Part 2 book “Atlas of pain medicine procedures” has contents: Sphenopalatine ganglion block, occipital nerve blocks, transforaminal epidural steroid injection, sacroiliac joint injections, percutaneous sacroplasty, percutaneous facet fusion, provocative discogram, intradiscal electrothermal therapy,… and other contents.
SECTION V MUSCULOSKELETAL INJECTIONS CHAPTER 50 Fluoroscopy and Ultrasound-Guided Joint Injections Jennifer Solomon, Christine Roque-Dang, and James Wyss IMAGE-GUIDED PERIPHERAL JOINT INJECTION INDICATIONS The most common clinical indication for an image-guided interventional procedure is pain in the targeted anatomic location, which has either failed other conservative treatments or as an adjunctive treatment The primary advantage of image-guided interventional procedures over blind injections includes needle placement confirmation and the ability to view the targeted area and relevant anatomy Corticosteroid injections are frequently used as conservative treatments in the management of various conditions, including osteoarthritis, tendonitis, bursitis, and impingement conditions Injectate mixtures typically comprise a local anesthetic and a corticosteroid (triamcinolone or methylprednisolone) In addition, patients at higher risk for developing nonsteroidal anti-inflammatory drug (NSAID)–induced renal dysfunction or gastric and duodenal ulcers are candidates for intra-articular steroid injections to avoid the potential systemic effects that occur with oral anti-inflammatory medications However, the detrimental effects of repeated steroid injections on soft tissue structures like articular cartilage and tendons have not yet been determined The advantages of ultrasound-guided percutaneous interventional procedures are as follows: • Real-time assessment • Guidance, and continuous needle visualization • Lack of radiation exposure • Technological portability • Relatively low cost • Improved accessibility Fluoroscopic guidance also allows real-time needle visualization and the acquisition of imaging frames throughout the injection course The visualization occurs at different C-arm angles The primary disadvantage of fluoroscopy is radiation exposure to both the patient and physician BASIC CONCERNS AND CONTRAINDICATIONS With therapeutic interventions, the benefits and risks of the procedure must be considered Generally, peripheral joint corticosteroid injections are considered to be safe and conservative treatments However, each patient’s risk factors for complications must be carefully considered prior to undergoing the procedure Some basic concerns for injection are following: • Patients with primary or metastatic tumors in the target area • Immunocompromised patients, who are at increased risk for infection • Patients with thrombocytopenia • Patients who may be unable to tolerate positioning • Patients with allodynia or complex regional pain syndrome (CRPS), who will be unable to tolerate the procedure • Patients on anticoagulant medications, who have been unable to stop these medications at an appropriate time interval • For fluoroscopically guided procedures with the use of contrast dye, patients with allergies to contrast, shellfish, or iodine may be considered for interventional procedures without contrast Contraindications for injection include: • Infection, systemic or localized • Coagulopathy • Distorted or complicated anatomy • Pregnancy for fluoroscopically guided procedures • Patient refusal GENERAL IMAGE-GUIDED INTERVENTIONAL PROCEDURE PREOPERATIVE CONSIDERATIONS • Informed consent must be obtained and the risks and benefits of the procedure should be properly explained to the patient or consenting individual • The area must be examined for infection, skin lesions, and disease extent • Proper exposure of the targeted area is necessary If clothing is restrictive, the patient should be requested to change into a gown • Ideally, the patient should be able to remain in the appropriate position throughout the procedure • Intravenous access is not necessary, but may be considered if the patient has a history of postprocedural vasovagal or hypotension responses • The