C-arm

[topwise]

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I apologize in advance if this is a stupid question:

In the real world, about what percent of doctors doing interventional spine injections use a C-arm? (as opposed to just a regular X-ray machine or god forbid, injecting blindly)

 

[lobelsteve]

I apologize in advance if this is a stupid question:

In the real world, about what percent of doctors doing interventional spine injections use a C-arm? (as opposed to just a regular X-ray machine or god forbid, injecting blindly)

Two schools of thought:

1. If you perform a spinal injection (including SIJ, facet, ESI, LSB) and do not use fluoro and contrast where appropriate- and a complication occurs- Many of us on this forum would don our black hats and sit with the patient's attorney.

2. If you perform a spinal injection (including SIJ, facet, ESI, LSB) and do not use fluoro and contrast where appropriate- and an insurance panel or medicare claims fraud or is just seeking a precert- Many of us on this forum would don our black hats and sit with the folk's paying.


Do it right or get another job.

 

[topwise]

Don't read me wrong, I personally have no intention of performing spine injections now or ever without fellowship training using a C-arm.

 

[Finally M3]

Don't read me wrong, I personally have no intention of performing spine injections now or ever without fellowship training using a C-arm.

I think Matt would kill you if you did.

 

[RUOkie]

In the real world (which is what the question was) there are still many anesthesiologists who perform the above injections without fluoro. However the statistics clearly do support the use of fluoro for ALL ESI/ZP/SI injections. I used to do SI injections and piriformis TPI without imaging (I am pretty old), and now always use c-arm for SI's and ultrasound for pirifomis trigger points. It is just safer, and have MUCH better outcomes (the literature supports it, and the everyone will pay for the c-arm). I do not personally know of any physiatrists who do not use a c-arm for the above injections, but I know of many anesthesiologists who do not.

 

[PMR 4 MSK]

I apologize in advance if this is a stupid question:

In the real world, about what percent of doctors doing interventional spine injections use a C-arm? (as opposed to just a regular X-ray machine or god forbid, injecting blindly)

Except ESI, probably 90%+, for ESI, lower due to older training or inaccesibility. We have an FP occ med guy in town who does blind ESI's, and only recently obtained a C-arm and has started to learn how to use it. We have 2 rheums in my group who routinely do SIJI blind - we have fluoro available, they just choose not to utilize it.

I have an anesthesia pain guy in town who does facets blind, at least that's what he calls them.

 

[RUOkie]

Except ESI, probably 90%+, for ESI, lower due to older training or inaccesibility. We have an FP occ med guy in town who does blind ESI's, and only recently obtained a C-arm and has started to learn how to use it. We have 2 rheums in my group who routinely do SIJI blind - we have fluoro available, they just choose not to utilize it.

I have an anesthesia pain guy in town who does facets blind, at least that's what he calls them.

Hey! I do facets blind too, I just call them trigger points!

 

[topwise]

I think Matt would kill you if you did.

Haha.. yes, I believe he would. 🙂 Actually, watching the expertise of someone like him or our other pain doc is kind of intimidating. I can't imagine how anyone could be as skilled as that without fellowship training. But I know a lot of people go out and practice without fellowships.

My understanding is that the chance of actually getting the steroid in the SI without use of fluoro is not very good.

 

[dc2md]

topwise,
the issue is that some studies have shown that PERI-articular SI steroid injections are just as effective as INTRA-articular injections. therefore blindly shooting it around the joint is fine.

 

[bedrock]

the issue is that some studies have shown that PERI-articular SI steroid injections are just as effective as INTRA-articular injections. therefore blindly shooting it around the joint is fine.

I respectively disagree. There are intra-articular and extra-articular sources of SIJ pain. It has been shown that a certain percentage of patients with SIJ pain will respond to intra-articular SIJ blocks who don't respond to blocking the lateral S1-S3 branches (which supply the dorsal ligaments etc). Likewise a certain percentage of folks with SIJ pain will respond to blocks of the lateral S1-S3 branches but not to intra-articular blocks. These are the kind of people who would respond to blind SIJ injections like some of the old docs and rheumatologists perform.

Bottom line- You need to be able to 1-perform and 2-consider both interventions/innervations for SIJ pain. Without fluoro capabilities, you're handicapped treating SIJ pain.

