(BQ) Part 2 book The handbook of C-ARM fluoroscopy guided spinal injections has contents: Fluoroscopic images of the cervical spine, cervical injections, fluoroscopic images of the sacrum and pelvis, pelvic and sacral injections, sympathetic blocks.
Chapter Fluoroscopic Images of the Cervical Spine 151 This page intentionally left blank Fluoroscopic Images of the Cervical Spine 153 Positioning the Patient Cervical spinal injections can be done in either the supine (Figure 7.1A), prone (Figure 7.1B), or lateral positions (Figure 7.1C) A B C FIGURE 7.1 Cervical spine injection positions (A) Supine position (B) Prone position (c) Lateral position Handbook of C-Arm Fluoroscopy-Guided Spinal Injections 154 Positioning the C-Arm The C-arm can be positioned in many ways for cervical spinal injections (Figure 7.2) For example, the C-arm can be positioned from the patient’s side, as when performing lumbar procedures (Figure 7.2A) The C-arm can also be positioned from behind the patient’s head (Figure 7.2B) The C-arm can be positioned to get a lateral view of the cervical spine as seen in Figure 7.2C and Figure 7.2D A B C D FIGURE 7.2 C-arm positions (A) At side (B) At patient’s head (C) and (D) Positioned for lateral view of cervical spine Fluoroscopic Images of the Cervical Spine 155 A/P (P/A) View and Lateral View of the Cervical Spine Images of both the anterior–posterior (A/P) view in the prone position, the posterior–anterior (P/A) view in the supine position and the lateral view of the cervical spine, look quite different from images of the A/P and lateral view of the lumbar spine (Figure 7.3) This is due to the unique shapes of the cervical vertebrae B A C D Mandible FIGURE 7.3 The cervical and the lumbar spine (A) P/A view of the cervical spine (B) A/P view of the lumbar spine (C) Lateral view of the cervical spine (D) Lateral view of the lumbar spine Handbook of C-Arm Fluoroscopy-Guided Spinal Injections 156 Comparison of Cervical Vertebrae and Lumbar Vertebrae Like a lumbar vertebra (Figure 7.4B), a cervical vertebra (Figure 7.4A) consists of the vertebral body, two transverse processes, two pedicles, lamina, two superior articular processes, two inferior articular processes, and a spinous process However, the cervical vertebra differs from the lumbar vertebra Their differences are summarized in Table 7.1 Figure 7.5 is a P/A view image of the cervical spine A B C D FIGURE 7.4 (A) Cervical vertebra (superior view) (B) Lumbar vertebra (superior view) (C) Lateral view of the cervical spine from C4 to C7 (D) Lateral view of the lumbar vertebra TABLE 7.1 Comparison of Cervical Vertebrae and Lumbar Vertebrae Cervical Vertebra Lumbar Vertebra Vertebral body Small Large Transverse process Quite small Connects to lateral surface of vertebral body Anterior to the pedicle Has transverse foramen Anterior to the superior articular process Large Connects to posterior surface of vertebral body Posterior to the pedicle Lateral to the superior articular process Pedicle Short Connects to posterior surface of transverse process Long Connects to posterior surface of lumbar vertebral body Spinous process Varies in length Ends in two tips (called bifid tips) Long Ends in only one tip Superior articular process Connects to pedicle only Connects to pedicle and transverse process Inferior articular process Articular pillar connects the superior and inferior articular processes Pars interarticularis (part of lamina) connects to superior and inferior articular processes Fluoroscopic Images of the Cervical Spine 157 FIGURE 7.5 Fluoroscopic image of the P/A view of the cervical spine (1) Spinous process, (2) transverse process with transverse foramen, (3) articular pillar, (4) vertebral body Handbook of C-Arm Fluoroscopy-Guided Spinal Injections 158 Lateral and Oblique Views of the Cervical Spine Figure 7.6 is a