patient must be asked whether he or she takes any anticoagulant medications (ie, aspirin, NSAIDs, etc) and, if applicable, when these medications were stopped prior to the procedure If stopping the anticoagulant medications increases cardiac risks, it is highly recommended to obtain medical clearance from the patient’s cardiologist • The physician performing the procedure should have access to fluoroscopy or ultrasound • For fluoroscopically guided procedures, female patients in reproductive age should be asked about potential pregnancy and may require a urine pregnancy test • For fluoroscopically guided shoulder injections, the patient must be asked about prior allergic reactions to contrast, shellfish, and iodine BASIC ULTRASONOGRAPHY Depending on the ultrasound probe and machine used, the shoulder, hip, and elbow regions may be examined with high-frequency (>10 MHz) linear array transducers If the patient has a large body habitus, a mid-range frequency transducer (6-10 MHz) may need to be used to optimize image resolution and facilitate proper examination An appropriate initial depth is cm Also, the frequency may be adjusted to visualize deeper structures (ie, glenoid labrum or labrum of the hip) or shallower ones (ie, acromioclavicular joint [AC] joint) For ultrasound examination, tissues are described by their properties of echogenicity, echotexture, degree of anisotropy, compressibility, and blood flow on Doppler examination Blood vessels are not susceptible to anisotropy, but exhibit compressibility and presence of blood flow on Doppler examination In the shoulder, rotator cuff tendons display a high degree of anisotropy, which is particularly pronounced at the musculotendinous junction Tissue echogenicity is characterized as hyperechoic, hypoechoic, anechoic, or isoechoic Due to lack of echoes, anechoic structures have a black appearance Isoechogenic tissues have similar brightness in comparison with surrounding tissues Hyperechoic structures (ie, normal tendons and ligaments) appear brighter than adjacent tissues In contrast, hypoechoic structures appear darker than surrounding structures Both muscles and nerves have mixed echogenicity patterns Blood vessels either appear to be hypoechoic or anechoic Echotexture refers to the internal pattern of echoes and may vary based on the axis used to assess the structure Both tendons and ligaments have “broom end” appearance when viewed in the transverse axis and a fibrillar pattern when viewed in the longitudinal axis Nerves have a “honeycomb” appearance on transverse imaging and a fascicular pattern on longitudinal imaging Muscles have a “starry night” appearance on a transverse axis and a pennate or “feather like” pattern on a longitudinal axis [7, 9] BASIC POSTPROCEDURE FOLLOW-UP The patient should be contacted via telephone on the day following the interventional procedure to determine pain relief achieved from the local anesthetic and if there were any complications If the patient received a corticosteroid injection, the patient should be reminded that the antiinflammatory property has a variable onset and may take up to 2 to 3 weeks to achieve symptomatic improvement The primary postinjection concern is infection Therefore, the patient should monitor the injection site for erythema, warmth, increased swelling or systemic features of an infection, including fever and chills If the patient develops any complications, he or she should be advised to contact the injectionist for further guidance For severe procedurally related adverse events, ie, fever >101°F, weakness, dyspnea, severe pain exacerbation, etc, the patient should be recommended to seek immediate emergency medical services and to notify the injectionist All adverse reactions should be properly documented in the patient’s chart Clinical Pearls • Image-guided interventional procedures are powerful diagnostic and therapeutic tools to aid in the diagnosis and management of various musculoskeletal disorders • The duration of benefit is variable, but steroid injections tend to produce substantial short-term relief of symptoms (eg, pain, swelling) with variable duration of