 

[dc2md]

good point bedrock. but in my experience, physicians use the tools they have available in their box. the fluoro guys will use fluoro and go for intra-articular only. and the non-fluoro guys will go for the fast, peri version. i haven't seen a fluoro doc go straight for extra-articular before...unless they just can't get the contrast pattern they like, so they quit wasting time and just inject where they are (extra-articular) and say "good enough".

also, with the rational you mentioned, it seems most wise to load a syringe with steroid/local and (under fluoro) inject half into the joint, then pull out just enough, and inject the other half outside. hmmmm...i should try this next time i have a pain rotation at the VA.

 

[rehab_sports_dr]

Only 42% of epidurals are done with fluoro

J Bone Joint Surg Am. 2008 Aug;90(8):1730-7.
Geographic variation in epidural steroid injection use in medicare patients.
Friedly J, Chan L, Deyo R.

It's a great article (and, as an aside, Janna Friedly has been doing some tremendous research on how epidurals are actually being used in the real world. She also had a fantastic poster at the AAP meeting- easily one of the best)

So, considering that most professional societies like ISIS consider fluoro a minimal requirement for appropriately performed injections, that means that the upper limit of how many spine procedures are being done appropriately is 42%

when you factor in wrong choice of approach (e.g., interlaminar or caudal when a transformanal may have been more appropriate), or wrong level, or wrong structure (e.g., interlaminar epidurals for what is clearly SI joint pain), I would estimate that the % of injections that are appropriate is probably quite a bit lower than the 42% upper limit. I am just guessing, but it's probably in the 20-30% range

I think this is very important to consider when you hear people questioning the efficacy of interventional spine procedures- if only 20-30% are being performed correctly, then you would not anticipate a huge benefit.

My personal belief is that appropriately administered spine injections can be very effective

 

[bedrock]

I think this is very important to consider when you hear people questioning the efficacy of interventional spine procedures- if only 20-30% are being performed correctly, then you would not anticipate a huge benefit.

My personal belief is that appropriately administered spine injections can be very effective

I completely agree on both points. Spine injections performed at the right location and for the appropriate indications can be quite effective.

This is something that is not always understood by those who don't perform these procedures. The old guard that still does them blind and the
"proceduralists" who would needle a ham sandwich, give the entire field a bad reputation, when minimally invasive spinal procedures are very useful when appropriately selected and performed.

 

[bedrock]

i haven't seen a fluoro doc go straight for extra-articular before...unless they just can't get the contrast pattern they like, so they quit wasting time and just inject where they are (extra-articular) and say "good enough".

dc2md,

As I was commenting to rehab sports doc, there is too much polarity between physicians who have fluoro skills and those that don't.

This is where physiatry can shine (in contrast to anesthesia and proceduralists). If we can learn and appropriately apply fluoro-procedures without forsaking our history and physical examination skills.

For example, if you suspect someone has SIJ pain but you don't have a reason to suspect intra vs extra-articular SIJ source of pain, why not start with the quickest and cheapest treatment option? If you think they would benefit from an SIJ injection, you can do a blind SIJ in 3 minutes at the end of your clinic eval, treating the dorsal capsular structures. Quick, inexpensive, and no exposure to radiation. If they don't respond you can have them scheduled for the fluoro-guided SIJ injection. A significant percentage won't need the fluoro SIJ injection. But you can still provide it to those that do and you won't have lost any time.

 

[dc2md]

bedrock,
good points. as a resident, we aren't taught anything (and i haven't asked) about the billing/reimbursement differences between guided and "blind" SI injections. yes, i know it varies by insurance company, but in general, is it significantly more for a fluoro-guided SI injection??

 

[topwise]

For example, if you suspect someone has SIJ pain but you don't have a reason to suspect intra vs extra-articular SIJ source of pain, why not start with the quickest and cheapest treatment option? If you think they would benefit from an SIJ injection, you can do a blind SIJ in 3 minutes at the end of your clinic eval, treating the dorsal capsular structures. Quick, inexpensive, and no exposure to radiation. If they don't respond you can have them scheduled for the fluoro-guided SIJ injection. A significant percentage won't need the fluoro SIJ injection. But you can still provide it to those that do and you won't have lost any time.