lateral fluoroscopic image of the cervical spine We usually rotate the fluoroscopic image horizontally if the patient is in a supine position (Figure 7.7) Mandible FIGURE 7.6 Fluoroscopic image of the lateral view of the cervical spine (1) Spinous process, (2) articular pillar, (3) superior articular process, (4) inferior articular process, (5) vertebral body, (6) pedicle, (7) transverse process with transverse foramen Fluoroscopic Images of the Cervical Spine 159 Mandible FIGURE 7.7 Fluoroscopic image of the lateral view of the cervical spine (rotation of fluoroscopic image in Figure 7.6) (1) Spinous process, (2) articular pillar, (3) superior articular process, (4) inferior articular process, (5) vertebral body, (6) transverse process with transverse image of the foramen Handbook of C-Arm Fluoroscopy-Guided Spinal Injections 160 In true lateral images of the cervical spine (Figure 7.8), the vertebral body is squared, the articular pillar is a trapezoid shape, the facet joint space is open, the transverse process with transverse foramen cover the posterior–superior portion of the vertebral body, and the spinous process has sharp superior–posterior and inferior margins Mandible Transverse processes with transverse foramina cover posterior–superior portion of vertebral body Vertebral body is squared off Vertebral body Transverse process with transverse foramen Articular pillar Spinous process A trapezoid shape of Articular pillar Spinous process has sharp margins FIGURE 7.8 Lateral images of cervical spine Facet space is open Sympathetic Blocks 261 Superior Hypogastric Plexus Block Indications: Chronic pelvic pain Contraindications: Patient refusal Systemic anticoagulation or coagulopathy Systemic or localized infection at the site Step 1: Indentify the Target Area The target area is the anterior surface of the lower portion of the L5 vertebral body, the disc between L5 and the sacrum, and the anterior surface of the sacral promontory (Figure 11.23 to Figure 11.25) The target area FIGURE 11.23 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections 262 Superior hypogastric plexus L5 L5 A Superior hypogastric plexus B FIGURE 11.24 (A) Anterior view of the superior hypogastric plexus (B) Lateral view of the superior hypogastric plexus Step 2: Position the Patient The patient is in a prone position, and the C-arm is pushed in from the patient’s side (Figure 11.25) FIGURE 11.25 Sympathetic Blocks 263 Step through Step 6: The needle is inserted from posterior laterally to the spine (Figure 11.26) We prefer not to go through the disc between L5 and the sacrum Left Right FIGURE 11.26 Get an A/P view of the lower portion of the lumbar spine including L5 and squaring the lower margin of L5 or open the disc space between L5 and the sacrum (Figure 11.27) L5/S1 disc space is open FIGURE 11.27 264 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections The C-arm is rotated to the injecting side (e.g., to the right; Figure 11.28) until obtaining a large triangle area that is formed by the iliac crest, the lower margin of transverse process, and the lateral margin of the superior articular process of the sacrum Target needle entry site FIGURE 11.28 Sympathetic Blocks 265 Insert the needle at the junction between the iliac crest and the superior articular process (Figure 11.29) Target needle entry site FIGURE 11.29 Initial needle placement for a left-sided superior hypogastric block 266 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections Advance the needle in the lateral view until the needle tip reaches the anterior margin of L5 (Figure 11.30) Contrast is spread in the A/P view and the lateral view (Figure 11.31) Inject cc of appropriate local anesthetic FIGURE 11.30 FIGURE 11.31 Sympathetic Blocks 267 Repeat Step through Step for another side injection After verifying the needle