relief (1-3 months) • Body habitus may influence the image-guided approach used In obese patients, fluoroscopy may be used to improve visualization of deeper anatomic structures that would be more difficult to visualize under ultrasound guidance Conversely, in leaner patients, use of ultrasound guidance eliminates radiation exposure and usually most anatomic structures can be easily identified • Success of image-guided procedures is dependent on numerous factors, which include target localization through use of anatomic landmarks, patient cooperation, and the experience of the physician with image-guided interventions • Image-guided injections are well tolerated and have an excellent safety profile • These procedures can be repeated to manage recurrent symptoms, but patients should be cautioned that the detrimental effects of repeated steroid injections on soft tissue structures, ie, articular cartilage and tendons have not yet been determined THE GLENOHUMERAL (GH) JOINT OF THE SHOULDER Indications The glenohumeral joint of the shoulder is susceptible to premature arthritic development from various conditions that may damage the joint cartilage Of these conditions, glenohumeral osteoarthritis is the most common form of arthritis that results in shoulder joint pain The indications include: • Glenohumeral osteoarthritis • Rotator cuff arthropathy • Post-traumatic osteoarthritis • Acute and chronic adhesive capsulitis • Rheumatoid arthritis • Collagen vascular diseases Oftentimes, patients present with generalized shoulder and upper arm pain and it may be difficult to localize the primary pain generator intra-articular glenohumeral joint injections are excellent diagnostic tools, which can aid in elucidating the primary pain generator Therapeutically, intra-articular glenohumeral joint corticosteroid injections are relatively safe interventional procedures These procedures may be performed if shoulder pain remains refractory to more conservative measures such as occupational therapy, pharmacologic intervention, and activity modification Accuracy of blind glenohumeral joint injections has been found to be extremely variable, ranging from 25% to 95% accuracy Image-guided intra-articular glenohumeral joint injection enables dynamic real-time visualization of the process, improves needle visualization, augments target accuracy, reduces damage to surrounding structures, ie, glenoid labrum, and decreases the risk of neurovascular injury, particularly to the brachial plexus Relevant Anatomy The large and round head of the humerus articulates with the relatively flat glenoid fossa of the scapula to form the glenohumeral (GH) joint The articular surface is covered with hyaline cartilage Due to the relative incongruence of these surfaces, the glenohumeral joint is susceptible to degenerative changes and instability The glenoid labrum is a fibrocarti-laginous layer, which envelops the rim of the glenoid fossa With humeral dislocation and subluxation, the glenoid labrum is exposed and has an increased risk for trauma The glenohumeral joint is encompassed by a lax capsule that permits a wide range of motion of the joint However, this laxity compromises joint stability The glenohumeral joint is lined by a synovial membrane, which attaches to the articular cartilage and forms synovial tendon sheaths and bursae These synovial structures are particularly vulnerable to inflammation The glenohumeral joint are innervated by the axillary and suprascapular nerves The glenohumeral, transverse humeral, and cora-cohumeral ligaments are the major ligaments of the shoulder joint The rotator cuff muscles that surround the shoulder joint are the supraspinatus, infraspinatus, teres minor, and subscapularis muscles The rotator cuff musculature and ligaments provide strength to the joint However, due to misuse and overuse injuries, the rotator cuff muscles and their tendons are susceptible to trauma and inflammation The key to successfully locating the glenohumeral joint from a posterior approach is identifying the following structures (Figure 50-1): • Humeral head, which is the primary bony landmark for locating the