If you do this though, now you've given the patient two injections with steroid. If the second one doesn't work because it turns out you were wrong about the SIJ, and you now want to do a facet jt injection, now you're on your third dose of steroids. Isn't it better to try to do it right the first time?

 

[ampaphb]

topwise,
the issue is that some studies have shown that PERI-articular SI steroid injections are just as effective as INTRA-articular injections. therefore blindly shooting it around the joint is fine.

1. Could you post the abstract from these studies so we can all learn from them?
2. Fluoro is used for two purposes -
   • to put medication in the right place, and
   • to prevent you from injecting it intravascularly.

IMHO, blind injections are never acceptable

 

[dc2md]

hey ampaphb. don't know if this is the study dr. kishner is always quoting, but here it is. and yes, i know it's far from perfect...but let's face it, there aren't too many blinded, controlled studies with large "n's" in interventional pain of any sort. this study at least has to put some question into your mind about whether fluoro-guided SI is without a doubt superior.
--------------------------------------------------
Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study
Authors: Eiichi Murakami, Yasuhisa Tanaka, Toshimi Aizawa, Masato Ishizuka, Shoichi Kokubun
BACKGROUND: The sacroiliac joint (SIJ) can be a source of low back pain. Previous studies indicated that SIJ pain could originate from both the joint capsule and the posterior ligamentous tissues. It has not been clarified as to whether an intraarticular or periarticular injection procedure is more effective for this type of pain. The purpose of this study was to evaluate the effect of two injection procedures prospectively. METHODS: After a pain provocation test, an intraarticular injection of local anesthetic (2% lidocaine) was performed on the first 25 consecutive patients with SIJ pain and a periarticular injection on another 25. The periarticular injections were given to one or more sections of the posterior periarticular area of the SIJ and to another section in the extracranial portion. The effect of these injections was assessed using the "restriction of activities of daily life" scoring system from the Japanese Orthopaedic Association. RESULTS: The periarticular injection was effective in all patients, but the intraarticular one was effective in only 9 of 25 patients. An additional periarticular injection was performed in 16 patients who experienced no effect from the initial intraarticular injection and was considered effective in all of them. The injection into the middle of the periarticular area was more effective for SIJ pain. The improvement rate after the periarticular injection was 96%, which was significantly higher than that after the intraarticular injection, which was 62%. CONCLUSIONS: For patients with SIJ pain, periarticular injection is more effective and easier to perform than the intraarticular injection and should be tried initially.

Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.2007/05;12(3):274-80.
ISSN: 0949-2658

 

[ampaphb]

Chris:

LSU's library doesn't subscribe to that journal, so my comments are based only on the abstract of Dr. Murakami's study.

No one provocative test provides more than 64% sensitivity for SIJ pain (Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests, Man Ther. 2005 Aug;10(3):207-18.) Selection criteria is also the primary flaw in another study Dr. Kishner may be referencing from last year:

Sources of sacroiliac region pain: insights gained from a study comparing standard intra-articular injection with a technique combining intra- and peri-articular injection.
Borowsky CD, Fagen G.
Arch Phys Med Rehabil. 2008 Nov;89(11):2048-56

OBJECTIVES: To present evidence supporting the existence of extra-articular sources for sacroiliac region pain and to present evidence that intra-articular anesthetic blockade may underestimate the true prevalence of sacroiliac region pain. DESIGN: Retrospective review of 2 large case series comparing patient responses to intra-articular injection versus combined intra-articular and peri-articular injection of anesthetic and corticosteroid. SETTING: Private practice chronic pain clinic set in a hospital outpatient clinic. PARTICIPANTS: Patients (N=120) sequentially enrolled from practice billing records. Inclusion criteria included pain in the low back below L4 and in the buttock, thigh, groin, or lower leg. If disk herniation, lumbar stenosis, or facet syndrome was previously treated with appropriately chosen injections, response to treatment had to be negative. Patients failed to respond to treatment with physical therapy. Exclusion criteria included records with an incomplete database, patients increasing pain medication use greater than 15% for pain not related to the sacroiliac region, severe psychiatric illness, and nonspecific anesthetic blockade. One hundred sixty-seven records were reviewed to obtain the 120 study subjects. INTERVENTIONS: Intra-articular injection was done according to the standard technique described by Fortin. Peri-articular injection was done by a slight modification of the procedure described by Yin. MAIN OUTCOME MEASURES: Percentage change in visual analog scale (VAS) pain scores at 3 weeks and 3 months postinjection; patients' self reported activities of daily living (ADLs) improvement at 3 weeks and 3 months postinjection; and percentage change in VAS pain score within 1 hour of injection. RESULTS: For intra-articular injection alone, the rate of positive response at 3 months was 12.50% versus 31.25% for the combined injection (P=.025). Positive response was defined as greater than 50% drop in VAS pain score or patients describing ADLs as "greatly improved." Anesthetic response rates were higher in the combined injection group (62.5% vs 42.5%; P=.037). CONCLUSIONS: Significant extra-articular sources of sacroiliac region pain exist. Intra-articular diagnostic blocks underestimate the prevalence of sacroiliac region pain.
​