placement, inject another cc of local anesthetic (Figure 11.32) (a) (b) FIGURE 11.32 A/P view of the needle placement of the right-sided superior hypogastric plexus block (A) without contrast and (B) with contrast Bibliography Brown, D.L., Ed., Atlas of Regional Anesthesia, 2nd ed., Saunders, Philadelphia, 1999 Fenton, D.S and Czervionke, l.F., Eds., Image-Guided Spine Intervention, Saunders, Philadelphia, 2003 Netter, F.H., Ed., Atlas of Human Anatomy,, Ciba Geigy Corporation, Tarrytown, 1989 Walkman, S.D., Ed., Atlas of Interventional Pain Management, 2nd ed., Saunders, Philadelphia, 2004 This page intentionally left blank Index A Annulogram, lumbar spinal injection, lateral view, 134–135 Axial skeleton, C-arm rotations, spine, anterior view, 10 B Bones, fluoroscopic view of, 18–26 flat bones patella, 18 rib, 18 irregular lumbar bone facial bones, 19 vertebra, 19 radius, 18 rib on top of patella, 19 short bone, first phalange, 18 C C-arm components of, 32 positioning of, 180, 188, 198, 216 (See also under specific view) C2/C3 to C6/C7 intra-articular joint injection, 180–186 C-arm position, 180 contraindications to, 180 patient position, 180 C2 root injection, 198 A/P view, 200 C-arm position, 198 lateral view, 199 patient position, 198–201 procedure, 199–201 C3 to C7 transforaminal injection, 201–209 C-arm position, 216 C-arm positioning, 202 equipment/materials, 216 patient position, 201, 216 patient preparation, 216 procedure, 202–209, 216–218 Caudal epidural steroid injection, 238–245 contraindications to, 238 dorsal wall, sacrum, 240 fluoroscopic lateral view of, 244 indications, 238 lateral view, 244 epidural needle, 244 sacral hiatus, 241 needle insertion into, 243 needle travel via, 238 sacrum, 241 lateral view, 242 lateral view of, 243 subcutaneous insertion, 245 Cervical epidural injection, 196–218 Cervical facet injection, 172–173 lateral approach, 173 Cervical injection, 169–218 C2/C3 to C6/C7 intra-articular joint injection, 180–186 C-arm position, 180 contraindications to, 180 patient position, 180 C2 dorsal root ganglion injection, 198 C-arm position, 198 patient position, 198–201 procedure, 199–201 C3 to C7 transforaminal injection, 201–209 C-arm positioning, 202, 216 equipment/materials, 216 patient position, 201, 216 patient preparation, 216 procedure, 202–209, 216–218 cervical epidural injection, 196–218 cervical facet injection, 172–173 lateral approach, 173 cervical medial branch injection, 186–191 C-arm position, 188 contraindications to, 188 patient position, 188 cervical transforaminal injection, 196–198 complications of, 180 269 270 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections interlaminar epidural steroid injection, 216–218 intra-articular facet injection, 174–180 C-arm position, 175 C1/C2 intraarticular injection, patient position for, 175 C1/C2 joint lateral view, 177–178 spine model of, 174 C1/C2 joint injection, 174 C1/C2 joint space, dye within, A/P views, 179 mouth closed, C1/C2 view with, 176 patient position, 175 procedure, 175–179 nerve root injection, 196–218 preparation for, 171 patient preparation, 171 equipment/materials, 171 sedation, 171 radiofrequency denervation, 191–196 C2 dorsal root ganglion injection, 198 C3 to C8 medial branches, 192 C3 to C7 transforaminal injection, 201–209 contraindications, 192 equipment/materials, 192–196 procedure, 192–196 Cervical medial branch injection, 186–191 C-arm position, 188 contraindications to, 188 patient position, 188 Cervical spinal nerve roots, counting of, 166 Cervical spine, 151–167 C-arm positions, 154, 165 cervical spinal nerve roots, counting of, 166 inferior view, 163 injection positions, 153 intervertebral foramina, counting of, 166 lateral view, 158–162 lumbar vertebrae, comparison, 156 model, 197–198 oblique view, 163 P/A view, 157 right-sided obliquely viewed view, 164 superior view, 