GH joint • Posterior labrum • Infraspinatus muscle and tendon • Tendon sheath of the bicipital tendon Figure 50-1 Illustrations of the posterior (left) and anterior (right) views of the right glenohumeral joint with relation to nearby anatomical structures From an anterior approach, the following structures should be identified (Figure 50-1): • Lesser tubercle of the humerus • Coracoid process • Tendon sheath of the bicipital tendon Other relevant anatomy that should be taken into consideration while performing these injections is: • Brachial plexus, which is at increased risk for neurovascular injury from the anterior approach • Calcifications of the rotator cuff muscle and bicipital tendons Preoperative Considerations for GH Joint Injections • For the ultrasound-guided approaches to the glenohumeral joint, the patient must be able to sit upright for the procedure duration Preferably, the patient will be able to sit upright on a stool with a rotating seat, but without wheels • Alternatively, the patient may lie prone or supine on the examination table for, respectively, ultrasound-guided posterior and anterior approaches to the glenohumeral joint However, assessment and procedural efficiency would likely be sacrificed • For most fluoroscopic interventional procedures, the patient should be able to maintain his or her position for the length of the procedure For glenohumeral joint injections utilizing the posterior approach, the patient must be able to lie prone For the anterior approach, the patient must be able to supine Selection of Needles, Medication, and Equipment Needles • 22-gauge 3.5-in spinal needle or, for ultrasound-guided injections, a 22-gauge echogenic needle, which will be connected to extension tubing • 22-gauge 1.5-in needle to prepare the injectate medication • 25-gauge 1.5-in needle for local anesthetic Stellate ganglion block anatomy in carotid and vertebral arteries in, 341–342 cervical sympathetic chain and, lying over longus colli muscle, 336, 338f cervicothoracic (stellate) ganglion, 336, 337f anterior paratracheal (classic) approach, 340, 341f contraindications to, 336 equipment for, 338 fluoroscopic views in anteroposterior approach, 337, 339f oblique approach, 337, 339f indications for, 336 medications for, 338 needles and supplies, 337–338 oblique approach to anteroposterior view of injectate, 340, 340f AP view in, 339, 339f fluoroscopic oblique view in, 339, 340f injection of anesthetic or steroid, 340, 340f injection of contrast in, 339–340, 340f needle placement in, 339 patient preparation for, 338–339 patient positioning for, 337 posterior approach, 342 postprocedure considerations, 341 preoperative considerations patient education in post procedural effects, 336–337 previous neck or thyroid surgery, 336 Subarachnoid neurolysis agents used for, 680–681, 681t with alcohol, intraoperative steps, 682–683 with phenol, intraoperative steps, 683 Sufentanil non-FDA-approved for intrathecal use, 566 Superior hypogastric plexus neurolysis anatomy in, 676 complications of, 677, 679 contraindications to, 676 described, 675–676 fluoroscopic views, 676 anterior-posterior, 675f lateral, 675f intraoperative steps in advancement of needle, 677 injection of contrast, 677 injection of phenol in glycerin, 677 patient positioning, 677 scout film of lumbar spine, 677 patient position for, 676 selection of needles, medications, and equipment for, 676 Supraclavicular nerve block anatomy in brachial plexus, 495–496 relationship of brachial plexus trunks to subclavian artery, 495f relationship of subclavian artery and vein in, 496, 496f indications for, 495 nerve stimulator technique landmarks for, 496, 497f ultrasound technique anatomy for supraclavicular brachial plexus block, 498f probe in, 497 probe position in, 497, 498f setup of probe and needle in, 499, 499f Supraorbital nerve peripheral nerve stimulation trial, 641, 641f, 642f permanent implant, 642–643 Supraorbital nerve cryoneuroablation anatomy in, 695 supratrochlear nerve, 695, 695f indications for, 694–695 patient position for, 695 technique, 696f closed, 695 open operative, 695 Supraorbital neuralgia, 694–695 