The Japanese study you cite claims effectiveness in ALL patients who received peri-articular injections. The Archives study reports 31.25% positive response for combination intra and extra-articular injections. The inadequate physical exam ("After a pain provocation test") sensitivity leads me to believe there is no way every patient included in the Japanese study had primary SIJ pain. The Archives study inclusion criteria (pain in the low back below L4 and buttock, thigh, calf, or groin pain) was equally suspect, because facetogenic pain was never ruled out. Their results are much more reasonable in light of that selection criteria failing, and the 100% success of the Japanese study is quite simply unbelievable.

The Archives study addressed both the posterior interosseous ligament and S1-3 lateral branches. Given the variability of the location of the lateral branches, as well as the 10-20% likelihood of vascular uptake of your therapeutic solution, injecting those structures without the benefit of fluorscopic guidance seems futile.

Lastly, when studies report long-term relief from an injection of materials into unconstrained spaces (e.g. MBBs), I personally am forced to question their construct validity. From my perspective, I remain baffled how we can ascribe therapeutic benefit at three months to local anesthetic and steroid that likely floated off no more than a few minutes to hours after they were injected.

 

[PMR 4 MSK]

bedrock,
good points. as a resident, we aren't taught anything (and i haven't asked) about the billing/reimbursement differences between guided and "blind" SI injections. yes, i know it varies by insurance company, but in general, is it significantly more for a fluoro-guided SI injection??

Overall costs to the insurance company is higher - fluoro bills out typically high 3 figures to low 4. Reimbursement varies widely, from nothing to a gold mine. Depending on where it is done, the physician using the fluoro may get anywhere from 10 - 100% of what the insurance company pays for the fluoro - the rest goes to whoever owns the fluoro.

 

[nvrsumr]

Since you are epidural more often than intraarticular with blind "SI" injections who knows what you are treating. Unless you have Fortin's magic finger.
Blind SI injections are never warranted.

Clin J Pain. 2000 Mar;16(1):18-21. Links
Computerized tomographic localization of clinically-guided sacroiliac joint injections.Rosenberg JM, Quint TJ, de Rosayro AM.
Department of Anesthesiology, University of Michigan Hospitals, Ann Arbor, USA. [email protected]

OBJECTIVE: The goal of this study was to use computed tomographic (CT) scanning to localize clinically guided sacroiliac (SI) joint injections and identify other structures affected by this procedure. DESIGN: A prospective, double-blind, correlational outcome study design was used. Injection of 39 SI joints with a mixture of bupivacaine (0.25%), methylprednisolone (40 mg), and iohexol (Omnipaque; 180 mg/dl) using a clinically guided technique, (i.e., no image guidance) was performed. Patients had CT scans obtained both immediately after needle placement and after contrast injection. Neither the patients nor their clinicians were aware of the CT findings at the time of injection. SETTING: Academic multidisciplinary pain center. PATIENTS: Patients with SI disease by clinical criteria. RESULTS: Intra-articular injection was accomplished in 8 of 37 (22%) patients. Injected material was identified within 1 cm of the joint 68% of the time. Epidural (spinal canal) injected material was seen 24% of the time. CONCLUSIONS: The low rate of intra-articular injection seen with this clinically-guided technique suggests restraint in its use for injection therapy. Some image guidance (e.g., fluoroscopy, CT) is probably necessary to reliably inject the SI joint. Perhaps in clinical settings, where image guidance is not readily available, a clinically-guided technique could initially be tried in patients at low risk for complications from such injections. This study also provides an anatomic explanation for the occasional weakness observed after SI joint injection.