156 vertebral artery on lateral view of cervical spine, 167 on obliquely viewed cervical spine, 167 Cervical transforaminal injection, 196–198 Circumferential annular tear, lumbar spinal injection, 146 Circumferential collimation See Iris collimation Classification of bones, 18–26 facial bones, 19 first phalange, 18 flat bones, 18 irregular lumbar bone, 19 long bone, 18 patella, 18 pedicles, 25–26 radius, fluoroscopic view, 18 rib, 18 rib on top of patella, 19 short bone, 18 vertebra, 19 Contrast agent, lumbar spinal injection, improper spread of, 100 Contrast injection within disc space, lumbar spinal, 136–141 Curvature, adult lumbar spine, injection, 113 D Depth of needle placement, lateral view, 51 Discography, lumbar spinal injection, 124–127 A/P view of, 138 mature disc, A/P view, 139 Dye spread within disc, lumbar spinal injection, lateral view, 143 E Epidural steroid injection, 210–215 lumbar transforaminal, 88–111 Equipment/materials, 192–196, 216 F Facial bones, 19 First phalange, 18 Flat bones, 18 patella, 18 rib, 18 Fluoroscopic view of bones, 18–26 Foramen, needle approaching, posterior view, lumbar spinal injection, 89 H High intensity zone, lumbar spinal injection, 125 I Iliac crest, lumbar spinal injection, 120 left oblique view, 121 Injection, spinal, 41–53 axis of C-arm, 47 depth of needle placement, lateral view, 51 fluoroscopic view, 44 initial needle placement, 51 Index levels of vertebral view, 48 location of spine, 43 lumbar spine A/P view, 53 lateral view, 52 prone patient, 48 needle insertion, 43 needle placement, 50 prone position, patient placement, 44 rotation, C-arm, 47, 49 target area identification, 43 Interlaminar epidural steroid injection, 216–218 Interlaminar needle placement with catheter threaded, dye lateralized to left side, 217 Intervertebral foramen, between L5, first sacral segment, insertion of needle into, 112 Intervertebral foramina, counting of, 166 Intra-articular facet injection, 174–180 A/P views of dye within left C1/C2 joint space, 179 C-arm position, 175 C1/C2 intraarticular injection, patient position for, 175 C1/C2 joint dye within, A/P views, 179 lateral view, 177–178 with mouth closed, 176 spine model of, 174 C1/C2 joint, 174 lateral view of C1/C2 joint, with needle approaching joint, 177–178 mouth closed, C1/C2 view with, 176 patient position, 175 procedure, 175–179 spine model of C1/C2 joint, 174 Intraarticular injection performed in patient in prone position, with dye spread along joint space, 186 Intramuscular injection, dye spread, 215 Intravascular injection, 209 Iris collimation, 34 Irregular lumbar bone, 19 facial bones, 19 vertebra, 19 L L3/4, lateral view of contrast within, 140 L5 dorsal ramus injection, 82–84 L4/L5, right side, needle placement between, 110–111 L5 left oblique view, 118 L5 medial branch block, lateral view, needle position recheck, 87 L5 right-sided obliquely viewed, 84 L5/S1 discogram, mature disc at, 146 entry site, 142 epidurogram, left-sided, 125 fluoroscopic beam aligned with, 117 271 lack of alignment, with disc between fluoroscopic beam, 116 lumbar transforaminal epidural steroid injection, 111–124 needle in center of, 145 needle in position for, 144 vertebral end plates squared in AP view, 142 Lamina, 25 Lateral cervical spine labeled with positions of cervical medial branches, 187–188 Lateral view cervical medial branch injection, 190 interlaminar needle placement at C7/T1, 217 Leaf collimation, 33 Left oblique view, initial needle insertion in, 99 Left-sided superior hypogastric block, 265 Levels of vertebral view, 48 Linear collimation See Leaf collimation Location of spine, 43 Long bone, 18 Longitudinal, circumferential, collimation, 38 Low dose imaging setting application, C-arm control panel, 37 Lower portion, posterior view of, 82 L5/S1, discography at, 141–147 L5/S1 injection, 142–147 