Suprascapular nerve block anatomy in important to performance of block, 538 motor nerves to supraspinatus and infraspinatus muscle, 537 sensory nerve branches, 537 suprascapular artery, 538 suprascapular nerve in relation to muscles and vasculature, 538f suprascapular notch, 537–538 supraspinous fossa, 537 classic approach (Wertheim), 539–540, 539f, 540f Dangoisse-modified method, 540, 540f fluoroscopic image of, 540f equipment for in blind approach, 538 in fluoroscopic procedure, 539 in ultrasound block, 538 fluoroscopy-guided, 541, 541f historical perspective on, 537 indications for, 537 medications for, 539 pneumothorax risk with, 540, 541 preoperative considerations, 538 suprascapular nerve described, 537 ultrasound-guided, 541 Supraspinous/interspinous ligaments anatomy of, 477–478, 478f injection of, 482–483, 483f Syringes, specialized, 40, 40f T Tendinopathy/tendonosis tendon injection for, 476, 477f Tendon injection(s) anatomy in bicipital tendonitis/tendonosis, 476, 477f distal piriformis, 478–479, 478f iliolumbar ligament, 479, 479f lateral epicondylosis/epidondylitis, 477, 478f levator scapula, 477, 477f supraspinous/interspinous ligaments, 477–478, 478f of bicipital tendon, 480, 480f, 481f complications of, 485 contraindications to, 476 of distal piriformis, 484–485, 484f equipment and medications, 480 fluoroscopic/ultrasound views, 479–480 of iliolumbar ligament, 483, 484f indications for, 476 intraoperative steps in, 480–485 of lateral epicondyle, 481–482, 482f of levator scapula, 481, 481f postoperative considerations, 485 preoperative considerations, 479 of supraspinous/interspinous ligament, 482–483, 483f Tennis elbow extensor carpi radialis brevis muscle and common extensor tendon injections for, 415 Tetracaine metabolism and unique properties, 61–62 Thermal rhizotomy, for trigeminal ganglion block, 126, 128 Thoracic disc anatomy, 234 Thoracic discogram See also Provocative discogram injection of contrast in, 237 needle advancement to middle of disc under fluoroscopic guidance, 237 patient position in, 237 Thoracic DRG block fluoroscopic views oblique, 197, 197f patient position for, 197, 197f preferred technique digital subtraction fluoroscopy in, 197 needle position in, 197, 197f pulsed-dose low-frequency in, 198 sensory and motor stimulation in, 198 Thoracic (T2-3) ganglion block anatomy and autonomic nervous system, 344 radiologic landmarks for oblique technique, 345, 345f sympathetic trunk and, 344f thoracic ganglia, 344–345 basic concerns risk of pneumothorax, 345, 347 complications of pneumothorax, 349 equipment for, 345 indications for, 343t pain syndromes, 343 vascular insufficiency, 344 intercostal oblique approach to sympathetic ganglia AP fluoroscopic view and, 347, 348f “gunsight” view of needle and target in, 347, 348f laser sighting device and, 347 needle insertion in, 347, 348f needle position in, 347, 349f patient positioning for, 347 ribs and their articulations in, 346f, 347 medications for, 345 neurolytic procedure phenol in, 349 radiofrequency ablation in, 349 oblique technique, 345, 345f advantages of, 345 paraspinous approach anatomy, 346f needle insertion in, 346 radiofrequency lesioning in, 346–347 postprocedure follow-up, 349 Thoracic interlaminar epidural steroid injections See also Interlaminar epidural steroid injection paramedian approach, 158, 159f positioning for, 158 Thoracic outlet syndrome anterior scalene muscle injection with local anesthetic for, 443 scalene muscle injections for, 442 Thoracolumbar spine interventions, vascular complications in, 319–320 Ticlid (ticlopidine), anticoagulation guidelines for, 82 Ticlopidine (Ticlid), anticoagulation guidelines for, 82 Touhy needle, 37, 38f with flexible introducer cannula, 38, 38f Transducers in portable ultrasound machine frequency ranges in, 20–21 types of, 20, 21f–22f Transforaminal epidural steroid injection (TFESI) advantages of, 162 cervical spine, 327–331 safe performance of, Kambin vs “safe triangle” approach for, 324–325, 324f, 325f technique in Kambin triangle final needle position, 325, 326f, 327f injection of dye following, 327f oblique approach, 325, 325f skin entry