 

[PMR 4 MSK]

Since you are epidural more often than intraarticular with blind "SI" injections who knows what you are treating. Unless you have Fortin's magic finger.
Blind SI injections are never warranted.

Clin J Pain. 2000 Mar;16(1):18-21. Links
Computerized tomographic localization of clinically-guided sacroiliac joint injections.Rosenberg JM, Quint TJ, de Rosayro AM.
Department of Anesthesiology, University of Michigan Hospitals, Ann Arbor, USA. [email protected]

OBJECTIVE: The goal of this study was to use computed tomographic (CT) scanning to localize clinically guided sacroiliac (SI) joint injections and identify other structures affected by this procedure. DESIGN: A prospective, double-blind, correlational outcome study design was used. Injection of 39 SI joints with a mixture of bupivacaine (0.25%), methylprednisolone (40 mg), and iohexol (Omnipaque; 180 mg/dl) using a clinically guided technique, (i.e., no image guidance) was performed. Patients had CT scans obtained both immediately after needle placement and after contrast injection. Neither the patients nor their clinicians were aware of the CT findings at the time of injection. SETTING: Academic multidisciplinary pain center. PATIENTS: Patients with SI disease by clinical criteria. RESULTS: Intra-articular injection was accomplished in 8 of 37 (22%) patients. Injected material was identified within 1 cm of the joint 68% of the time. Epidural (spinal canal) injected material was seen 24% of the time. CONCLUSIONS: The low rate of intra-articular injection seen with this clinically-guided technique suggests restraint in its use for injection therapy. Some image guidance (e.g., fluoroscopy, CT) is probably necessary to reliably inject the SI joint. Perhaps in clinical settings, where image guidance is not readily available, a clinically-guided technique could initially be tried in patients at low risk for complications from such injections. This study also provides an anatomic explanation for the occasional weakness observed after SI joint injection.

Now why did they not do an adject study of the response to intra- vs extra-articular injection. I.e. does it matter?

I've never had weakness of SIJI (I usually inject 2-3 cc 1 % lido). How's it getting epidural? Similar to facets?

 

[nvrsumr]

As i remember the needle was in one of the sacral foramen.

 

[Ligament]

You are not going to get injectate into the SI joint doing it blindly unless you are very, very, lucky. Furthermore, I question whether you can reliably get the dorsal sacroiliac ligaments reliably without imaging. Try this without image guidance then xray it. I bet most of the time your needle tip is WAAY off target.

 

[Finally M3]

Since you are epidural more often than intraarticular with blind "SI" injections who knows what you are treating. Unless you have Fortin's magic finger.
Blind SI injections are never warranted.

Clin J Pain. 2000 Mar;16(1):18-21. Links
Computerized tomographic localization of clinically-guided sacroiliac joint injections.Rosenberg JM, Quint TJ, de Rosayro AM.
Department of Anesthesiology, University of Michigan Hospitals, Ann Arbor, USA. [email protected]

OBJECTIVE: The goal of this study was to use computed tomographic (CT) scanning to localize clinically guided sacroiliac (SI) joint injections and identify other structures affected by this procedure. DESIGN: A prospective, double-blind, correlational outcome study design was used. Injection of 39 SI joints with a mixture of bupivacaine (0.25%), methylprednisolone (40 mg), and iohexol (Omnipaque; 180 mg/dl) using a clinically guided technique, (i.e., no image guidance) was performed. Patients had CT scans obtained both immediately after needle placement and after contrast injection. Neither the patients nor their clinicians were aware of the CT findings at the time of injection. SETTING: Academic multidisciplinary pain center. PATIENTS: Patients with SI disease by clinical criteria. RESULTS: Intra-articular injection was accomplished in 8 of 37 (22%) patients. Injected material was identified within 1 cm of the joint 68% of the time. Epidural (spinal canal) injected material was seen 24% of the time. CONCLUSIONS: The low rate of intra-articular injection seen with this clinically-guided technique suggests restraint in its use for injection therapy. Some image guidance (e.g., fluoroscopy, CT) is probably necessary to reliably inject the SI joint. Perhaps in clinical settings, where image guidance is not readily available, a clinically-guided technique could initially be tried in patients at low risk for complications from such injections. This study also provides an anatomic explanation for the occasional weakness observed after SI joint injection.