Lumbar medial branch block, lateral view, 84 denervation, 87–88 Lumbar spinal injection, 71–147 A/P view, 83 target points on lumbar vertebra in, 77 A/P viewed fluoroscopic view, target points on lumbar vertebra in, 77 annular placement of needle, difficulties with, 132–135 annulogram, lateral view, 134–135 C-arm neutral position, 85 position, 129 circumferential annular tear, 146 contrast agent, improper spread of, 100 contrast injection within disc space, 136–141 curvature, adult lumbar spine, 113 discogram A/P view of, 138 mature disc, A/P view, 139 dye spread within disc, lateral view, 143 equipment/materials, 73 foramen, needle approaching, posterior view, 89 high intensity zone, 125 iliac crest, 120 left oblique view, 121 initial entry point, 88 initial needle placement, 92 intervertebral foramen, between L5, first sacral segment, insertion of needle into, 112 L4, L5, right side, needle placement between, 110–111 L5 left oblique view, 118 right-sided obliquely viewed, 84 272 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections S1, lack of alignment, with disc between fluoroscopic beam, 116 L3/4, lateral view of contrast within, 140 L3/4 disc, lateral view of contrast within, 140 L4/5 disc, lateral view of contrast within, 140 L4/L5, right side, needle placement between, 110–111 L5 medial branch block, lateral view, needle position recheck, 87 L5/S1 discogram, mature disc at, 146 entry site, 142 epidurogram, left-sided, 125 fluoroscopic beam aligned with, 117 lack of alignment, with disc between fluoroscopic beam, 116 lateral view of contrast within, 140 needle in center of, 145 needle in position for, 144 post-procedure, 147 vertebral end plates squared in AP view, 142 left oblique view, initial needle insertion in, 99 left-sided L5/S1 epidurogram, 125 lower portion, posterior view of, 82 lumbar medial branch block, lateral view, 84 lumbar vertebra above L5, right-sided oblique view, 88 manometry syringes, discography, 127 mechanically vs chemically sensitive discs, 141 medial branch block, 78 needle entering disc, 131–133 needle entry point, oblique view, 122 needle placement, 130–132 lateral view of, 124 needle placements, posterior view, 75 neutral position, C-arm in, 94 nucleus in AP view, needle within, 136–137 oblique view needle placements in, 107 target lumbar vertebra, 129 obliquely viewed fluoroscopic view, 80 over-rotated to right, 98 pain response, of patient, 141 patient position, 128 patient preparation, 73, 127 posterior annular tear, L5/S1 discogram, 147 posterior view, needle in, 95 preparation for needle placement, 127–128 prone position patient, 89 patient in, 75, 112, 128–129 properly rotated vertebrae, 97 right oblique view, needle entry from, 96 right-sided L5 medical branch block, A/P view, 86 right-sided oblique view, lumbar vertebrae, 74 origin of lumbar medial branch in, 74 right-sided obliquely viewed, 79, 81 right-sided obliquely viewed view, 80 S1 superior articular process, needle contacts lateral margin, 123 sedation, 73, 127 steps in, 88–92, 94–124 superior articular process, needle entry lateral to, 130–131 transforaminal epidural steroid injection, 91 left-side L5/S1, needle placement, 122 transverse process, superior articular process, angle between, 103–104 under-rotated lumbar vertebrae, 96 view orientation, 90 Lumbar spine, 55–69 A/P to oblique, 60 A/P view, 53, 57–58, 68 in checking needle depth, 69 lateral view, 52, 63 in checking needle depth, 69 needle depth unchanged, 67 prone position, 63 oblique view, 61 pedicle, 62 prone patient, 48 prone position, 57 right oblique view, 59 Lumbar sympathetic block, 253–260 A/P view, 259 A/P view of lumbar spine, including T12, 256 C-arm at side of prone patient, 255 contraindications to, 253 indications, 253 lumber spine, lateral view of, 254 needle entry point, 257 needle placement, lateral view, 