site, 325, 325f thoracolumbar, 319 vascular complications of, 324–325, 324f, 325f Triamcinolone acetonide, depot adrenal suppression with, 45t Trigeminal ganglion anatomy of external landmarks, 123 mandibular division, 122 maxillary division, 122 Meckel cavity and, 122 ophthalmic division, 122 radiographic, 122 Trigeminal ganglion nerve block chemical rhizotomy, 126 complications of, 127 contraindications to, 123 equipment for, 123–124 fluoroscopic views of AP, 123, 123f lateral, 123, 124f oblique, 123, 124f, 125 submental, 123, 124f indications for, 122 medications for, 124 preoperative considerations in anticoagulation, 123 conscious sedation, 123 pulsed radiofrequency, 126–127 technique advance needle through foramen ovale, 125, 125f aspirate, 125–126 inject contrast and local anesthetic, 125 insert block needle, 125, 125f oblique image intensifier, 125, 125f patient preparation, 124 thermal rhizotomy lesioning in, 126 lesioning of ophthalmic division, 128 radiofrequency needle in, 126 Trigeminal nerve division blocks mandibular nerve block complications of, 128 maxillary nerve block, 127 intraorbital, 127 maxillary, 128 radiofrequency, 128 ophthalmic for supraorbital nerve, 127 for supratrochlear nerve, 127 Trigeminal neuralgia balloon compression for, 661 characterization of, 656 diagnosis of, 656 glycerol infusion for, 661 medical therapy for, 657 problems with, 657 microvascular decompression for, 657–658 complications of, 658–659 procedure in, 658, 659f of superior cerebellar artery, 658, 658f motor cortex stimulation for, 662 neuromodulation therapies for, 661–662 versus other facial pain disorders, 656 pathophysiology of, 656–657 percutaneous lesioning at gasserian ganglion for, 659 anatomy in, 660f biplane fluoroscopy in, 659, 660f radiofrequency thermocoagulation lesioning, 659 recurrence rate with, 660 steps in, 659–660 peripheral facial stimulation advantages of, 662 localization of electrode for, 662, 663f nonapproved, 662 uses of, 663 stereotactic radiosurgery for, 661 surgical therapy for, 657 Trigeminal neurolysis complications of, 670 CT-guided advancing needle tip in relationship to foramen ovale, 668f, 669f, 670 contrast in Meckel cave, 669f, 670 injection of absolute alcohol, 670 needle placement in, 668f needle tip entering foramen ovale, 668f patient position in, 668f, 670 postoperative considerations, 670 Trigger point injections, 434 basic concerns, 434 complications of, 429 contraindications to, 434 defined, 428, 434 equipment and medications for, 435 equipment and supplies for, 428–429, 429f example of, 430f goal of, 428 indications for, 428 mark trigger points with reference zone marked, 429, 430f needle insertion in, 429, 430f patient positioning for, 429, 429f physical examination for, 428 postinjection instructions, 429 preoperative considerations in, 435 technique, 435 trigger points and, 434 U Ultrasound advantages of, 20t basic physics of acoustic impedance, 19 attenuation, 19 common procedures performed with, 20t principles of in medical imaging, 20 scattering in, 20 specular reflection in, 20 transducers in, 20 Ultrasound imaging advances in echogenic needles coated with nanoparticles, 28, 28f needle optimization technology, 29, 29f three-dimensional, 28, 28f artifacts in anisotropy, 28–29 comet tail, 27, 27f enhancement, 26, 27f mirror images, 26f, 27 reverberation, 27, 27f ergonomics during, 27–28 limitations of, 26, 26f recommendations for, 29 Ultrasound portable machine image optimization during scanning, 26t image optimization functions depth, 22, 23f focus, 22 gain, 22, 23f tissue harmonic imaging, 23–24 zoom, 23 transducers in frequency ranges in, 20–21 types of, 20, 21f–22f troubleshooting if needle not visualized, 25–26 Ultrasound sonopathology, 26, 26f Upper extremity electromyography of, 88f, 92, 94f V Vascular complications of spinal interventions anatomy and artery of Adamkiewicz, 321, 322f, 323–324 radiculomedullary arteries, 321, 321f, 322–323, 322f “safe triangle “ in, 321f in cervical spine, 319–320, 327–329 embolism theories of vascular injury, 330 other mechanisms of, 330 intravascular uptake technique modifications to detect, 