As of a couple of years ago, the primary author felt that with the experience he has since obtained since initial data collection/publication of his article, he felt his % success rate for blinded SI injections would be much higher than the publication. And he attributed to low % to relative inexperience. I +think+ he still does all SI injections with fluoro guidance however.

 

[db36jp78]

Chris:

LSU's library doesn't subscribe to that journal, so my comments are based only on the abstract of Dr. Murakami's study.

No one provocative test provides more than 64% sensitivity for SIJ pain (Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests, Man Ther. 2005 Aug;10(3):207-18.) Selection criteria is also the primary flaw in another study Dr. Kishner may be referencing from last year:

Sources of sacroiliac region pain: insights gained from a study comparing standard intra-articular injection with a technique combining intra- and peri-articular injection.
Borowsky CD, Fagen G.
Arch Phys Med Rehabil. 2008 Nov;89(11):2048-56

OBJECTIVES: To present evidence supporting the existence of extra-articular sources for sacroiliac region pain and to present evidence that intra-articular anesthetic blockade may underestimate the true prevalence of sacroiliac region pain. DESIGN: Retrospective review of 2 large case series comparing patient responses to intra-articular injection versus combined intra-articular and peri-articular injection of anesthetic and corticosteroid. SETTING: Private practice chronic pain clinic set in a hospital outpatient clinic. PARTICIPANTS: Patients (N=120) sequentially enrolled from practice billing records. Inclusion criteria included pain in the low back below L4 and in the buttock, thigh, groin, or lower leg. If disk herniation, lumbar stenosis, or facet syndrome was previously treated with appropriately chosen injections, response to treatment had to be negative. Patients failed to respond to treatment with physical therapy. Exclusion criteria included records with an incomplete database, patients increasing pain medication use greater than 15% for pain not related to the sacroiliac region, severe psychiatric illness, and nonspecific anesthetic blockade. One hundred sixty-seven records were reviewed to obtain the 120 study subjects. INTERVENTIONS: Intra-articular injection was done according to the standard technique described by Fortin. Peri-articular injection was done by a slight modification of the procedure described by Yin. MAIN OUTCOME MEASURES: Percentage change in visual analog scale (VAS) pain scores at 3 weeks and 3 months postinjection; patients' self reported activities of daily living (ADLs) improvement at 3 weeks and 3 months postinjection; and percentage change in VAS pain score within 1 hour of injection. RESULTS: For intra-articular injection alone, the rate of positive response at 3 months was 12.50% versus 31.25% for the combined injection (P=.025). Positive response was defined as greater than 50% drop in VAS pain score or patients describing ADLs as "greatly improved." Anesthetic response rates were higher in the combined injection group (62.5% vs 42.5%; P=.037). CONCLUSIONS: Significant extra-articular sources of sacroiliac region pain exist. Intra-articular diagnostic blocks underestimate the prevalence of sacroiliac region pain.
​

The Japanese study you cite claims effectiveness in ALL patients who received peri-articular injections. The Archives study reports 31.25% positive response for combination intra and extra-articular injections. The inadequate physical exam ("After a pain provocation test") sensitivity leads me to believe there is no way every patient included in the Japanese study had primary SIJ pain. The Archives study inclusion criteria (pain in the low back below L4 and buttock, thigh, calf, or groin pain) was equally suspect, because facetogenic pain was never ruled out. Their results are much more reasonable in light of that selection criteria failing, and the 100% success of the Japanese study is quite simply unbelievable.

The Archives study addressed both the posterior interosseous ligament and S1-3 lateral branches. Given the variability of the location of the lateral branches, as well as the 10-20% likelihood of vascular uptake of your therapeutic solution, injecting those structures without the benefit of fluorscopic guidance seems futile.

Lastly, when studies report long-term relief from an injection of materials into unconstrained spaces (e.g. MBBs), I personally am forced to question their construct validity. From my perspective, I remain baffled how we can ascribe therapeutic benefit at three months to local anesthetic and steroid that likely floated off no more than a few minutes to hours after they were injected.

I have to add to this discussion. Having read both of these articles (archives and japanese) and agree that they are poorly constructed and very little can be taken from these articles.