258 psoas muscles, lumbar spine with, A/P view of, 254 Lumbar vertebra above L5, right-sided oblique view, 88 M Manometry, 127–141 Manometry syringes, discography, 127 Marker shows target site for needle in posterior superior aspect of foramen, 203 Mechanically vs chemically sensitive discs, 141 Medial branch block, 78 lumbar, 73–87 contraindications to, 73 indications, 73 N Needle Needle Needle Needle Needle at midpoint of facetal column, 207–208 entry site for cervical intraarticular injection, 183 insertion, 43 placement, 50 placements for spinal injection, axial view, 3–4 Index Needle tip laterally placed within foramen to avoid epidural spread, 210 Needles placed in oblique view, 194 Nerve root injection, 210–215 Nucleus in AP view, needle within, 136–137 O Oblique C-arm position for cervical medial branch injection, 189 Oblique view needle placements in, 107 target lumbar vertebra, 129 Oblique view of nerve root injection, 212 Oblique views of transforaminal injection revealing epidural spread, 213–214 Obliquely viewed fluoroscopic view, 80 P P/A view of cervical medical branch injection, 191 P/A view of intraarticular facet injection with dye spread along joint, 185 Pain response, of patient, 141 Patella, 18 rib on top of, 19 Patient in prone position, 182 Patient position, 180, 188, 198–201, 216 Patient preparation, 216 Pedicles, 25–26, 62 Pelvic girdle, 13–17 Pelvis, fluoroscopic view, 221–228 Phalange, first, 18 Posterior annular tear, L5/S1 discogram, 147 Posterior view, needle in, 95 Preparation for, 171 patient preparation, 171 equipment/materials, 171 sedation, 171 Preparation for needle placement, 127–128 Procedure, 192–196, 199–209, 216–218 Prone position lumbar spine, 63 patient in, 75, 89, 112, 128–129 patient placement, 44 Pulse, low dose imaging setting application, C-arm control panel, 37 Q Quantification of radiation exposure, 31–32 273 R Radiation safety, 29–39 C-arm, components of, 32 iris collimation, 34 longitudinal, circumferential, collimation, 38 low dose imaging setting application, C-arm control panel, 37 pulse, low dose imaging setting application, C-arm control panel, 37 quantification, radiation exposure, 31–32 shielding, 39 Radiofrequency denervation, 191–196 C2 dorsal root ganglion injection, 198 C3 to C8 medial branches, 192 C3 to C7 transforaminal injection, 201–209 contraindications, 192 equipment/materials, 192–196 procedure, 192–196 Radiofrequency denervation (C3 to C8) medial branches, 192 Radiofrequency lesion at C7 medial branch, A/P view, 195 Radiofrequency needles approaching cervical facets from lateral view, 193 Radiographic background axial skeleton, C-arm rotations, spine, anterior view, 10 classification of bones, pedicles, 25–26 fluoroscopic view, 18–26 flat bones, patella, 18 irregular lumbar bone, vertebra, 19 radius, 18 rib on top of patella, 19 short bone, first phalange, 18 nerve root injection, 210–215 skeletal anatomy, 13–17 axial skeleton, 13–14 iliac spine lateral view, 17 posterior superior, 17 lumbar vertebra, 15–16 anterior view, 16 lateral view, 15 oblique view, 16 posterior view, 16 superior/oblique view, 15 pelvis, 17 posterior view, 17 sacrum, 17 spine, fluoroscopic view, 10 vertebral column, 5–27 Radius, 18 Rib, 18 on top of patella, 19 Right-sided L5 medical branch block, A/P view, 86 Right-sided oblique view, lumbar vertebrae, 74 origin of lumbar medial branch in, 74 274 Handbook of C-Arm Fluoroscopy-Guided Spinal Injections Right-sided obliquely viewed, 79, 80, 81 Right-sided superior hypogastric plexus block, 267 Rotated view, 47 Rotation of C-arm, 49 S S1 superior articular process, needle contacts lateral margin, 123 Sacral hiatus, needle travel via, 238 Sacroiliac joint injection, 231–237 angles of posterior opening of, 233 articular surface on sacrum for, 232 contraindications to, 231 improper needle placement, 