330–331, 332f intravascular uptake prevention epimed blunt-tipped needle, 332f interlaminar approach with steerable catheter, 332, 332f technique modifications for, 330–332, 333 use of nonparticulate steroid, 331–332 radiculomedullary arteries, 322, 322f in lumbar spine, 322 nervous system branches, 323 spinal canal branches, 323 in thoracic spine, 322 spinal cord injury from lumbar transforaminal procedures, 320, 321f from vascular ischemia, 320–321 sympathetic blocks or neurolytic procedures in sympathetic blocks or neurolytic procedures, 325–326, 327f oblique approach, 326 transdiscal approach, 326, 327f in thoracolumbar spine, 319–320 indications for interventional procedures in, 320 procedures and procedure-related complications, 320 in transforaminal epidural steroid injections, 324–325, 324f, 325f vascular injury, theories of, 321 vascular supply of spinal cord artery of Adamkiewicz, 321, 322f radiculomedullary arteries, 321f, 322, 433f vascular uptake of dye and steroid, protective strategies against, 324 Vertebral augmentation See also Kyphoplasty; Vertebroplasty anatomy in, 299 contraindications to, 299 historical perspective on, 298 indications for, 299 kyphoplasty for, 306f, 307–308 for osteoporotic vertebral compression fracture, 298–299 goal of, 299 vertebroplasty for, 299–306 Vertebral compression fracture, 298, 299 Vertebroplasty See also Kyphoplasty; Vertebral augmentation complications of aortic embolism, 309, 311f cement embolization into lungs and cerebral circulation, 309 cement extravasation in, 308, 308f, 309 cement extrusion, 308 intradural leakage, 310f nerve root severed, 309, 311f pedicle fracture, 309, 311f posterior leakage, 309, 310f transient radiculopathy, 308 needle placement in AP and lateral views for correct, 312, 312f guide for, 312, 312f needle trajectories, unsafe, 312, 313f parapedicular approach needle insertion in, 306, 306f in thoracic spine above T8, 306 preoperative considerations in C-arm fluoroscopy, 301f CT guidance, 299 fluoroscopy, 301, 302f imaging in, 300 real-time imaging in, 299, 300 spinal needle entry into vertebral body, 300f transpedicular approach danger zone in, 305, 305f injection of cement, 303, 305, 305f safe deposit of cement in, 303 “Scottie dog” view of vertebral body in, 301, 303f unipedicular versus bipedicular needle in, 303, 305f views of vertebroplasty needle in pedicle, 301–302, 303f Viscosupplement FDA approval of, 419 intra-articular injection in knee, 423f, 424–425, 424f complications of, 425 injection site preparation for, 423f, 424 marking anatomical landmarks, 423f, 424 needle directed to enter joint capsule, 424–425, 424f needles and equipment for, 424 patella tilt for, 424f, 425 positioning for, 422–423, 423f postprocedure follow-up, 425 manufacturer and brand information, 419t W Warfarin (Coumadin), anticoagulation guidelines for, 79–80 X X-rays fluoroscopic image analogous to photographic negative, 3, 3f physics of, 2–3 plain radiography, chest, analogous to photograph, 4f Z Ziconotide, intrathecal for neuropathic pain, 565 Ziconotide trialing bolus trials, single or multiple injections, 572 continuous intrathecal infusion, 570–571 equipment for needle placement, 566, 567f procedure for, 571–572 psychosis as side effect of, 570–571 single-shot trial procedure, 572–583 limited duration trials, 571 single-shot trial procedure, 572 post-trial considerations, 572–573 ... The injectate is drawn up using a 10-cc syringe which consists of 40 to 80 mg of either triamcinolone or methylprednisolone and 2 to 4 cc of 1% lidocaine with the option to include additional 2 cc of 0 .25 % bupivacaine • The 22 -gauge 3.5-in spinal needle with this 10-cc syringe attached is then... attachments, including the iliofemoral ligament to intertrochanteric line of the femur and the pubofemoral ligament to the lesser tuberosity of the femur On the right, a posterior view of the hip capsule and ischiofemoral ligament is... the suspected source of pain For therapeutic purposes, intra-articular steroid injections are often considered as the next step of treatment for intra-articular sources of hip pain (eg, OA or labral pathology) that