique: 0–5°
    • Caudal tilt: 0–5°
Lumbar discography
  • Ipsilateral oblique 35–45° (SAP bisects the VB)
SCS-lumbar
  • AP view
  • Needle entry lateral to the pedicle below the target interspace at a 20–30° angle toward midline
Intrathecal trial
  • Below the L1-2 interspace
  • AP view
Sacroiliac joint injection
  • Target: posterior, inferior SIJ opening
  • Cephalad tilt: 10–15°
  • Ipsilateral oblique: 5–10°
Sacral lateral branch block/RFA
  • AP view (optional: Caudal tilt 0–5°; ipsilateral oblique 0–5°)
Lumbar sympathetic block
  • Target inferior anterolateral margin of L2, or the anterolateral margins of L3, or L4
  • Ipsilateral oblique: 25–35°
Hip intra-articular injection
  • AP view
Articular branches of the hip—femoral and obturator nerves
  • Target: AIIS and the incisura of the acetabulum
  • Caudal tilt: 10–15°
  • Ipsilateral rotation: 0–5°
Knee intra-articular injection
  • AP view
Genicular nerve block
  • AP view
(RFA: Radiofrequency ablation; TON: Third occipital nerve; ESI: Epidural steroid injection; AP: Anteroposterior; TFESI: Transforaminal epidural steroid injection; SCS: Spinal cord stimulator; AIIS: Anterior Inferior Iliac Spine).
8
REFERENCES
  1. Schueler BA. The AAPM/RSNA physics tutorial for residents: general overview of fluoroscopic imaging. Radiographics. 2000;20(4):1115–26.
  1. Stocker DM, Bonsu B. A rule based on body weight for predicting the optimum depth of spinal needle insertion for lumbar puncture in children. Acad Emerg Med. 2005;5:105–6.
  1. http://www.cms.gov/ICD10; accessed September 2017.