237 indications, 231 needle placement, 236 posterior, needle inserted below, 231 posterior opening of, 235 right, posterior opening of, 232 right-sided injection, C-arm position for, 234 Sacrum, fluoroscopic view, 221–228 A/P view of sacrum, 227, 230 fluoroscopic view, 226 posterior aspect, 228 posterior view, 223 prone position, 224–225 sacrum from posterior aspect, 228 spine in prone position, 224–225 x-ray view, 226 Safety with radiation, 29–39 C-arm, components of, 32 iris collimation, 34 leaf collimation, 33 longitudinal, circumferential, collimation, 38 low dose imaging setting application, C-arm control panel, 37 pulse, low dose imaging setting application, C-arm control panel, 37 quantification, radiation exposure, 31–32 shielding, 39 Sedation, 73, 127 Shielding, 39 Short bone, 18 first phalange, 18 Skeletal anatomy, 13–17 axial skeleton, 13–14 lumbar vertebra, 15–16 anterior view, 16 lateral view, 15 oblique view, 16 posterior view, 16 superior/oblique view, 15 pelvis, 17 lateral view, 17 posterior view, 17 posterior superior iliac spine, 17 sacrum, 17 Small amount of dye injected, 211 Spinal injection, 41–53 axis of C-arm, 47 depth of needle placement, lateral view, 51 fluoroscopic view, 44 initial needle placement, 51 levels of vertebral view, 48 location of spine, 43 lumbar spine A/P view, 53 lateral view, 52 prone patient, 48 needle insertion, 43 needle placement, 50 prone position, patient placement, 44 rotated view, 47 rotation of C-arm, 49 target area identification, 43 Spine, 10 Spinous process, 25 Stellate ganglion block, 250–253 C-arm at patient's head, 250 C-arm at patient's side, 251 contrast spreads, cephalical, caudal, 253 needle tip, 252 P/A viewed C7-T1 vertebrae, 251 right side, 249–253 Steps in, 32–39 Superior articular process, needle entry lateral to, 130–131 Superior hypogastric plexus block, 260–267 anterior view of superior hypogastric plexus, 261 contraindications to, 260 indications, 260 Supine position, C-arm aligned for lateral view, 181 Sympathetic block lumbar, 253–260 A/P view, 259 A/P view of lumbar spine, including T12, 256 C-arm at side of prone patient, 255 contraindications to, 253 indications, 253 lumber spine, lateral view of, 254 needle entry point, 257 needle placement, lateral view, 258 psoas muscles, lumbar spine with, A/P view of, 254 superior hypogastric plexus block, 260–267 contraindications to, 260 indications, 260 Sympathetic blocks, 247–270 left-sided superior hypogastric block, 265 right-sided superior hypogastric plexus block, 267 stellate ganglion block, 250–253 C-arm at patient's head, 250 C-arm at patient's side, 251 contrast spreads, cephalical, caudal, 253 Index needle tip, 252 P/A viewed C7-T1 vertebrae, 251 right side, 249–253 superior hypogastric plexus block, 262–267 anterior view of superior hypogastric plexus, 261 T Target area identification, 43 Transforaminal epidural steroid injection, 91 left-side L5/S1, needle placement, 122 Transverse process, superior articular process, angle between, 103–104 275 U Under-rotated lumbar vertebrae, 96 V Vertebral artery on lateral view of cervical spine, 167 on obliquely viewed cervical spine, 167 Vertebral column, 13–17 pelvic girdle, 13–17 radiographic background of, 5–27 ... Lateral view of the C1/C2 joint, with the needle approaching the joint (B) The needle has advanced toward the C1/C2 (AA) joint in the lateral view 178 Handbook of C-Arm Fluoroscopy- Guided Spinal Injections... position Handbook of C-Arm Fluoroscopy- Guided Spinal Injections 154 Positioning the C-Arm The C-arm can be positioned in many ways for cervical spinal injections (Figure 7 .2) For example, the C-arm. .. Photo of the lateral view of cervical spine 163 164 Handbook of C-Arm Fluoroscopy- Guided Spinal Injections A unique oblique image of the cervical spine (Figure 7. 12) can be obtained by tilting the