The archives paper used intraarticular injections (sij) in BOTH groups but added S1-3 lateral branches to their "treatment" group. I'm not sure what can be gleamed from SIJ versus SIJ AND a periarticular block. Also their patient population is not the cleanest-I question wether this article should have been published.

The japanese used a confirmatory block of hypertonic saline either in the joint or ligament (4 seperate areas) prior to the "treatment" injection. 5 of the 25 patients in the intrarcticular group did NOT have pain with the confirmatory block but were still treated with an intraarticular SIJ injection. Also 100% of the periarticular injections were "successful" which is always a dubious finding. The authors used an equation which I haven't seen before to define "success". Also you would have to, in theory, follow their protocal for periartcular injections to get their results.

I agree that there is intra and extra articular pain sources for the SIJ but
I have witnessed the old can't get in, 10-15 minutes go by, and then "well periarcticular is just as good" excuse a few to many times.

 

[meccos12]

although i fully agree with using radio guidance for things like SIJI and facet injections, i do not understand why ppl are so insistent about fluoro for ESI. I think people that have no or little experience with epidurals can feel the need for fluro guidance but for others who have placed hundreds if not thousands of epidurals without guidance, there is simply no need. Epidurals are a procedure that many people can literally do blind because after you do a certain number of them, you honestly get a "feel" for them.

 

[lobelsteve]

although i fully agree with using radio guidance for things like SIJI and facet injections, i do not understand why ppl are so insistent about fluoro for ESI. I think people that have no or little experience with epidurals can feel the need for fluro guidance but for others who have placed hundreds if not thousands of epidurals without guidance, there is simply no need. Epidurals are a procedure that many people can literally do blind because after you do a certain number of them, you honestly get a "feel" for them.

Troll? Maybe

Idiot- yes.

 

[meccos12]

Troll? Maybe

Idiot- yes.

inteligent reply: no
lack of experience with epidurals: yes


how do you think labor epidurals are done? with fluoro???? how do you think blood patches are done? with fluoro????

listen. the fact of the matter is... thousands of epidurals are done daily without fluoro.

are you sure you are an attending?

 

[lobelsteve]

inteligent reply: no
lack of experience with epidurals: yes


how do you think labor epidurals are done? with fluoro???? how do you think blood patches are done? with fluoro????

listen. the fact of the matter is... thousands of epidurals are done daily without fluoro.

are you sure you are an attending?

Great 1st 2 posts for the community. It's not my place to educate you. But you may want to do a bit of reading. THen when you get out of time out, you may have something more to add. Start with Standards of care as in guidelines from ISIS and ASIPP. Then find out who you are talking to to before making well publicized replies. Or is this just paindefender's other login?

 

[meccos12]

Great 1st 2 posts for the community. It's not my place to educate you. But you may want to do a bit of reading. THen when you get out of time out, you may have something more to add. Start with Standards of care as in guidelines from ISIS and ASIPP. Then find out who you are talking to to before making well publicized replies. Or is this just paindefender's other login?

I would think if you had any sort of inteligence and courtesy you might want to respond with an appropriate or helpful comment. That is obviously not the case with you. Instead you are simply quick to insult first.. then think later. The FACT is that thousands of epidurals are done without fluoro.. which is my only argument. Standard is standard and i understand that. Does not mean you cant question it. Please in future act civilized... you are in fact a frequent commenter on here... I would think you would have more tact. Or maybe they dont teach you that at carribbean med schools... Thanks and have a nice saturday. bye bye only reason i came to this site was because a search brought me here. I wont waste any more time... you will without doubt.

 

[olafa]

one of the authors for the study below is C.Aprill and probably had good selection criteria. However, its had to say with rading it.... and guessing based on reputation.

No one provocative test provides more than 64% sensitivity for SIJ pain (Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests, Man Ther. 2005 Aug;10(3):207-18.)

Just happened to notice is search for the other article, he also coauthored another "Archives" study.
Provocation sacroiliac joint tests have validity in the diagnosis of sacroiliac joint pain.
Laslett M, Aprill CN, McDonald B.
Arch Phys Med Rehabil. 2006 Jun;87(6):874; author reply 874-5. No abstract available.
PMID: 16731225 [PubMed - indexed for MEDLINE]
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